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Introduction: In a population-based study of the incidence of stroke conducted on a broad denominator, it is wise first to carry out a pilot study., Aim: To present the results of the pilot phase of the study on stroke incidence in Spain, entitled Iberictus., Patients and Methods: Population of the study: all cases involving the first episode of acute cerebrovascular disease (stroke or transient ischaemic attack) diagnosed among residents over 17 years of age with their habitual place of abode registered in the areas of study between 15th and 31st October 2005 (total denominator: 1,440,997 inhabitants)., Source of Data: prospective, hospital records (basic minimum data set, discharge abstracts) and casualty department registers. Standardised definitions: diagnostic categorisation and pathological, topographical and aetiological classification. Inter-observer agreement analysis among researchers (kappa)., Results: A total of 128 cases were identified. Age range, 37-103 years; mean age, 75.7 +/- 13.4 years; 54% were females. In all, 71.1% of the cases were collected by means of a basic minimum data set. There were 91 ischaemic events (29.7% atherothrombotic and 29.7% cardioembolic). Of the 15 haemorrhagic strokes, 40% due to arterial hypertension, six were lobar hemispheric, six were deep basal ganglia, and there were three cerebellar haemorrhages. The incidence of stroke was seen to increase exponentially with age. Inter-observer agreement was good for the classifications that were employed (range of kappa indices, 0.57-0.78). Several problems were detected and corrected in the fieldwork., Conclusions: The Iberictus pilot study yielded data that were consistent with the literature and provided us with the opportunity to detect and correct issues that would hinder us from conducting the main study.

Introduction: Epidemiological data on the incidence of cerebrovascular diseases in our country are scarce. A representative population-based study with a large denominator is required., Aim: To present the design of the study on stroke incidence in Spain, entitled Iberictus., Subjects and Methods: We conducted a prospective, population-based study on the incidence of strokes and transient ischemic attacks, in which it is possible to distinguish: 1) population with a steady risk, which was well defined and had a broad denominator. We included all the cases in which the first episode of acute cerebrovascular disease was diagnosed among those over the age of 17 years (with no upper age limit) with their habitual residence in the areas of study between the 1st January and 31st December 2006: Lugo, Segovia, Talavera de la Reina, Mallorca and Almeria (total denominator, 1,440,997 inhabitants; minimum denominator per area, 100,000 inhabitants); 2) source of multiple and complementary data: hospital records (minimum basic data set, discharge abstracts), emergency and primary care records for the area with diagnostic codes 430-39 and 674.0 (International Classification of Diseases-9), population-based mortality records; 3) standardised definitions: diagnostic categorisation (MONICA-World Health Organisation, 1987), pathological classification (ischaemia, haemorrhagic), topography and aetiology; 4) presentation of data in suitable age groups, by sex and overall; 5) pilot study and analysis of inter-observer agreement among researchers., Conclusions: With this design, the Iberictus study satisfies the methodological criteria as an 'ideal' study of the incidence of acute cerebrovascular diseases proposed by Malgrem, Sudlow and Warlow, and represents a unique opportunity to further our knowledge of the epidemiology of strokes in our country.

Aim: To summarise the methodological aspects and main findings of the NEDICES (Neurological Disorders in Central Spain) cohort study of the elderly population, with over 5000 participants., Development: The article outlines the findings concerning the following chronic neurological diseases (CND): dementia, Parkinson's disease and Parkinsonisms, stroke and essential, or senile, tremor. The NEDICES study examined the health, mortality and a series of sociological aspects of the cohort that are not discussed here. The paper does describe, however, the objectives, methods, population and development, with the baseline (1994) and incidence (1997) cut-off points, and the main findings regarding the CND under study are discussed., Conclusions: The prevalence and incidence of the CND are comparable to those of other Spanish and European population-based studies, but with certain peculiarities, such as the fact that incidence of senile tremor is the highest of those reported in the literature and that this CND is associated with dementia. Over half the cases of Parkinson's disease were reported de novo with the study and Alzheimer's disease was associated with vascular risk factors.

Aims: To determine the number of complaints received by the Neurology Service in one year, to carry out a qualitative analysis, and to examine how they are dealt with in order to provide patients with a solution., Materials and Methods: The work involved a retrospective study of the complaints from patients in the Neurology Service throughout the year 2004, using the information provided by the Patient Advice and Liaison Service. The following quality indicators were used to evaluate how these claims were managed: the percentage of complaints that were attended in less than 30 days after being received and the percentage of complaints that were resolved., Results: Throughout the period under study a total of 183 complaints were received: 1/478 hospital admissions (0.21%), 71/43,841 medical visits (0.16%), 110/5,522 neurophysiological studies (2%) and 3 due to other reasons. It was found that 90.2% of all complaints had to do with waiting lists, 3.3% were related to dealings with staff and the rest were due to other causes. 86.3% of the complaints were resolved, 10.2% were dismissed and the others were passed on or shelved. 77.5% of the claims were attended within 30 days (quality parameter), the mean delay being 21.3 days (standard deviation: 11.3)., Conclusions: Our rate of complaints is low, although improvements must be introduced both quantitatively and in their management. Practically no data has been published to date concerning these aspects of clinical management in neurology services.

Aims: A study is made to contrast the prevalence and severity of periodontal disease, the needs for periodontal treatment, and the prevalence of lesions of the oral mucosa in pregnant (study group) and non-pregnant women., Study Design: During the period 1991-1999, a prospective observational study was made of 7952 women seen in the Dental School of De La Salle Bajío University (Leon, Gto. Mexico). The following variables were documented: age, disease antecedents, simplified periodontal index, and lesions of the oral mucosa. Two patient groups were defined: pregnant and non-pregnant women exhibiting a similar age distribution. The data were presented as percentages, and comparisons were made based on the chi-square test., Results: Pregnancy was not found to be a decisive factor for the development of periodontal disease, no differences in the prevalence of gingivitis (54.54 and 50.50%) and periodontitis (31.82 and 31.75%) being observed between the two groups. However, the severity of periodontitis was significantly greater among the pregnant women (18.18% versus 9.88%; p< 0.01). The prevalence of oral mucosal lesions was similar in both groups (30%), 13 lesions being identified in the study group, with a predominance of leukoedema, traumatic ulceration, red traumatic lesions, benign migratory glossitis (geographic tongue), irritative keratosis and pyogenic granuloma. The non-pregnant women in turn exhibited 57 lesions. Pyogenic granuloma and benign migratory glossitis exhibited significant differences between the two groups (p< 0.005)., Conclusions: Gingivitis and periodontitis showed similar prevalences in pregnant and non-pregnant women, though severe periodontitis was more frequent among the former. Pyogenic granuloma and benign migratory glossitis were the lesions with the greatest prevalences during pregnancy.

Introduction: The term pseudochoreoathetosis is used to refer to the choreoathetoid movements that are produced by alterations in the proprioceptive sensitivity due to damage it has suffered at some point along its course. Proprioceptive sensitivity is considered to go up as far as the cortex along the posterior cords of the spinal cord, which means that if they are injured in the cervical region there should be a sensory deficit in both the upper (UL) and lower limbs (LL)., Case Reports: We describe five cases of transverse myelitis with localised cervical injury that selectively and mainly affected the posterior cords of the spinal cord. In the five patients there was selective involvement of the proprioceptive sensitivity in the UL respecting the LL and pseudochoreoathetoid movements of the limb that has been deafferented for proprioceptive sensitivity. The dissociation between the UL and the LL occurs because the spinocerebellar and spinocervical tracts take the proprioceptive information from the LL in parallel to the posterior cords, which receive the proprioceptive sensitivity from the UL., Conclusions: At present, the most widely accepted physiopathological mechanism explaining pseudochoreoathetosis consists in a failure in the integration of the sensory-motor afferences in the striatum, which causes faulty sensory-motor integration at this level and gives rise to pseudochoreoathetosis.

Diagnostic reasoning is a cognitive proccess that has various performance and results. There are several kinds of clinical reasoning, such as model or pattern recognizing, causal or physiopathologic reasoning, deterministic, exhaustive, and hypotetic-deductive ones. Each form of reasoning may be relevant in certain clinical context, and all of the forms are also complementary. The logical consequence of diagnostic reasoning, like every cognitive proccess, is a clinical error. It is necessary that the neurologist knows the principles of diagnostic reasoning and the more frequent errors and biases. These can be summarized as: errors associated with the proccess of taking history and clinical examination, mnesic and semantic components of clinical reasoning, failure of hipotetic- deductive reasoning, and inadequate use of probability theory in Medicine.

Introduction: MELAS syndrome (mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke like episodes) is a mitochondrial disease related to the mitochondrial DNA mutation. The tRNALeu(UUR) mutation at the base pair 3234 is associated to 80% of cases of MELAS syndrome. The onset with the stroke like episodes is often before the age 40. Herpes simplex encephalitis (HSE) presents as acute episodes of focal neurologic deficit that are often related to the temporal lobe. Occasionally MELAS syndrome and HSE may have a similar clinical presentation., Clinical Case: A 33-year-old woman presented with seizures and a right parietotemporal syndrome of acute onset. The differential diagnosis between HSE and MELAS syndrome was established. MELAS syndrome was suspected based on her phenotype. The diagnosis of MELAS syndrome was confirmed by the presence of the mitochondrial tRNALeu(UUR) mutation at the base pair 3243., Conclusion: The clinical presentation of the MELAS syndrome may mimic that of the HSE, and antiviral treatment should be given until the diagnosis of MELAS syndrome is definitive. The study of the mitochondrial DNA helps diagnosing in a non invasive way many patients with MELAS syndrome.

Introduction: Nasopharyngeal carcinoma is a condition which usually has an insidious onset and non-specific features in the initial stages, so it is difficult to make an early diagnosis. The most usual presenting features are otological (serous otitis media) and involvement of adjacent cranial nerves. We report a case of Gradeningo's syndrome due to the tumour spreading towards the base of the skull. We review the literature on the aetiology of this syndrome., Clinical Case: A 53 year old patient required neurological assessment for a clinical condition which was compatible with Gradenigo's syndrome that involved both right V and VI cranial nerves. This study permitted diagnosis of a nasopharyngeal carcinoma which had been undetected because of its non-specific features, until this complication occurred. Otorhinolaryngological assessment proved the presence of a neoplasm in the cavum. Biopsy of the lesion showed it to be a well-differentiated squamous cell carcinoma. Cranial magnetic resonance imaging showed extension of the tumour to the base of the skull, adjacent to the right sinus cavernosus. The cerebrospinal fluid was normal. Treatment by radiotherapy was indicated., Conclusions: Diagnosis of nasopharyngeal carcinoma requires a high index of suspicion in view of its initial, sparse, non-specific symptoms. Although ideally the disease should be detected in its early stages, we believe that it is useful to recommend that in cases of Gradenigo's syndrome a full systematic otorhinolaryngological exploration be made so as to effectively rule out this disorder.

Tuberculosis is a potentially fatal infectious disease. Although it typically manifests in populations subjected to crowding and living in poor conditions of hygiene, in the past decade the morbidity and mortality associated to pulmonary tuberculosis has increased throughout the world--particularly due to the appearance of strains resistant to a range of drugs, and to the vulnerability of human immunodeficiency virus (HIV)-positive individuals to tuberculosis infection. In this context, dental professionals should implement schemes and protocols designed to identify patients with lung tuberculosis, in order to both refer such patients to specialized medical care and to avoid infection of the dental personnel and other patients. A review is made of the etiology, pathogenesis, clinical manifestations, diagnosis and treatment of patients with pulmonary tuberculosis, with particular emphasis on the management measures indicated in the dental clinic.

Background: The variability in the diagnostic observations could be a problem both in the clinical and in the epidemiological field. Scarce data exist in the literature on this phenomenon, relatives to the field of the cerebrovascular illness, in their nosologic, semiologic and etiologic aspects. We pretend to study the interobserver variability in the diagnosis of the stroke, classifying it as absentee, present or possible in front of a given case., Methods: 1. A questionnaire of 99 clinical cases has been elaborated, in order to be subjected to the evaluation of 10 neurologists (3 "junior", residents, 3 "senior" residents, and 4 "staff"); 2. The categories are: a) not stroke either transient ischaemic attack; b) probable stroke or transient ischaemic attack; c) transient ischaemic attack and d) stroke. 3., Statistical Analysis: by means of the statistic kappa of Fleiss (kappa) for several observers and several categories, determination of the standard error and 95% confidence intervals., Results: In the diagnosis of the cerebrovascular illness: a) among all the observers: kappa = 0.49 (0.44-0.50); b) among staff: kappa = 0.51 (0.46-0.56); c) among residents: kappa = 0.47 (0.44-0.50). Global data in transient ischaemich attack diagnosis: kappa = 0.52 (0.49-0.55); in the diagnosis of the stroke: kappa = 0.57 (0.54-0.60); in the exclusion of stroke: kappa = 0.64 (0.62-0.67)., Conclusions: With Fleiss' criteria, an acceptable to good agreement exists in the diagnosis of the stroke in base to the mere description of the clinical picture. This interobserver agreement is better if it is tried to exclude the stroke, and it could increase with the training of the neurologist.

Neurological complications caused by varicella-zoster virus, excluding post-herpetic neuralgia and aseptic meningitis, are infrequent and varied. Other complications, which have been described are peripheral motor neuropathy, cranial nerve palsies, meningoencephalitis, Guillain-Barré syndrome, myelitis, herpes zoster ophthalmicus with delayed contralateral hemiparesis and Reye syndrome. We present 4 patients with infrequent neurological complications associated with varicella-zoster virus: 3 cases of meningoencephalitis and one case of myelitis.

Introduction: HTLV-I is a human retrovirus which has been implicated in the genesis of tropical spastic paraparesis (HTLV-I-associated myelopathy). So far five cases of this illness have been detected in Spain, five of them in immigrants. We present a new case in Spain, with a characteristic chronic clinical picture., Case Report: A 36-year-old black woman native of Ecuatorial Guinea, developed along 10 years a progressive paraparesis of asymmetric onset with important back pain, that arrives to paraplegic spastic phase at the present time. She presents distal amyotrophies, ulcers of decubitus and loss of control of sphincters, with normal mental status. Laboratory tests: blood, biochemistry and microbiologic studies: normal, or negative. She presented positive Western Blot serology for HTLV-I, confirmed by means of PCR technique. Cranial MRI: small and hyperintense subcortical lesions on T2 weighted images; spinal MRI: local atrophy at high thoracic level. A lumbar puncture was performed, with no cells, and with presence of oligoclonal bands, and a high IgG index. Urodynamic study: neurogenic spastic bladder. EMG: mild axonal polyneuropathy with prevalence in legs., Conclusions: In the differential diagnosis of progressive paraperesis, and mainly with epidemic antecedents, it is necessary to include a determination of HTLV-I between the diagnostic tests.

Vertigo is an unpleasant sensation of movement of the subject or of his surroundings. There are many causes of vertigo. Traditionally these are divided into 'central' and 'peripheral'. It is unusual to find it as a symptom of myelopathy. We describe the case of a 67 year-old woman with no significant previous clinical history who complained of the sudden onset of vertigo a few hours previously, which worsened on turning her neck towards the left. On examination, the vertigo recurred on turning her neck to the left after a latent period of a few seconds together with the appearance of ipsilateral conjugated nystagmus, which gradually disappeared. On neurological examination, there was amyotrophy of both arms with weakness, considerably reduced reflexes, except for clonus of the left wrist. There was slight paraparesia with bilateral cutaneoplantar flexion and a level of sensitivity at C2-C3. The sensitivity disorder was more marked in the arms with a bilateral distribution approximately at C5-C7 affecting predominantly thermoanalgesia. Cervical MRI showed a mass consistent with ependymoma. This was removed surgically 2 weeks after admission. The findings of the intraoperative biopsy confirmed the radiological diagnosis. The vertigo improved one week after admission, although the patient died of pneumonia one month after operation. Despite the vertigo was an atypical symptom, it was the clue that led to the diagnosis. Hypotheses about the cause of vertigo are discussed.

Varicella-zoster infection consists of well-recognized cutaneous manifestations. However, in several cases it is complicated with central nervous system disorders. We present a 79-year-old diabetic woman with zoster ophthalmicus, who developed an acute confusional syndrome. EEG, cranial computed tomographic, biochemical and haematologic and liquoral studies were performed. An increased in the CSF-IgG index was founded, and it was related with Varicella-Zoster Herpes antibodies. She was treated with intravenous acyclovir, and her encephalopathy was resolved.

Four newborn patients with symptomatic Chiari II malformations were studied retrospectively. Clinical manifestations and surgical results are presented. All of these patients had hydrocephalus, which was symptomatic in two patients from the first day of life. Three of them had bradycardia and apnea spells. Two patients had lower cranial nerve palsies. Cranial sonography was the first neuroimaging procedure used and it played an important role during the follow-up period, especially for the study of the hydrocephalus. Two newborns could be studied with Magnetic Resonance Imaging (MRI). It defined the level of the decent of the fossa posterior structures and the associated malformations. All of the patients were treated with surgical repair of the spinal dysraphism, ventricular shunt and decompressive surgery. Two patients died before the age of three months. Two other patients showed better evolution after their two year and four year check-ups, respectively. Bradycardia and apnea spells are features that worsen the prognosis as compared with other manifestations.

Reports on supratentorial metastases of medulloblastoma are infrequent. Computed tomography has increased the possibilities of detecting then in a silent clinical phase. Five children with supratentorial metastasis of medulloblastoma were retrospectively reviewed. Diagnosis was established by cranial CT between three and sixty months following treatment of the tumor. Dissemination through the ventricular system was found in all the cases. Other lesions were found in the transition zone between the white and grey matter (2/5) and the left frontal lobe (1/5). The routes of dissemination are discussed. Early diagnosis of supratentorial metastasis of medulloblastoma require periodic cranial CT or magnetic resonance imaging (MRI), at least during the first years after diagnosis and treatment of the primary tumor.

Neuroleptic malignant syndrome (NMS) is an adverse reaction of an idiosyncratic nature to drugs having antidopaminergic activity. Pathogenesis is largely disputed. An NMS case is presented which was triggered by flupentixol and was associated with severe hyponatremia (116 mmol/l upon admission). Both clinically and analytically, the hyponatraemia fulfills criteria to be considered secondary to an inappropriate secretion of antidiuretic hormone (SIADH). Other possible causes of hyponatraemia were ruled out. After early treatment with dopaminergic agonists and water restriction, both conditions improved in parallel. The different pathogenetic possibilities which may explain the temporal coexistence of both syndromes in the same patient are discussed. The association of these two conditions is in favour of a probable central pathogenetic cause for NMS. On the other hand, it is suggested that hyponatraemia may mask the diagnosis of NMS.

To our Knowledge, this is the first work in a number population (higher than 500 sample WHO) that is carried out in our country about lesions in the Oral Mucosa. The advantages in this Kind of studies are recognized particularly in the fields of academic, research and services. This work presents the first view of a permanent research project of Oral Mucosa Lesions at the admission clinic, School of Dentistry, Universidad del Bajío. The findings are from the evaluation of 7,297 patients, 15 years or older, that seek dental services between January 1982 and June 1989 (7.5 years). The lack of national data and the oldest population samples in other countries studies stopped wider evaluations, even though the study purpose was not affected, it was possible to offer qualitative data in the respect of prevalecence, variety and etiopathogenesis of those type of pathosis in the Oral Mucosa. The general prevalecence in the group was approximately 13%, identifying lesions more frequently in males, but higher variety in females. Report on 40 different entities, presented in general according to a descent order of prevalencece and reagrouped by sex and pathology. In half the lesions was possible to identify as the cause, acute and cronic traumatic agents; The infectious associations were also very frequent. Those last observations are of high relevance concerning the prevention of Oral Mucosa lesions.

A description is made of occlusal, articular and craniomandibular alterations that become present in the advance adult and old age and in some way they induce to the implementation of preventive and curative aspects from early stages or specific in posterior ages.