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Objective: To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment. Materials 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. Resumen: Objetivo: Actualización de la guía para el diagnóstico y tratamiento de la hemorragia subaracnoidea de la Sociedad Española de Neurología. Material y métodos: Revisión y análisis de la bibliografía existente. Se establecen recomendaciones en función del nivel de evidencia que ofrecen los estudios revisados. Resultados: La causa más frecuente de hemorragia subaracnoidea espontánea (HSA) es la rotura de un aneurisma cerebral. Su incidencia se sitúa en torno 9 casos por 100.000 habitantes/año y supone un 5% de todos los ictus. La hipertensión arterial y el tabaquismo son sus principales factores de riesgo. Se ha de realizar el tratamiento en centros especializados. Se debe considerar el ingreso en unidades de ictus de aquellos pacientes con HSA y buena situación clínica inicial (grados I y II en la escala de Hunt y Hess). Se recomienda la exclusión precoz de la circulación del aneurisma. El estudio diagnóstico de elección es la tomografía computarizada (TC) craneal sin contraste. Si esta es negativa y persiste la sospecha clínica se aconseja realizar una punción lumbar. Los estudios de elección para identificar la fuente de sangrado son la resonancia magnética (RM) y la angiografía. Los estudios ultrasonográficos son útiles para el diagnóstico y seguimiento del vasoespasmo. Se recomienda el nimodipino para la prevención de la isquemia cerebral diferida. La terapia hipertensiva y el intervencionismo neurovascular pueden plantearse para tratar el vasoespasmo establecido. Conclusiones: La HSA es una enfermedad grave y compleja que debe ser atendida en centros especializados, con suficiente experiencia para abordar el proceso diagnóstico y terapéutico. Keywords: Subarachnoid haemorrhage, Cerebral aneurysm, Diagnosis, Vasospasm, Delayed cerebral ischaemia, Rebleeding, Medical treatment, Palabras clave: Hemorragia subaracnoidea, Aneurisma cerebral, Diagnóstico, Vasoespasmo, Isquemia cerebral diferida, Resangrado, Tratamiento médico

Resumen: Objetivo: Actualización de la guía para el diagnóstico y tratamiento de la hemorragia subaracnoidea de la Sociedad Española de Neurología. Material y métodos: Revisión y análisis de la bibliografía existente. Se establecen recomendaciones en función del nivel de evidencia que ofrecen los estudios revisados. Resultados: La causa más frecuente de hemorragia subaracnoidea espontánea (HSA) es la rotura de un aneurisma cerebral. Su incidencia se sitúa en torno 9 casos por 100.000 habitantes/año y supone un 5% de todos los ictus. La hipertensión arterial y el tabaquismo son sus principales factores de riesgo. Se ha de realizar el tratamiento en centros especializados. Se debe considerar el ingreso en unidades de ictus de aquellos pacientes con HSA y buena situación clínica inicial (grados I y II en la escala de Hunt y Hess). Se recomienda la exclusión precoz de la circulación del aneurisma. El estudio diagnóstico de elección es la tomografía computarizada (TC) craneal sin contraste. Si esta es negativa y persiste la sospecha clínica se aconseja realizar una punción lumbar. Los estudios de elección para identificar la fuente de sangrado son la resonancia magnética (RM) y la angiografía. Los estudios ultrasonográficos son útiles para el diagnóstico y seguimiento del vasoespasmo. Se recomienda el nimodipino para la prevención de la isquemia cerebral diferida. La terapia hipertensiva y el intervencionismo neurovascular pueden plantearse para tratar el vasoespasmo establecido. Conclusiones: La HSA es una enfermedad grave y compleja que debe ser atendida en centros especializados, con suficiente experiencia para abordar el proceso diagnóstico y terapéutico. Abstract: 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. Palabras clave: Hemorragia subaracnoidea, Aneurisma cerebral, Diagnóstico, Vasoespasmo, Isquemia cerebral diferida, Resangrado, Tratamiento médico, Keywords: Subarachnoid haemorrhage, Cerebral aneurysm, Diagnosis, Vasospasm, Delayed cerebral ischaemia, Rebleeding, Medical treatment

Resumen: Fundamento y objetivo: Actualizar las guías terapéuticas del Comité ad hoc del Grupo de Estudio de Enfermedades Cerebrovasculares de la SEN en el tratamiento preventivo de ictus isquémico (II) y ataque isquémico transitorio (AIT). Métodos: Revisión de evidencias disponibles sobre la prevención del ictus isquémico y AIT en función del subtipo etiológico. Los niveles de evidencia y grados de recomendación se han basado en la clasificación del Centro de Medicina Basada en la Evidencia. Resultados: En el II de origen aterotrombótico reducen el riesgo de recurrencias el tratamiento antiagregante y los procedimientos revascularizadores en casos seleccionados de estenosis carotidea ipsilateral (70-99%). La prevención de II de origen cardioembólico (fibrilación auricular, valvulopatías, prótesis valvulares y en infarto de miocardio con trombo mural) se basa en el uso de anticoagulantes orales. En el II de origen inhabitual, las terapias preventivas dependerán de la etiología; en la trombosis venosa cerebral la anticoagulación oral es eficaz. Conclusiones: Se concluye con recomendaciones de práctica clínica en prevención de ictus isquémico y AIT adaptadas al subtipo etiológico de II que ha presentado el paciente. Abstract: 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. Palabras clave: Guía de práctica clínica, Ictus isquémico, Ataque isquémico transitorio, Prevención, Keywords: Guidelines, Ischaemic stroke, Transient ischemic attack, Prevention

Background and objective: To update the ad hoc Committee of the Cerebrovascular Diseases Study Group of The Spanish Neurological Society guidelines on prevention of ischemic 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 (70–99%) 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. Resumen: Fundamento y objetivo: Actualizar las guías terapéuticas del Comité ad hoc del Grupo de Estudio de Enfermedades Cerebrovasculares de la SEN en el tratamiento preventivo de ictus isquémico (II) y ataque isquémico transitorio (AIT). Métodos: Revisión de evidencias disponibles sobre la prevención del ictus isquémico y AIT en función del subtipo etiológico. Los niveles de evidencia y grados de recomendación se han basado en la clasificación del Centro de Medicina Basada en la Evidencia. Resultados: En el II de origen aterotrombótico reducen el riesgo de recurrencias el tratamiento antiagregante y los procedimientos revascularizadores en casos seleccionados de estenosis carotidea ipsilateral (70-99%). La prevención de II de origen cardioembólico (fibrilación auricular, valulopatías, prótesis valvulares y en infarto de miocardio con trombo mural) se basa en el uso de anticoagulantes orales. En el II de origen inhabitual, las terapias preventivas dependerán dela etiología; en la trombosis venosa cerebral la anticoagulación oral es eficaz. Conclusiones: Se concluye con recomendaciones de práctica clínica en prevención de ictus isquémico y AIT adaptadas al subtipo etiológico de II que ha presentado el paciente. Keywords: Guidelines, Ischaemic stroke, Transient ischemic attack, Prevention, Palabras clave: Guía de práctica clínica, Ictus isquémico, Ataque isquémico transitorio, Prevención

Resumen: Introducción: Actualización de la guía para el tratamiento del infarto cerebral agudo de la Sociedad Española de Neurología basada en la revisión y análisis de la bibliografía existente sobre el tema. Se establecen recomendaciones en base al nivel de evidencia que ofrecen los estudios revisados. Desarrollo: Los sistemas de asistencia urgente extrahospitalaria se organizarán para asegurar la atención especializada de los pacientes y el ingreso en unidades de ictus (UI). Deben aplicarse cuidados generales para mantener la homeostasis (tratar la tensión arterial sistólica > 185 mmHg o diastólica > 105 mmHg, evitar hiperglucemia > 155 mg/dl y controlar la temperatura, tratando con antitérmicos cifras > 37,5 °C), y prevenir y tratar las complicaciones. La craniectomía descompresiva debe ser considerada en casos seleccionados de edema cerebral maligno. La trombólisis intravenosa con rtPA se administrará en las primeras 4,5 horas en pacientes sin contraindicación. La trombólisis intraarterial farmacológica puede indicarse en las primeras 6 horas de evolución y la trombectomía mecánica hasta las 8 horas. En el territorio posterior la ventana puede ampliarse hasta 12-24 horas. No hay evidencias para recomendar el uso rutinario de los fármacos denominados neuroprotectores. Se recomienda la anticoagulación en pacientes con trombosis de senos venosos. Se aconseja el inicio precoz de rehabilitación. Conclusiones: El tratamiento del infarto cerebral se basa en la atención especializada en UI, la aplicación urgente de cuidados generales y el tratamiento trombolítico intravenoso en las primeras 4,5 horas. La recanalización intraarterial farmacológica o mecánica pueden ser útiles en casos seleccionados. Terapias de protección y reparación cerebral están en desarrollo. Abstract: 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 Palabras clave: Infarto cerebral, Ictus isquémico, Trombólisis, Cerebroprotección, Unidades de ictus, Trombosis venosa cerebral, Keywords: Cerebral infarct, Ischaemic stroke, Thrombolysis, Brain protection, Stroke units, Cerebral venous thrombosis

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: Organised 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. Resumen: Introducción: Actualización de la guía para el tratamiento del infarto cerebral agudo de la Sociedad Española de Neurología basada en la revisión y análisis de la bibliografía existente sobre el tema. Se establecen recomendaciones en base al nivel de evidencia que ofrecen los estudios revisados. Desarrollo: Los sistemas de asistencia urgente extrahospitalaria se organizarán para asegurar la atención especializada de los pacientes y el ingreso en unidades de ictus (UI). Deben aplicarse cuidados generales para mantener la homeostasis (tratar la tensión arterial sistólica > 185 mmHg o diastólica > 105 mmHg, evitar hiperglucemia > 155 mg/dl y controlar la temperatura, tratando con antitérmicos cifras > 37,5 °C), y prevenir y tratar las complicaciones. La craniectomía descompresiva debe ser considerada en casos seleccionados de oedema cerebral maligno. La trombólisis intravenosa con rtPA se administrará en las primeras 4,5 horas en pacientes sin contraindicación. La trombólisis intraarterial farmacológica puede indicarse en las primeras 6 horas de evolución y la trombectomía mecánica hasta las 8 horas. En el territorio posterior la ventana puede ampliarse hasta 12–24 horas. No hay evidencias para recomendar el uso rutinario de los fármacos denominados neuroprotectores. Se recomienda la anticoagulación en pacientes con trombosis de senos venosos. Se aconseja el inicio precoz de rehabilitación. Conclusiones: El tratamiento del infarto cerebral se basa en la atención especializada en UI, la aplicación urgente de cuidados generales y el tratamiento trombolítico intravenoso en las primeras 4,5 horas. La recanalización intraarterial farmacológica o mecánica pueden ser útiles en casos seleccionados. Terapias de protección y reparación cerebral están en desarrollo. Keywords: Cerebral infarct, Ischaemic stroke, Thrombolysis, Brain protection, Stroke units, Cerebral venous thrombosis, Palabras clave: Infarto cerebral, Ictus isquémico, Trombólisis, Cerebroprotección, Unidades de ictus, Trombosis venosa cerebral

Intracerebral haemorrhage accounts for 10% to 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 from onset, and determines the 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. Resumen: La hemorragia intracerebral sólo representa entre el 10 y el 15% de todos los ictus, sin embargo condiciona un peor pronóstico, con unas tasas más elevadas de morbilidad y mortalidad. Es frecuente que durante las primeras horas tras el inicio de los síntomas se produzca un empeoramiento clínico, lo cual condiciona un peor pronóstico, por lo que la hemorragia intracerebral constituye una emergencia neurológica en la que debe realizarse un diagnóstico y tratamiento adecuado de manera precoz. En esta guía realizamos una revisión de los procedimientos diagnósticos y los factores que influyen en el pronóstico de los pacientes con hemorragia intracerebral y establecemos unas recomendaciones para la estrategia asistencial, sistemática diagnóstica, tratamiento en fase aguda y prevención secundaria en la hemorragia intracerebral. Keywords: Intracerebral haemorrhage, Guidelines, Stroke, Palabras clave: Hemorragia intracerebral, Guías, Ictus

Resumen: La hemorragia intracerebral sólo representa entre el 10 y el 15% de todos los ictus, sin embargo condiciona un peor pronóstico, con unas tasas más elevadas de morbilidad y mortalidad. Es frecuente que durante las primeras horas tras el inicio de los síntomas se produzca un empeoramiento clínico, lo cual condiciona un peor pronóstico, por lo que la hemorragia intracerebral constituye una emergencia neurológica en la que debe realizarse un diagnóstico y tratamiento adecuado de manera precoz. En esta guía realizamos una revisión de los procedimientos diagnósticos y los factores que influyen en el pronóstico de los pacientes con hemorragia intracerebral y establecemos unas recomendaciones para la estrategia asistencial, sistemática diagnóstica, tratamiento en fase aguda y prevención secundaria en la hemorragia intracerebral. Abstract: Intracerebral haemorrhage accounts for 10%-15% of all strokes; however it has a poor prognisis 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. Palabras clave: Hemorragia intracerebral, Guías, Ictus, Keywords: Intracerebral haemorrhage, Guidelines, Stroke

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 IS 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 (HRT) 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 IS. Resumen: Objetivo: Actualizar las guías terapéuticas del Comité ad hoc del Grupo de Estudio de Enfermedades Cerebrovasculares de la SEN en el tratamiento preventivo de ictus isquémico (II) y ataque isquémico transitorio (AIT). Métodos: Revisión de evidencias disponibles sobre los factores de riesgo y la oportunidad de su modificación para prevenir el ictus isquémico y AIT. Los niveles de evidencia y grados de recomendación se han basado en la clasificación del Centro de Medicina Basada en la Evidencia. Resultados: En esta primera parte se resumen las recomendaciones sobre la actuación sobre los siguientes factores: presión arterial, DM, lípidos plasmáticos, consumo de tabaco y alcohol, dieta y actividad física, cardiopatías embolígenas, estenosis carotídea asintomática, terapia hormonal sustitutiva y anticonceptivos, hiperhomocisteinemía, estados protrombóticos y síndrome de apnea del sueño. Conclusiones: La modificación de los estilos de vida y el tratamiento farmacológico de la hipertensión arterial, diabetes méllitus y dislipemia según criterios de prevención primaria y secundaria se recomiendan en la prevención de ictus isquémico. Keywords: Guidelines, Ischaemic stroke, Transient ischaemic attack, Prevention, Palabras clave: Guías de práctica clínica, Prevención de ictus, Ictus, Ataque isquémico transitorio

Resumen: Objetivo: Actualizar las guías terapéuticas del Comité ad hoc del Grupo de Estudio de Enfermedades Cerebrovasculares de la SEN en el tratamiento preventivo de ictus isquémico (II) y ataque isquémico transitorio (AIT). Métodos: Revisión de evidencias disponibles sobre los factores de riesgo y la oportunidad de su modificación para prevenir el ictus isquémico y AIT. Los niveles de evidencia y grados de recomendación se han basado en la clasificación del Centro de Medicina Basada en la Evidencia. Resultados: En esta primera parte se resumen las recomendaciones sobre la actuación sobre los siguientes factores: presión arterial, DM, lípidos plasmáticos, consumo de tabaco y alcohol, dieta y actividad física, cardiopatías embolígenas, estenosis carotídea asintomática, terapia hormonal sustitutiva y anticonceptivos, hiperhomocisteinemía, estados protrombóticos y síndrome de apnea del sueño. Conclusiones: La modificación de los estilos de vida y el tratamiento farmacológico de la hipertensión arterial, diabetes méllitus y dislipemia según criterios de prevención primaria y secundaria se recomiendan en la prevención de ictus isquémico. Abstract: 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. Palabras clave: Guías de práctica clínica, Prevención de ictus, Ictus, Ataque isquémico transitorio, Keywords: Guidelines, Ischaemic stroke, Transient ischemic attack, Prevention

Objective: To describe persistent pulmonary abnormalities detected on HRCT after 18 months of SARS-CoV-2 pneumonia, and to determine their extension and correlation with pulmonary function., Patients and Methods: A prospective cross-sectional study with an initial cohort of 90 patients in follow-up due to persisting lung abnormalities on imaging, functional respiratory impairment and/or respiratory symptoms. Of these, 31 (34%) were selected for analysis due to the persistence of their lung abnormalities on HRCT at 18 months after infection. A double reading was performed for each HRCT (62 observations)., Results: Of the 31 patients included: 20 (65%) were men; mean age was 67 years; 17 (55%) were smokers/ex-smokers. The mean hospitalisation time was 38 days. Eighteen (58%) patients were admitted to intensive care units. Five patients (16%) suffered an acute pulmonary thromboembolism and three (9.7%) had a pneumothorax. The mean time between the onset of pneumonia and the follow-up HRCT was 20.34 months. Nineteen percent of patients suffered from total lung function abnormalities; and ground-glass opacities and reticulation were present in 12% and 4.5% respectively. The findings of the 62 readings were: ground-glass opacities (100%), reticulation (83%), subpleural curvilinear lines (62%), parenchymal bands (34%), traction bronchiectasis (69%), displacement of vessels/fissures (46%) and honeycombing (4.9%). Pulmonary function 18 months after the acute episode revealed a mean FVC of 92% of predicted value, with an FVC < 80% of predicted value in 11 patients (35.4%). Mean DLCO was 71% of predicted value, with a DLCO < 80% in 22 patients (70%). We observed a statistically significant relationship between total lung function abnormalities on HRCT and FVC (P < 0.05), and a trend towards statistical significance with DLCO (P = 0.051); there was a statistically significant relationship between the presence of ground-glass opacities and FEV1/FVC (P < 0.01). The relationships between reticulation and FVC, FVC%, FEV1, FEV1% and DLCO% were also considered statistically significant (P < 0.05)., Conclusion: Persistent interstitial lung abnormalities are seen on HRCT for a subset of patients infected with SARS-CoV-2 pneumonia. Seventy percent of these patients suffered a slight decrease in DLCO., (Copyright © 2024. Published by Elsevier España, S.L.U.)

Introduction: In order to deal with the current pandemic caused by the novel SARS-CoV-2 coronavirus several serological immunoassays have been recently developed with the objective of being used as a complementary diagnostic tool and to support the RT-PCR technique currently considered the "gold-standard" method. However, these new assays need to be evaluated and validated. The purpose of this study was to assess the performance of five immunoassays (two ELISA and three CLIA assays) and one rapid immunochromatographic test for the detection of anti-SARS-CoV-2 antibodies., Methods: Five semiquantitative immunoassays (MENARINI®, PALEX®, VIRCLIA®, ROCHE® and SIEMENS®) and one lateral flow rapid test (WONDFO®) were performed. A total of 124 samples were studied. Case serum samples (n=78) were obtained from COVID-19 patients confirmed by real-time RT-PCR/epidemiological-clinical-radiological criteria, and control non-SARS-CoV-2 samples (n=46) belonged to healthy healthcare workers involved in a seroprevalence study., Results: Overall, the tests showed sensitivities around 70-90% and specificities greater than 95%, including the immunochromatographic test. In addition, we observed very good agreements among them, being better for the detection of IgG than for IgM antibodies (Cohen's kappa index of 0.95 for VIRCLIA® IgG with ROCHE®), as well as good diagnostic power of the tests as determined by the ROC curves., Conclusions: This study demonstrates the proper performance of the different immunoassays in order to be applied in the clinical practice as support in the diagnostic approach and in the development of vaccines and seroepidemiological studies of COVID-19., (Copyright © 2021 Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. Published by Elsevier España, S.L.U. All rights reserved.)

Objective: To analyze the assessment of the care of children with medical complexity (CMC) in Primary Care (PC), from the point of view of their doctors and their families., Design: Observational, descriptive and transversal study. SITE: PC Pediatrics and Complex Chronic Pathology Unit (UPCC) of Hospital Universitario La Paz (HULP)., Participants: Patients and relatives of the UPCC and their PC physicians of the Community of Madrid (CAM)., Interventions: Face-to-face and online validated surveys were conducted., Main Measurements: Degree of satisfaction in the training, education and specific management of the CMC according to Likert-type scales., Results: Fifty-three families and 170 PC physicians (96.5% pediatricians) were surveyed. The results of the family survey reveal lack of coordination between levels of care (73.6%), little confidence in the first level of care, and an impression of poor problem-solving capacity by PC pediatricians (50%). Among PC physicians, there is little training in the follow-up of CMC (96.5%), little experience in their management (93%) and insufficient communication with the hospital (80.5%). Lack of time in consultations is a common problem, perceived by pediatricians and patients., Conclusions: The lack of coordination between PC and Hospital Care is detected as an important problem in the continuity of care at CMC. Interventions are needed to improve this coordination. The PC is close to the family but needs to improve the education and training of professionals in health problems and technical support from CMC, as well as increase the time necessary for their care., (Copyright © 2021 The Authors. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: In order to deal with the current pandemic caused by the novel SARS-CoV-2 coronavirus several serological immunoassays have been recently developed with the objective of being used as a complementary diagnostic tool and to support the RT-PCR technique currently considered the "gold-standard" method. However, these new assays need to be evaluated and validated. The purpose of this study was to assess the performance of five immunoassays (two ELISA and three CLIA assays) and one rapid immunochromatographic test for the detection of anti-SARS-CoV-2 antibodies., Methods: Five semiquantitative immunoassays (MENARINI®, PALEX®, VIRCLIA®, ROCHE® and SIEMENS®) and one lateral flow rapid test (WONDFO®) were performed. A total of 124 samples were studied. Case serum samples (n=78) were obtained from COVID-19 patients confirmed by real-time RT-PCR/epidemiological-clinical-radiological criteria, and control non-SARS-CoV-2 samples (n=46) belonged to healthy healthcare workers involved in a seroprevalence study., Results: Overall, the tests showed sensitivities around 70-90% and specificities greater than 95%, including the immunochromatographic test. In addition, we observed very good agreements among them, being better for the detection of IgG than for IgM antibodies (Cohen's kappa index of 0.95 for VIRCLIA® IgG with ROCHE®), as well as good diagnostic power of the tests as determined by the ROC curves., Conclusions: This study demonstrates the proper performance of the different immunoassays in order to be applied in the clinical practice as support in the diagnostic approach and in the development of vaccines and seroepidemiological studies of COVID-19., (Copyright © 2021 Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. Publicado por Elsevier España, S.L.U. All rights reserved.)

Percutaneous endoscopic gastrostomy (PEG) is an effective and safe method for nutritional support in patients with malnutrition and impossibility of oral intake with an estimated survival higher than the months that require enteral nutrition beyond four weeks. The main indications include neoplasms of the upper air-digestive tract and neurological diseases, with dementia currently considered a controversial indication. Anatomical alterations and infectious diseases are the most frequent contraindications. There are different endoscopic techniques; the most widely used being the "pull" method, with a low mortality. Complications are more frequent in patients with multiple pathologies and the elderly. Wound infection, extraction of the tube, tube blockage and bronchoaspiratory pneumonia are the most prevalent complications. Adequate prior preparation of the patient and exhaustive maintenance of the tube can reduce the appearance of these., (Copyright © 2018 Elsevier España, S.L.U. All rights reserved.)

Despite its clinical relevance and its importance as a public health problem, there are major gaps in the management of depression. Evidence-based clinical guidelines are useful to improve processes and clinical outcomes. In order to make their implementation easier these guidelines have been transformed into computerised clinical decision support systems. In this article, a description is presented on the basics and characteristics of a new computerised clinical guideline for the management of major depression, developed in the public health system in Catalonia. This tool helps the clinician to establish reliable and accurate diagnoses of depression, to choose the best treatment a priori according to the disease and the patient characteristics. It also emphasises the importance of systematic monitoring to assess the clinical course, and to adjust therapeutic interventions to the patient's needs at all times., (Copyright © 2016 Elsevier España, S.L.U. All rights reserved.)

Introduction: It is important to make distinction between bipolar and unipolar depression because treatment and prognosis are different. Since the diagnosis of the two conditions is purely clinical, find symptomatic differences is useful., Objectives: Find differences in subjective experience (first person) between unipolar and bipolar depression., Methods: Phenomenological-oriented qualitative exploratory study of 12 patients (7 with bipolar depression and 5 with unipolar depression, 3 men and 9 women). We used a semi-structured interview based on Examination of Anomalous Self-Experience (EASE)., Results: The predominant mood in bipolar depression is emotional dampening, in unipolar is sadness. The bodily experience in bipolar is of a heavy, tired body; an element that inserts between the desires of acting and performing actions and becomes an obstacle to the movement. In unipolar is of a body that feels more comfortable with the stillness than activity, like laziness of everyday life. Cognition and the stream of consciousness: in bipolar depression, compared with unipolar, thinking is slower, as if to overcome obstacles in their course. There are more difficult to understand what is heard or read. Future perspective: in bipolar depression, hopelessness is stronger and broader than in unipolar, as if the very possibility of hope was lost., Conclusions: Qualitative differences in predominant mood, bodily experience, cognition and future perspective were found between bipolar and unipolar depression., (Copyright © 2015 Asociación Colombiana de Psiquiatría. Publicado por Elsevier España. All rights reserved.)

Mental health disorders are health problems with a high health, social and economic impact and with relevant effects on the quality of life of both the patients and their families. The objective of this article is to measure the prevalence of mental disorders in Catalonia and to analyze changes the changes in the results obtained in the Goldberg General Health Questionnaire in the Catalan Health Survey editions developed in 1994 and 2006. The prevalence of population at risk of suffering of a mental health disorder does not differ in both years (12.6% in 1994 and 11.6% in 2006). Women showed a higher risk than men in both surveys. Paradoxically, it is amongst the people without risk where the highest number of cases of depression, anxiety, antidepressant use, psychiatry visits or bad perception of health was declared. The results agreed with the risk and prevention paradox and are relevant at the time of designing strategies for mental health disorders prevention., (Copyright © 2011 Elsevier España S.L. All rights reserved.)

Introduction and Objectives: Patent foramen ovale (PFO) is the most common cause of cryptogenic stroke in patients younger than 55. Transesophageal echocardiography (TEE) has been accepted as the reference diagnostic technique. The purpose of this study was to compare the accuracy of transthoracic echocardiography (TTE), TEE and transcranial Doppler (TCD) in the diagnosis and quantification of patent foramen ovale., Methods: We studied 134 patients prospectively. Simultaneous TTE with TCD and TEE with TCD were performed, using agitated saline solution to detect right to left shunt., Results: In 93 patients diagnosed with PFO, the shunt was visualized at baseline by TCD in 69% of cases, by TTE in 74% and by TEE in 58%. The Valsalva maneuver produced a similar improvement in shunt diagnosis with all 3 techniques (26%-28%). TTE and TCD showed higher sensitivity (100% vs 97%; non significant difference) than TEE in the diagnosis of PFO (86%; P<.001). TCD performed during TEE did not diagnose 12 (13%) shunts previously diagnosed during TTE. Similarly, TEE underestimated shunt severity., Conclusions: TTE enables adequate diagnosis and quantification of PFO. TEE is less sensitive and tends to underestimate the severity of the shunt., (Copyright © 2010 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)

Introduction: Well-being and its association with distinct factors have played a central role in the arena of psychogerontology research. Given the importance of this topic, the present study examined several factors that could influence well-being among the elderly of two countries., Material and Methods: This cross-cultural study was based on a survey of two samples of elderly people, one from the Dominican Republic (N=1,296) and another from Spain (N=476), sampled, respectively, by stratification and quota sampling. Analyses included descriptive statistics, correlations and a multivariate analysis of covariance., Results: Overall, sociodemographic factors were found to affect well-being both in the univariate and multivariate analyses. Nevertheless, the effect sizes were, in general, rather low. These effects were basically due to main effects rather than interactions. Age was negatively related to well-being. Marriage was associated with the highest levels of some well-being dimensions. The highest educational levels were also associated with higher levels of some well-being dimensions. The largest effect was due to country, with Dominicans scoring lower on all well-being dimensions, even after statistically controlling for other factors., Conclusions: A main conclusion of this study was that sociodemographic factors did not differentially affect the two countries, given the rather low interaction effects. However, systematic effects were found for sociodemographic factors, independently of country. These effects were analyzed in light of the distinction between subjective and psychological well-being, and the data failed to support the idea of a different profile of results on these two types of well-being dimensions. Finally, given the large effect of country on all well-being dimensions, the relative importance of several sociopolitical and cultural factors was analyzed.

Background: Respiratory syncytial virus and Influenza virus infections are known causes of hospital admission in infants. It is less well known the pattern of virus infections in infants under 6 months of age in the outpatient setting., Objective: To describe the clinical and epidemiological pattern of community-acquired viral respiratory infections in infants under 6 months., Patients and Methods: A cohort of infants from the 8 and 9 Madrid Health Districts was followed by telephone calls every two weeks since birth during the epidemic winter season. Clinical and epidemiological data were collected in pre-designed questionnaires. Nasopharyngeal aspirate was obtained in every patient with symptoms compatible with respiratory infection. Diagnosis of the more common virus was made with direct immunofluorescence and nucleic acid amplification test (PCR)., Results: Were recruited 316 newborns. The 1,865 phone calls made (median 4 for every child), produced 106 visits, and the illness confirmed in 89 illness. Rhinitis (91%) and cough (69%) were the most common symptoms. Upper respiratory infection was the principal clinical diagnosis (84.5%), and 17 of the 72 samples (23.2%) were positive. Most common viruses were RSV (41.1%) and rhinovirus (35.2%). Of the children visited, 17 out of 106 (16%) (5.3% of the cohort) were admitted to hospital. Diagnoses were febrile syndrome and bronchiolitis. We did not find any epidemiological factor associated with viral respiratory infection in positive cases., Conclusions: In our population most of the respiratory infections in infants are minor and do not need hospital assistance. Rhinovirus and RSV are the major pathogens. We did not find any epidemiological factor associated with viral respiratory infection.

Acute lobar nephronia is a focal form of acute bacterial renal infection. The prevalence of this disease is low. We report four cases of acute lobar nephronia. Three patients were diagnosed among 77 patients admitted to hospital for acute pyelonephritis. The fourth case was atypical and associated with epidermolysis bullosa. All cases were diagnosed by renal ultrasonography and the diagnosis was confirmed by computed tomographic examination in two patients with poor clinical course. A small abscess was detected in one patient. Urine cultures were positive in three of the four patients. Acute lobar nephronia is a radiological diagnosis and requires aggressive treatment and strict follow-up due to the risk of renal abscesses. Because the clinical manifestations are insidious and laboratory findings can be contradictory, this entity should be suspected in patients with poor clinical course or alterations on renal ultrasonography. Medical treatment is usually sufficient and prognosis is generally good.

Objectives: The main objective is to assess the effect of a respiratory rehabilitation programme on the quality of life of patients with COPD. Secondary aims are to determine whether the intervention, as against the habitual monitoring, improves tolerance to exercise and pulmonary function, and reduces dyspnoea, the number of crises and hospital admissions due to COPD and the medication used to control the disease., Design: Pragmatic cluster-randomised clinical trial., Setting: Clinics of 16 PC teams in various health areas of the Community of Madrid., Participants: 476 patients with light-moderate COPD, who sign their informed consent., Variables: Quality of life, number of crises, packages of medicines used to control the disease, unscheduled attendance, pulmonary function, dyspnoea and tolerance to exercise., Method: The consultations will be assigned to the control and intervention groups at random. At each clinic there will be a randomised selection from all patients with COPD and in a stable clinical condition. 238 patients are needed in each group, in order to detect a minimum difference of 4 points in quality of life, assuming a standard deviation of 16, 95% confidence level, 80% power and 20% losses. The effect between each factor and the variables evaluated through multivariate analysis will be calculated., Discussion: This research project aims to show that a basic recuperative intervention, which is feasible and primary care-based, can achieve improvements in the quality of life of patients with COPD.

Introduction: Specific immunotherapy consists in administering increasing doses of antigen, to which the patient is sensitive, to determine a protective immune response., Patients and Methods: A descriptive and retrospective review of 30 patients diagnosed of seasonal allergic rhinitis, all treated with specific immunotherapy. Data on age, gender, symptoms, prick test before and after the immunotherapy administration, drugs, efficacy and side effects, were recorded using the SPSS statistical program., Results: 90% had moderated symptoms and 10% had severe symptoms and asthma. 33% were sensitized to grass pollen. 60% needed antihistamines and intranasal corticosteroids before the immunotherapy. In a lot of cases (80%) there were no side effects. The complete desensitization occurred in 53.3% and the reduction of symptoms in 73% of the cases. 54% of the patients didn't need treatment after specific immunotherapy., Conclusions: The specific immunotherapy is the only curative therapy. Sublingual therapy is one of the most accepted because is well tolerated, it uses a higher allergen concentration, it reduces the symptoms and the needs of drugs and side effects are uncommon.

Background and Objective: Several strategies as stroke teams, stroke code teams, or stroke units development have demonstrated to improve stroke care quality. The potential benefit of implementing them as a whole has not been studied. We aimed to test the clinical efficacy of a specialized and urgent stroke assistance system in a University Hospital, as well as the specific impact of each part of the system on several clinical indicators., Patients and Method: The implementation of the system followed three consecutive steps: stroke team and stroke code development, stroke unit creation and finally on-call stroke neurologists incorporation. Several clinical indicators to evaluate results have been selected. We compared data available before system onset (1992-1997) with data obtained during the system implementation (1998-2002). Modification in the results indicators following each of the individual steps of the system was also evaluated., Results: During the five years of the system implementation, 5843 stroke patients have been prospectively studied. Admission and readmission necessities were reduced up to 34.2% and 81.8% respectively. Length of stay progressively decreased from 18 (pre-1998) to 7 days (2002). In-hospital mortality and institutionalization necessities were reduced to 50.1% and 50.5% respectively. The third step, in which on-call stroke neurologist were incorporated to the system, has demonstrated to be the most efficient in decreasing the length of stay, hospital mortality and institutionalization necessities., Conclusions: The creation of a specialized urgent stroke care system, protocol based and developed in stroke units, improves the medical assistance quality for stroke patients. Stroke neurologists on-call have a relevant role in the system working.

Background: To evaluate differences in the temporal profile of acute phase response (APR) between ischemic stroke (IS) and intracerebral hemorrhage (ICH)., Patients and Method: We studied APR parameters (< 24 h and 3-5 day) in 88 consecutive patients (43 ICH and 45 IS). The increase/decrease of the parameters between both dates was analyzed., Results: Leukocyte increase (LI) and fibrinogen increase (FI) is significantly higher in ICH than in IS (p = 0.047 and p = 0.035)., Conclusions: APR temporal profile is different for ICH and IS.

Background: "Stroke Code" is a system for the rapid identification, pre-notification and transport of acute ischemic stroke patients. The objective of this study was to evaluate the impact of delay reduction for thrombolytic therapy in these patients., Subjects and Methods: We evaluated acute ischemic stroke patients admitted in the emergency unit within the first 6 hours after onset of symptoms and included into reperfusion clinical trials. We compared the delay for initiating reperfusion treatment related to the activation or not of the stroke code., Results: From 454 patients evaluated, 25% were admitted to the hospital in less than 6 hours from stroke onset. 59% of these patients were candidates for reperfusion treatment. "Stroke Code" was activated in 13 (55%). We observed a significant reduction in the delay since the onset of symptoms in relation to "Stroke Code" activation or not (mean X [SD]): emergency room arrival: 49.6 (48) vs 80 (48) min; Stroke Team evaluation: 65.3 (57) vs 133.6 (58) min; CT scan performing: 86.2 (60) vs 171.8 (62) min; Start of treatment; 212.9 (51) vs 287.3 (59) min., Conclusions: "Stroke Code" activation reduced in 50% pre- and in-hospital delay to start reperfusion treatment in acute ischemic stroke patients.

Metastatic tumors to the paranasal sinuses are uncommon. Symptoms and imaging studies are non-specific and usually similar to primary neoplasms in this region. Histological study of the neoplastic tissue is essential in order to ascertain its origin. A case of breast adenocarcinoma that metastasized to the ethmoid sinus is reported and the literature is reviewed.

The relationship between atrioseptal aneurysm and ischemic stroke has not been clearly demonstrated. We present three patients with transient cerebrovascular events and one patient with transient medullar ischemia related with the presence of atrioseptal aneurysm. Other causes of cerebrovascular disease have been excluded. Following anticoagulation treatment all the patients remain asymptomatic.

Describing the most relevant findings in the benign tumors of the nose, we present a case of cyst that eroded the dorsum of the nose and produced an aesthetic deformity. The treatment was a rhinoplasty operation including the removal of the cyst and the hump. After the anatomopathological findings we studied the different cysts, arriving at the concluding diagnosis that the cyst is sebaceus.