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Background and purpose For patients with acute ischaemic stroke due to large-vessel occlusion, it has recently been shown that mechanical thrombectomy ( MT) with stent retrievers is better than medical treatment alone. However, few hospitals can provide MT 24 h/day 365 days/year, and it remains unclear whether selected patients with acute stroke should be directly transferred to the nearest MT-providing hospital to prevent treatment delays. Clinical scales such as Rapid Arterial Occlusion Evaluation ( RACE) have been developed to predict large-vessel occlusion at a pre-hospital level, but their predictive value for MT is low. We propose new criteria to identify patients eligible for MT, with higher accuracy. Methods The Direct Referral to Endovascular Center criteria were defined based on a retrospective cohort of 317 patients admitted to a stroke center. The association of age, sex, RACE scale score and blood pressure with the likelihood of receiving MT were analyzed. Cut-off points with the highest association were thereafter evaluated in a prospective cohort of 153 patients from nine stroke units comprising the Madrid Stroke Network. Results Patients with a RACE scale score ≥ 5, systolic blood pressure <190 mmHg and age <81 years showed a significantly higher probability of undergoing MT (odds ratio, 33.38; 95% confidence interval, 12-92.9). This outcome was confirmed in the prospective cohort, with 68% sensitivity, 84% specificity, 42% positive and 94% negative predictive values for MT, ruling out 83% of hemorrhagic strokes. Conclusions The Direct Referral to Endovascular Center criteria could be useful for identifying patients suitable for MT. [ABSTRACT FROM AUTHOR]

Introduction: The minimum basic dataset is the largest available hospital care administrative database that is used in clinical studies and hospital management in association with diagnosis-related groups (DRGs). In 2011, the quality of the national MBDS in hospital discharges was audited, in order to assess its reliability. This paper presents a sub-analysis of the results from that analysis which are referred to cerebrovascular disease (CVD)., Methods: Using all discharge reports from the Spanish MBDS in 2009, a representative sample was obtained by stratified sampling and 11 209 records were evaluated. Outcome indicators were obtained to measure any differences observed between the national MBDS being evaluated and the hospital's original MBDS. Analysis of codes for CVD as a primary diagnosis was performed for ICD-9-CM diagnostic categories 430 through 438. We evaluated error rates in the selection and classification of main diagnoses, as well as in DRG assignment., Results: There were 397 discharges of cases of CVD which included 21 different DRGs. Diagnostic coding showed a concordance rate of 81.87%; the selection error rate was 2.26% and the classification error rate was 15.87%. The error rate in the DRG was 16.12% and associated with the greatest impact on the mortality risk level., Conclusions: While the errors we observed must be taken into account, data suggest that the quality of the MBDS for CVD is sufficient to ensure delivery of valid information. The hospital discharge registry serves as a valuable tool for use in studies of this disease., (Copyright © 2014 Sociedad Española de Neurología. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Streptococcus agalactiae is frequently an asymptomatic coloniser and a cause of neonatal and puerperal sepsis. Infections in nonpregnant adults are uncommon. The frequency of neurological complications caused by invasive infection with this microorganism in adults remains unknown. Here, we study the frequency and characteristics of central nervous system (CNS) involvement in adults with invasive S. agalactiae infection., Patients and Methods: Review of all adults with invasive S. agalactiae infection between 2003 and 2011 in a tertiary hospital., Results: S. agalactiae was isolated from blood, CSF or synovial fluid in 75 patients. Among them, 7 (9,3%) displayed neurological involvement: 5 men and 2 nonpregnant women, aged between 20 and 62 years. Diagnoses were spinal epidural abscess due to spondylodiscitis with spinal cord compression; acute bacterial meningitis; ischemic stroke as presentation of bacterial endocarditis (2 patients each); and meningoventriculitis after neurosurgery and ventricular shunting. One patient with endocarditis caused by S. agalactiae and S. aureus died in the acute phase, and another died 3 months later from metastatic cancer. The other patients recovered without sequelae. All patients had systemic predisposing factors for infection and 5 (71,4%) had experienced disruption of the mucocutaneous barrier as a possible origin of the infection., Conclusions: CNS involvement is not uncommon in adult patients with invasive infection caused by S. agalactiae. Isolating S. agalactiae, especially in cases of meningitis, should lead doctors to search for predisposing systemic disease and causes of mucocutaneous barrier disruption., (Copyright © 2013 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.)

Aim: To analyze the neurological attention of a county hospital of recent creation, with a special emphasis in the health care indicators, both in hospital out-patients consultations and in patients admitted to the hospital., Patients and Methods: We have made a descriptive analysis of the neurological attention developed by our Neurology Section between the years 2008 and 2013. We also made a comparative analysis of health care indicators corresponding to the years 2012 and 2013 (5th and 6th years of clinical activity) of our hospital with those of two other hospitals with similar features, other three hospitals of secondary level, and four of tertiary level., Results: The Neurology Section of our hospital was the best in the number of first visits divided by number of physicians, in the follow-up/first visit index, in the percentage of high-resolution visits, and was the best in the mean stay in hospital for the two most frequent diagnostic related groups (DRG) in our speciality, the second in number of hospital admissions divided by number of physicians for the DRG 'stroke with infarction' and the third in number of hospital admissions divided by number of physicians for the DRG 'other nervous system disorders'., Conclusions: The health care indicators of the Neurology Section of our hospital showed a very high efficiency model of medical assistance, which was only followed by other two hospitals with similar features to ours. The gradual implementation of assistance models similar to that used in these hospitals in other of secondary or tertiary levels could be useful in the improvement of their health care efficiency.

Objectives: Hyperechogenicity of the substantia nigra on transcranial sonography is used for diagnosing Parkinson disease (PD). Cutoff values for the substantia nigra echogenic area, defining substantia nigra hyperechogenicity, vary among ultrasound systems from different manufacturers. In this study we wanted to determine the cutoff criterion for a Toshiba (Tokyo, Japan) system and to assess its diagnostic value., Methods: Three hundred participants (controls, n = 138; patients with PD, n = 105; and patients with essential tremor, n = 57) underwent transcranial sonography following a standardized protocol., Results: The substantia nigra was assessable in 92.7% of all participants. The substantia nigra echogenic area (larger of bilateral measurements) was larger in patients with PD (mean ± SD, 0.24 ± 0.05 cm(2)) than controls (0.14 ± 0.05 cm(2); P < .001) and patients with essential tremor (0.14 ± 0.04 cm(2); P < .001). Substantia nigra echogenicity was larger in male participants (0.20 ± 0.07 cm(2)) than female participants (0.15 ± 0.06 cm(2); P< .001). Age did not correlate with substantia nigra echogenicity in any group. Frontal horn width was larger and lenticular nucleus hyperechogenicity and a discontinuous raphe were more frequent in the PD group than the other groups. On multivariate analysis, only substantia nigra hyperechogenicity was associated with the diagnosis of PD. The 90th-percentile substantia nigra echogenic area in the control group, which defined marked substantia nigra hyperechogenicity, also represented the optimum cutoff value for discrimination of PD from non-PD participants on receiver operating characteristic curve analysis (area under the curve, 0.913; Youden index, 0.73). This cutoff value (≥0.21 cm(2), larger of bilateral measurements) yielded sensitivity of 83% and specificity of 90% for the diagnosis of PD., Conclusions: Transcranial sonography shows good diagnostic validity for diagnosis of PD when implemented according to a strictly standardized protocol., (© 2013 by the American Institute of Ultrasound in Medicine.)

Background: To study the number of patients diagnosed with a stroke in the emergency service of a first level hospital and the proportion of these patients who were finally stroke mimics, as well as to describe and analyze the variables that can help in differential diagnosis in hospital emergency services., Method: Nine month prospective study. All patients evaluated in emergency services and admitted with a diagnosis of stroke were included. Different clinical variables were analyzed that included prior history, history of the current event, general physical and neurological examination, NIHSS classification and Oxfordshire Community Stroke Project Classification. The final diagnosis was made by a panel of experts with access to clinical characteristics, image studies and other tests. The univariate and multivariate analysis determined the characteristics that help in distinguishing strokes from stroke mimics., Results: One hundred and forty-four cases of stroke were registered; the final sample was made up of 140 patients. The final diagnosis was stroke in 103 out of 140 (73.6%) and stroke mimic in the rest. Eleven variables predicted the diagnosis in patients with a suspected stroke: age over 70 years (p=0.012), NIHSS classification > 5, reaching a clinical classification (p=0.019) capable of determining the exact start (p=0.000), abnormal vascular findings (p=0.014), gaze deviation (p=0.042), sight loss (p=0.052) and extensor plantar response (p=0.025) favored diagnosis of stroke, while epileptic seizures (p=0.029), neurological symptoms not congruent with the vascular territory (p=0.022) and abnormal findings in other systems (p=0.14) favored diagnosis of stroke mimic., Conclusion: Stroke mimics constitute one-third of the patients admitted from emergency services as strokes, with a highly varied etiology. Achieving a suitable clinical history and a precise physical examination is of great importance and can help less experienced doctors.

Introduction: Our aim was to analyze our clinical experience with dabigatran etexilate in secondary stroke prevention., Methods: We retrospectively included patients starting dabigatran etexilate for secondary stroke prevention from March 2010 to December 2012. Efficacy and safety variables were registered., Results: 106 patients were included, median follow-up of 12 months (range 1-31). Fifty-six females (52.8%), mean age 76.4 (range 50-95, SD 9.8), median CHADS2 4 (range 2-6), CHA2DS2-VASc 5 (range 2-9), and HAS-BLED 2 (range 1-5). Indication for dabigatran etexilate was ischemic stroke in 101 patients and acute cerebral hemorrhage (CH) due to warfarin in 5 (4.7%). Dabigatran etexilate 110 mg bid was prescribed in 71 cases (67%) and 150 mg bid was prescribed in the remaining. Seventeen patients (16%) suffered 20 complications during follow-up. Ischemic complications (10) were 6 transient ischemic attacks (TIA), 3 ischemic strokes, and 1 acute coronary syndrome. Hemorrhagic complications (10) were CH (1), gastrointestinal bleeding (6), mild hematuria (2), and mild metrorrhagia (1), leading to dabigatran etexilate discontinuation in 3 patients. Patients with previous CH remained uneventful. Three patients died (pneumonia, congestive heart failure, and acute cholecystitis) and 9 were lost during follow-up., Conclusions: Dabigatran etexilate was safe and effective in secondary stroke prevention in clinical practice, including a small number of patients with previous history of CH.

Introduction: Descompressive craniectomy (DC) for treatment of malignant infarction of the middle cerebral artery (MIMCA) reduces mortality and increases the probability of favourable outcome., Aim: To present the experience in daily practice after implantation of a clinical protocol of DC., Patients and Methods: Prospective register of patients with MIMCA treated with DC. Age, stroke severity -National Institute of Health Stroke Scale (NIHSS) score-, basal characteristics, delay until DC, mortality, modified Rankin Scale (mRS) score at three and twelve months and questionnaire of satisfaction are recorded., Results: From February 2008 to December 2010, 15 patients were treated. Mean age: 60 years (range: 35-69); basal NIHSS, median (p25/p75): 17 (15.5/21), NIHSS before craniectomy: 20 (18/23.5). DC was performed within 48 hours in 8 patients (53.3%). 5 subjects (33.3%) died during in-hospital stay. Mortality was 25% among those treated within 48 hours and 42.9% among those treated later and 37.5% among patients <= 60 years vs 28.6% in older patients. All survivors scored <= 4 in the mRS at three months and expressed satisfaction with surgery despite sequelae. Rate of favourable outcome (mRS <= 3) was higher among patients under 60 (63%) and among those treated before 48 h (50%)., Conclusion: DC is safe in clinical practice and reduces mortality after MIMCA, especially if it is performed within 48 hours from stroke onset. Benefit appears to be greater in younger patients, but older people may benefit also. The decision to perform DC should be made on an individual basis.

Background and Purpose. Intravenous thrombolysis using tissue plasminogen activator is safe and probably effective in patients >80 years old. Nevertheless, its safety has not been specifically addressed for the oldest old patients (≥85 years old, OO). We assessed the safety and effectiveness of thrombolysis in this group of age. Methods. A prospective registry of patients treated with intravenous thrombolysis. Patients were divided in two groups (<85 years and the OO). Demographic data, stroke aetiology and baseline National Institute Health Stroke Scale (NIHSS) score were recorded. The primary outcome measures were the percentage of symptomatic intracranial haemorrhage (SICH) and functional outcome at 3 months (modified Rankin Scale, mRS). Results. A total of 1,505 patients were registered. 106 patients were OO [median 88, range 85-101]. Female sex, hypertension, elevated blood pressure at admission, cardioembolic strokes and higher basal NIHSS score were more frequent in the OO. SICH transformation rates were similar (3.1% versus 3.7%, P = 1.00). The probability of independence at 3 months (mRS 0-2) was lower in the OO (40.2% versus 58.7%, P = 0.001) but not after adjustment for confounding factors (adjusted OR, 0.82; 95% CI, 0.50 to 1.37; P = 0.455). Three-month mortality was higher in the OO (28.0% versus 11.5%, P < 0.001). Conclusion. Intravenous thrombolysis for stroke in OO patients did not increase the risk of SICH although mortality was higher in this group.