Abstract Objective: Focal status epilepticus requires timely diagnosis and treatment. Stroke is a common cause of epileptic seizures, but stroke-induced epilepsia partialis continua (SIEPC) is a rare type of focal status epilepticus with unknown management and prognosis. The aim of the study was to present a single-center case series of patients admitted to a third-level referral hospital diagnosed with SIEPC. Methods: We performed a retrospective review assessing all in-hospital consultations from July 2021 to July 2022 describing patients who presented with a diagnosis of SIEPC during hospital admission. Patients received standard diagnostic approaches (including electroencephalographic assessment) and treatment protocols. We defined EPC as focal, continuously repeated seizures with preserved consciousness lasting at least 1 h, confirmed with electroencephalography. Results: We identified 1054 patients seen by the neurology department as in-patient consultations. We found 268 patients with a diagnosis of stroke or epilepsy and then excluded 265 patients due to an alternate diagnosis. We finally identified three patients with (SIEPC). Conclusions: Although cerebrovascular disorders are a common cause of hospital admission, and SIEPC is rare, this condition is relevant to the practicing clinician. This study draws attention to this distinct clinical entity with variable presentation, diagnosis, treatment, and prognostic issues.

Resumen Objetivo: El status epilepticus requiere un diagnóstico y tratamiento temprano. El ictus es una causa común de crisis epilépticas, pero la epilepsia partialis continua inducida por ictus es un tipo raro de status epilepticus focal con tratamiento y pronóstico desconocido. Presentar una serie de casos unicentrica de pacientes admitidos a un hospital de referencia de tercer nivel con diagnóstico de epilepsia partialis continua inducida por ictus. Métodos: Realizamos una revision retrospectiva, recopilando todas las interconsultas desde Julio del 2021 hasta Julio del 2022 que describieran pacientes quienes tuvieran un diagnóstico de epilepsia partialis continua inducida por ictus durante el ingreso hospitalario. Los pacientes recibieron abordajes diagnósticos (incluyendo realización de electroencefalograma) y terapéuticos estandar. Definimos epilepsia partialis continua como episodios convulsivos continuos focales con estado de consciencia preservado con duración mayor a una hora, confirmado por electroencefalografía. Resultados: Identificamos 1054 pacientes que fueron vistos por el servicio de neurología como interconsultas hospitalarias. A partir de dichos pacientes, encontramos 268 con diagnóstico de ictus o epilepsia, y excluimos 265 pacientes debido a diagnósticos alternativos. Finalmente, identificamos tres pacientes con epilepsia parcialis continua inducida por ictus. Conclusiones: A pesar de que las enfermedades cerebrovasculares son una causa frecuente de admisión hospitalaria, y la epilepsia parcialis continua inducida por infarto es rara, esta condición es relevante para el médico practicante. Este estudio llama la atención hacia esta distinta entidad clínica con presentación variable, y dificultades en el diagnóstico y tratamiento

ABSTRACT Background: Intracerebral hemorrhage (ICH) is associated with an ominous outcome influenced by the time to hospital presentation. Objective: This study aims to identify the factors that influence an early hospital arrival after ICH and the relationship with outcome. Methods: In this multicenter registry, patients with confirmed ICH on CT scan and well-known time of symptoms onset were studied. Clinical data, arrival conditions, and prognostic scores were analyzed. Multivariate models were built to find independent predictors of < 6 h arrival (logistic regression) and in-hospital death (Cox proportional-hazards model). Results: Among the 473 patients analyzed (51% women, median age 63 years), the median delay since onset to admission was 6.25 h (interquartile range: 2.5-24 h); 7.8% arrived in < 1 h, 26.3% in < 3 h, 45.3% in < 6 h, and 62.3% in < 12 h. The in-hospital, 30-day and 90-day case fatality rates were 28.8%, 30.0%, and 32.6%, respectively. Predictors of arrival in < 6 h were hypertension treatment (odds ratios [OR]: 1.675, 95% confidence intervals [CI]: 1.030-2.724), ≥ 3 years of schooling (OR: 1.804, 95% CI: 1.055-3.084), and seizures at ICH onset (OR: 2.416, 95% CI: 1.068-5.465). Predictors of death (56.9% neurological) were systolic blood pressure > 180 mmHg (hazards ratios [HR]: 1.839, 95% CI: 1.031-3.281), ICH score ≥ 3 (HR: 2.302, 95% CI: 1.300-4.074), and admission Glasgow Coma Scale < 8 (HR: 4.497, 95% CI: 2.466-8.199). Early arrival was not associated with outcome at discharge, 30 or 90 days. Conclusions: In this study, less than half of patients with ICH arrived to the hospital in < 6 h. However, early arrival was not associated with the short-term outcome in this data set.

ABSTRACT Background: The recognition of stroke symptoms by patients or bystanders directly affects the outcomes of patients with acute cerebrovascular disease. Objective: The objective of the study was to assess the predictive value of the medical history and clinical features recognized by the patients’ bystanders to classify neurovascular syndromes in pre-hospital settings. Methods: We included 150 stroke patients of two Mexican referral centers: 50 with acute ischemic stroke (AIS), 50 with intracerebral hemorrhage (ICH), and 50 with subarachnoid hemorrhage (SAH). The performance of clinical prediction rules (CPR) to identify the stroke types was evaluated with features recognized by the patients’ bystanders before hospital arrival. The impact of CPRs on early arrival and in-hospital mortality was also analyzed. Results: Overall, 72% of the patients had previous medical evaluations in other centers before final referral to our hospitals, and therefore, only 45% had a final onset-to-door time <6 h, even when the first medical assessment had occurred in ≤1 h in 75% of cases. Clinical features noticed by the patients’ bystanders had low positive predictive values (PPV) for any stroke type. The CPR “language or speech disorder + focal motor deficit” had 93% sensitivity and a negative predictive value (NPV) of 84% to distinguish AIS. In SAH, headache alone showed a sensitivity of 84% and NPV of 97%. No CPR had an adequate performance on ICH. CPRs were not associated with final onset-to-door time. Altered consciousness, age ≥65 years, indirect arrival with stops before final referral, and atrial fibrillation increased in-hospital mortality. Conclusion: Clinical features referred by the witness of a neurovascular emergency have limited PPV, but adequate NPV in ruling-out AIS and SAH among stroke types. The use of CPRs had no impact on onset-to-door time or in-hospital mortality when the final arrival to a third-level center occurs with previous medical referrals.

Abstract Background: Wallenberg syndrome (WS) is a classic neurologic disorder secondary to vascular pathology of the vertebrobasilar circulation. Methods: Consecutive patients > 18 years with WS and isolated lateral medullary infarction syndrome were included from two Mexican hospitals. Risk factors, initial signs, symptoms, radiological findings, and acute treatment were evaluated; the prognosis was assessed using the Glasgow Outcome Scale. Results: Twenty-six patients were studied in a 26-year period (1988-2014); 17 patients were men (67%); and the average age was 45 years (range 19-77). Fourteen patients were under 45 years old (54%). The most common risk factors were dyslipidemia (41%) and hypertension (37%). The main initial symptoms were vertigo-dizziness (89%) gait ataxia (70%), and crossed-sensory deficit; and the main signs were crossed-sensitive deficit (93%), Horner syndrome (85%), and nystagmus (82%). In the bivariate analysis, age under 45 years was associated with a vertebral arterial dissection (p = 0.001), and age > 45 with atherothrombotic etiology (p = 0.01). About 96% of patients presented good recovery at an average of 17 months follow-up. Conclusion: Non-atherosclerotic vasculopathy was the main cause of WS-ILBI in young people. The clinical characteristics were similar to those reported in other series with a usually benign prognosis.

Resumen Antecedentes: El síndrome de Wallenberg (SW) es un diagnóstico clásico en neurología, generalmente secundario a patología vascular de la circulación vertebro-basilar. Métodos: Se incluyeron a pacientes mexicanos consecutivos mayores de 18 años de edad con síndrome de SW e infarto bulbar lateral aislado (SW-IBLA) en dos hospitales mexicanos. Se evaluaron los factores de riesgo, signos y síntomas iniciales, hallazgos radiológicos, tratamiento agudo y pronóstico mediante el Glasgow Outcome Scale (GOS). Resultados: Se estudiaron 26 pacientes en un periodo de 26 años (1988-2014); Diecisiete pacientes fueron hombres (67%); el promedio de edad fue de 45 años (rango 19-77). Catorce pacientes fueron menores de 45 años (54%). Los factores de riesgo más frecuentes fueron dislipidemia (41%) e hipertensión arterial (37%). Los principales síntomas al inicio fueron vértigo-mareo (89%) y ataxia para la marcha (70%), así como déficit sensorial cruzado (93%), síndrome de Horner (85%) y nistagmo (82%) a la exploración neurológica. En el análisis bivariado, la edad menor a 45 años se asoció a disección arterial vertebral (p = 0.001), y la edad > 45 a etiología aterotrombótica (p = 0.01). El 96% de los pacientes presentaron buena recuperación en un seguimiento promedio de 17 meses. Conclusión: La vasculopatía no ateroesclerosa fue la principal causa de SW-IBLA en jóvenes. Las características clínicas para esta localización fueron similares a lo reportado en otras series con un pronóstico habitualmente benigno.

Abstract Background: Hyperglycemia at admission has been recognized as an independent predictor of poor outcome after aneurysmal subarachnoid hemorrhage (aSAH); however, it remains poorly characterized in multivariate models depicting representative population samples. Objective: The objective of the study was to identify if admission blood glucose can independently predict in-hospital mortality after subarachnoid hemorrhage in Mexican patients included in a nationwide multicenter registry. Design/methods:: Consecutive patients with aSAH due to ruptured intracranial aneurysm confirmed by 4-vessel angiography were registered in 25 tertiary referral centers from 14 states in Mexico. Multivariate analyses were modeled to find independent predictors of in-hospital mortality, with adjustment for relevant confounders, using the Hunt-Hess and Fisher scales. Results: A total of 231 patients were studied (66% women; mean age 52 years, range 16-90). Length of hospital stay was a median of 23 days (range 2-98) with in-hospital mortality of 20%, 54% due to a neurological cause. Survival analyses showed a higher probability of death with admittance blood glucose levels in the higher quartile (glycemia > 150 mg/dl) (p < 0.001). Predictors of in-hospital mortality were the Hunt-Hess score > 2 (odds ratio [OR]: 3.79, 95% confidence interval [CI]: 1.43-10.06) and glycemia in the higher quartile (OR: 2.98, 95% CI: 1.12-7.96). Conclusions: Hyperglycemia is an important independent factor associated with in-hospital mortality. Its early detection and management should be a priority to improve outcomes.

Resumen Antecedentes: La hiperglucemia al ingreso se ha reconocido como un predictor independiente de mal pronóstico después de una hemorragia subaracnoidea aneurismática (HSAA); sin embargo, este hallazgo aún está mal caracterizado en modelos multivariados de población representativa. Objetivo: Identificar si la glucosa en sangre al ingreso hospitalario puede predecir de forma independiente la mortalidad hospitalaria después de HSAA en pacientes mexicanos incluidos en un registro multicéntrico nacional. Diseño/métodos:: Se registró a pacientes consecutivos con HSA secundaria a un aneurisma intracraneal roto confirmado por angiografía de cuatro vasos en 25 centros de referencia terciarios de 14 estados en México. Los análisis multivariados se modelaron para identificar predictores independientes de mortalidad hospitalaria, con ajuste por factores de confusión relevantes, mediante las escalas de Hunt-Hess y Fisher. Resultados: Se estudió a un total de 231 pacientes (mujeres, 66%; edad media, 52 años; intervalo, 16-90). La duración de la estancia hospitalaria tuvo una mediana de 23 días (intervalo, 2-98) con una mortalidad hospitalaria del 20%, 54% debido a una causa neurológica. Los análisis de supervivencia mostraron una mayor probabilidad de muerte con los valores de glucosa en sangre en el cuartil superior (glucemia > 150 mg/dl; p < 0.001). Los predictores de mortalidad hospitalaria fueron la puntuación de Hunt-Hess > 2 (OR, 3.79; IC 95%, 1.43-10.06) y la glucemia en el cuartil superior (OR, 2.98; IC95%, 1.12-7.96). Conclusiones: La hiperglucemia es un importante factor independiente relacionado con la mortalidad hospitalaria. Su detección y gestión tempranas deben ser una prioridad para mejorar los resultados.

Abstract Background: Symptomatic palatal tremor (SPT) is an uncommon hyperkinetic movement disorder caused by the interruption of the dentato-rubro-olivary pathway due to a lesion in the brainstem or cerebellum. Methods: We describe a cohort of consecutive patients with SPT who were assessed by a single neurologist in a tertiary reference center. Results: A total of 27 patients were included in this cohort from 1998 to 2016; 16 males and 11 females, with a mean age of 47 years (range 19-89). The average time from initial insult to a diagnosis of SPT was 14.5 months (range 2-48 months). The most common etiology of SPT was cerebrovascular disease (CVD) in 21 (78%) patients. Other etiologies included infectious and demyelinating diseases of the central nervous system. The remaining unclassified case was accompanied by progressive ataxia pointing toward a neurodegenerative etiology. Twenty-six patients had a history of posterior fossa injury, and all patients had rhombencephalic signs with severe dysarthria. None of them responded significantly to pharmacological treatment. Conclusion: SPT is a more common finding than expected, especially in patients with posterior fossa injury secondary to CVD. The main clinical syndrome was the rhomboencephalic phenotype, with a predominance of dysarthria. There was no effective treatment in any of the patients.

Resumen Antecedentes: El temblor palatino sintomático (TPS) es un trastorno hipercinético del movimiento poco frecuente secundario a la interrupción de la vía dentato-rubro-olivar por una lesión en el tronco encefálico o el cerebelo. Métodos: Describimos una cohorte de pacientes consecutivos con TPS que fueron evaluados por un mismo neurólogo en un centro de tercer nivel. Resultados: Se incluyeron un total de 27 pacientes entre 1998 y 2016; 16 hombres y 11 mujeres, con una edad media de 47 años (rango 19-89 años). El tiempo promedio desde la lesión inicial hasta el diagnóstico de MPS fue de 14.5 meses (rango 2-48 meses). La etiología principal del TPS fue la enfermedad cerebrovascular (EVC) con 21 (78%) pacientes. Otras etiologías incluyeron: enfermedades infecciosas y desmielinizantes del sistema nervioso central. El caso restante presentó ataxia progresiva de probable etiología neurodegenerativa. Veintiséis pacientes tenían antecedentes de lesión en fosa posterior. Todos los pacientes tenían signos romboencefálicos con disartria severa y ninguno de los pacientes respondió significativamente al tratamiento farmacológico. Conclusión: El TPS es un hallazgo más común de lo esperado, principalmente en pacientes con lesión de fosa posterior secundaria a EVC. El principal síndrome clínico fue el romboencefálico con predominio de disartria. No hubo tratamiento efectivo en ninguno de los pacientes.

Abstract Background: Myasthenia gravis (MG) is a post-synaptic autoimmune disease of the neuromuscular junction, whose cardinal manifestations are weakness and fatigue. Objective: The objective of the study was to report a cohort of patients with a diagnosis of MG in a West Mexican hospital and compare the clinical profile, diagnostic, and therapeutic approach and prognosis against a previously published cohort of the same hospital. Materials and methods: Consecutive patients included in two cohorts: the first one already published from 1999 to 2007 and the second one reported here from 2008 to 2018. Results: The most recent cohort included 39 patients, 23 women (59%), with an average age of 50 years, and superior to the previous cohort (43 years). Hypertension (39%) and diabetes (18%) were observed with a marked increase in the current cohort. The distribution in the Osserman staging was very similar. The positivity of acetylcholine receptor antibodies (ACRA) increased from 37% to 88%. In both cohorts, most patients received pyridostigmine and in two-thirds steroids. The previous cohort recorded 4% of patients treated with a steroid-sparing immunosuppressant, contrasting with 90% (azathioprine 85%, and mycophenolate 5%) of the current cohort. Thymectomy was a less frequent practice in 12%. Mortality showed a significant decrease from 16% to 0%. Conclusion: Differences were observed among the cohorts, highlighting in the most recent one a higher age, the appearance of chronic-degenerative diseases, greater positivity to ACRA, optimization of pharmacological management, less thymectomy, and no mortality. Replicas of this work in other hospital settings are pertinent.

Resumen Antecedentes: La miastenia gravis (MG) es una enfermedad autoinmune postsináptica de la unión neuromuscular, cuyas manifestaciones cardinales son debilidad y fatiga. Objetivo: Reportar una cohorte de pacientes con diagnóstico de MG en un hospital del occidente de México y comparar el perfil clínico, el enfoque diagnóstico y terapéutico, y el pronóstico frente a una cohorte publicada previamente del mismo hospital. Material y métodos: Pacientes consecutivos incluidos en dos cohortes; la primera ya publicada (de 1999 al 2007) y la reportada aquí (del 2008 al 2018). Resultados: En la cohorte más reciente se incluyeron 39 pacientes, 23 mujeres (59%), con edad promedio de 50 años, superior a la cohorte previa (43 años). Hipertensión arterial (39%) y diabetes (18%) se observan con marcado incremento en la cohorte actual. La distribución en la estadificación de Osserman fue similar. La positividad de los anticuerpos contra el receptor de acetilcolina (ACRA) aumentó del 37 al 88%. En ambas cohortes la mayoría de los pacientes recibieron piridostigmina y dos terceras partes esteroides. La cohorte previa registró un 4% de pacientes tratados con inmunosupresores ahorradores de esteroides, contrastando con el 90% (azatioprina 85%, micofenolato 5%) de la cohorte actual. La timectomía fue una práctica menos frecuente, en el 12%. La mortalidad presentó un importante decremento, del 16% al 0%. Conclusión: Se observan diferencias entre las cohortes, destacando en la más reciente una mayor edad de presentación, aparición de enfermedades cronicodegenerativas, mayor positividad a ACRA, optimización del manejo farmacológico, menos timectomía y nula mortalidad. Son pertinentes réplicas de este trabajo.