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OBJECTIVES: To find out about stroke patients: who decides to seek medical help, where they go, how long it takes to contact the health system and to arrive at the ED. METHODS: Prospective study of patients admitted in our hospital for transient or established stroke. RESULTS: Among 388 stroke patients (mean NIHSS of 7.8 (±7.4), there were 37 intracerebral hemorrhage, 70 TIA, and 281 cerebral infarction. 39.2% arrived at the ED in less than 3h. The decision to seek medical help was taken by patients in 20.4% of the episodes. First contact was with primary care in 48.3% of the cases and with Emergency Medical Services in 18.2%. The median time of decision was 60min [P25:15; P75:323]. Considering the event as serious, recognizing the stroke, not going to a primary care physician, having a TIA and onset away from home significantly decreased delay. Age, sex and previous stroke were not associated with less delay in decision nor with an earlier arrival to the ED. CONCLUSIONS: In order to improve stroke treatment it is necessary to harness the use of the 112 emergency line and include primary care in the stroke assistance chain.

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Introducción. La trombólisis endovenosa en el infarto cerebral es el tratamiento de elección en las primeras horas y el retraso es la principal barrera para su empleo. El código ictus (CI) es un sistema que permite una rápida identificación y traslado del paciente con ictus al hospital adecuado para realizarla. Objetivo. Conocer el impacto de extender el CI intrahospitalario (CII) a CI provincial (CIP). Pacientes y métodos. Registro prospectivo de CI atendidos en un centro de ictus provincial. Se recogieron los infartos cerebrales ingresados de forma consecutiva el año previo y posterior al inicio del CIP (1 de noviembre de 2008). Resultados. En un año se atendieron 318 CI: el 61,2% fueron CI extrahospitalarios (CIE). Se trombolizaron 45 pacientes: el 14,2% de las activaciones y el 25,7% de los infartos cerebrales con código activado. La tasa bruta anual de trombólisis fue de 7,7 × 100.000 habitantes (intervalo de confianza del 95%, IC 95% = 5,7-10,4). Medicina primaria activó el 34% de los códigos. No hay diferencias significativas en el porcentaje de activaciones correctas y trombólisis entre CIE y CII. El retraso puerta-aguja es menor en los CIE (59,7 ± 24 frente a 74,4 ± 20 min; p = 0,012). La franja horaria de 22:00 a 08:00 h incluye el 23,6% de los CI y el 22,2% de los trombolizados. Del primer al segundo período, la activación del CI pasa del 11,1 al 37,9% de infartos cerebrales, y la trombólisis aumenta del 3,8 al 12,7% (p < 0,0001; odds ratio = 4,1; IC 95% = 1,9-8,6). Conclusión. El CIP permitió cuadruplicar la trombólisis del infarto cerebral, mejorar la cadena asistencial y extenderla a toda la provincia (AU)

Introduction. Endovenous thrombolysis is the preferred treatment in the early hours following cerebral infarction and delays are the main obstacle preventing it from being used on a more widespread basis. The stroke code (SC) is a system that allows stroke patients to be identified quickly and taken to the most suitable hospital for such treatment to be implemented. Aim. To determine the impact of extending the intra-hospital SC (ISC) to a provincial SC (PSC). Patients and methods. The system consists in a prospective register of cases of SC treated in a provincial stroke centre. Data on the cases of cerebral infarction admitted consecutively the year prior to and after beginning the PSC (1st November 2008) were collected. Results. In one year 318 SC were handled: 61.2% were extra-hospital SC (ESC). A total of 45 patients were thrombolysed: 14.2% of the activations and 25.7% of cerebral infarctions with the code activated. The gross annual rate of thrombolysis was 7.7/100,000 inhabitants (95% confidence interval, 95% CI = 5.7-10.4). Primary medicine activated 34% of the codes. There are no significant differences between ESC and ISC as regards the percentage of correct activations and thrombolysis. The door-to-needle delay is shorter in ESC (59.7 ± 24 versus 74.4 ± 20 minutes; p = 0.012). The time slot from 22 pm to 8 am covers 23.6% of the SC and 22.2% of cases of thrombolysed patients. From the first to the second period, SC activation rises from 11.1% to 37.9% of cerebral infarctions and thrombolysis increases from 3.8 to 12.7% (p < 0.0001; odds ratio = 4.1; 95% CI = 1.9-8.6). Conclusions. The PSC allowed thrombolysis of cerebral infarction to be carried out in four times as many cases, as well as improving the health care chain and extending it throughout the whole province (AU)

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INTRODUCTION: Endovenous thrombolysis is the preferred treatment in the early hours following cerebral infarction and delays are the main obstacle preventing it from being used on a more widespread basis. The stroke code (SC) is a system that allows stroke patients to be identified quickly and taken to the most suitable hospital for such treatment to be implemented. AIM. To determine the impact of extending the intra-hospital SC (ISC) to a provincial SC (PSC). PATIENTS AND METHODS: The system consists in a prospective register of cases of SC treated in a provincial stroke centre. Data on the cases of cerebral infarction admitted consecutively the year prior to and after beginning the PSC (1st November 2008) were collected. RESULTS: In one year 318 SC were handled: 61.2% were extra-hospital SC (ESC). A total of 45 patients were thrombolysed: 14.2% of the activations and 25.7% of cerebral infarctions with the code activated. The gross annual rate of thrombolysis was 7.7/100,000 inhabitants (95% confidence interval, 95% CI = 5.7-10.4). Primary medicine activated 34% of the codes. There are no significant differences between ESC and ISC as regards the percentage of correct activations and thrombolysis. The door-to-needle delay is shorter in ESC (59.7 ± 24 versus 74.4 ± 20 minutes; p = 0.012). The time slot from 22 pm to 8 am covers 23.6% of the SC and 22.2% of cases of thrombolysed patients. From the first to the second period, SC activation rises from 11.1% to 37.9% of cerebral infarctions and thrombolysis increases from 3.8 to 12.7% (p < 0.0001; odds ratio = 4.1; 95% CI = 1.9-8.6). CONCLUSIONS: The PSC allowed thrombolysis of cerebral infarction to be carried out in four times as many cases, as well as improving the health care chain and extending it throughout the whole province.

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Before thrombolytic treatment for acute ischemic stroke is undertaken, conditions associated with increased risk of hemorrhagic complications, such as an acute aortic dissection (AAD), should be excluded. We report an 80-year-old woman with acute ischemic stroke as the sole clinical manifestation of AAD who was treated with intravenous (IV) tissue plasminogen activator (tPA). She had no history of hypertension or any signs or symptoms suggestive of AAD. After IV tPA infusion was started, carotid color-coded duplex sonography demonstrated proximal left common carotid artery dissection suggestive of AAD. Infusion of tPA was stopped, and subsequent computed tomography angiography confirmed Stanford type A aortic dissection. In this case, prompt neurosonologic evaluation helped us make an appropriate diagnosis and avoid complications related to treatment. Neurosonologic evaluation should be considered as soon as possible in all patients with acute ischemic stroke, especially when thrombolytic treatment is being considered.

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INTRODUCTION: Despite the different epidemiological, neurophysiological and morphological studies published in the literature, it is still not known for sure whether there is a relation between Alzheimer's disease (AD) and peripheral hearing loss. In this work we conduct an auditory study in patients with AD and in volunteer controls in order to investigate this possible relationship. SUBJECTS AND METHODS: The sample studied consisted of 14 patients with a clinical diagnosis of probable AD (age: 79 Y 6 years) and 14 volunteers (age: 76 Y 5 years) who visited the Clinica Universidad de Navarra. After applying a set of thorough criteria to preclude any previous hearing problems, all the participants underwent a subjective hearing assessment by means of pure-tone threshold audiometry and vocal audiometry and an objective auditory assessment using a tympanometry study, stapedial reflex, otoacoustic emissions and brainstem auditory evoked potentials. For the analysis, patients with AD and controls were paired homogenously by sex and age. RESULTS: The main obstacle hindering the study was to recruit the participants, due to the fact that they did not see any direct benefit from the study and it demanded an excessive amount of their time. Pure-tone threshold audiometry showed that patients with AD had a pattern of greater hearing loss for acute frequencies, with statistically significant differences. No significant differences were found in the analysis of the rest of the subjective and objective hearing tests. CONCLUSIONS: The findings of our study both agree and disagree with some earlier works from the literature, which suggests that patients with AD may have their own auditory pattern.

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Introducción. Diversos estudios epidemiológicos, neurofisiológicos y morfológicos publicados no permiten conocer con certeza si existe una relación entre la enfermedad de Alzheimer (EA) y una pérdida auditiva periférica. En este trabajorealizamos un estudio auditivo a pacientes con EA y a voluntarios de control para investigar esta posible relación. Sujetos y métodos. Se estudiaron 14 pacientes con diagnóstico clínico de probable EA (edad: 79 ± 6 años) y 14 voluntarios (edad: 76 ± 5 años) que consultaron en la Clínica Universidad de Navarra. Tras la aplicación de unos criterios exhaustivosque descartaron problemas auditivos previos, a todos los participantes se les realizó una valoración auditiva subjetivamediante audiometría tonal liminar y logoaudiometría, y una valoración auditiva objetiva mediante estudio de timpanometría, reflejo estapedial, otoemisiones acústicas y potenciales evocados auditivos de tronco cerebral. Para el análisis se emparejaron homogéneamente los pacientes con EA y los controles según el sexo y edad.Resultados. El principal obstáculo para el estudio ha sido el reclutamiento de los participantes, debido a que no veían unbeneficio directo del estudio y que precisaban invertir un tiempo excesivo. La audiometría tonal liminar demostró que los pacientes con EA tenían un patrón de mayor pérdida auditiva para las frecuencias agudas, con diferencias estadísticamente significativas. El análisis del resto de pruebas auditivas subjetivas y objetivas no logró identificar diferencias significativas.Conclusiones. Los hallazgos de nuestro estudio concuerdan a la vez que contradicen algunos de los trabajos previos de la literatura, lo que sugiere la existencia de un patrón auditivo propio de los pacientes con EA (AU)

Introduction. Despite the different epidemiological, neurophysiological and morphological studies published in the literature, it is still not known for sure whether there is a relation between Alzheimer’s disease (AD) and peripheral hearing loss. In this work we conduct an auditory study in patients with AD and in volunteer controls in order to investigate this possiblerelationship. Subjects and methods. The sample studied consisted of 14 patients with a clinical diagnosis of probable AD (age: 79 ± 6 years) and 14 volunteers (age: 76 ± 5 years) who visited the Clínica Universidad de Navarra. After applying a set of thorough criteria to preclude any previous hearing problems, all the participants underwent a subjective hearing assessment by means of pure-tone threshold audiometry and vocal audiometry and an objective auditory assessmentusing a tympanometry study, stapedial reflex, otoacoustic emissions and brainstem auditory evoked potentials. For the analysis, patients with AD and controls were paired homogenously by sex and age. Results. The main obstacle hindering the study was to recruit the participants, due to the fact that they did not see any direct benefit from the study and it demanded an excessive amount of their time. Pure-tone threshold audiometry showed that patients with AD had a pattern of greater hearing loss for acute frequencies, with statistically significant differences. No significant differences were found in the analysis of the rest of the subjective and objective hearing tests. Conclusions. The findings of our study both agree and disagree with some earlier works from the literature, which suggests that patients with AD may have their own auditory pattern (AU)

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Reconstruction of pharyngeal defects continues to present a clinical challenge for the Head and Neck surgeon. We have different reconstructive options to preserve speech, airway and swallowing functions. Reconstructive surgery implies a balance between oncologic cure, patient morbidity and quality of life. Classical reconstructive techniques include pedicled cervical cutaneous or myocutaneous flaps and distal myocutaneous flaps such as from the pectoralis major. Current microvascular technique options have a differing incidence of complications but always with high success rates. This article reviews the most current options on reconstructive techniques in pharyngeal defects.

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La reconstrucción de defectos faríngeos sigue siendo un reto para el cirujano de cabeza y cuello. Las diferentes opciones reconstructivas van orientadas a mantener la función vocal, la vía aérea y la deglución. La técnica de reconstucción supone un equilibrio entre la curación oncológica, la morbilidad del paciente y la calidad de vida. Las técnicas reconstructivas clásicas incluyen los colgajos pediculados cutáneos y miocutáneos cervicales y los colgajos miocutáneos distales, como el de pectoral mayor. Actualmente, las técnicas de reconstrucción microvascular difieren en la incidencia de complicaciones, pero siempre con un alto nivel de viabilidad. Este trabajo tiene como objetivo revisar las opciones actuales en técnicas reconstructivas de defectos faríngeos (AU)

Reconstruction of pharyngeal defects continues to present a clinical challenge for the Head and Neck surgeon. We have different reconstructive options to preserve speech, airway and swallowing functions. Reconstructive surgery implies a balance between oncologic cure, patient morbidity and quality of life. Classical reconstructive techniques include pedicled cervical cutaneous or myocutaneous flaps and distal myocutaneous flaps such as from the pectoralis major. Current microvascular technique options have a differing incidence of complications but always with high success rates. This article reviews the most current options on reconstructive techniques in pharyngeal defects (AU)

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OBJECTIVES: Sialoendoscopy is a procedure used to visualize the salivary ducts and their pathology. It can be used either as a diagnostic method to rule out inflammatory processes in the parotid and submandibular glands (diagnostic sialoendoscopy) or to treat pathological areas (stenosis, extract foreign bodies or sialolithiasis) through the use of appropriate instruments (interventionist sialoendoscopy). We attempt to prove a declining rate of salivary gland excision. PATIENTS AND METHOD: Sialoendoscopy was performed in 8 patients. RESULTS: Of these, 50 % of patients were diagnosed as having sialolithiasis and the other 50 % had chronic sialoadenitis. In patients with sialolithiasis, sialoendoscopy allowed the extraction of the calculus in two patients (50 %). In the remainder, sialoendoscopy provided confirmation of the diagnosis in all cases. CONCLUSIONS: Sialoendoscopy is a new technique for use in the diagnosis, treatment and post-operative management of sialolithiasis, sialoadenitis and other salivary gland pathologies.

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Objetivos: La sialoendoscopia es un procedimiento cuya finalidad es visualizar los conductos salivales y sus procesos patológicos. Se utiliza como método diagnóstico, para descartar procesos inflamatorios de las glándulas (sialoendoscopia diagnóstica) y para tratar áreas patológicas (estenosis, retirar cuerpos extraños o cálculos), mediante instrumental (sialoendoscopia intervencionista). Queremos mostrar la disminución de extirpación glandular. Pacientes y método: Se estudia a 8 pacientes intervenidos con sialoendoscopia. Resultados: En el 50 % se trataba de sialolitiasis y en el otro 50 %, de sialodenitis crónica. En las sialolitiasis la sialoendoscopia intervencionista permitió extraer el cálculo en 2 (50 %) casos. En el resto la sialoendoscopia permitió confirmar el diagnóstico en todos los casos. Conclusiones: La sialoendoscopia es un nueva técnica que nos permite diagnosticar, tratar y hacer un adecuado seguimiento de las sialodenitis, sialolitiasis y otras afecciones glandulares

Objectives: Sialoendoscopy is a procedure used to visualize the salivary ducts and their pathology. It can be used either as a diagnostic method to rule out inflammatory processes in the parotid and submandibular glands (diagnostic sialoendoscopy) or to treat pathological areas (stenosis, extract foreign bodies or sialolithiasis) through the use of appropriate instruments (interventionist sialoendoscopy). We attempt to prove a declining rate of salivary gland excision. Patients and method: Sialoendoscopy was performed in 8 patients. Results: Of these, 50 % of patients were diagnosed as having sialolithiasis and the other 50 % had chronic sialoadenitis. In patients with sialolithiasis, sialoendoscopy allowed the extraction of the calculus in two patients (50 %). In the remainder, sialoendoscopy provided confirmation of the diagnosis in all cases. Conclusions: Sialoendoscopy is a new technique for use in the diagnosis, treatment and post-operative management of sialolithiasis, sialoadenitis and other salivary gland pathologies

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Sensorineural hearing loss has a high incidence in our population; as a matter of fact, 50% of people above 75 years of age suffer this impairment. Due to the advances in the devices to alleviate this condition and their verified efficacy, it is now appropriate to review the indications for these devices and provide a detailed description of the audioprosthetic systems used. These systems can be classified as external non-implantable devices (hearing aids) and implantable prostheses. The latter can be sub-divided into active implants in the external ear or middle ear, cochlear implants, and auditory brainstem implants (ABI). Indications for each group are determined by the type and location of the underlying condition as well as by the anatomic, functional, and social characteristics of each patient. It must be stressed that the selection and monitoring of the treatment is up to the specialist. Generally speaking, an attempt is made to facilitate the integration of the hypoacusic patients to their sound setting by enhancing their understanding of the spoken word and restoring binaurality, while at the same time, seeking to retain the plasticity of central auditory routes through the stimulation provided by any of these systems. In the course of this review, we refer to newly-emerging indications in both the field of cochlear implants (bimodal stimulation, implantation in patients with residual hearing, bilateral implants, etc) and in the area of ABI in patients with tumoural disease previously treated with radiosurgery or patients with non-tumour pathologies presenting malformations or bilateral cochlear ossification.

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La hipoacusia neurosensorial tiene alta incidencia en nuestra población. Sirva de ejemplo que el 50 % de las personas mayores de 75 años tiene este tipo de discapacidad. Los avances en los dispositivos utilizados para su tratamiento paliativo y su eficacia comprobada hacen necesaria la revisión de sus indicaciones y la descripción detallada de los sistemas audioprotésicos empleados. Éstos pueden ser clasificados en prótesis externas no implantables (audífonos) y prótesis implantables. El grupo de las prótesis implantables se subdivide a su vez en implantes activos de oído externo, implantes activos de oído medio, implantes cocleares e implantes auditivos de tronco cerebral (IATC). Las indicaciones establecidas para cada grupo audioprotésico se definen por la tipología y la topología de la enfermedad subyacente y por las características anatomofuncionales y socioculturales de cada paciente. En esta cuestión debe hacerse hincapié en el protagonismo del especialista a la hora de elegir y seguir el tratamiento. Como norma general, se procura favorecer el acceso del paciente hipoacúsico a su entorno sonoro realzando la comprensión de la palabra hablada restableciendo la binauralidad y, a la vez, se busca mantener la plasticidad de las vías auditivas centrales a través de la estimulación proporcionada por cualquiera de estos sistemas. Se expone las indicaciones emergentes, ya sea en el campo de los implantes cocleares (estimulación bimodal, implantación en pacientes con audición residual, implantaciones bilaterales, etc.) o en el campo de los IATC, en pacientes con afección tumoral previamente tratada con radiocirugía y en pacientes con trastornos no tumorales afectos de osificación coclear bilateral o malformaciones

Sensorineural hearing loss has a high incidence in our population; as a matter of fact, 50 % of people above 75 years of age suffer this impairment. Due to the advances in the devices to alleviate this condition and their verified efficacy, it is now appropriate to review the indications for these devices and provide a detailed description of the audioprosthetic systems used. These systems can be classified as external non-implantable devices (hearing aids) and implantable prostheses. The latter can be sub-divided into active implants in the external ear or middle ear, cochlear implants, and auditory brainstem implants (ABI). Indications for each group are determined by the type and location of the underlying condition as well as by the anatomic, functional, and social characteristics of each patient. It must be stressed that the selection and monitoring of the treatment is up to the specialist. Generally speaking, an attempt is made to facilitate the integration of the hypoacusic patients to their sound setting by enhancing their understanding of the spoken word and restoring binaurality, while at the same time, seeking to retain the plasticity of central auditory routes through the stimulation provided by any of these systems. In the course of this review, we refer to newly-emerging indications in both the field of cochlear implants (bimodal stimulation, implantation in patients with residual hearing, bilateral implants, etc) and in the area of ABI in patients with tumoural disease previously treated with radiosurgery or patients with non-tumour pathologies presenting malformations or bilateral cochlear ossification

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CONCLUSIONS: We recommend performing the test for nystagmus actively, both when the response is analyzed at bedside or with videonystagmography. If no nystagmus is observed with the active test, it should then be performed passively. OBJECTIVE: Head-shaking nystagmus (HSN) is a sign of vestibular dysfunction that is elicited after actively (patient) or passively (examiner) shaking a patient's head. The objective of this study was to analyze the frequency of HSN when the test is performed actively (aHSN) or passively (pHSN), and to determine whether any differences in the results might be due to age or disease state, or whether they reflect the results of different vestibular tests. PATIENTS AND METHODS: This was a prospective study conducted at a tertiary care center. The head-shaking test was carried out actively and passively on 100 patients. The caloric test, the rotatory chair tests and the measures of disability were performed on the same day and in the same setting. HSN was considered to be present when it was seen for a period longer than 5 s or if the maximum slow-phase velocity of HSN was higher than 3 degrees s(-1). Four groups were established according to the results of the two testing methods. RESULTS: The frequency of aHSN was 47% and of pHSN was 46% when the presence of nystagmus was established as the criterion. Moreover, in patients who had experienced vestibular neuritis previously, the type of nystagmus was age-dependent. When the velocity of the nystagmus elicited was considered, the results coincided with the method of testing in 74% of the patients, while they differed in 26% of subjects; the aforementioned age dependency was no longer seen. Differences in the caloric and rotatory chair test results, as well as in disability, were observed in the groups generated on the basis of the types of nystagmus.

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Of six patients registered in our center with nonparaneoplastic limbic encephalitis associated with antibodies to voltage-gated potassium channels, the five men had rapid eye movement sleep behavior disorder (RBD) coincident with voltage-gated potassium channel antibody-associated limbic encephalitis onset. In three patients, immunosuppression resulted in resolution of RBD in parallel with remission of the limbic syndrome. RBD persisted in two patients with partial resolution of the limbic syndrome. Our findings suggest that RBD is frequent in the setting of voltage-gated potassium channel antibody-associated limbic encephalitis and can be related to autoimmune-mediated mechanisms. In addition, these observations suggest that impairment of the limbic system may play a role in the pathogenesis of RBD.

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