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Introducción En 2008, Aragón tenía tasas de morbimortalidad y discapacidad por ictus superiores a las del conjunto de España. Se estableció la necesidad de desarrollar un Programa de Atención al Ictus (PAIA). Material y métodos Damos a conocer la dinámica de planificación, implantación, evaluación y mejora que se ha desarrollado entre los años 2009-2014 y sus resultados a 5 años. Resultados Se ha mejorado en la estructura, en los procesos y en los resultados, con mejoría en los indicadores clave de la asistencia (audit 2008-2010-2012) y otros: tasa ictus 2013: 2, 07 (2008: 2, 36); 78% ictus atendidos en áreas/unidades en 2014 (30%, 2008); tasa fibrinólisis 8, 3% en 2014 (4, 4%, 2010); fibrinólisis hospitales secundarios (30% total); fibrinólisis con teleictus 9%; descenso de la mortalidad por ictus, 38%; años de vida prematura perdidos 67, 7 (2013)/144 (2008); capacitación de enfermería, desarrollo de la neurosonología, trabajo en red, con protocolos y buenas prácticas compartidos entre sectores sanitarios, etc. Conclusiones La gestión por procesos y equipos multidisciplinares desplegados en una distribución territorial integral, con protocolos y referencias establecidas y una dinámica de evaluación y mejora continua, ha demostrado ser una herramienta potente para garantizar la calidad y la equidad. El PAIA, por su dinámica de mejora sostenida y la implicación de los clínicos, es un buen ejemplo de gestión clínica y trabajo en red. Introduction: In 2008, stroke mortality, morbidity, and disability rates in Aragon were higher than the average in Spain. These data underscored the need to develop a stroke care programme (PAIA). Material and methods: We present the dynamics of planning, implementation, evaluation, and improvement developed between 2009 and 2014 as well as the results of the PAIA after that 5-year period. Results: Structure, processes, and outcomes have improved with reference to the key indicators of healthcare (audit: 2008, 2010, 2012) among others: stroke rate in 2013 was 2.07 (2.36 in 2008); 78% of strokes were managed in stroke units in 2014 (30% in 2008); rate of fibrinolysis was 8.3% in 2014 (4.4% in 2010); fibrinolysis was administered in secondary hospitals (30% of the total); fibrinolysis was administered by Telestroke in 9%; stroke mortality decreased (38%); 67.7 years of potential life lost (YPLL) in 2013 (144 in 2008); nurse training; development of neurosonology; networking; sharing protocols and best practices between health sectors, etc. Conclusions: Integrated process management and multidisciplinary teams distributed and deployed over an entire territory with established protocols, references, evaluations, and continuous development, have been proven powerful tools to ensure both quality and equality. The PAIA is a good example of clinical governance and networking due to its dynamic and sustained improvement and cooperation between clinicians.

BACKGROUND: It is unclear whether patients age 65 years and over with a recent stroke or TIA benefit from statin treatment to a similar degree as younger patients. METHODS: The 4,731 patient cohort in the SPARCL study was divided into an elderly group (65 and over) and a younger group. The primary endpoint (fatal or nonfatal stroke) and secondary endpoints were analyzed, with calculation of the hazard ratio (HR) and p values from a Cox regression model. RESULTS: There were 2,249 patients in the elderly group and 2,482 in the younger group. The baseline LDL (133 mg/dL) and total cholesterol were comparable in the two groups. The elderly and younger groups had a 61.4 mg/dL and 58.7 mg/dL decrease in mean LDL during the trial. The primary endpoint was reduced by 26% in younger patients (HR 0.74, 0.57-0.96, p = 0.02) and by 10% in elderly subjects (HR 0.90, 0.73-1.11, p = 0.33). A test of heterogeneity for a treatment-age interaction was not significant (p = 0.52). The risk of stroke or TIA (HR 0.79, p = 0.01), major coronary events (HR 0.68, p = 0.035), any coronary heart disease event (HR 0.61, p = 0.0006), and revascularization procedures (HR 0.55, p = 0.0005) was reduced in the elderly group. CONCLUSIONS: There was no heterogeneity in the stroke reduction seen with atorvastatin in the elderly and younger groups. Cardiac events and revascularization procedures were also lower in both the elderly and younger subgroups treated with atorvastatin. These results support the use of atorvastatin in elderly patients with recent stroke or TIA.

Background and Purpose— In SPARCL, treatment with atorvastatin 80 mg daily reduced stroke risk in patients with recent stroke or TIA and no known coronary heart disease by 16% versus placebo over 4.9 years of follow-up. The purpose of this secondary analysis was to determine whether men and women similarly benefited from randomization to statin treatment. Methods— The effect of sex on treatment-related reductions in stroke and other cardiovascular outcomes were analyzed with Cox regression modeling testing for sex by treatment interactions. Results— Women (n=1908) constituted 40% of the SPARCL study population. At baseline, men (n=2823) were younger (62.0±0.21versus 63.9±0.27 years), had lower systolic BPs (138.1±0.35 versus 139.5±0.47 mm Hg), higher diastolic BPs (82.2±0.20 versus 81.0±0.25 mm Hg), more frequently had a history of smoking (73% versus 38%), and had lower total cholesterol (207.0±0.54 versus 218.9±0.67 mg/dL) and LDL-C levels (132±0.45 versus 134±0.57 mg/dL) than women. Use of antithrombotics and antihypertensives were similar. After prespecified adjustment for region, entry event, time since event, and age, there were no sex by treatment interactions for the combined risk of nonfatal and fatal stroke (treatment Hazard Ratio, HR=0.84, 95% CI 0.68, 1.02 in men versus HR=0.84, 95% CI 0.63, 1.11 in women; treatment×sex interaction P =0.99), major cardiac events (HR=0.61, 95% CI 0.42, 0.87 in men versus HR=0.76, 95% CI 0.48, 1.21 in women; P =0.45), major cardiovascular events (HR=0.78, 95% CI 0.65, 0.93 in men versus HR=0.84, 95% CI 0.65, 1.07 in women; P =0.63), revascularization procedures (HR=0.50, 95% CI 0.37, 0.67 in men versus HR=0.76, 95% CI 0.46, 1.24 in women; P =0.17), or any CHD event (HR=0.54, 95% CI 0.41, 0.72 in men versus 0.67 95% CI 0.46, 0.98 in women; P =0.40). Conclusion— Stroke and other cardiovascular events are similarly reduced with atorvastatin 80 mg/d in men and women with recent stroke or TIA.

The application of treatments in the acute phase of a stroke makes it necessary to reduce as far as possible the time required for patients to reach hospital. One of the factors associated with delayed care is the population's scant knowledge about the disease.Our aim is to analyse what the population knows about strokes and vascular risk factors, as well as their attitude towards it. To do so, we interviewed both patients who visited neurology departments and their relatives.Altogether 386 interviews were carried out, with 158 females and 228 males and a mean age of 52 years. Two hundred and thirty subjects (59%) were unfamiliar with the Spanish term ictus, although they had heard of others, such as infarto or embolia. One hundred and seventy-five (45%) did not know any symptoms of a completed stroke, or answered incorrectly. The most widely recognised symptom (86%) is (partial) paralysis in one side of the body. Almost a third (32%) of the interviewees would not take a correct attitude if faced with symptoms of a stroke and if it were a transient ischaemic attack, 25% would not think it was serious. One hundred and ninety-eight (51%) did not know any vascular risk factors. Of those who answered correctly, the most frequently named factor is arterial hypertension. The factors related independently with a better knowledge of the disease are a high educational level and being young.The general population knows little about strokes and vascular risk factors. Information campaigns are needed to improve the population's attitude towards this disease.

Diplejia facial es una manifestación clínica poco frecuente que puede presentarse como consecuencia de múltiples etiologías. Presentamos un paciente con una infección periodontal crónica que sufrió de forma brusca una parálisis facial inicialmente izquierda, que rápidamente se hizo bilateral. La aparición posterior de parestesias distales en extremidad superior derecha e hiporreflexia, junto con la disociación albúmino-citológica en el LCR, permitieron establecer el diagnóstico de variante regional del Síndrome de Guillian-Barré (SGB). La diplejia facial es idiopática en el 25% de casos, siendo la causa más frecuente. Sin embargo, existe un elevado porcentaje de casos secundarios a múltiples etiologías como el SGB donde es frecuente la afectación del nervio facial habitualmente asociado a otros trastornos motores siendo infrecuente la diplejia facial aislada. Concluimos la necesidad de sospecha clínica para realización de punción lumbar y RNM para descartar procesos neoplásicos y poder determinar la etiología responsable para establecer un adecuado abordaje terapéutico. Facial palsy is a uncommon clinical manifestation that it can be caused by different ethiologies. We show a patient with a chronic periodontal disease who presented a sudden facial palsy, initially in left-face but it becomes bilateral quickly. In few days he associated paresthesias in his right arm and hiporreflexia. These clinical findings with albumin-citological dissociation, they had allowed to establish the diagnosis of regional variant of Guillain-Barré Syndrome (SGB). Facial diplejia is an idiopathic manifestation in 25% of patients, and this is the most common cause. However, facial diplejia can be secondary to many ethiologies as SGB. The affectation of facial nerve associated to other motor symptoms in SGB is frequent, but it is not frequent the presentation as facial diplejia alone. In conclusion, it is necessary a high clinical suspicion to do a lumbar punction (PL) and MRI to reject neoplasic pathologies and to obtain a diagnosis and an adequatted treatment.

Introduccion. La aplicacion de tratamientos en fase aguda del ictus obliga a reducir al maximo el tiempo de llegada de los pacientes al hospital. Uno de los factores de demora en la atencion es el desconocimiento de la enfermedad por la poblacion. Sujetos y metodos. Nuestro objetivo es analizar el conocimiento que tiene la poblacion del ictus y de los factores de riesgo vascular, asi como la actitud ante este. Para ello hemos realizado entrevistas a pacientes que acuden a consultas de neurologia y a sus familiares. Resultados. Han sido 386 entrevistas, 158 mujeres y 228 hombres, con una edad media de 52 anos. 230 sujetos (59%) no conocen el termino ictus, aunque si reconocen otros, como infarto o embolia. 175 (45%) no conocen ningun sintoma de infarto cerebral o responden incorrectamente. El sintoma mas reconocido (86%) es la perdida de fuerza en un hemicuerpo. Un 32% de los entrevistados no toma una actitud correcta ante los sintomas del ictus y, si se tratase de un ataque isquemico transitorio, un 25% no lo consideraria urgente. 198 (51%) no conocen ningun factor de riesgo vascular. De los que responden correctamente, el mas nombrado es la hipertension arterial. Los factores relacionados de forma independiente con un mejor conocimiento de la enfermedad son el nivel cultural alto y la edad joven. Conclusion. Existe un escaso conocimiento en la poblacion del ictus y los factores de riesgo vascular. Son necesarias campanas informativas para mejorar la actitud de la poblacion ante la enfermedad.

Introduccion. Las tareas de fluidez verbal semantica (FVS) implican la activacion del lenguaje, la memoria semantica, la memoria de trabajo y las funciones ejecutivas. En la segunda mitad del test aumentan las demandas sobre la memoria de trabajo y la busqueda lexical, lo que puede aumentar su dificultad relativa respecto de la primera mitad. Objetivo. Estudio piloto de estandarizacion de las dos mitades del test de FVS, categoria ?animales?, en adultos mayores de 50 anos. Sujetos y metodos. Se aplicaron dos tareas de fluidez verbal (semantica y fonologica) y el miniexamen cognitivo con memoria de trabajo en 122 controles (rango: 50-89 anos), distribuidos por edad y escolarizacion. Resultados. Existe una diferencia significativa entre las dos mitades del test ajustado por edad y escolarizacion (p < 0,0001). La puntuacion en la segunda mitad mostro una correlacion mas alta que la primera mitad con la edad, la escolarizacion y la memoria de trabajo. El rendimiento en ambas mitades se estandarizo para tres grupos por edad (50-59, 60-79 y 80-89 anos) y dos niveles de escolarizacion (alta y baja). Conclusiones. El numero de nombres en la segunda mitad del test de FVS fue inferior a la primera mitad en todos los grupos, lo que apoya la hipotesis de una mayor demanda cognitiva, probablemente en memoria de trabajo y busqueda lexical en la memoria semantica. La disponibilidad de valores normativos para las dos mitades del test de FVS permite la interpretacion simultanea e independiente del rendimiento en dos niveles de dificultad intra-task. Este modelo de analisis complementa la valoracion tradicional y se puede aplicar de forma sencilla en la clinica diaria

Introduccion. La presencia de anomia y/o parafasias en pacientes con deterioro cognitivo sugiere un deterioro asociado del lenguaje. La denominacion visual permite explorar estos signos de forma controlada al conocerse la palabra diana. Objetivo. Estudio semiologico de la denominacion en el envejecimiento normal, deterioro cognitivo y deterioro del lenguaje. Sujetos y metodos. Analisis de nueve tipos de signos (respuesta correcta, incremento de latencias, circunloquios, ausencia de respuesta, parafasias verbales semanticas, parafasias verbales con similitud formal, parafasias verbales no relacionadas, parafasias fonemicas y neologismos), en una tarea de denominacion visual (6 items), en dos grupos con lenguaje normal ?controles > 70 anos y pacientes con enfermedad de Alzheimer (EA) de inicio amnesico? y dos grupos con deterioro del lenguaje ?afasia vascular y EA anomico?. Resultados. La denominacion fallo en el 4,2% de las respuestas en controles, el 10% en pacientes con EA amnesico, el 30% en pacientes con afasia vascular y el 50% en pacientes con EA anomico. En los dos grupos con lenguaje normal (controles y EA amnesico) se observaron parafasias semanticas, con frecuencias bajas. Los signos que sugieren dificultad en el acceso/ recuperacion lexica fueron mas frecuentes en los pacientes con EA, de forma paralela al grado de anomia. Destaca la ausencia de signos de disfuncion fonologica en los dos grupos con EA, de forma independiente del grado de anomia. Conclusion. La cuantificacion semiologica permite objetivar diferencias en el grado de anomia y en el perfil de errores, tanto entre controles y pacientes con EA de inicio amnesico, como entre los pacientes con afasia vascular y anomia neurodegenerativa.

The presence of anomia and/or paraphasias in patients with cognitive impairment suggests an associated deterioration of their language. Visual naming makes it possible to examine these signs in a controlled manner as the target word is already known. AIM. To conduct a semiological study of naming in normal aging, cognitive impairment and language impairment conditions.The study consisted in an analysis of nine types of signs (correct response, increased latencies, circumlocutions, absence of response, semantic verbal paraphasias, verbal paraphasias with a similar form, unrelated verbal paraphasias, phonemic paraphasias and neologisms) in a visual naming task (6 items), in two groups with normal language--controls70 years and patients with Alzheimer's disease (AD) with onset of amnesia--and two groups with language impairment--vascular aphasia and anomic AD-.Patients failed to perform naming correctly in 4.2% of the responses in controls, 10% in patients with amnesic AD, 30% in patients with vascular aphasia and 50% in patients with anomic AD. Semantic paraphasias were observed in the two groups with normal language abilities (controls and amnesic AD), although frequencies were low. Signs that suggest difficulties in accessing/retrieving lexical items were more frequent in patients with AD and ran parallel to the degree of anomia. One notable finding was the absence of signs of phonological dysfunction in the two groups with AD, regardless of the degree of anomia.Semiological quantification makes it possible to distinguish differences in the degree of anomia and in the pattern of errors both in controls and in patients with amnesic onset AD and among patients with vascular aphasia and neurodegenerative anomia.

Semantic verbal fluency (SVF) tasks involve the activation of language, semantic memory, working memory and the executive functions. The second half of the test increases the demands on working memory and search for lexical items, which can make it more difficult than the first half.To conduct a pilot study in order to standardise the two halves of the SVF test ('animals' category) in adults over 50 years of age.Two verbal fluency tasks (semantic and phonological) and the Spanish version of the Mini-Mental State Examination with working memory were applied in 122 controls (range: 50-89 years), who were distributed according to age and schooling.There is a significant difference between the two halves of the test adjusted for age and schooling (p0.0001). Scoring in the second half showed a higher correlation with age, schooling and working memory than the first half. Performance in the two halves was standardised for three age groups (50-59, 60-79 and 80-89 years) and two levels of schooling (high and low).The number of names in the second half of the SVF test was lower than in the first half in all the groups, which supports the hypothesis of a greater cognitive demand, probably on working memory and the search for lexical items in semantic memory. Having normative values available for the two halves of the SVF test allows simultaneous and independent interpretation of the performance at two levels of intra-task difficulty. This model of analysis complements the traditional assessment and can easily be applied in day-to-day clinical practice.