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Introduction: Cerebrovascular disease (CVD) is responsible for the majority of disability-adjusted life years and is a leading cause of mortality. This impact justifies having up-to-date data on its incidence., Patients and Methods: We conducted a systematic review of the studies published since 2010 that provided information on the crude incidence rate (CIR) and adjusted incidence rate of CVD during the second decade of the 21st century., Results: Thirty-five articles were identified. Twenty-eight provided information on the overall incidence of CVD, 19 on the incidence of ischaemic stroke (IS), 19 on the incidence of haemorrhagic stroke (HS) and 10 on the incidence of subarachnoid haemorrhage (SAH). The incidence was heterogeneous across countries. Thus, the median CIR was 149.5 - confidence interval 95% (CI 95%): 122-256 - cases per 100,000 inhabitants for CVD; 155 (CI 95%: 95.6-246.12) for SI; 29 (CI 95%: 19-43) for HS; and 6.5 (CI 95%: 4.8-13.5) for SAH. The incidence for both CVD and IS and HS was higher in men than in women in most studies, with the exception of some Asian, European and North American studies. The majority of studies showed a decreasing or stabilising trend in incidence, with the exception of studies conducted in China, Singapore, France and Australia., Conclusion: There are few studies that analyse the incidence of CVD and even fewer that analyse its evolution. The overall median remains high, although the figures are heterogeneous across studies. Worldwide the trend is towards its decrease, and there are geographical areas, especially in Asia, with an alarming upward trend.

Introduction: The delay in seeking medical care in patients who suffer a cerebrovascular disease (CVD) event depends, largely, on knowledge of the disease. Our aim is to study the evolution of the knowledge of patients admitted to hospital due to an ischaemic stroke., Patients and Methods: A structured interview was used to determine the level of knowledge of CVD (terminology, risk factors, symptoms and attitude) of patients admitted due to an ischaemic stroke without language impairment or cognitive impairment in two distinct time periods: January 2011 and December 2013 (n = 295), and October 2015 and December 2016 (n = 325)., Results: Better knowledge of the disease was observed over time, both in the number of terms recognised - 4.1 (standard deviation: 2) vs. 4.8 (standard deviation: 1.7); p < 0.001 - and in a good knowledge of symptoms (more than three factors and less than two distractors) (56.6 vs. 69.8%; p < 0.001). The proportion of patients who called the emergency services directly was significantly higher (17.3 vs. 24.6%; p = 0.003), as was the recognition of the term 'stroke' (51.9 vs. 74.5%; p < 0.001). There was no difference in the degree of knowledge of risk factors. Improvement in knowledge did not translate into a decrease in the delay between symptom onset and arrival at the hospital., Conclusion: Despite improved knowledge of CVD, further efforts still need to be made to improve attitudes towards CVD and reduce the delay prior to hospital arrival.

Introduction: Hypokalemic periodic paralysis is a neuromuscular disease characterized by a combination of flaccid paralysis episodes (or muscular weakness) that are related to low levels of potassium in blood. As a consequence of its low prevalence, there are still clinical and management aspects to characterize., Patients and Methods: A systematic review of the clinical cases published in the last decade has been developed by analyzing demographic and genetic features, the episodes' characteristics, the received treatments, the response to them and also, the differences and evolution of patients depending on the most prevalent genetic alterations: CACNA1S and SCN4A., Results: A total of 33 articles were included, allowing 40 individuals to be reviewed. The average age of onset of symptoms was 15.3 ± 9.7 years. The most frequent altered gene was CACNA1S in 20 (60.5%) cases. It was observed that subjects presenting an alteration of the gene responsible for the calcium channel, CACNA1S, presented lower serum potassium levels, own triggers and a higher proportion of subjects showing dyspnea during the crisis. Only 50% of the subjects respond to classical oral treatment with acetazolamide. Potassium-sparing diuretics and antiepileptics drugs emerge as an alternative., Conclusion: Hypokalemic periodic paralysis has an heterogeneous clinical expression with phenotypic differences linked to different genetic mutations. The common preventive treatment response is suboptimal. Prospective studies are needed to discern the best therapeutic option based on genetic load.

Introduction: Alarm criteria make it possible to identify persons who visit emergency services because of severe secondary headaches., Aims: To determine the socio-demographic characteristics of the patients who visit emergency departments due to headache, the incidence of alarm criteria, treatment and the diagnosis after one year's follow-up., Patients and Methods: We conducted a retrospective observational cross-sectional study of the persons attended in the emergency department of the Arnau de Vilanova Hospital between June 2014 and May 2015 due to headache., Results: A total of 303 persons were identified, of whom 165 were finally included in the study. There was a predominance of women (66.7%). The mean age was 41.2 ± 15.9 years. Only 16.4% were referred from primary care and 52 (31.5%) presented alarm criteria. A computerised tomography head scan was performed in half of these cases, and lumbar puncture was carried out in four of them (7.7%). A serious cause of headache was found in four cases (2.4%). After one year of follow-up, three patients who did not initially visit because of alarm criteria were diagnosed with severe diseases of the central nervous system, and 23 (13.9%) returned to the emergency department for the same reason., Conclusions: Only one out of every two patients meets the alarm criteria. The proportion of severe secondary headache is really low. The multidisciplinary management of headache needs to be improved in our setting to prevent people visiting the emergency department due to primary headaches without any alarm criteria.

Introduction: The concept of embolic stroke of undetermined source (ESUS) has recently appeared to better characterise patients with cryptogenic stroke., Patients and Methods: A systematic review of studies published since 2014 was performed to evaluate the epidemiology, clinical features and prognosis of patients with ESUS and their proportion among patients with cryptogenic stroke., Results: Ten studies were identified with a total of 14,810 patients. The frequency of ESUS varied between 6% and 42%. We observed a high percentage of patients with cryptogenic stroke who met ESUS criteria (37-82%). The mean age of these patients was 65-68 years. The mean severity of the stroke, as measured using the National Institutes of Health Stroke Scale, was found to be 3-7 points. A high degree of variability was seen in the proportion of atrial fibrillation (detected during follow-up) related to the electrocardiogram monitoring technique. In five studies, some minor source of cardioembolism was observed in one out of every two patients, the most frequent being the persistence of patent foramen ovale. The risk of recurrence was 5-14.5%., Conclusion: The application of the new ESUS criteria provides a better definition of patients with cryptogenic stroke. Applying the concept of ESUS requires not only adequate electrocardiogram monitoring, but also routine complementary examinations to rule out the presence of minor sources of cardioembolism and other sources of embolism other than atrial fibrillation.

Introduction: Brain death is a death situation which is diagnosed by means of neurological criteria and is the ideal situation for organ donation, as, thanks to intensive care, the organs maintain their viability. Very few studies have analysed the knowledge that the population has about this situation., Aim: To determine how much university students know about brain death by comparing the results between undergraduates pursuing a degree in medicine and those on other bachelor's degree courses., Subjects and Methods: A closed on-line survey was administered to undergraduate students at the Universitat de Lleida about their knowledge regarding the concept of brain death, donor legislation and willingness to donate., Results: The survey was answered by a total of 488 people, 192 (39.3%) from the degree in medicine. Only 164 (33.6%) were males. The mean age was 22.1 ± 4.4 years. Only 63 (12.9%) respondents defined brain death as death. While 19.1% replied correctly to the question about organ donation legislation, 79.7% said they would be willing to donate their organs. The level of knowledge was significantly higher in the later courses of the degree in medicine, although there was still plenty of room for improvement in this respect. Only 31.7% of sixth-year students had a good idea of the concept of brain death., Conclusion: The extent of knowledge about brain death and legislation on organ donation is poor among university students, even in the degree in medicine. It would be advisable to design strategies aimed at improving this knowledge, especially among future healthcare professionals.

Introduction: There are discrepancies in the different studies that attempt to correlate the risk factors of developing amyotrophic lateral sclerosis (ALS) and the impact on their prognosis. Some of these factors are intrinsic to the rural livelihood. Therefore, we propose to study if any of these influence the onset and/or prognosis of the disease in the health region of Lleida, a predominantly rural area., Patients and Methods: Variables related to general factors, clinical, environmental and laboratory were collected and analyzed at the time of diagnosis of ALS in 38 patients and were retrospectively related to the onset of the disease and its survival., Results: The family history of ALS (p < 0.02) and elevated CK (p < 0.0001) were associated with increased survival. Smoking (p < 0.04), physical work (p < 0.03), low creatinine (p < 0.03), elevated CK (p = 0.0005) were associated with an early onset of the disease. The bulbar onset form was significantly related to a late onset of the disease (p < 0,01). Total cholesterol and PCR did not influence the onset or course of ALS. There is a non-significant trend at statistical level in favor of moderate physical exercise being associated with a later onset, while intense exercise at an early onset of ALS., Conclusions: The results suggest that there are a number of factors that influence the development and prognosis of ALS, some of which are more prevalent in rural areas, such as physical work.

Introduction: Stroke is a leading cause of disability in adults. The development of depressive symptoms is the most common emotional complication. To date, most studies of post-stroke depression have excluded patients who have suffered a minor stroke or transient ischaemic attack (TIA), although they are equally vulnerable subgroups of this sickness., Aim: We present a review of published studies of post-stroke depression to elucidate aspects that have already been widely demonstrated and those who need more evidence., Development: The post-stroke depression is both frequent in patients with established stroke and minor stroke or TIA. Although there are discrepancies in the definition used, in up to one out of three patients will develop this complication. We have identified risk factors of post-stroke depression with a broad scientific background (female, history of depression or other psychiatric disorders, stroke severity, functional impairment) and other without it (quality of life, cognitive impairment and neuroimaging biomarkers). The main methodological limitations found are: confusion between post-stroke depression and depressive symptoms; variability in rating scales used; and temporal variability in the time of the evaluation of mood. To date very few studies focused on minor stroke or TIA., Conclusions: Further studies are required with improved design in order to help establish the risk of post-stroke depression at different times after the stroke, minor stroke or TIA and the importance of all the factors described above.

The study of biomarkers related with ischaemic stroke is becoming increasingly more important as a way to further our knowledge of the pathophysiological changes that occur in cerebrovascular disease and to make it easier to reach an early diagnosis. Within this field, metabolomics offers a novel approach. The field is defined as the study of the small-molecule metabolites derived from cell metabolism. Its interest lies in the fact that, using a biological sample, it offers a snapshot of the cellular changes that are taking place. Today, the application of metabolomics requires a complex methodology that includes the application of laboratory separation techniques, multivariant statistical analyses and the use of bioinformatic tools. A number of studies conducted within the field of cardiovascular disease have focused on the application of this approach. In recent years there has been a steady growth in the number of publications referring to the metabolic changes related with ischaemic stroke, both in animal models and in patients. Metabolomics makes it possible to obtain the profiles of metabolites that identify patients who have suffered an ischaemic stroke. Furthermore, since studies have been carried out that relate certain metabolites with the most common causations of ischaemic stroke, metabolomics may eventually play a significant role in the study of cryptogenic stroke. The most exhaustive knowledge of the changes in the metabolic pathways involved in cerebrovascular disease could lay the foundations for the development of new neuroprotector strategies.

Patients and Methods: The carotid intima media thickness (IMT) is a new prognostic marker of vascular events. We studied its usefulness in the diagnosis workup of 211 consecutive transient ischemic attack (TIA) patients from the REGITELL registration. GIM was measured according to Mannheim criteria. It was established its relationship to the main prognostic variables described in TIA: ABCD2 scale, symptomatology and etiologic subtypes according to TOAST classification., Results: Men value of carotid IMT was 0.91 ± 0.20 mm. After Bonferroni adjustment, IMT was associated with age of 60 years or older (0.95 ± 0.19 mm; p < 0.001), male sex (0.95 ± 0.20 mm; p = 0.003), ABCD2 scale (p < 0.001), association of risk factors are greater than or equal to 2 (0.94 ± 0.20 mm; p < 0.001), carotid plaque presence (0.98 ± 0.19 mm; p < 0.001), intracranial stenosis (1.09 ± 0.18 mm; p = 0.001), presence of ischemic chronic lesions on head CT (p <0.001) and etiology (p < 0.001). The patients presented with isolated sensory symptoms had significantly lower IMT (0.77 ± 0.18 mm; p = 0.002). Belonging to the third tertile of IMT was only an independent predictor of large-artery atherosclerosis (OR = 3,06; CI 95% = 1.31-7.13; p = 0.01)., Conclusion: Based on our results, IMT determination seems to not improve the diagnostic accuracy of other ultrasonographic characteristics like the presence of plaques or the degree of stenosis.

Aim: The transient ischemic attack (TIA) is a medical emergency because of their high risk of early recurrence. We study the evolution and management of patients with a TIA in our hospital before establishing a process management and treatment of this condition., Patients and Methods: We included 180 consecutive patients with suspected TIA attended in the emergency department of our hospital between January 2006 and March 2007. We collected clinical variables (risk factors, age, clinical symptoms, duration, ABCD2). Cases were reviewed by two neurologists to establish the correlation with the diagnosis. We established the risk of cerebral infarction after one year follow-up., Results: 31% of patients were discharged home. There were differences between the two groups regarding age (82.9 Y 7.5 vs 70.53 Y 10.7 years); ABCD2 scale score (1.5 Y 5.32 vs 4.44 Y 1.37); and atrial fibrillation (27.5% vs 8.6%). There was much greater delay and lack of complementary explorations. During follow-up, 23% of patients not hospitalized had recurrent stroke versus 6.7% of hospitalized patients. Despite the fact that only age more than 80 years was identified as predictor of stroke recurrence (hazard ratio = 8,72; 95% CI = 2.4-31.74; p = 0.001) in regression multivariate model, the Kaplan-Meier model showed a higher risk of stroke recurrence among not admitted patients (p = 0.012)., Conclusion: In our area, the management of TIA patients in the emergency room had high impact on the evolution of these patients. A process management should be performed in order to achieve improvement in clinical praxis.

Introduction: Although stroke continues to be a significant cause of morbidity and mortality, the knowledge of warning signs and risk factors among general population is still insufficient., Aim: To assess the current knowledge of stroke (terminology, signs and symptoms, risk factors and attitude) among rural population of Baix Segria in Lleida in order to the best target and message, prior to educational campaigns., Subjects and Methods: A structured interview using closeended questions was conducted among 153 users of Primary Health Centers., Results: In our cohort, 6.5% ignored the disease, while 48 (31,4%) had good knowledge of risk factors (more than three risk factors) and 62 (40,5%) identified more than three warnings signs correctly. Only 31,1% would correctly act if stroke occurred. Transient ischemic attack was not considered as emergency. Most participants, 78,5%, would contact to primary care. Surprisingly, knowledge of stroke symptoms and risk factors was not associated with an increased chance of calling 061 or going to the hospital. Older respondents were less likely to recognize symptoms and to consider stroke as an emergency, while the university education was associated with good knowledge and actuation., Conclusion: The level of knowledge of established stroke risk factors, warning signs, and treatment in rural population of Lleida is low. Our data suggested not only that a community-based education program to increase public knowledge of stroke among rural population is necessary, but also we need to inform the people stroke is treatable.