José Vivancos

Universidad Autónoma de Madrid, Madrid, Madrid, Spain

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Publications (80)361.87 Total impact

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    ABSTRACT: The complexity of endovascular revascularization treatment (ERT) in acute ischemic stroke and the small number of patients eligible for treatment justify the development of stroke center networks with interhospital patient transfers. However, this approach might result in futile transfers (ie, the transfer of patients who ultimately do not undergo ERT). Our aim was to analyze the frequency of these futile transfers and the reasons for discarding ERT and to identify the possible associated factors. We analyzed an observational prospective ERT registry from a stroke collaboration ERT network consisting of 3 hospitals. There were interhospital transfers from the first attending hospital to the on-call ERT center for the patients for whom this therapy was indicated, either primarily or after intravenous thrombolysis (drip and shift). The ERT protocol was activated for 199 patients, 129 of whom underwent ERT (64.8%). A total of 120 (60.3%) patients required a hospital transfer, 50 of whom (41%) ultimately did not undergo ERT. There were no differences in their baseline characteristics, the times from stroke onset, or in the delays in interhospital transfers between the transferred patients who were treated and those who were not treated. The main reasons for rejecting ERT after the interhospital transfer were clinical improvement/arterial recanalization (48%) and neuroimaging criteria (32%). Forty-one percent of the ERT transfers were futile, but none of the baseline patient characteristics predicted this result. Futility could be reduced if repetition of unnecessary diagnostic tests was avoided. © 2015 American Heart Association, Inc.
    Stroke 06/2015; DOI:10.1161/STROKEAHA.115.009282 · 6.02 Impact Factor
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    ABSTRACT: The complexity and expense of endovascular treatment (EVT) for acute ischaemic stroke (AIS) can present difficulties in bringing this approach closer to the patients. A collaborative node was implemented involving three stroke centres (SCs) within the Madrid Stroke Network to provide round-the-clock access to EVT for AIS. A weekly schedule was established to ensure that at least one SC was 'on-call' to provide EVT for all those with moderate to severe AIS due to large vessel occlusion, >4.5 h from symptom onset, or within this time-window but with contraindication to, or failure of, systemic thrombolysis. The time-window for treatment was 8 h for anterior circulation stroke and <24 h in posterior stroke. Outcomes measured were re-canalization rates, modified Rankin Scale (mRS) score at 3 months, mortality and symptomatic intra-cranial haemorrhage (SICH). Over a 2-year period (2012-2013), 303 candidate patients with AIS were considered for EVT as per protocol, and 196 (65%) received treatment. Reasons for non-treatment were significant improvement (14%), spontaneous re-canalization (26%), clinical worsening (9%) or radiological criteria of established infarction (31%). Re-canalization rate amongst treated patients was 80%. Median delay from symptom onset to re-canalization was 323 min (p25; p75 percentiles 255; 430). Mortality was 11%; independence (mRS 0-2) was 58%; SICH was 3%. Implementation of a collaborative network to provide EVT for AIS is feasible and effective. Results are good in terms of re-canalization rates and clinical outcomes. © 2015 EAN.
    European Journal of Neurology 06/2015; DOI:10.1111/ene.12749 · 3.85 Impact Factor
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    ABSTRACT: Las canalopatías del músculo esquelético abarcan una serie de enfermedades caracterizadas típicamente por la presencia de miotonía, parálisis muscular o una combinación de ambas. Son entidades de base genética y de incidencia muy baja, por lo que su diagnóstico clínico requiere de un alto índice de sospecha ante la presencia de síntomas compatibles. En este artículo se presenta una actualización con las características fisiopatológicas, clínicas, diagnósticas, neurofisiológicas y terapéuticas de estas enfermedades.
    Medicine - Programa de Formación Médica Continuada Acreditado 04/2015; 11(75). DOI:10.1016/j.med.2015.03.003
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    ABSTRACT: In the diagnostic approach of patients with distal muscle weakness we must consider conditions at different levels of motor nervous system, the most characteristics those affecting the peripheral nerves and motor neuron (the latter in its earliest phases). Less commonly find that some diseases of the muscle itself may present with this presentation, being the most characteristic of this group predominantly proximal weakness. A detailed medical history and a neurological allow accurate assessment locate the level of injury and thus direct the additional studies needed to confirm the diagnosis.
    Medicine - Programa de Formación Médica Continuada Acreditado 04/2015; 11(75). DOI:10.1016/j.med.2015.03.007
  • Neurologia (Barcelona, Spain) 01/2015; DOI:10.1016/j.nrl.2014.10.002 · 1.35 Impact Factor
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    ABSTRACT: Atrial fibrillation is the most frequent arrhythmia seen in clinical practice and is one of the most important risk factors for suffering a stroke. Strokes associated to atrial fibrillation are more severe, present higher mortality and disability rates, and there is a greater risk of recurrence. Consequently, both primary and secondary prevention of stroke associated to atrial fibrillation by means of suitable antithrombotic treatment is clearly essential in order to lower this risk. Chronic oral anticoagulants are the cornerstone of antithrombotic treatment in patients with non-valvular atrial fibrillation, especially in those who have already had a stroke. Vitamin K antagonists have traditionally been used for this purpose. Yet, these drugs have several important disadvantages (narrow therapeutic window, unpredictable response, numerous interactions with drugs and foods, as well as starting and finishing their action slowly), which limit their use in clinical practice. The new oral anticoagulants not only overcome these disadvantages but also have proved to be at least as effective as warfarin in the prevention of strokes and systemic embolism in patients with non-valvular atrial fibrillation. Additionally, they have been shown to have a better safety profile, especially with an important drop in the risk of intracranial haemorrhage, regardless of the antecedents of stroke or transient ischaemic attack, which makes them first-choice drugs in the treatment of these patients.
  • Revista de neurologia 05/2014; 58(10):478-9. · 0.93 Impact Factor
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    ABSTRACT: PPARγ-achieved neuroprotection in experimental stroke has been explained by the inhibition of inflammatory genes, an action in which 5-LO, Alox5, is involved. In addition, PPARγ is known to promote the expression of CD36, a scavenger receptor that binds lipoproteins and mediates bacterial recognition and also phagocytosis. As phagocytic clearance of neutrophils is a requisite for resolution of the inflammatory response, PPARγ-induced CD36 expression might help to limit inflammatory tissue injury in stroke, an effect in which 5-LO might also be involved. Homogenates, sections, and cellular suspensions were prepared from brains of WT and Alox5(-/-) mice exposed to distal pMCAO. BMMs were obtained from Lys-M Cre(+) PPARγ(f/f) and Lys-M Cre(-) PPARγ(f/f) mice. Stereological counting of double-immunofluorescence-labeled brain sections and FACS analysis of cell suspensions was performed. In vivo and in vitro phagocytosis of neutrophils by microglia/macrophages was analyzed. PPARγ activation with RSG induced CD36 expression in resident microglia. This process was mediated by the 5-LO gene, which is induced in neurons by PPARγ activation and at least by one of its products-LXA4-which induced CD36 independently of PPARγ. Moreover, CD36 expression helped resolution of inflammation through phagocytosis, concomitantly to neuroprotection. Based on these findings, in addition to a direct modulation by PPARγ, we propose in brain a paracrine model by which products generated by neuronal 5-LO, such as LXA4, increase the microglial expression of CD36 and promote tissue repair in pathologies with an inflammatory component, such as stroke.
    Journal of leukocyte biology 12/2013; 95(4). DOI:10.1189/jlb.0613326 · 4.99 Impact Factor
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    ABSTRACT: Cerebral vasculopathy have been described in Fabry disease, in which altered cerebral blood flow, vascular remodelling or impairment of endothelial function could be involved. Our study aims to evaluate these three possibilities in a group of Fabry patients, and compare it to healthy controls. Cerebral hemodynamics, vascular remodelling and systemic endothelial function were investigated in 10 Fabry patients and compared to data from 17 healthy controls. Transcranial Doppler was used to study blood flow velocity of intracranial arteries and cerebral vasomotor reactivity. For the study of vascular remodelling and endothelial function, intima-media thickness of common carotid arteries, flow-mediated dilation in brachial artery and serum levels of soluble VCAM-1, TNF-alpha, high-sensitive CRP and IL-6 were measured. Differences between groups were evaluated using appropriate tests. No relevant differences were observed in cerebral hemodynamic parameters, intima-media thickness or flow-mediated dilation. There was a trend for low serum levels of IL-6 and high serum levels of TNF-alpha and high-sensitive CRP in Fabry patients; plasma concentrations of soluble VCAM-1 were significantly higher in Fabry disease patients than in healthy volunteers (p = 0.02). In our sample, we did not find relevant alterations of cerebral hemodynamics in Fabry disease patients. Increased levels of plasmatic endothelial biomarkers seem to be the most important feature indicative of possible vascular dysfunction in Fabry disease patients.
    BMC Neurology 11/2013; 13(1):170. DOI:10.1186/1471-2377-13-170 · 2.49 Impact Factor
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    ABSTRACT: Rivaroxaban is an oral highly selective direct factor Xa inhibitor. Rivaroxaban is currently approved for the prevention of venous thromboembolism in adult patients undergoing elective hip or knee replacement surgery, for the treatment of deep vein thrombosis and pulmonary embolism and long-term secondary prevention of venous thromboembolism, and for stroke and systemic embolism prevention in patients with nonvalvular atrial fibrillation. Rivaroxaban has many advantages over vitamin K antagonists and this may facilitate its use in clinical practice. As a result, it is expected that new oral anticoagulants may change patient management strategies. On the other hand, rivaroxaban has some particularities that are necessary to know. The aim of this manuscript was to review the use of rivaroxaban not only in general population, but also in specific patients groups and clinical situations to achieve an optimal management with this drug in daily clinical practice.
    Revista de neurologia 11/2013; 57(9):411-21. · 0.93 Impact Factor
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    ABSTRACT: Neutrophils have been traditionally recognized as major mediators of a deleterious inflammatory response in acute ischemic stroke, but their potential as a therapeutic target remains unexplored. Recent evidence indicates that neutrophils may acquire different phenotypes and contribute to resolution of inflammation through the release of anti-inflammatory mediators. Thus, similar to M2 macrophages, neutrophils have been proposed to shift toward an N2 phenotype, a polarization that is peroxisome proliferator-activated receptor-γ dependent in macrophages. We hypothesize that peroxisome proliferator-activated receptor-γ activation with rosiglitazone induces changes in neutrophilic mobilization and phenotype that might influence stroke outcome. Brain sections and cell suspensions were prepared from mice exposed to permanent distal middle cerebral artery occlusion. Double immunostaining with stereological counting of brain sections and flow-cytometry analysis of brain cell suspensions were performed. Rosiglitazone accelerated neutrophil infiltration to the ischemic core, concomitantly to neuroprotection. Some neutrophils (≈31%) expressed M2 markers, namely Ym1 and CD206 (mannose receptor). After treatment with the peroxisome proliferator-activated receptor-γ agonist rosiglitazone, most neutrophils (≈77%) acquired an N2 phenotype. Interestingly, rosiglitazone increased neutrophil engulfment by microglia/macrophages, a clearance that preferentially affected the N2 subset. We present the first evidence of neutrophil reprogramming toward an N2 phenotype in brain inflammation, which can be modulated by activation of the peroxisome proliferator-activated receptor-γ nuclear receptor. We also show that N2 polarization is associated with an increased neutrophil clearance, thus suggesting that this switch is a crucial event for resolution of inflammation that may participate in neuroprotection.
    Stroke 10/2013; 44(12). DOI:10.1161/STROKEAHA.113.002470 · 6.02 Impact Factor
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    ABSTRACT: INTRODUCTION. CLIPPERS syndrome (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) is an inflammatory process of the central nervous system whose distinguishing features are the enhancing punctiform lesions in the brainstem that appear in the magnetic resonance images. Clinically, it is accompanied by dysarthria, ataxia and diplopia, and usually responds to treatment with corticoids. Pathologically, T lymphocytes appear infiltrated in the perivascular spaces of the brainstem. CASE REPORT. We report the case of a 40-year-old woman with an initial subacute clinical picture of binocular diplopia, ataxia and dysarthria. The magnetic resonance brain scan revealed T2 hyperintense punctiform lesions in the stem, cerebellum, diencephalons and cortico-subcortical areas of both hemispheres, which were enhanced with contrast. An aetiological study was performed to rule out any underlying infectious, neoplastic or inflammatory origin, the results being negative. The patient was treated on two occasions with methylprednisolone, with a gradual lowering of the dosage, the response being favourable. CONCLUSIONS. Diplopia and ataxia, as in our case, are practically always present. The MR findings consist of punctiform enhancing lesions located in the pons extending towards the cerebellum, basal ganglia and corpus callosum, the enhancement gradient becoming lower as the distance increases rostrally away from the cortex, and caudally towards the spinal cord. In the case of our patient, this gradient is not respected, and the density found was similar to that of lesions at the supratentorial level. The differential diagnosis is wide-ranging and justifies an extensive diagnostic study with, in certain cases, a biopsy study of brain tissue. The disease courses in a relapsing-remitting pattern and the earlier steroid therapy is established and the more prolonged it is, the better the prognosis will be.
    Revista de neurologia 10/2013; 57(8):354-358. · 0.93 Impact Factor
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    ABSTRACT: Ischemic stroke is a devastating condition, for which there is still no effective therapy. Acute ischemic stroke is associated with high concentrations of glutamate in the blood and interstitial brain fluid. The inability of the tissue to retain glutamate within the cells of the brain ultimately provokes neuronal death. Increased concentrations of interstitial glutamate exert further excitotoxic effects on healthy tissue surrounding the infarct zone. We developed a strategy based on peritoneal dialysis to reduce blood glutamate levels, thereby accelerating brain-to-blood glutamate clearance. In a rat model of stroke, this simple procedure reduced the transient increase in glutamate, consequently decreasing the size of the infarct area. Functional magnetic resonance imaging demonstrated that the rescued brain tissue remained functional. Moreover, in patients with kidney failure, peritoneal dialysis significantly decreased glutamate concentrations. Our results suggest that peritoneal dialysis may represent a simple and effective intervention for human stroke patients.
    The Journal of clinical investigation 09/2013; DOI:10.1172/JCI67284 · 13.77 Impact Factor
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    ABSTRACT: Introducción El tratamiento endovascular (trombólisis farmacológica intraarterial y trombectomía mecánica) en el ictus isquémico agudo se está implantando en la práctica clínica cotidiana, aunque continúa en desarrollo su investigación. En ausencia de datos suficientes que permitan fundamentar sólidamente las recomendaciones para su uso, es necesario elaborar protocolos de actuación basados en el conocimiento acumulado, así como monitorizar las actuaciones. Desarrollo Tras revisión bibliográfica, en reuniones de trabajo de expertos para llegar a un consenso, se ha elaborado un protocolo de actuación que incluye indicaciones y contraindicaciones para la aplicación de tratamiento endovascular y recomendaciones referentes a la metodología de diagnóstico y selección de los pacientes, de los procedimientos de revascularización y manejo posterior, con el objetivo de incrementar las probabilidades de eficacia y beneficio del tratamiento y minimizar los riesgos de complicaciones y de recanalización fútil. En función del análisis de las necesidades asistenciales y los recursos disponibles se ha elaborado un sistema organizativo de colaboración interhospitalaria, para asegurar la accesibilidad al tratamiento garantizando el menor tiempo de respuesta y una relación coste/eficacia favorable. Incluye un registro prospectivo común con fines de monitorización para detectar oportunidades de mejora. Conclusiones Para la implantación de técnicas endovasculares de tratamiento del ictus isquémico agudo es imprescindible la elaboración de protocolos de actuación basados en las evidencias disponibles y el establecimiento de sistemas adecuados de organización asistencial para garantizar el rigor y la eficacia de las actuaciones. Es necesario monitorizar los procedimientos con el fin de optimizar la metodología.
    09/2013; 28(7):425–434. DOI:10.1016/j.nrl.2014.02.009
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    ABSTRACT: Introduction Endovascular therapies (intra-arterial thrombolysis and mechanical thrombectomy) after acute ischaemic stroke are being implemented in the clinical setting even as they are still being researched. Since we lack sufficient data to establish accurate evidence-based recommendations for use of these treatments, we must develop clinical protocols based on current knowledge and carefully monitor all procedures. Development After review of the literature and holding work sessions to reach a consensus among experts, we developed a clinical protocol including indications and contraindications for endovascular therapies use in acute ischaemic stroke. The protocol includes methodology recommendations for diagnosing and selecting patients, performing revascularisation procedures, and for subsequent patient management. Its objective is to increase the likelihood of efficacy and treatment benefit and minimise risk of complications and ineffective recanalisation. Based on an analysis of healthcare needs and available resources, a cooperative inter-hospital care system has been developed. This helps to ensure availability of endovascular therapies to all patients, a fast response time, and a good cost-to-efficacy ratio. It includes also a prospective register which serves to monitor procedures in order to identify any opportunities for improvement. Conclusions Implementation of endovascular techniques for treating acute ischaemic stroke requires the elaboration of evidence-based clinical protocols and the establishment of appropriate cooperative healthcare networks guaranteeing both the availability and the quality of these actions. Such procedures must be monitored in order to improve methodology.
    Neurologia (Barcelona, Spain) 09/2013; 28(7):425–434. DOI:10.1016/j.nrl.2012.12.009 · 1.35 Impact Factor
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    ABSTRACT: INTRODUCTION. Vagus nerve stimulation (VNS) has been approved for the treatment of refractory epilepsy when resective surgery is not possible, and has proved to be highly effective. Series published in the literature suggest a beneficial effect of VNS in the treatment of migraine. AIMS. To determine the degree to which headaches improve in patients with migraine after the placement of VNS to treat refractory epilepsy, and to evaluate what variables are associated with an increased chance of success with this measure. PATIENTS AND METHODS. An observation-based retrospective study was conducted from 1st January 1999 until 31st December 2010. Patients with VNS for refractory epilepsy were contacted by telephone, after selecting those who fulfilled International Headache Society criteria for migraine. Data collected included age, gender, year of placement, age at onset of epilepsy and migraine, improvement of seizures and migraine, presence of migraine with aura and coexistence of anxious-depressive syndrome. Ninety-four patients with VNS were contacted and 13 patients with migraine were selected. RESULTS. Following placement of the VNS, the number of episodes of migraine was seen to decrease by at least 50% in nine patients (69%) (p = 0.004) and there was a drop in the number of episodes of migraine in those patients who had also reduced their epileptic seizures (p = 0.012). No statistically significant associations were observed as regards sex, age, length of disease history, existence of migraine with aura or coexistence of anxious-depressive syndrome. CONCLUSIONS. VNS could have beneficial effects for patients with migraine, especially in cases that are difficult to control. Due to the type of study, these conclusions must be taken with caution. Prospective clinical studies are needed before introducing the technique into daily clinical practice.
    Revista de neurologia 07/2013; 57(2):57-63. · 0.93 Impact Factor
  • Gustavo Zapata-Wainberg, Jose Vivancos
    New England Journal of Medicine 06/2013; 368(24):e32. DOI:10.1056/NEJMicm1213006 · 54.42 Impact Factor
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    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.
    Neurologia (Barcelona, Spain) 05/2013; 28(4):236–249. DOI:10.1016/j.nrl.2011.03.010 · 1.35 Impact Factor
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    ABSTRACT: Purpose:To investigate if glutamate levels also increase in carotid angioplasty and stent placement (CAS) procedures, since high plasma glutamate levels are associated with ischemic infarction and transient ischemic attacks, but the length of ischemia needed to elicit such elevation has not been assessed.Materials and Methods:All patients or their relatives signed informed consent. By using high-performance liquid chromatography, plasma glutamate concentrations were determined in 74 patients treated with CAS. Blood samples were obtained with arterial and peripheral venous catheterization before and after the procedure, and venous blood samples were obtained 24, 48, and 72 hours after CAS. Glutamate concentrations were also analyzed in two different control groups: 16 patients without carotid stenosis before and after diagnostic cerebral angiography and 20 patients treated with coronary angioplasty and stent placement. The χ(2) test, t test, and analysis of variance were used to compare glutamate concentrations among the groups.Results:Baseline glutamate concentrations were similar between patients who underwent CAS and both control groups. In CAS patients, glutamate concentrations in venous blood increased immediately after the procedure (354.1 μmol/L ± 132.8) and returned to baseline levels at 24 hours (129.5 μmol/L ± 56.8) (P < .0001). Glutamate concentrations remained unchanged over time in both control groups.Conclusion:A rapid increase in plasma glutamate levels occurs after CAS procedures, unrelated to stroke.© RSNA, 2013.
    Radiology 03/2013; 268(2). DOI:10.1148/radiol.13112104 · 6.21 Impact Factor

Publication Stats

1k Citations
361.87 Total Impact Points

Institutions

  • 2009–2015
    • Universidad Autónoma de Madrid
      Madrid, Madrid, Spain
    • University of Santiago de Compostela
      • Servicio de Neurología
      Santiago de Compostela, Galicia, Spain
  • 2005–2013
    • Hospital Universitario de La Princesa
      • Servicio de Neurología
      Madrid, Madrid, Spain
  • 2012
    • Hospital General Universitario Gregorio Marañón
      • Department of Neurology
      Madrid, Madrid, Spain
  • 2011
    • Hospital Universitario La Paz
      • Servicio de Neurología
      Madrid, Madrid, Spain