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Utilidad de la ecografía de nervio óptico como predictor de progresión en esclerosis múltiple
Usefulness of optic nerve ultrasound to predict clinical progression in multiple sclerosis
S. Pérez Sáncheza,
Autor para correspondencia
soledad.perez.sanchez@gmail.com

Autor para correspondencia.
, S. Eichau Madueñoa, M. Rus Hidalgoa, A.M. Domínguez Mayorala, A. Vilches-Arenasb, G. Navarro Mascarella, G. Izquierdoa
a Servicio de Neurología, Hospital Universitario Virgen Macarena, Sevilla, España
b Servicio de Medicina Preventiva, Hospital Universitario Virgen Macarena, Sevilla, España
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Ecograf&#237;a orbitaria&#58; imagen longitudinal del nervio &#243;ptico en un paciente con esclerosis m&#250;ltiple&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La esclerosis m&#250;ltiple &#40;EM&#41; es la enfermedad inflamatoria desmielinizante autoinmune m&#225;s com&#250;n del sistema nervioso central&#46; Se caracteriza por la presencia de procesos patol&#243;gicos que incluyen inflamaci&#243;n&#44; desmielinizaci&#243;n&#44; degeneraci&#243;n axonal y p&#233;rdida neuronal<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">1-3</span></a>&#46; En los &#250;ltimos a&#241;os&#44; se ha reconocido que la p&#233;rdida neuronal y axonal contribuyen&#44; en gran medida&#44; a la discapacidad en EM&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El nervio &#243;ptico &#40;NO&#41; es una de las estructuras que con mayor frecuencia se afecta en el curso de la enfermedad<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">4</span></a> y es una de las causas de mayor discapacidad en estos pacientes por afectar negativamente a su calidad de vida<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">5</span></a>&#46; El desarrollo de t&#233;cnicas no invasivas&#44; como la tomograf&#237;a de coherencia &#243;ptica &#40;OCT&#41;&#44; ha permitido identificar la p&#233;rdida axonal en la v&#237;a visual anterior y el NO ha emergido como un modelo accesible para el estudio de la patogenia de la enfermedad y la monitorizaci&#243;n de estos cambios<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">En 1999 se public&#243; el primer estudio de OCT aplicado a la EM&#44; demostrando una reducci&#243;n de la capa de fibras nerviosas de la retina &#40;CFNR&#41; de pacientes con neuritis &#243;ptica previa respecto a sujetos sanos y al ojo no afectado del mismo paciente<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">7</span></a>&#46; Tambi&#233;n se ha demostrado que el adelgazamiento de la CFNR se relaciona con los cambios en la escala <span class="elsevierStyleItalic">Expanded Disability Status Scale</span> &#40;EDSS&#41;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">8&#44;9</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En los &#250;ltimos a&#241;os&#44; se est&#225; demostrando que el grosor de la CFNR se correlaciona con la atrofia cerebral y cl&#237;nicamente con la disfunci&#243;n visual&#44; lo que permite que el ojo pueda ser un modelo apropiado para estudiar los mecanismos de neurodegeneraci&#243;n e incluso puede servir para detectar la neuroprotecci&#243;n en EM<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">10-12</span></a>&#46; Por ello&#44; los ensayos cl&#237;nicos de EM han incorporado la OCT como resultados exploratorios con la intenci&#243;n de acumular conocimientos sobre la relaci&#243;n entre los cambios en la estructura retiniana y la funci&#243;n visual de los pacientes<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">13</span></a>&#46; Tambi&#233;n se ha observado una disminuci&#243;n progresiva durante el curso de la enfermedad&#44; incluso en aquellos ojos que no han presentado previamente una neuritis &#243;ptica<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Actualmente&#44; el auge de los ultrasonidos en las enfermedades neurol&#243;gicas nos ha permitido aplicar esta t&#233;cnica a la EM con la ecograf&#237;a orbitaria y la medici&#243;n del grosor del NO&#46; En estudios realizados con ecograf&#237;a del NO se obtuvieron diferencias entre el di&#225;metro del NO de pacientes con EM y controles sanos&#44; independientemente de si presentaron neuritis &#243;ptica aguda con anterioridad o no&#46; Esta observaci&#243;n lleva a considerarla como una t&#233;cnica &#250;til para monitorizar la p&#233;rdida axonal asociada a EM&#44; siendo una t&#233;cnica sencilla&#44; sensible y reproducible<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">15</span></a>&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Pacientes y m&#233;todos</span><p id="par0030" class="elsevierStylePara elsevierViewall">Se llev&#243; a cabo un estudio observacional anal&#237;tico ambispectivo&#44; con una cohorte de pacientes concurrente&#46; Se recogieron los datos de pacientes atendidos en la Unidad de Esclerosis M&#250;ltiple del Hospital Universitario Virgen Macarena de Sevilla a los que se les realiz&#243; ecograf&#237;a orbitaria con medici&#243;n del grosor del NO&#46; El estudio fue aprobado por el Comit&#233; de &#201;tica e Investigaci&#243;n del hospital&#46; Todos los datos de estos pacientes se recogieron previa firma del consentimiento informado para tal fin&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Los criterios de inclusi&#243;n fueron&#58; edad comprendida entre 18 y 75 a&#241;os&#44; ambos inclusive&#59; diagn&#243;stico de EM&#44; en cualquiera de sus formas evolutivas &#40;s&#237;ndrome cl&#237;nico aislado&#44; remitente recurrente&#44; primaria progresiva o secundaria progresiva&#41;&#59; pacientes que hubieran otorgado su consentimiento informado para participar en el estudio&#46; Los criterios de exclusi&#243;n fueron&#58; pacientes menores de 18 a&#241;os o mayores de 75 a&#241;os&#59; patolog&#237;a oftalmol&#243;gica grave &#40;glaucoma&#44; maculopat&#237;a&#44; etc&#46;&#41; y pacientes que no hubieran otorgado su consentimiento informado&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Para el estudio se us&#243; el transductor lineal de 7&#44;5<span class="elsevierStyleHsp" style=""></span>Hz del equipo ecogr&#225;fico Esaote&#174;&#46; El nivel de potencia del ultrasonido se ajust&#243; seg&#250;n el principio ALARA <span class="elsevierStyleItalic">&#40;as low as reasonably achievable&#41;</span><a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">16</span></a> y la medici&#243;n del NO &#40;visi&#243;n longitudinal&#41; se hizo a unos 3<span class="elsevierStyleHsp" style=""></span>mm de la papila<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">15</span></a>&#46; En nuestro caso se us&#243; la medici&#243;n junto a las cubiertas&#44; por la dif&#237;cil diferenciaci&#243;n entre ax&#243;n y cubiertas en la mayor&#237;a de los pacientes &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Se recogieron datos demogr&#225;ficos y datos retrospectivos y prospectivos sobre la enfermedad&#46; En el estudio prospectivo se defini&#243; progresi&#243;n como un aumento sostenido mayor de 0&#44;5 puntos en la escala EDSS durante m&#225;s de 3 meses&#46; Tambi&#233;n se recogieron datos de la OCT en aquellos pacientes que ten&#237;an realizadas ambas pruebas&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">El an&#225;lisis estad&#237;stico se efectu&#243; con el programa SPSS&#44; versi&#243;n 22&#46;0&#46; En todos los contrastes de hip&#243;tesis se consider&#243; un nivel de significaci&#243;n de 0&#44;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Resultados</span><p id="par0055" class="elsevierStylePara elsevierViewall">Se incluyeron 63 sujetos con EM a los cuales se les realiz&#243; una ecograf&#237;a orbitaria para la medici&#243;n del NO&#46; El seguimiento medio de los pacientes desde la realizaci&#243;n de la ecograf&#237;a fue de 9&#44;16 meses &#40;m&#225;ximo &#91;m&#225;x&#46;&#93; 18&#44; m&#237;nimo &#91;m&#237;n&#46;&#93; 3&#59; desviaci&#243;n est&#225;ndar &#91;DE&#93;&#58; 4&#44;37&#59; intervalo de confianza al 95&#37; &#91;IC 95&#37;&#93;&#58; 8&#44;06-10&#44;26&#41;&#46; No se perdieron pacientes en el seguimiento&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Las caracter&#237;sticas basales de los enfermos se describen en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; La edad media al diagn&#243;stico fue de 35&#44;5 a&#241;os &#40;m&#237;n&#46; 17&#44; m&#225;x&#46; 58&#59; DE&#58; 10&#44;06&#59; IC 95&#37;&#58; 32&#44;83-37&#44;9&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Los datos retrospectivos de la enfermedad se presentan en la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">El di&#225;metro medio del ojo derecho &#40;OD&#41; fue de 4&#44;54<span class="elsevierStyleHsp" style=""></span>mm &#40;m&#237;n&#46; 2&#44;29&#59; m&#225;x&#46; 6&#44;66&#59; DE&#58; 0&#44;95&#59; IC 95&#37;&#58; 4&#44;30-4&#44;78&#41; y el del ojo izquierdo &#40;OI&#41; de 4&#44;63<span class="elsevierStyleHsp" style=""></span>mm &#40;m&#237;n&#46; 2&#44;13&#59; m&#225;x&#46; 5&#44;89&#59; DE&#58; 0&#44;79&#59; IC 95&#37;&#58; 4&#44;43-4&#44;83&#41;&#46; Tambi&#233;n se calcul&#243; la diferencia entre ambos di&#225;metros &#40;asimetr&#237;a&#41;&#44; con un valor medio de 0&#44;69<span class="elsevierStyleHsp" style=""></span>mm &#40;m&#237;n&#46; 0&#59; m&#225;x&#46; 2&#44;20&#59; DE&#58; 0&#44;59&#59; IC 95&#37;&#58; 0&#44;54-0&#44;84&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">El tiempo medio de seguimiento tras la realizaci&#243;n de la ecograf&#237;a y el resto de pruebas paracl&#237;nicas fue de 9&#44;16 meses &#40;m&#225;x&#46; 18&#44; m&#237;n&#46; 3&#59; DE&#58; 4&#44;37&#59; IC 95&#37;&#58; 8&#44;06-10&#44;26&#41;&#46; El 15&#44;9&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#41; de los pacientes presentaron alg&#250;n brote en el seguimiento posterior&#46; Se registraron una media de 0&#44;24 brotes &#40;m&#237;n&#46; 0&#44; m&#225;x&#46; 3&#59; DE&#58; 0&#44;56&#59; IC 95&#37;&#58; 0&#44;10-0&#44;38&#41; con una tasa anualizada de brotes &#40;TAB&#41; promedio de 0&#44;26 &#40;m&#237;n&#46; 0&#44; m&#225;x&#46; 2&#44;40&#59; DE&#58; 0&#44;61&#59; IC 95&#37;&#58; 0&#44;11-0&#44;41&#41;&#46; El tiempo medio en aparecer el primer brote en el seguimiento fue de 7&#44;80 meses &#40;m&#237;n&#46; 0&#44;30&#44; m&#225;x&#46; 17&#44;80&#59; DE&#58; 4&#44;46&#59; IC 95&#37;&#58; 6&#44;68-8&#44;92&#41;&#46; La EDSS media registrada al final del estudio fue de 2&#44;81 &#40;m&#237;n&#46; 0&#44; m&#225;x&#46; 7&#44;5&#59; DE&#58; 2&#44;07&#59; IC 95&#37;&#58; 2&#44;29-3&#44;33&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Se encontr&#243; una progresi&#243;n mantenida con un aumento mayor de 0&#44;5 puntos en la EDSS en el 27&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>17&#41; de los pacientes&#46; El tiempo medio en aparecer esta progresi&#243;n fue de 7&#44;90 meses &#40;m&#237;n&#46; 1&#44;87&#59; m&#225;x&#46; 17&#44;84&#59; DE&#58; 4&#44;17&#59; IC 95&#37;&#58; 6&#44;85-8&#44;95&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">En el an&#225;lisis retrospectivo no se encontraron diferencias significativas entre las medidas ecogr&#225;ficas y las variables cl&#237;nicas&#46; No hubo diferencias en cuanto a la presencia de neuritis &#243;ptica previa&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Se analizaron los datos ecogr&#225;ficos en funci&#243;n de la presencia de brotes y de progresi&#243;n mantenida&#44; y los resultados se detallan en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46; El an&#225;lisis&#44; junto con los datos evolutivos en el periodo de seguimiento&#44; se presenta en la <a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Se realizaron 52 estudios de OCT&#44; pero solo pudieron recogerse datos de ambos ojos en 50 pacientes&#46; En los otros 2 pacientes no pudo completarse el estudio en el otro ojo por imposibilidad t&#233;cnica &#40;nistagmo intenso que no permit&#237;a fijar la vista&#41;&#46; Los datos se exponen en la <a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#46; Los resultados del estudio realizado buscando una correlaci&#243;n entre los datos ecogr&#225;ficos y los de OCT se muestran en la <a class="elsevierStyleCrossRef" href="#tbl0030">tabla 6</a>&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discusi&#243;n</span><p id="par0100" class="elsevierStylePara elsevierViewall">Las lesiones del sistema nervioso central detectadas en la EM se caracterizan por la disrupci&#243;n de la barrera hematoencef&#225;lica&#44; inflamaci&#243;n&#44; desmielinizaci&#243;n&#44; p&#233;rdida de oligodendrocitos&#44; gliosis reactiva y degeneraci&#243;n neuronal&#47;axonal<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">1&#44;17&#44;18</span></a>&#46; La p&#233;rdida neuronal&#47;axonal progresiva se considera la causa m&#225;s importante de discapacidad neurol&#243;gica en la EM y es detectable desde estadios iniciales<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">19</span></a>&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">La ecograf&#237;a orbitaria ha sido usada con anterioridad para valorar el NO en condiciones de hipertensi&#243;n intracraneal<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">20</span></a> y para valorar la neuritis &#243;ptica aguda<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">21</span></a>&#46; Tambi&#233;n ha sido comparada con resonancia magn&#233;tica de 3 teslas&#44; encontrando una buena precisi&#243;n en la medida&#44; con reproducibilidad y buena relaci&#243;n interobservador e intraobservador<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">22</span></a>&#46; Los valores ecogr&#225;ficos obtenidos en nuestro estudio son similares a los encontrados en la literatura previamente<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">23</span></a>&#44; as&#237; como los datos referentes a la enfermedad y su evoluci&#243;n&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">En el seguimiento de los pacientes&#44; encontramos una puntuaci&#243;n EDSS media al final del estudio ligeramente mayor que al inicio del estudio&#44; cambio esperable por la evoluci&#243;n de la enfermedad<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">24&#44;25</span></a>&#46; Encontramos una correlaci&#243;n negativa estad&#237;sticamente significativa entre los di&#225;metros de ambos ojos y esta EDSS&#44; de tal manera que a menor di&#225;metro de NO&#44; mayor puntuaci&#243;n en la escala al final del estudio&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">En nuestro estudio tambi&#233;n encontramos diferencias estad&#237;sticamente significativas entre pacientes con progresi&#243;n y sin progresi&#243;n&#44; siendo menores los di&#225;metros en el grupo con progresi&#243;n para ambos ojos&#46; No obtuvimos el mismo resultado para la presencia de brotes&#44; n&#250;mero de brotes&#44; la TAB y el tiempo transcurrido hasta el primer brote&#46; Este hecho viene sustentado por el car&#225;cter inflamatorio subyacente al desarrollo de brotes&#46; Sin embargo&#44; cuando hablamos de progresi&#243;n&#44; al igual que la EDSS y la discapacidad&#44; se relaciona en funci&#243;n de cambios de neurodegeneraci&#243;n y p&#233;rdida axonal<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">26</span></a>&#44; cambios que pueden ser valorados con la ecograf&#237;a&#44; de igual manera que el grosor de la CFNR y&#47;o el volumen cerebral han sido designados como marcadores subrogados<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">27</span></a>&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Hasta la actualidad no se ha estudiado la relaci&#243;n entre los grosores del NO medido por ecograf&#237;a y la OCT en pacientes con EM&#44; debido&#44; por un lado&#44; a la reciente incorporaci&#243;n de esta t&#233;cnica a este campo y&#44; por otro&#44; a que a&#250;n se encuentra en fase de estudio&#46; S&#237; se ha prestado atenci&#243;n a los par&#225;metros hemodin&#225;micos de la &#243;rbita&#44; principalmente en relaci&#243;n con la neuritis &#243;ptica<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">28-32</span></a>&#46; En nuestro estudio encontramos una relaci&#243;n positiva estad&#237;sticamente significativa entre el grosor del di&#225;metro del NO medido por ecograf&#237;a&#44; la CFNR y el grosor medio de la capa granulosa en el OD&#46; Esta relaci&#243;n positiva &#40;a mayor grosor de nervio por ecograf&#237;a&#44; mayores grosores en las capas medidas por OCT&#41; apunta a que la ecograf&#237;a es capaz de medirlo de forma simple y menos precisa&#44; al no poder diferenciar entre capas&#46; Esta medida&#44; sencilla de adquirir&#44; puede darnos una idea aproximada de la integridad del nervio en estos enfermos&#46; La disparidad entre ambos ojos puede deberse a que hay mayor presencia de neuritis &#243;pticas previas en el OD &#40;20&#44;6&#37; vs&#46; 15&#44;9&#37;&#41;&#59; sin embargo&#44; confirmar esta hip&#243;tesis requerir&#237;a de m&#225;s estudios&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">La medici&#243;n del di&#225;metro del NO por ecograf&#237;a podr&#237;a utilizarse como medida predictiva en la evoluci&#243;n de la enfermedad&#44; ya que la disminuci&#243;n del mismo se asocia con progresi&#243;n cl&#237;nica y mayor discapacidad&#44; medidas por la EDSS en el seguimiento&#46; A falta de un &#171;patr&#243;n oro&#187; para la evaluaci&#243;n de la neurodegeneraci&#243;n y del da&#241;o axonal&#44; la ecograf&#237;a del NO puede servir como una herramienta &#250;til en la evaluaci&#243;n de los pacientes con EM&#44; aunque ser&#237;an necesarios m&#225;s estudios para corroborarlo&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflicto de intereses</span><p id="par0130" class="elsevierStylePara elsevierViewall">No existe conflicto de intereses en ninguno de los autores&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Introducci&#243;n La p&#233;rdida neuronal&#47;axonal progresiva se considera la causa m&#225;s importante de discapacidad neurol&#243;gica en la esclerosis m&#250;ltiple &#40;EM&#41;&#46; El sistema visual est&#225; frecuentemente afectado en esta enfermedad y su accesibilidad a test funcionales y estructurales ha permitido que se convierta en un modelo para estudiar in vivo la patogenia de la EM&#46; La ecograf&#237;a orbitaria permite evaluar&#44; de forma no invasiva y en tiempo real&#44; las diversas estructuras de la &#243;rbita&#44; incluido el nervio &#243;ptico&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se ha llevado a cabo un estudio observacional ambispectivo en pacientes con EM recogi&#233;ndose datos evolutivos de la enfermedad&#46; La ecograf&#237;a orbitaria se realiz&#243; en todos los pacientes seg&#250;n el principio de m&#237;nima potencia necesaria &#40;ALARA&#41;&#46; Tambi&#233;n se recogieron los datos de tomograf&#237;a de coherencia &#243;ptica &#40;OCT&#41; en aquellos que ten&#237;an realizadas ambas pruebas&#46; El estudio estad&#237;stico se efectu&#243; con el programa SPSS 22&#46;0&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se encontraron correlaciones estad&#237;sticamente significativas entre las medidas ecogr&#225;ficas y la progresi&#243;n de la enfermedad &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;041 para el ojo derecho y p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;037 para el ojo izquierdo&#41;&#44; y la <span class="elsevierStyleItalic">Expanded Disability Status Scale</span> &#40;EDSS&#41; final en el seguimiento &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;07 para el ojo derecho y p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;043 para el ojo izquierdo&#41;&#46; No fue as&#237; para los datos referentes a brotes y a otras variables cl&#237;nicas&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La medici&#243;n del di&#225;metro del nervio &#243;ptico por ecograf&#237;a podr&#237;a utilizarse como medida predictiva en la evoluci&#243;n de la EM&#44; ya que la disminuci&#243;n del mismo se asocia con progresi&#243;n cl&#237;nica y mayor discapacidad&#44; medidas con la EDSS&#46;</p></span>"
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            "identificador" => "abst0015"
            "titulo" => "Resultados"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Progressive neuronal and axonal loss are considered the main causes of disability in patients with multiple sclerosis &#40;MS&#41;&#46; The disease frequently involves the visual system&#59; the accessibility of the system for several functional and structural tests has made it a model for the in vivo study of MS pathogenesis&#46; Orbital ultrasound is a non-invasive technique that enables various structures of the orbit&#44; including the optic nerve&#44; to be evaluated in real time&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Material and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We conducted an observational&#44; ambispective study of MS patients&#46; Disease progression data were collected&#46; Orbital ultrasound was performed on all patients&#44; with power set according to the &#8216;as low as reasonably achievable&#8217; &#40;ALARA&#41; principle&#46; Optical coherence tomography &#40;OCT&#41; data were also collected for those patients who underwent the procedure&#46; Statistical analysis was conducted using SPSS version 22&#46;0&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Disease progression was significantly correlated with ultrasound findings &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;041 for the right eye and <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;037 for the left eye&#41; and with Expanded Disability Status Scale &#40;EDSS&#41; score at the end of the follow-up period &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;07 for the right eye and <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;043 for the left eye&#41;&#46; No statistically significant differences were found with relation to relapses or other clinical variables&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Ultrasound measurement of optic nerve diameter constitutes a useful&#44; predictive factor for the evaluation of patients with MS&#46; Smaller diameters are associated with poor clinical progression and greater disability &#40;measured by EDSS&#41;&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">El trabajo ha sido presentado parcialmente en las siguientes reuniones&#58; LXVIII Reuni&#243;n de la Sociedad Espa&#241;ola de Neurolog&#237;a &#40;presentaci&#243;n tipo p&#243;ster y comunicaci&#243;n oral&#41;&#59; 32<span class="elsevierStyleSup">nd</span> Congress of ECTRIMS &#40;presentaci&#243;n tipo p&#243;ster&#41;&#59; 22<span class="elsevierStyleSup">nd</span> Meeting of the European Society of Neurosonology and Cerebral Hemodynamics &#40;presentaci&#243;n tipo p&#243;ster&#41;&#46;</p>"
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Ecograf&#237;a orbitaria&#58; imagen longitudinal del nervio &#243;ptico en un paciente con esclerosis m&#250;ltiple&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">CIS&#58; <span class="elsevierStyleItalic">clinical isolated syndrome</span> &#40;s&#237;ndrome neurol&#243;gico aislado&#41;&#59; EM&#58; esclerosis m&#250;ltiple&#59; IC&#58; intervalo de confianza&#59; PP&#58; primaria progresiva&#59; RR&#58; remitente recurrente&#59; SP&#58; secundaria progresiva&#46;</p>"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">TAB &#250;ltimos 2 a&#241;os</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;65 &#40;0&#44;67&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;48-0&#44;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;5 &#40;0-1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2552297.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas de la enfermedad</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Tabla 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Tabla "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">DE&#58; desviaci&#243;n est&#225;ndar&#59; IC&#58; intervalo de confianza&#59; NS&#58; no significativo&#59; OD&#58; ojo derecho&#59; OI&#58; ojo izquierdo&#46;</p><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">En negrita est&#225; el valor de p que es estad&#237;sticamente significativo &#40;p &#60; 0&#44;05&#41;&#46;</p>"
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            0 => array:2 [
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                0 => """
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n &#40;m&#237;n&#46;&#59; m&#225;x&#46;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Media &#40;DE&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IC 95&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n &#40;m&#237;n&#46;&#59; m&#225;x&#46;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Media &#40;DE&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IC 95&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="9" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Progresi&#243;n</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">4&#44;14 &#40;0&#44;69&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#44;79-4&#44;49&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " rowspan="2" align="center" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;041</span></td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;58 &#40;0&#44;94&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#44;91-5&#44;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46 &#40;2&#44;29&#59; 6&#44;67&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;69 &#40;0&#44;99&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;39-4&#44;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46 &#40;2&#44;13&#59; 5&#44;90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;72 &#40;0&#44;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;48-4&#44;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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ISSN: 02134853
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