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Background: Disequilibrium of unknown cause in older people has been associated with white matter lesions on neuroimaging studies., Objective: To investigate the relationship between gait and balance problems in the elderly, white matter hyperintensities, and vascular risk factors., Methods: We studied clinical and neuroimaging features in 30 people older than 65 years of age with gait disorders of unknown cause and 30 age- and sex-matched controls. Patients and controls underwent the same extensive quantitative test battery. White matter lesions on MRI scans were graded in different brain regions., Results: History of hypertension was more common among patients than controls (60% vs. 27%, p=0.012). On all scales, patients with gait disorders scored worse than controls. The frequency of white matter lesions was significantly higher in patients than in controls (p<0.001). In a multivariate logistic regression analysis in which diagnosis (patient vs. control) was the dependent variable, there was an association between diagnosis and white matter signal hyperintensity score (p<0.001) and history of hypertension (p=0.039)., Conclusions: Gait disorders of unknown cause in older people are associated both with white matter lesions on MRI scans and with history of hypertension.

Introduction: Gait and stability disorders of the elderly are frequent and a cause of disability, but studies on their clinical features and etiology are scarce, including the relationship between both disorders., Objectives: To evaluate an extensive series of patients with gait and stability disorders, its clinical variants and posible pathogenic significance., Patients and Methods: 259 patients older than 70 years consulting for chronic gait and stability symptoms in an outpatients neurologic clinic were retrospectively reviewed. Several clinical and evolution data are analyzed., Results: Mean age was 78.8 years and 61.8% were women. 52 % were hypertensive. 161 cases had disequilibrium, 91 a cautious gait and seven other types of gait abnormality. 11 % had associated dementia. 27 % showed subcortical white matter abnormalities on computed tomography scan. In 28 cases a specific cause could be established. In follow-up 33.5 % worsened. Significant differences between cases of disequilibrium and cautious gait were increased age, functional disability and turn abnormality in the latter., Conclusions: Disequilibrium and cautious gait of the elderly share some clinical features, have few specific causes and vary from mild cases to a disabling <>.

The purpose of this study is to evaluate in a rat model if the early removal of an experimental intracerebral mass mimicking an extensive subcortical hematoma improves neurological outcome. Fifty six male Wistar rats were studied. A balloon was placed sterotactically at the level of the striatum. The balloon was inflated to 100 microl for periods of 10, 60 or 120 min (with 10 animals in each group). In 10 animals the balloon was not deflated and there were four sham operated cases. Neurological deficit was evaluated by a blinded observer by means of a clinical scale from 0 to 8 points at 24 and 72 h after inflation. Three additional animals at each inflation period were sacrificed after 6 h for pathological study with hematoxylin-eosin staining. Death rate was 9/10 animals who had permanent inflation, 4/10 in those with 2 h inflation, 2/10 for 1 h inflation and 0/10 for 10 min inflation (P<0.01 in chi square test). Many animals developed a particular clinical syndrome not previously described. Mean 72 h clinical scores (0-8 points) were 7.6 (S.D.: 1. 2) for the permanent inflation group, 4.4 (S.D.: 3.2) for 2 h of inflation, 2.3 (S.D.: 3.2) for 1 h and 0.4 (0.9) for 10 min of inflation (P<0.01 in Kruskal Wallis test). In the pathological study the rate of damaged neurons was significantly higher in the permanent than in transient inflation groups. In conclusion, in this balloon model evacuation of an extensive acute expanding subcortical (hematoma-like) mass must be performed within a limited time window to prevent the development of irreversible neurological deficits or death.

Objectives: To analyse the demand for neurologic care and the neurological resources in a health district., Patients and Methods: Demographic, medical care aspects, neurologic care demands and neurological resources of the health district 11 of Madrid (University Hospital "12 de Octubre"), referred to 1996, were reviewed., Results: The rate of aging (17%) and the consulting rates in the National Health System (86%) versus private care were high in this health district. The neurologic care demands were 17.5-18.1 and 36 consultations respectively per 1,000 inhabitants/year. There were 2 patient-care neurologists and 3.7 neurologic beds per 100,000 inhabitants., Conclusions: The neurologic care was considered high and with a tendency to increase. The available neurological resources were judged to be insufficient.

Introduction: The dementias are one of the commonest conditions seen in Neurology Clinics. Potentially reversible causes are described amongst the various aetiologies although there are doubts as to whether the use of indiscriminate testing to detect them is worthwhile., Objective: In a group of demented persons to determine how many had a potentially reversible condition and how many improved, in a prospective, descriptive study in a Neurology Outpatient Clinic., Patients and Methods: Using the Mini-Mental State Examination of Folstein and the DSM-III-R criteria for dementia, 121 demented patients were selected. An ordinary biochemical study was made (vitamin B12, thyroid hormones), serology (lues) and neuroimaging (cerebral CT), and when a potentially reversible condition was found, each case was treated. The patients treated were followed-up periodically for an average of 9.6 months (range 2 to 24 months)., Results: A potentially reversible condition was seen in 19.8% of the patients. On prospective evaluation only 3.3% had reversible symptoms and in no case were these completely reversed. Improvement was seen in conditions of depressive pseudo-dementia., Conclusions: Since some causes of dementia are reversible, the neurologist is obliged to investigate and seek these possible aetiologies. This study should be individualized according to clinical criteria to improve profitability of the complementary tests. Our results suggest that there are doubts as to the usefulness of indiscriminate investigation of possible reversible causes of the cases of dementia referred to Outpatient neurologists.

Background: The work of neurologists in the Public Health Service is absolutely determined by the demand of the general physicians, who have occasionally been considered to be not too selective. For this reason we have tried to change this demand., Methods: In our outpatient clinic we have developed some guidelines for the general physicians to orientate them in the selection of patients referred with neurological disease. In this study the impact of the implementation of headache and dizziness guidelines on the annual frequentation from 1993 to 1997 is analysed. We also reviewed 200 cases of patients referred in 1996-1997 and assessed their adequacy to the guidelines, and inquired the general physicians after their demand and percentage of patients with neurologic disease that they referred to the neurologist., Results: There were no significant changes on the demand of consultations on headache or dizziness. We found that 39% of patients referred with headache and 23% of those with dizziness didn't adequate to the guidelines. General physicians referred only 3.3% of the patients seen by them with headache, and 3.7% of those with dizziness., Conclusions: Sending guidelines to the general physicians has not demonstrated to be effective on improving their selection of patients, and a better implementation of guidelines should be studied, admitting that the care demand of headache and dizziness is high, and that general physicians make an important selective effort.

Chronic instability is a frequent complaint in elderly patients. As literature on the subject is scarce, we investigated reversible causes, evaluating patients over 65 years of age referred to a regional neurological practice for disequilibrium lasting longer than three months. Clinical features were analyzed. Computerized tomography (CT) of the brain, and thyroid hormone and cyanocobalamin (Cc) serum levels were studied for all patients, as was clinical course. No CT abnormalities were found. Low Cc levels were observed in 6 patients, and 2 were diagnosed of previously undetected hypothyroidism. During the mean follow-up period of 12 months, improvement was seen in 3 specifically-treated patients, one with hypothyroidism and two with Cc deficit. We conclude that chronic instability in the older patient cannot usually be traced to a specific cause, but that it is important to protocolize the assessment of such patients, including routine tests for thyroid hormone and Cc levels, in order to rule out treatable causes.

We present seven patients with multiple spontaneous cerebral haemorrhages, diagnosed by CT scan, in a 10-year period in the Hospital 12 de Octubre. The clinical presentation, radiologic features, and prognosis of this entity are analyzed, and the diverse etiologic factors are discussed. All of the patients in this series were over 50 years of age, the majority not hypertensive (57%, n = 4), and in almost half the cases (43%, n = 3) the brain haemorrhages were associated with diverse coagulation disorders. The localization of the haemorrhages was exclusively supratentorial. Four patients presented with a moderate global confusional state, and one patient with deep coma. All the patients had focal signs. The mortality was elevated, with three patients dying, but the clinical evolution and outcome of those who survived was favourable.

We describe a rat model for middle cerebral artery occlusion and discuss its usefulness for the study of structural consequences of various ischemic periods. We inserted 4/0 polyethylene sutures into the external carotid artery of 48 Wistar rats. The tips were rounded and coated with a thin layer of dental silicone. By inserting a section 18 mm long we assured that placement of the tip was between the origins of the middle and anterior cerebral arteries. The suture was withdrawn at predetermined times to allow complete reflux through the common carotid. The animals were sacrificed 24 hours after this procedure and tested for the presence of infarct by staining with 2,3,5 triphenyl-tetrazolium on 2 mm coronal cuts. We identified several differences regarding areas of infarction after the different occlusion periods, as shown by ANOVA and Newman-Keuls testing. Thus, occlusion for 15 minutes did not provoke infarction; occlusion of 30, 45 and 60 minutes produced selective infarction of the caudate nucleus and putamen; and finally, incomplete cortical infarction appeared after 90 minutes and was complete after 2 hours, at which time infarction was similar to that seen after 24 hours of occlusion. Intravascular occlusion is a reliable method for inducing focal cerebral ischemia, enabling us to confirm the existence of an infarction time threshold that is longer for the cortex than for the caudate nucleus and putamen.

We report a case of acute confusional state (ACS) resulted from bilateral occlusion of anterior cerebral artery. This case is outstanding because development of ACS was caused by a focal lesion, without the presentation of focal neurologic signs. Then, cerebrovascular disease must be included in differential diagnosis of ACS, despite the lack of clinically detectable deficit.

In a prospective study conducted in the Emergency Area of a general hospital during a period of 6 months, the Neurology Service was consulted in 45 cases of acute confusional syndrome. Twenty nine of these patients had no immediate apparent etiology. Among the studied patients 5 had a subarachnoid hemorrhage, 4 suffered a central nervous system infection, 3 had a cerebral infarction, 3 presented a metabolic encephalopathy, and the remaining patients had variate etiologies. Clinical signs and symptoms were insufficient to establish the diagnosis and in several cases complementary tests were required (cerebral tomography and cerebrospinal liquid examination). Even in these cases the diagnosis could not be obtained in some patients. The clinical implications of the present findings were discussed.

Three patients with myoclonic encephalopathy caused by bismuth salts are reported, one with the severe and another with the mild form; dimercaprol was effective for the rapid improvement of the symptoms in both. In one of the patients in whom the clearance of bismuth was calculated it was found to be increased after dimercaprol therapy. We think that dimercaprol is an effective drug for the therapy of myoclonic encephalopathy caused by bismuth salts.