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Introducción: El tiempo sigue siendo una variable determinante para los tratamientos de reper-fusión del ictus isquémico agudo. A pesar de las recomendaciones de las guías clínicas, soloalrededor de la tercera parte de los pacientes con ictus isquémico agudo son fibrinolizadosen = 60 min. El objetivo de este trabajo es describir nuestra experiencia implementando unprotocolo específico de atención del ictus isquémico agudo y evaluar su impacto en nuestrostiempos puerta-aguja. Métodos: A finales del 2015, se implantaron gradualmente unas medidas dise ~nadas para acortarlos tiempos de actuación y optimizar la atención del ictus isquémico agudo incluyendo unaguardia específica de Neurovascular. Se compararon los tiempos de actuación antes (2013-2015)y después (2017-2019) de la introducción de este protocolo. Resultados: Se incluyó a 182 pacientes antes y 249 después de la intervención. Cuando todas lasmedidas fueron introducidas, la mediana global de tiempo puerta-aguja fue de 45 min (previa74 min, 39% menos, p < 0, 001) con un 73, 5% de pacientes tratados en = 60 min (47% más quepreintervención, p < 0, 001). El tiempo global al tratamiento (inicio síntoma-aguja) se redujo en20 min de mediana (p < 0, 001). Conclusiones: Las medidas asociadas en nuestro protocolo han conseguido una disminución deltiempo puerta-aguja de forma significativa y sostenida, aunque todavía nos queda margen demejora, la dinámica establecida de control de resultados y mejora continua hará posible seguiravanzando en este sentido. Introduction: Time continues to be a fundamental variable in reperfusion treatments for acute ischaemic stroke. Despite the recommendations made in clinical guidelines, only around one-third of these patients receive fibrinolysis within 60 minutes. In this study, we describe our experience with the implementation of a specific protocol for patients with acute ischaemic stroke and evaluate its impact on door-to-needle times in our hospital. Methods: Measures were gradually implemented in late 2015 to shorten stroke management times and optimise the care provided to patients with acute ischaemic stroke; these measures included the creation of a specific on-call neurovascular care team. We compare stroke management times before (2013-2015) and after (2017-2019) the introduction of the protocol. Results: The study includes 182 patients attended before implementation of the protocol and 249 attended after. Once all measures were in effect, the overall median door-to-needle time was 45 minutes (vs 74 minutes before, a 39% reduction; P

Introduction: Despite the impact of cerebrovascular disease (CVD) on global health, its morbidity and time trends in Spain are not precisely known. Objective: The purpose of our study was to characterise the epidemiology and trends pertaining to stroke in Aragon over the period 1998-2010. Methods: We conducted a retrospective, descriptive study using the data of the Spanish health system's Minimum Data Set and included all stroke patients admitted to acute care hospitals in Aragon between 1 January 1998 and 31 December 2010. We present data globally and broken down by stroke subtype, sex, and age group. Results: The number of cases increased by 13% whereas age- and sex-adjusted hospitalisation rates showed a significant decrease for all types of stroke (mean annual decrease of 1.6%). Men and women in younger age groups showed opposite trends in hospitalisation rates for ischaemic stroke. Case fatality rate at 28 days (17.9%) was higher in patients with intracerebral haemorrhage (35.8%) than in those with subarachnoid haemorrhage (26.2%) or ischaemic stroke (13%). CVD case fatality showed a mean annual decline of 2.8%, at the expense of the fatality rate of ischaemic stroke, and it was more pronounced in men than in women. Discussion: Understanding stroke epidemiology and trends at the regional level will help establish an efficient monitoring system and design appropriate strategies for health planning. Resumen: Introducción: A pesar de la relevancia sanitaria de la enfermedad cerebrovascular (ECV), su morbilidad en España y sus tendencias temporales no se conocen con precisión. Objetivo: El objetivo de nuestro estudio fue caracterizar la epidemiología del ictus en Aragón y su evolución en el periodo 1998-2010. Métodos: Estudio descriptivo retrospectivo a partir de una base de datos extraída del Conjunto Mínimo Básico de Datos, incluyendo todas las altas por ECV de los hospitales de Aragón en el periodo 1998-2010. Se presentan los datos de manera global y separada por tipo de ictus, sexo y franja etaria. Resultados: El número de casos aumentó un 13%, mientras que las tasas de hospitalización ajustadas por edad y sexo han mostrado un descenso significativo para el conjunto de los ictus (descenso medio anual del 1,6%). Hemos observado tendencias opuestas en las tasas de ictus isquémico entre varones y mujeres de los grupos de edad más jóvenes. La tasa de letalidad a los 28 días fue del 17,9%, y fue superior en los pacientes con hemorragia cerebral (35,8%) con respecto a los pacientes con hemorragia subaracnoidea (26,2%) e ictus isquémico (13%). La letalidad por ECV presentó un descenso medio anual del 2,8%, a expensas del descenso observado en el ictus isquémico, y fue más pronunciada en los hombres que en las mujeres. Discusión: El conocimiento de la epidemiología del ictus a nivel regional y sus tendencias contribuirá a establecer un sistema eficiente de vigilancia y diseñar estrategias adecuadas de planificación sanitaria. Keywords: Epidemiology, Cerebrovascular disease, Time trends, Hospitalisation rates, In-hospital mortality, Hospital-based registry, Palabras clave: Epidemiología, Enfermedad cerebrovascular, Tendencias temporales, Tasas de hospitalización, Letalidad hospitalaria, Registros hospitalarios

With the advent of new disease-modifying drugs, the treatment of multiple sclerosis is becoming increasingly complex. Using consensus statements is therefore advisable. The present consensus statement, which was drawn up by the Spanish Society of Neurology's study group for demyelinating diseases, updates previous consensus statements on the disease.The present study lists the medications currently approved for multiple sclerosis and their official indications, and analyses such treatment-related aspects as activity, early treatment, maintenance, follow-up, treatment failure, changes in medication, and special therapeutic situations.This consensus statement includes treatment recommendations for a wide range of demyelinating diseases, from isolated demyelinating syndromes to the different forms of multiple sclerosis, as well as recommendations for initial therapy and changes in drug medication, and additional comments on induction and combined therapy and practical aspects of the use of these drugs. Resumen: La incorporación de nuevos medicamentos para modificar el curso de la esclerosis múltiple y la complejidad de su uso plantea la conveniencia de utilizar consensos terapéuticos. El consenso actual ha sido elaborado por el grupo de enfermedades desmielinizantes de la Sociedad Española de Neurología y actualiza consensos previamente publicados.Se enumeran los medicamentos aprobados para la esclerosis múltiple con sus indicaciones oficiales. Se analizan aspectos relacionados con el tratamiento, como la presencia de actividad, la precocidad, el mantenimiento terapéutico, el seguimiento, el fallo terapéutico, los cambios de medicación y el tratamiento en situaciones especiales.Se elaboran indicaciones de tratamiento desde el síndrome desmielinizante aislado a las distintas formas de esclerosis múltiple detallando recomendaciones de tratamiento inicial, cambios de medicación, con consideraciones sobre terapia combinada e inducción y aspectos prácticos del uso de medicamentos. Keywords: Multiple sclerosis, Consensus statement, Disease-modifying drugs, Lines of therapy, Changes in medication, Algorithm, Palabras clave: Esclerosis múltiple, Consenso, Medicamentos para el curso de la enfermedad, Líneas terapéuticas, Cambios de medicación, Algoritmo

Objectives. To assess the capability of the vision monitor unit Monpack One of detecting visual function alterations in patients with multiple sclerosis (MS) and to evaluate the correlation between structural retinal parameters and functional measurements obtained with this device. Methods. Forty-eight patients with MS and 46 healthy controls were included in a cross-sectional study. All participants underwent a complete functional evaluation of the visual pathway, which included low-contrast visual acuity (LCVA), contrast sensitivity vision (CSV), automated perimetry, multifocal visual evoked potentials (mfVEPs), and pattern electroretinogram (ERG). All tests were performed using the vision monitor unit Monpack One (Metrovision, France), a multifunction stimulator device. Retinal structural measurements were obtained in all subjects using Triton swept source optical coherence tomography (Topcon, Japan). Results. Patients with MS presented reduced low-contrast VA (p<0.001) and reduced CSV at medium (p=0.001, p=0.013) and low (p=0.001, p=0.002) spatial frequencies. All visual field parameters were found to be altered in MS patients compared with controls (≤0.001). Patients with MS presented lower amplitude of the P100 waveform of the mfVEP in areas corresponding to central (p<0.001), inferonasal (p=0.001), and inferotemporal (p=0.003) retina. The pattern ERG did not show significant differences. Significant correlations were observed between structural retinal measurements and functional parameters, especially between the inner macular areas and measurements corresponding to contrast sensitivity and perimetry indexes. Conclusions. Patients with MS present visual dysfunction detectable with the vision monitor unit Monpack One. This device may be a fast and useful tool to provide a full evaluation of axonal damage in patients with multiple sclerosis.

Objective: To determine discontinuation rate and degree of adherence to first-line treatment with interferon-beta (INF ) in patients with multiple sclerosis (MS), identifying causes and associated factors. Material and Method: A retrospective observational study that included patients with MS treated with INF during 2001. The patients were followed-up from the beginning of treatment until the end of 2006. The data sources used were a computer database compiled in the outpatients’ area, medical records and application protocols for beginning and monitoring treatment for MS. Patient characteristics at baseline, treatment and continuity were included in the information collected. Results: The study included 131 patients. Mean follow-up was 74 ± 26 years. 641% of the patients were treated with only one drug during the study. At 2 years follow-up 99% of patients had discontinued INF therapy and at 5 years 412% had done so. Men, patients with relapsingremitting MS and those treated with INF 1a i.m. continued treatment for a longer period, but this was statistically significant only in patients with 10 years or less of disease progression at the beginning of therapy. Main causes of discontinuation were lack of efficacy (388%) and adverse effects (328%). Compliant patients presented lower discontinuation rates (558% vs. 75%). Conclusions: treatment of MS patients with IFN is discontinued mainly due to lack of efficacy and adverse effects. Greater understanding of patients’ views can help to identify those at greatest risk of lack of adherence, thereby helping to improve treatment.

Objective: The objective of this research was to study the effect of optic neuritis (ON) on axonal damage in multiple sclerosis (MS) patients. Specifically, we compared changes over 2 years in the retinal nerve fibre layer (RNFL) between affected and contralateral eyes in MS patients with a prior history of ON. Methods: Thirty-four patients with one unilateral definitive episode of ON were included and underwent a complete ophthalmic examination, optical coherence tomography (OCT), scanning laser polarimetry, visual evoked potentials (VEP) and pattern electroretinogram (pERG). All patients were re-evaluated at 12 and 24 months. Parameters were compared between ON-affected and contralateral eyes in an initial exploration and over the course of the follow-up. Correlations between parameter changes were analysed. Results: RNFL thickness and functional parameters showed more affection in ON eyes ( p ≤ 0.05), but changes in measurements during the study were similar between both groups of eyes. Conclusions: Progressive axonal loss can be detected in the optic nerve, but ON is not a risk factor for increased chronic damage in MS patients without ophthalmic relapses. Loss of the RNFL is caused by progressive degeneration associated with the disease.

Summary Objective The aim of this study was to evaluate the correlation between functional eye examinations (visual evoked potentials: VEPs; pattern electroretinogram: PERG) and structural measurements of the optic nerve (optical coherence tomography: OCT; scanning laser polarimetry: GDx) in patients with multiple sclerosis (MS). Methods Patients with definite MS and disease-free controls were enrolled in the study. VEPs and PERG were recorded in all subjetcs. Ophthalmologic examination, including visual acuity, visual field determination, OCT and GDx were performed. Results Nineteen MS patients and 19 age- and sex-matched controls were included in the study. Significant differences between both groups were observed with respect to VEP (P100 latency and amplitude), PERG (N95 amplitude and N95/P50 ratio) and OCT parameters (average, temporal and macular volume). There were a statistically significant correlation between VEP or PERG parameters and OCT or GDx results. Conclusions In MS patients, axonal loss in ganglion cells can be detected with OCT and GDx. PERG is a useful complementary tool to identify this damage.

Objective To evaluate the effect of pathogenic treatments in the reduction of the retinal nerve fiber layer (RNFL) in patients with Multiple Sclerosis (MS) by means of ocular imaging technologies. Material and methods A total 155 eyes of 79 patients with MS were enrolled in this study. All patients underwent a complete ophthalmic examination including best corrected visual acuity using Snellen chart, colour vision using Ishihara pseudoisochromatic plates, visual field examination, optical coherence tomography (OCT), scanning laser polarimetry (GDx) and visual evoked potentials. The patients were re-evaluated after a one year period and changes were assessed in order to detect differences between treatments using the Anova statistical test. The patients were divided into four groups: 1) Patients without treatment, 2) Patients treated with interferon beta-1a, 3) Subjects who received interferon beta-1b, 4) Patients treated using glatiramer acetate. Results There were no statistically significant differences between patients with or without treatment and between the four groups (P>0.05, t test), but functional and structural parameters showed greater loss in RNFL thickness in non-treated patients. Temporal quadrant RNFL thickness measured by OCT was the parameter with the highest variation (reduction of 4.97μm in patients without treatment vs 1.08μm in treated patients). Conclusions MS pathogenic treatment may be a protective factor in the RNFL loss that is associated to the disease progression. More studies are needed.

RESUMEN Objetivos Evaluar los cambios que se producen en la capa de fibras nerviosas de la retina (CFNR) de pacientes con esclerosis multiple (EM) durante 2 anos. Comparar la utilidad de la tomografia de coherencia optica (TCO), polarimetria laser (GDx), potenciales evocados visuales (PEV) y campo visual en la deteccion del dano axonal. Material y metodo Se incluyeron 50 ojos de pacientes con EM que no hubiesen presentado brotes ni neuritis opticas durante el seguimiento. Se realizo una exploracion oftalmologica completa, que consto de agudeza visual (AV), defecto de refraccion, vision de colores, campimetria, TCO, GDx y PEV. Todos los pacientes fueron reevaluados transcurridos 12 y 24 meses. Se estudio la correlacion entre los parametros mediante la prueba de Pearson. Resultados Al comparar las exploraciones basal y a los 2 anos, se detectaron diferencias estadisticamente significativas (t de Student, p ≤ 0,05) en el espesor medio, superior e inferior de la CFNR y en el volumen macular medidos con la TCO, mientras que no se encontraron diferencias significativas en las pruebas funcionales (AV, prueba de Ishihara, campimetria, PEV) ni en el GDx. La mayor diferencia fue observada en el cuadrante inferior (113,67 frente a 105,39 μm, p Conclusiones En la evolucion de la EM aparece dano axonal progresivo. Las mediciones de la TCO son eficaces para detectar variaciones del espesor de la CFNR y del volumen macular; sin embargo, estos cambios no fueron detectados mediante las pruebas funcionales ni con el GDx. © 2009 Sociedad Espanola de Oftalmologia. Publicado por Elsevier Espana, S.L. Todos los derechos reservados.

Objective To quantify axonal loss in the retinal nerve fiber layer (RNFL) in patients with multiple sclerosis (MS), with and without a history of optic neuritis, by means of ocular imaging technologies. Methods This cross-sectional study enrolled 50 patients with MS and 25 age- and sex-matched healthy controls. All patients underwent neurologic assessment and a complete ophthalmic examination that included visual acuity, visual field examination, optical coherence tomography (OCT), scanning laser polarimetry (GDx) and visual evoked potentials (VEPs). Visual parameters and RNFL measurements were evaluated in MS eyes with a prior optic neuritis episode (MS-ON), with no prior episode (MS-NON) and control subjects. Results There were significant differences ( p < 0.05, analysis of variance) between MS-ON ( n = 25 eyes) and healthy eyes ( n = 25 eyes) for all RNFL parameters measured by OCT and GDx. Significant differences between MS-NON ( n = 75 eyes) and healthy eyes were also found for most of these parameters. RNFL thickness in the temporal quadrant was the parameter with the greatest differences between groups (71.79 μm in healthy eyes, 60.29 μm in MS-NON and 53.92 μm in MS-ON, p < 0.0005). Although there was a highly significant but moderate correlation between RNFL thickness and duration of the disease, no correlation was observed between RNFL thickness and neurologic impairment (Expanded Disability Status Scale). Conclusions Axonal loss was detected not only in MS eyes with a previous acute optic neuritis, but also in MS eyes with no known optic neuritis episode. Structural abnormalities correlate with functional assessments of the optic nerve.

Resumen Objetivos Evaluar el efecto del tratamiento patogenico de la esclerosis multiple (EM) sobre la perdida de fibras nerviosas de la retina (CFNR) mediante tecnicas de analisis digital de imagen. Material y metodo Se incluyeron 155 ojos de 79 pacientes con EM, a los que se exploro la agudeza visual medida con optotipos de Snellen, el defecto de refraccion y la vision de colores, y se realizo perimetria automatizada, tomografia de coherencia optica (OCT), polarimetria laser (GDx) y potenciales evocados visuales (PEV). Este protocolo se repitio al ano y los cambios observados fueron comparados segun el tratamiento asignado mediante el test de Anova; para lo que se dividio la poblacion en 4 grupos en funcion del tratamiento recibido: 1) sin tratamiento 2) interferon beta 1a, 3) interferon beta 1b, 4) acetato de glatiramero. Resultados No se detectaron diferencias significativas (test t, p > 0,05) entre los pacientes con o sin tratamiento ni entre los 4 grupos, pero la mayoria de los parametros funcionales y estructurales mostraron una tendencia a presentar mayores reducciones de la CFNR en el grupo sin tratamiento. La mayor variacion aparecio en el cuadrante temporal de la CFNR en la OCT (reducion de 4,97 μm en pacientes sin tratamiento vs 1,08 μm en los tratados). Conclusion El tratamiento patogenico de la EM puede ser un factor protector para la reduccion del espesor de la CFNR que se produce con la progresion de la enfermedad. Se necesitan mas estudios.

Objetivos: Evaluar los cambios que se producen en la capa de fibras nerviosas de la retina (CFNR) de pacientes con esclerosis múltiple (EM) durante 2 años. Comparar la utilidad de la tomografía de coherencia óptica (TCO), polarimetría láser (GDx), potenciales evocados visuales (PEV) y campo visual en la detección del daño axonal. Material y método: Se incluyeron 50 ojos de pacientes con EM que no hubiesen presentado brotes ni neuritis ópticas durante el seguimiento. Se realizó una exploración oftalmológica completa, que constó de agudeza visual (AV), defecto de refracción, visión de colores, campimetría, TCO, GDx y PEV. Todos los pacientes fueron reevaluados transcurridos 12 y 24 meses. Se estudió la correlación entre los parámetros mediante la prueba de Pearson. Resultados: Al comparar las exploraciones basal y a los 2 años, se detectaron diferencias estadísticamente significativas (t de Student, p < 0,05) en el espesor medio, superior e inferior de la CFNR y en el volumen macular medidos con la TCO, mientras que no se encontraron diferencias significativas en las pruebas funcionales (AV, prueba de Ishihara, campimetría, PEV) ni en el GDx. La mayor diferencia fue observada en el cuadrante inferior (113,67 frente a 105,39 µm, p < 0,001). Se encontró correlación entre los parámetros estructurales obtenidos mediante GDx y TCO. Conclusiones: En la evolución de la EM aparece daño axonal progresivo. Las mediciones de la TCO son eficaces para detectar variaciones del espesor de la CFNR y del volumen macular; sin embargo, estos cambios no fueron detectados mediante las pruebas funcionales ni con el GDx. Objective: To evaluate the changes over two years in the retinal nerve fibre layer (RNFL) of patients with multiple sclerosis (MS). To compare the ability of optical coherence tomography (OCT), scanning laser polarimetry (GDx), visual evoked potentials (VEP) and visual field examination to detect axonal loss in these patients. Material and methods: Fifty eyes of MS patients without episodes or optic neuritis during follow-up were enrolled in this study. All patients underwent a complete ophthalmic examination that included visual acuity (VA), colour vision, refractive evaluation, visual field examination, OCT, GDx and VEP. All the patients were re-evaluated over a period of 12 and 24 months. Correlations between parameters were analysed by Pearson's test. Results: There were changes in the RNFL thickness in MS patients with a 12 and 24-month follow-up. Differences between baseline and 2-year evaluation were statistically significant (p < 0.05, t test) in the mean, superior and inferior RNFL thickness and macular volume provided by OCT, while no significant differences were found using functional parameters (VA, colour vision, visual field and VEP) and GDx. The greater differences were obtained in the inferior RNFL thickness (113.67 frente a 105.39 µm, p < 0.001). Correlations were observed between structural parameters using GDx and TCO. Conclusions: Progressive axonal loss can be detected in the optic nerve of MS patients. Measurements provided by TCO are useful tools to evaluate structural abnormalities in the RNFL and changes in macular volume, however these changes were not detected using functional tests or GDx.

Spinal epidural abscesses account for approximately one of every 10, 000 admissions to tertiary hospitals. The midthoracic vertebrae are the most frequently affected, whilst the cervical spine is involved in fewer patients. Staphylococcus aureus is identified as the cause in most cases of epidural abscess; other bacteria responsible include Gram-negative bacteria, Streptococcus species and Brucella species. We report the case of a patient with cervical spondylodiscitis at level C4-C5 and an epidural abscess which was compressing the spinal cord and the retropharyngeal space. The previous symptoms of brucellosis were atypical. We discuss the clinical manifestations, diagnosis, treatment and prognosis of the case.

We undertook an epidemiologic study to ascertain the prevalence of multiple sclerosis (MS) in the Sanitary District of Calatayud, in the north-east of Spain. Methods: The study was performed from October 1990 to July 1996. The total number of residents in the area was 58,591. An extensive search was carried out to identify all cases of known or suspected MS through general practitioners and specialists, sanitary authorities in the area, the reference hospital, the Spanish Multiple Sclerosis Society, the newspaper and radio. Results: April 1, 1995 was chosen as prevalence day. The crude prevalence rate for the area was 58 per 100,000 (95% CI: 39–78). The approximate annual incidence rate was 2.6/100,000 (1980–1989). Conclusions: This study and others conducted recently in Spain show that MS is more prevalent than was previously thought and afflicts at least 53–65 per 100,000 population.

PURPOSE To evaluate the ability of Fourier-domain (FD) optical coherence tomography (OCT) to detect retinal nerve fiber layer (RNFL) atrophy in multiple sclerosis (MS) patients. To test the intrasession reproducibility of RNFL thickness measurements in MS and healthy subjects using Cirrus (Carl Zeiss Meditec, Dublin, CA) and Spectralis (Heidelberg Engineering, Heidelberg, Germany) OCT. METHODS Two hundred twenty-two eyes of 111 subjects (50 MS patients and 61 healthy subjects) underwent three 360° circular scans centered on the optic disc by the same experienced examiner using the Cirrus and Spectralis OCT instruments. Differences between healthy and MS eyes were compared. The relationship between average thicknesses with each OCT was evaluated. Repeatability was studied by intraclass correlation coefficients and coefficients of variation (COV). RESULTS RNFL atrophy was detected in the MS eyes for all OCT parameters (P < 0.05). Cirrus and Spectralis showed an RNFL average thickness of 99.4 and 102.5 μm, respectively, in healthy subjects, and 86.0 and 90.4 μm in the MS eyes. RNFL average thickness in the MS eyes determined by both OCTs correlated (r = 0.812; P < 0.001), but were significantly different (P < 0.001). Reproducibility was good. In the MS eyes, Cirrus measurements showed a mean COV of 5.85%, Spectralis 6.80%, and Spectralis with a progression feature 4.16%. Intraclass correlation coefficients were higher than 0.840. RNFL average thickness correlated with disease duration and an optic neuritis antecedent. CONCLUSIONS There are significant differences in RNFL thickness measurements between Cirrus and Spectralis despite a high correlation of measurement between the two instruments. Fourier-domain OCT can be considered a valid device for detecting RNFL atrophy in MS patients.