Tratamiento médico de la estenosis arterial intracraneal. ¿Es el mismo en prevención primaria que en secundaria?

In this study we review the risk factors associated with the formation and progression of an atheroma plaque, the mechanism involved in cerebral ischemia secondary to intracranial atheromatosis and possible medical treatment in primary and secondary prevention. DEVELOPMENT: Medical treatment of intracranial stenoses (ICS) is aimed at stopping the progression of the atheroma plaque and at preventing recurrences in the case of symptomatic stenoses. It is based on the control of vascular risk factors, the use of statins and antithrombotic therapy (antiplatelet or anticoagulation drugs). Although antiplatelet agents have not proved to be beneficial in the primary prevention of stroke, they are recommended in patients with ICS in order to lower the risk of heart attack associated with this pathology. The use of antiplatelet drugs in the secondary prevention of ischemic stroke secondary to an ICS is based on clinical trials which have shown that antiaggregation prevents non-cardioembolic strokes. Nevertheless, several retrospective studies have observed that oral anticoagulation is better than antiaggregation with aspirin. Two prospective clinical trials are currently being conducted which will, in the next few years, help to determine what the first choice medical treatment is for this group of patients. CONCLUSIONS: Medical treatment of ICS patients must include the control of vascular risk factors and the use of statins. New studies are needed to be able to establish the first choice antithrombotic drug in secondary prevention

Urgencias neurológicas y guardias de Neurología

In recent years different studies have highlighted a progressive increase in the demand for neurological care in emergency departments. To analyze the convenience of specific neurology shifts or the role that the neurologist should play in the emergency department, it is necessary to answer questions such as: What is the demand for emergency neurological care? What are the most frequent neurological emergencies? Who should attend to neurological emergencies and why? Are specific neurology shifts necessary? Neurological emergencies account for between 2.6% and 14% of medical emergencies. Stroke represents a third of all neurological emergencies, while the diagnoses of acute cerebrovascular disease, epilepsy and cephalea constitute 50% of all neurological care in the emergency department. On the basis of quality of care criteria and professional competence, the best care for patients with a neurological emergency is provided by a specialist in neurology. The implementation of specific neurology shifts, with a 24 hour physical presence, is associated with greater quality of care, better diagnostic and therapeutic orientation from the moment the patient arrives in emergency department, reduces unnecessary admissions, reduces costs and strengthens the neurology service

Cefalea en urgencias

Headache is among the most frequent neurological symptoms in the Emergency department. Although most of the patients suffer from primary headaches (migraine), an acute headache might be the only symptom of a serious disease, such as subarachnoid haemorrhage. The physician’s task is to make the diagnosis, carry out an appropriate selection of the patients who require further diagnostic evaluation and relieve the pain. An accurate history will identify most of the patients with secondary headaches. Clinicians should suspect secondary causes in sudden onset headache, headache in patients aged over 50 years, and also in those patients with abnormalities on neurological examination

Fisioterapia en cefalea tensional. ¿Debe recomendarse a nuestros pacientes?

La cefalea tensional es la patología neurológica más prevalente, y a pesar de su elevada frecuencia, la investigación en esta cefalea primaria es escasa, su fisiopatología es desconocida y el número de tratamientos médicos disponibles es muy limitado. Por ello, resulta muy gratificante encontrar publicaciones de grupos españoles abordando el tratamiento de la cefalea tensional desde el punto de vista de la atención fisioterápica

Trastornos neuropsiquiátricos en la enfermedad de Parkinson

This paper reviews the main neuropsychiatric disorders associated with Parkinson’s disease (PD) and describes the neuropathological hypothesis proposed to explain these symptoms. Development. This disease is usually associated with neuropsychiatric complications such as depression, anxiety and apathy. Besides, psychiatric symptoms are one of the most common side effects of antiparkinsonian drug-therapy. Conclusions. Depression is the most frequent emotional disorder reported in patients with PD. Up to 20% of parkinsonian patients meet DSM-IV criteria for major depressive episode and another 20% for dysthymia, while the prevalence of depression in normal aged population is about 2-8%. The relationship between PD and depression has not been fully established. Some investigators have suggested that depressive symptoms in PD are causally related to the underlying neuropathological process, affecting predominantly serotoninergic and dopaminergic pathways. Alternatively, depression in PD may represent a normal reaction to the progressive physical impairment induced by the disease. Otherwise, up to 20% of parkinsonian patients present levodopa-induced psychiatric complications. Visual hallucinations are the commonest, but delusions, confusional states, sexual disorders and sleep disorders have also been described. Serotonine and dopamine have been implicated in the neuropathological basis of these disorders

Reversible cerebral vasoconstriction syndrome induced by adrenaline

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by acute severe thunderclap headaches and evidence of multifocal, segmental, reversible vasoconstrictions of the cerebral arteries. Several precipitating factors have been identified and reported, including the use of recreational substances or sympathomimetic drugs and the postpartum state. Case description: Here we present the case of a woman who developed RCVS after the administration of adrenaline (epinephrine) in the setting of an anaphylactic reaction during antibiotic allergy testing. Discussion: To our knowledge, this is the first reported case of RCVS following the administration of exogenous adrenaline. This case contributes to the understanding of the physiopathological mechanisms underlying reversible cerebral vasoconstrictio

Upper gastrointestinal bleeding related to migraine: the importance of education for migraine care

Physicians involved in care of migraine patients should make a considerable effort to educate themselves and their patients. It is fundamental that doctors, patients and their families understand the causes of migraine, and know the different treatment strategies available to improve migraine care. Mallory-Weiss tears are lacerations in the region of the cardioesophageal junction due to vomiting. We report a case of Mallory-Weiss tear secondary to migraine that could had been reasonably avoided had the patient been treated with triptans since the first attack, according to the stratified care strategy. This case illustrates that inadequate management can cause serious medical consequences. It also proves that it is necessary to improve education about migraine for both patients and doctors

Excess abdominal fat is associated with cutaneous allodynia in individuals with migraine: a prospective cohort study

Objective: To investigate the specific relationship between cutaneous allodynia (CA) and the percentages of body fat (BF) and abdominal fat in migraineurs. Additionally, we compared serum levels of inflammatory biomarkers in patients with and without CA. Background: Excess abdominal fat might facilitate progressive changes in nociceptive thresholds causing central sensitization, clinically reflected as CA, which could drive migraine progression. Methods: This prospective cohort study included 80 patients with migraine (mean age 39 years, 81.2% female) and 39 non-migraine controls. We analysed each participant’s height, body weight, and body mass index (BMI). The amount and distribution of BF was also assessed by air displacement plethysmography (ADP) and ViScan, respectively. We analysed serum levels of markers of inflammation, during interictal periods. Results: We studied 52 patients with episodic migraine (EM) and 28 with chronic migraine (CM). Of the 80 patients, 53 (53.8%) had CA. Migraineurs with CA had a higher proportion of abdominal fat values than patients without CA (p = 0.04). The independent risk factors for CA were the use of migraine prophylaxis (OR 3.26, 95% CI [1.14 to 9.32]; p = 0.03), proportion of abdominal fat (OR 1.13, 95% CI [1.01 to 1.27]; p = 0.04), and presence of sleep disorders (OR 1.13, 95% CI [00.01 to 1.27]; p = 0.04). The concordance correlation coefficient between the ADP and BMI measurements was 0.51 (0.3681 to 0.6247). CA was not correlated with the mean plasma levels of inflammatory biomarkers. Conclusions: There is a relation between excess abdominal fat and CA. Abdominal obesity might contribute to the development of central sensitization in migraineurs, leading to migraine chronification