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Background: The development of endovascular techniques has put Interventional Neuroradiology (INR) as the first-option treatment in the majority of vascular diseases of the central nervous system. Scientific societies in developed countries have created standard procedures for training and accreditation for a safe practice in these procedures., Discussion: In Spain, we are waiting for the development of the legislation on the accreditation for specialists which will establish the official formative model to achieve an accreditation in INR. Until this moment comes, it is necessary to establish standards that define desirable minimums for the formative period in INR. Radiology specialists as well as neurologists and neurosurgeons will have access to INR accreditation. Specific requirements for the hospitals that wish to offer this technique and training should also be defined., Conclusion: The Spanish Group of Interventional Neuroradiology (GENI), the Spanish Society of Neuroradiology (SENR), the Spanish Group of Cerebrovascular Diseases (GEECV), the Spanish Society of Neurology (SEN) and the Spanish Society of Neurosurgery (SENEC) have approved the content of this document and will create a committee in order to put into practice the accreditation of formative centres and INR specialists., (Copyright © 2016 Sociedad Española de Neurología. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Prionopathy is the cause of 62% of the rapidly progressive dementias (RPD) in which a definitive diagnosis is reached. The variability of symptoms and signs exhibited by the patients, as well as its different presentation, sometimes makes an early diagnosis difficult., Methods: Patients withdiagnosis of definite or probable prionopathy during the period 1999-2012 at our hospital were retrospectively reviewed.The clinical features and the results of the complementary tests (14-3-3 protein, EEG, MRI, FDG-PET, and genetic analysis) were evaluated in order to identify some factors that may enable an earlier diagnosis to be made., Results: A total of 14 patients are described: 6 with definite sporadic Creutzfeldt-Jakob (sCJD) disease, 3 with probable sCJD, 4 with fatal familial insomnia, and 1 with the new variant. The median age at diagnosis was 54 years old. The mean survival was 9.5 months. Mood disorder was the most common feature, followed by instability and cognitive impairment. 14-3-3 protein content in the cerebrospinal fluid was positive in 7 of 11 patients, and the EEG showed typical signs in 2 of 12 patients. Neuroimaging (FDG-PET, MRI) studies suggested the diagnosis in 13 of the 14 patients included., Conclusions: Most patients presenting with RPD suffer from a prion disease. In our series the most useful complementary tests were MRI and FDG-PET, being positive in 13 of the 14 patients studied., (Copyright © 2013 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.)

Introduction: The Spanish Health System's stroke care strategy (EISNS) is a consensus statement that was drawn up by various government bodies and scientific societies with the aim of improving quality throughout the care process and ensuring equality among regions. Our objective is to analyse existing healthcare resources and establish whether they have met EISNS targets., Material and Methods: The survey on available resources was conducted by a committee of neurologists representing each of Spain's regions; the same committee also conducted the survey of 2008. The items included were the number of stroke units (SU), their resources (monitoring, neurologists on call 24h/7d, nurse ratio, protocols), SU bed ratio/100,000 inhabitants, diagnostic resources (cardiac and cerebral arterial ultrasound, advanced neuroimaging), performing iv thrombolysis, neurovascular interventional radiology (neuro VIR), surgery for malignant middle cerebral artery (MCA) infarctions and telemedicine availability., Results: We included data from 136 hospitals and found 45 Stroke Units distributed unequally among regions. The ratio of SU beds to residents ranged from 1/74,000 to 1/1,037,000 inhabitants; only the regions of Cantabria and Navarre met the target. Neurologists performed 3,237 intravenous thrombolysis procedures in 83 hospitals; thrombolysis procedures compared to the total of ischaemic strokes yielded percentages ranging from 0.3 to 33.7%. Hospitals without SUs showed varying levels of available resources. Neuro VIR is performed in every region except La Rioja, and VIR is only available on a 24h/7 d basis in 17 cities. Surgery for malignant MCA infarction is performed in 46 hospitals, and 5 have telemedicine., Conclusion: Stroke care has improved in terms of numbers of participating hospitals, the increased use of intravenous thrombolysis and endovascular procedures, and surgery for malignant MCA infarction. Implementation of SUs and telemedicine remain insufficient. The availability of diagnostic resources is good in most SUs and irregular in other hospitals. Regional governments should strive to ensure better care and territorial equality, which would achieve the EISNS objectives., (Copyright © 2013 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.)

Objective: To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment., Material and Methods: A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed., Results: The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm., Conclusions: SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes., (Copyright © 2012 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.)

Background and Objective: To update the ad hoc Committee of the Cerebrovascular Diseases Study Group of The Spanish Neurological Society guidelines on prevention of ischaemic stroke (IS) and Transient Ischaemic Attack (TIA)., Methods: We reviewed the available evidence on ischaemic stroke and TIA prevention according to aetiological subtype. Levels of evidence and recommendation levels are based on the classification of the Centre for Evidence-Based Medicine., Results: In atherothrombotic IS, antiplatelet therapy and revascularization procedures in selected cases of ipsilateral carotid stenosis (70%-90%) reduce the risk of recurrences. In cardioembolic IS (atrial fibrillation, valvular diseases, prosthetic valves and myocardial infarction with mural thrombus) prevention is based on the use of oral anticoagulants. Preventive therapies for uncommon causes of IS will depend on the aetiology. In the case of cerebral venous thrombosis oral anticoagulation is effective., Conclusions: We conclude with recommendations for clinical practice in prevention of IS according to the aetiological subtype presented by the patient., (Copyright © 2011 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.)

Introduction: Update of Acute Ischaemic Stroke Treatment Guidelines of the Spanish Neurological Society based on a critical review of the literature. Recommendations are made based on levels of evidence from published data and studies., Development: Organized systems of care should be implemented to ensure access to the optimal management of all acute stroke patients in stroke units. Standard of care should include treatment of blood pressure (should only be treated if values are over 185/105 mmHg), treatment of hyperglycaemia over 155 mg/dl, and treatment of body temperature with antipyretic drugs if it rises above 37.5 °C. Neurological and systemic complications must be prevented and promptly treated. Decompressive hemicraniectomy should be considered in cases of malignant cerebral oedema. Intravenous thrombolysis with rtPA should be administered within 4.5 hours from symptom onset, except when there are contraindications. Intra-arterial pharmacological thrombolysis can be considered within 6 hours, and mechanical thrombectomy within 8 hours from onset, for anterior circulation strokes, while a wider window of opportunity up to 12-24 hours is feasible for posterior strokes. There is not enough evidence to recommend routine use of the so called neuroprotective drugs. Anticoagulation should be administered to patients with cerebral vein thrombosis. Rehabilitation should be started as early as possible., Conclusion: Treatment of acute ischaemic stroke includes management of patients in stroke units. Systemic thrombolysis should be considered within 4.5 hours from symptom onset. Intra-arterial approaches with a wider window of opportunity can be an option in certain cases. Protective and restorative therapies are being investigated., (Copyright © 2011 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.)

Introduction: Patients with stroke associated with non-valvular atrial fibrillation (NVAF) are a specific group, and their disease has a considerable social and economic impact. The primary objective of the CONOCES study, the protocol of which is presented here, is to compare the costs of stroke in NVAF patients to those of patients without NVAF in Spanish stroke units from a societal perspective., Materials and Methods: CONOCES is an epidemiological, observational, naturalistic, prospective, multicentre study of the cost of the illness in a sample of patients who have suffered a stroke and were admitted to a Spanish stroke unit. During a 12-month follow-up period, we record sociodemographic and clinical variables, score on the NIH stroke scale, level of disability, degree of functional dependency according to the modified Rankin scale, and use of healthcare resources (hospitalisation at the time of the first episode, readmissions, outpatient rehabilitation, orthotic and/or prosthetic material, medication for secondary prevention, medical check-ups, nursing care and formal social care services). Estimated monthly income, lost work productivity and health-related quality of life measured with the generic EQ-5D questionnaire are also recorded. We also administer a direct interview to the caregiver to determine loss of productivity, informal care, and caregiver burden., Results and Conclusions: The CONOCES study will provide more in-depth information about the economic and clinical impact of stroke according to whether or not it is associated with NVAF., (Copyright © 2012 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.)

Intracerebral haemorrhage accounts for 10%-15% of all strokes; however it has a poor prognosis with higher rates of morbidity and mortality. Neurological deterioration is often observed during the first hours after onset and determines poor prognosis. Intracerebral haemorrhage, therefore, is a neurological emergency which must be diagnosed and treated properly as soon as possible. In this guide we review the diagnostic procedures and factors that influence the prognosis of patients with intracerebral haemorrhage and we establish recommendations for the therapeutic strategy, systematic diagnosis, acute treatment and secondary prevention for this condition., (Copyright © 2011 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.)

Objective: To update the ad hoc Committee of the Cerebrovascular Diseases Study Group of The Spanish Neurological Society guidelines on prevention of ischaemic stroke (IS) and transient ischaemic attack (TIA)., Methods: We reviewed available evidence on risk factors and means of modifying them to prevent ischaemic stroke and TIA. Levels of evidence and recommendation grades are based on the classification of the Centre for Evidence-Based Medicine., Results: This first section summarises the recommendations for action on the following factors: blood pressure, diabetes, lipids, tobacco and alcohol consumption, diet and physical activity, cardio-embolic diseases, asymptomatic carotid stenosis, hormone replacement therapy and contraceptives, hyperhomocysteinemia, prothrombotic states and sleep apnea syndrome., Conclusions: Changes in lifestyle and pharmacological treatment for hypertension, diabetes mellitus and dyslipidemia, according to criteria of primary and secondary prevention, are recommended for preventing ischemic stroke., (© 2011 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.)

Therapy with vitamin K antagonists (VKA) is especially feared because of its variable therapeutic effect. Direct thrombin inhibitors have been demonstrated to be safe and effective in preventing stroke in patients with atrial fibrillation (AF) eligible for inclusion in the RE-LY trial. Dabigatran provides equal or superior efficacy to VKA (110mg BID) and is much safer than VKA, with a similar safety margin (150mg BID). Dabigatran does not lead to liver dysfunction and does not require monitoring. The choice of dose should be based on specific patient characteristics (coronary disease, decreased renal function, age, low body weight, administration of other drugs for AF or P-glycoprotein inhibitors, history of gastrointestinal bleeding). Dabigatran is a viable alternative to VKA that provides many advantages over these drugs and is certainly preferred by most patients due to the problems of VKA follow-up., (Copyright © 2012 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.)

Introduction: The stroke network considers the presence of hospitals with stroke teams (STH), stroke units (SUH) and Comprehensive Stroke Centers (CSC). The aim of the current study is to identify, according to specialized vascular neurologists, the main components needed in different kind of stroke centers., Methods: A survey was carried out between February and March 2008 to know the opinion of 36 vascular neurologists. Questions were about the components needed in each hospital level treating stroke patients., Results: Neurologists considered that STH must have as indispensable requirements the following components: emergency department, laboratory and computerized tomography scan facilities with full time availability (24 hours a day/7 days a week), multidisciplinary team including physiotherapists, action plans and pre-established referral circuits to SUH and CSC. Experts considered indispensable for SUH the aforementioned components and specific beds with multiparametric vitals monitoring, expert vascular neurologists, specialized nursery, neurologist on call, intravenous thrombolysis (full time), intensive care unit (ICU), neurorehabilitation specialists, diagnosis neuroradiologists, social workers, echocardiography, full time available neurosurgery, stroke register and educational programmes for patients and relatives. CSC must have the same components as STH-SUH and neurosurgeons specialized in stroke surgery, vascular surgeons specialized in carotid surgery and doctors specialized in endovascular intervention with full time availability., Conclusions: The results show the components or requirements that are considered necessary by specialized vascular neurologists, evaluated on the basis of different hospital levels treating stroke patients.

Introduction: Paraneoplastic neurological syndromes are important complications of cancer that are usually immune mediated. According to the clinical and immunological features, two groups of disorders can be considered. One group includes disorders mediated by antibodies against cell surface neuronal antigens; these syndromes often respond to treatment and have a favorable outcome. The other group includes disorders associated with antibodies against intracellular antigens; these syndromes are likely mediated by T-cell mechanisms, respond poorly to treatment, and have a less favorable outcome., Methods: Clinical and immunological analysis, and follow-up of four patients with classical paraneoplastic syndromes., Results: Three patients had serum and CSF antibodies to intracellular antigens and one had no detectable antibodies. Despite the severity of the symptoms, prompt detection and treatment of the tumor and immunotherapy modified the course of the disease and resulted in substantial improvement of the quality of life., Conclusions: Prompt diagnosis of the tumor and immunotherapy may positively impact the clinical outcome and improve the quality of life of patients with paraneoplastic syndromes believed to have a poor prognosis.

Introduction: Spontaneous non-aneurysmal subarachnoid hemorrhages generally have a good short and long term outcome, especially those with a perimesencephalic location. Vasospasm is an uncommon complication of this type of subarachnoid hemorrhage, and ischemic cerebral lesions related to vasospasm are even less frequent., Case Report: A 46 year-old man was admitted with a perimesencephalic subarachnoid hemorrhage. Angiographic study performed on admission was normal. Two weeks later he developed dysarthria and right faciobrachial paresis. Transcranial doppler showed a diffuse and moderate increase of medium velocity flow at basilar artery level suggestive of moderate vasospasm. An angioresonance confirmed this finding and a paramedian pontine infarction was found on resonance images. The patient was treated with nimodipine and he was discharged from hospital with only mild residual deficit., Conclusion: Cerebral infarction related to vasospasm as complication of subarachnoid perimesencephalic hemorrhage is exceptional. The factors that could have been involved in the development of this complication are discussed.

Introduction: The appearance of movement disorders in vascular disease of the brainstem has hardly been described in the literature. Its frequency is probably underestimated due to their briefness and that they are often misinterpreted as epileptic seizures. Their pathophysiological mechanism is uncertain. Several mechanisms, such as the existence of a seizure-generating brainstem center, capable of generating epileptic activity or the interruption of the corticospinal tracts due to ischemia, have been proposed., Clinical Cases: We present three patients with disease of the basilar artery and extensive brainstem infarction who have the presentation of sudden, involuntary movements in limbs in the initial phase, in paroxysms of short duration and of varied semiology in common. We described this in all of them. An electroencephalographic functional study during these episodes was done in one of the cases., Conclusions: Preservation of conscious level, its variability of presentation, the null response to antiepileptic drugs and normality of the electroencephalogram in one of them leads us to ratify the hypothesis of failure of the cortical inhibitory projections as subcortical centers in trunk or spinal cord as pathophysiological origin of these involuntary movements. We stress the importance of recognizing these clinical manifestations of appearance in the initial phases of the disease, that permit a rapid diagnosis with the help of the transcranial Doppler to establish an early and aggressive treatment of this disease having known seriousness and bad prognosis. Further prospective studies would be interesting to know what the real incidence of these movements is, and functional ones to clarify the pathophysiological nature of this phenomenon.

Introduction: 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., Objective: To create an organized healthcare system able to offer the needed care for each patient, optimizing the use of the existing resource., Methods: A committee of 14 neurologists specialized in neurovascular diseases representing different regions of Spain evaluated the available scientific evidence according to the published literature., Results: 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.

We report on the case of a 69-year-old man admitted with a transient ischemic attack preceded by a two months history of severe headache. Giant cell arteritis was diagnosed by means of temporal artery biopsy. Angiography showed an intra- and extracranial stenosis of the left internal carotid artery. The possible relationship between this stenosis and vasculitis is discussed and stroke as a clinical manifestation of the giant cell arteritis is reviewed.

In the present study 84 patients with the diagnosis of multiple sclerosis were identified as living in Navarra on the date of prevalence (December 31, 1986). The raw yearly incidence rate was 0.49/100000, which is similar to that in Mediterranean countries. A significant increase of this rate was found between 1951 and 1986, which was interpreted as a consequence of higher economic status and/or progressive industrialization. The raw prevalence rate was 16.4/100000 and age-specific prevalence was 26.5. Therefore, Navarra is a medium risk area for MS. Mean age at onset was 29.3 years, with a significant female predominance. In addition, MS presented earlier in females. The relationship between MS and latitude of the residence area was confirmed. The most common presenting symptoms were motor (paresia) and sensory (paresthesia). Cerebrospinal fluid was abnormal in 86.5% of patients, evoked potentials (mostly visual) in 85.9%, and magnetic resonance in 100%. Demyelinizing signs were detected with CT in 29.4% of patients. The diagnostic criteria of the Boston University Workshop were highly reliable. The most common evolutive pattern was the pure remitting one. The mean degree of disability was 3.6 in Kurtzke's scale. The evolutive form and the duration of the disease were identified as predictive of disability. 43.5% of benign forms and 13.1% of late onset forms were identified.