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Since the most decisive factor related to the cost of stroke is disability, any acute phase intervention to reduce disability will probably be cost-effective. The present acute stroke phase analysis is the first cost-benefit study on intraarterial procedures in acute stroke phase.Case-control study focusing on the cost of stroke including acute stroke patients subjected to interventionism in Hospital Virgen del Rocío in 2003-2004 was conducted. The data obtained was subsequently extrapolated to the number of patients who would have been treated if intraarterial procedures could be performed on a 24 hour-day basis.32 patients were treated in 2003-2004. Direct cost (devices and human resources) of each treated patient was 10,502 euros and global saving in hospital stay and rehabilitation was 11,069 euros, resulting in 567 euros net saving per patient. Nevertheless, 92 patients would have been treated if intraarterial procedures could have been performed on a 24 hour-day basis, resulting in better financial results with 5,792 saving for each treated patient.Intracraneal procedures in acute stroke has been shown to be cost-effective since cost of material and human resources is greatly exceeded by the saving in hospitalization and rehabilitation as a result of reduction in patient disability.

In addition to the thrombolytic agents, mechanical devices are being used in intraarterial procedures in acute stroke patients. The intervention protocol and outcomes of intraarterial procedures performed in the Hospital Virgen del Rocío in 2003-2004 are described.The results in each arterial occlusion site and case-control study of the middle cerebral artery (MCA), the placebo group in PROACT II study (Prolyse in Acute Cerebral Thromboembolism II) as historic control group, are described.A total of 32 procedures were performed: 18 MCA occlusions, 8 basilar thrombosis and 6 intracranial carotid occlusions. Urokinase, abciximab and mechanical devices were used in 60%, 26% and 60% of the cases, respectively. MCA occlusions: 60% of the cases improved in 24 hours (25% remained asymptomatic). Only 25% controls remained independent versus 55% of the treated patients (p=0.001). Recanalization and complete recanalization rates were 95 % and 45 %, respectively (18% and 2% in the control group). Symptomatic intracranial hemorrhage (SICH) rate was 18% vs 4% in cases and controls. Basilar thrombosis: only one patient died and 57% of the remaining patients were independent. Carotid occlusions: no complete recanalization was achieved and only one patient was independent. Evolution time in SICH patients was longer (p=0.04), with increased international normalized ratio (INR) for thromboplastin time (p=0.06) and old ischemic lesions in brain CT scan (p=0.02) and they were more dependent at three months (p=0.01).Intraarterial procedures in MCA occlusions achieve high rates of recanalization and better clinical outcomes than those described in isolated intraarterial thrombolysis. Long-term outcomes in basilar thrombosis were also excellent. Nevertheless, the natural evolution of carotid occlusions was not modified.

All stroke patients should receive the same degree of specialized healthcare attention according to the stage of their disease, independently of where they live, their age, gender or ethnicity.To create an organized healthcare system able to offer the needed care for each patient, optimizing the use of the existing resource.A committee of 14 neurologists specialized in neurovascular diseases representing different regions of Spain evaluated the available scientific evidence according to the published literature.During the acute phase, all stroke patients must be evaluated in hospitals that offer access to specialized physicians (neurologists) and the indicated diagnostic and therapeutic procedures. Hospitals that deliver care to acute stroke patients must be prepared to attend these patients and need to arrange a predefined transferring circuit coordinated with the extrahospitalary emergency service. Since resources are limited, they should be structured into different care levels according to the target population. Thus, three types of hospitals will be defined for stroke care: reference stroke hospital, hospital with stroke unit, hospital with stroke team.

Carotid atheromatosis is the most frequent disease of the internal extracranial carotid artery. Although important advances have been made in the knowledge of its pathophysiology, relevant points remain unknown. The need for early diagnosis is conditioned by the high sociosanitary load of secondary cerebral ictus. Modification and treatment of the vascular risk factors are necessary for both primary and secondary prevention. The current diagnosis is fundamentally based on Doppler ultrasonography and imaging studies in B-mode in real time, angio MR, helicoidal CT and overall on digital angiography. The need to treat the neurologically asymptomatic stenoses, greater than 70% is still questioned by the slight benefit provided. To the contrary, the need for surgical treatment by endarterectomy in stenoses of greater than 70% is well established. Careful analysis of the ECST and NASCET series, however, leads to the suspicion that at the time of making surgical decisions, a series of predictive variables of the long term results should be considered to individualize the cases which may most benefit from this treatment. On the other hand, given the surgical morbimortality it seems reasonable to search for therapeutic alternatives to endarterectomy. One of these is percutaneous transluminal angioplasty, the results of which appear to provide a valid alternative, specially in the cases which can not undergo surgery.

Cervicocerebral arterial dissections is responsible for 20% of first strokes in young adults. Several diseases of the connective tissue and wall vessels anomalies are considered predisposing of arterial dissection. Familiar cases have been reported in 5%, according to hereditary primary arteriopathy, such as fibromuscular dysplasia. However, the nature of this arteriopathy has been rarely proved. We present two sisters with spontaneous dissection of the internal carotid artery with details suggestive of an atypical way of fibromuscular dysplasia in one of them.

Occlusion of the internal carotid artery (ICA) due to atherosclerosis, or more rarely thromboembolism, is a fairly frequent cause of stroke. Spontaneous ICA occlusion is associated with a 40 to 69% incidence of profound neurologic deficit and a 16 to 55% death rate. Management of this entity, however, continues to be controversial, as currently used treatments have not yet been shown to modify morbidity/morbility rate. Acute-phase performance of thromboendarterectomy or percutaneous transluminal angioplasty may play a role in ICA treatment. Emergency revascularization has not generally been considered to benefit stroke patients: clinical improvement is only slight in many cases and the incidence of perioperative complications, particularly brain hemorrhage, is high. Review of the literature, however, demonstrates that adequate restoration of flow is achievable in a subgroup of patients with spontaneously occluded symptomatic ICAs without severe neurological deficit, without decreased level of consciousness and without intracerebral hemorrhage manifest in computed tomography or magnetic resonance images. The outcome of emergency intervention also seems to depend on the duration of symptoms, individual collateral blood flow and the angiographic reflux pattern in the ICA. Given the potential usefulness of these surgical techniques, controlled clinical comparison of operated and non-operated groups seems highly recommendable in spite of the significant difficulties involved.

A 45-years-old woman developed palilalia without other neurologic symptoms or signs. Cranial MR and CT scan showed only bilateral thalamic infarcts; the SPECT showed bilateral frontoparietal hypoactivity. We conclude that involvement of the supplementary motor area by diaschisis after bilateral thalamic lesions may produce palilalia.

Primary antiphospholipid syndrome (PAS) is characterized by the isolated presence of antiphospholipid antibodies in the absence of other immunological changes. Its association with ischemic cerebrovascular disease is rarely reported. This study analyzes this association in 10 patients (8 women) first presenting with ischemic cerebrovascular accident (ICVA) that met the criteria for PAS. The average age of the patients was 50.4 years. Two patients had Sneddon's syndrome. Prolonged thromboplastin partial activation time was found in only three patients. Eight started aspirin therapy. The average time of follow-up was 17.2 months, during which there was one relapse. PAS should be included as a possible cause when examining individuals with ICVA, particularly when patients are young, when abortion has occurred or when no other cause is evident. Acetylsalicylic acid is effective for preventing relapse when other vascular risk factors are carefully controlled.

In young patients episodes of amaurosis fugax usually correspond to processes not related with atherosclerosis of the extracranial vessels such as migraine, cardiac embolism, vasospasm, vasculitis, oral contraceptives or hematologic disease. In 11% of the cases, however, no cause can be found. These idiopathic cases generally have a benign course and their frequency decreases spontaneously allowing them to be described as benign amaurosis fugax. We describe four cases of amaurosis fugax in which no responsible cause was found despite extensive clinical, laboratory ultrasonographic and angiographic studies. The episodes progressively remitted. In these cases of benign amaurosis fugax the risk of a permanent deficit is exceptional and treatment is not necessary.

Neoplastic lumbosacral plexopathy is a frequent and disabling complication in subjects with cancer. Its clinical presentation is characterized by pain, muscle weakness, sensory complaints in one or occasionally both limbs associated with the tumoral symptoms. The presence of autonomic symptoms is less frequent; one of these is the "hot and dry foot". We present two patients, one with prostatic cancer and the other with myxoid liposarcoma, who developed a lumbosacral plexopathy as a manifestation of the extension of the neoplastic process; in both cases there was in addition a clear difference in the temperature of the affected limb. Although infrequent, the "hot and dry foot" it constitutes an early sign of metastatic plexopathy which facilitates the differential diagnosis with preforaminal lumbosciatic radiculopathies.

The coexistence of arterial dissection in several cervical vessels is exceptional and is usually an accidental finding detected upon performance of an extensive angiographic examination in patients with unilateral manifestations. The absence of previous clinical manifestations related with asymptomatic vessel dissection impedes the knowledge of the time between the different dissections. The case of a bilateral carotid dissection (CD) is presented in which the clinical course permitted the authors to know the interval between both dissections. The patients initially presented manifestations of right CD and, at 15 days, an ictus due to left CD in which the presence of right unilateral asterixis was of note. The time span between both dissections was established as 12-15 days.