Protocolo de actuación médica para el tratamiento del hematoma subdural crónico

Hemos leído el reciente trabajo publicado en su revista por A. Barbosa y colaboradores, titulado: "Protocolo de actuación médica para el tratamiento del hematoma subdural crónico" y nos gustaría hacer algún comentario a este, ya que en nuestro Hospital tenemos una larga y amplia experiencia en el tipo de patología investigada.En primer lugar, deseamos felicitar a los autores(as) por la elaboración del protocolo. Consideramos que el hematoma subdural crónico (HSC) es una patología con la suficiente entidad y repercusión social para que exista una guía o protocolo para su diagnóstico, tratamiento y seguimiento, pues en numerosos hospitales no disponemos de ella. No podemos olvidar que Balser y otros calculan que, debido al envejecimiento progresivo de la población, en el año 2030 se operarán en Norteamérica unos 60 000 HSC, situación que contribuirá a aumentar la frecuencia de dicha patología neuroquirúrgica, en nuestra opinión calculamos que podría extenderse a todos los países. Además, el HSC en esta población mayor, tiene niveles altos de mortalidad y reduce de manera notable las expectativas de vida. Nos llama la atención que en la sección introductoria, los autores(as) mencionen a los aneurismas intracraneales rotos o a las malformaciones arteriovenosas cerebrales (MAV) como posibles causas de hematoma subdural crónico. En nuestra serie de este tipo de hematomas y con un número ya cercano a 2 000 pacientes operados, no hemos observado ningún caso de hemorragia subaracnoidea o MAV y se escapa a nuestras observaciones por cuál mecanismo estas patologías puedan dar lugar a los hematomas. Así también, ellos citan a las hemorragias profusas como posibles complicaciones. En nuestra experiencia, solo se han presentado en cuatro casos (0,51 %) y en la reciente revisión de Rahujala y otros, solo representan el 1,1 %. Además, se encuentran por detrás de las recidivas (18 %), las crisis epilépticas (4,8 %), y la infección, con un 3 %.(5) Las complicaciones más frecuentes y que más preocupan por su mayor incidencia en estos pacientes, son la médicas al tratarse de pacientes de edad avanzada en su mayoría, y con múltiples comorbilidades sistémicas

Effects of external ventricular drainage decompression of intracranial hypertension on rebleeding of brain aneurysms: A fluid structure interaction study

Objectives: The treatment of hydrocephalus using external ventricular drainage (EVD) seems to favour rebleeding of an untreated ruptured aneurysm. FSI studies are valuable to study this environment. Patients and methods: From December 2014 to December 2017, 61 patients with SAH required EVD due to hydrocephalus, 6 patients had aneurysm rebleeding after the procedure. Two controls for each case was included. DSA studies were used for fluid–structure interaction simulations using two scenarios high ICP (5332 Pa) and low ICP (133 Pa). Results: Maximum displacement of the wall in HICP was 0.34 mm and 0.26 mm in rebleeding and no rebleeding cases respectively, after EVD (LICP), it was 0.36 mm and 0.27 mm. The difference after implantation of EVD (HICP-LICP) had an average of 0.01567 mm and 0.00683 mm in rebleeding and no rebleeding cases (p = 0.05). This measure in low shear areas of the aneurysm was 0.026 and 0.0065 mm in rebleeding and no rebleeding cases (p = 0.01). Effective stress in the HICP was 4.77 MPa and 3.26 MPa in rebleeding and no rebleeding cases (p = 0.25). In LICP condition, this measure was 2.28 MPa and 1.42 MPa respectively (p = 0.33). TAWSS had no significant differences in the conditions of HICP and LICP. Conclusion: Changes after EVD placement includes an increase in the wall displacement with greater differences over low shear areas, this had a strong association with rebleeding.Xunta de Galicia | Ref. POS-A/2013/161Xunta de Galicia | Ref. ED481B 2016/047-0Xunta de Galicia | Ref. ED481D 2017/01

Impact of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients: A nationwide study in Spain

Objective To assess the effect of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients in Spain. Settings The initial flood of COVID-19 patients overwhelmed an unprepared healthcare system. Different measures were taken to deal with this overburden. The effect of these measures on neurosurgical patients, as well as the effect of COVID-19 itself, has not been thoroughly studied. Participants This was a multicentre, nationwide, observational retrospective study of patients who underwent any neurosurgical operation from March to July 2020. Interventions An exploratory factorial analysis was performed to select the most relevant variables of the sample. Primary and secondary outcome measures Univariate and multivariate analyses were performed to identify independent predictors of mortality and postoperative SARS-CoV-2 infection. Results Sixteen hospitals registered 1677 operated patients. The overall mortality was 6.4%, and 2.9% (44 patients) suffered a perioperative SARS-CoV-2 infection. Of those infections, 24 were diagnosed postoperatively. Age (OR 1.05), perioperative SARS-CoV-2 infection (OR 4.7), community COVID-19 incidence (cases/10 5 people/week) (OR 1.006), postoperative neurological worsening (OR 5.9), postoperative need for airway support (OR 5.38), ASA grade =3 (OR 2.5) and preoperative GCS 3-8 (OR 2.82) were independently associated with mortality. For SARS-CoV-2 postoperative infection, screening swab test <72 hours preoperatively (OR 0.76), community COVID-19 incidence (cases/10 5 people/week) (OR 1.011), preoperative cognitive impairment (OR 2.784), postoperative sepsis (OR 3.807) and an absence of postoperative complications (OR 0.188) were independently associated. Conclusions Perioperative SARS-CoV-2 infection in neurosurgical patients was associated with an increase in mortality by almost fivefold. Community COVID-19 incidence (cases/10 5 people/week) was a statistically independent predictor of mortality. Trial registration number CEIM 20/217

Treatment with tocilizumab or corticosteroids for COVID-19 patients with hyperinflammatory state: a multicentre cohort study (SAM-COVID-19)

Objectives: The objective of this study was to estimate the association between tocilizumab or corticosteroids and the risk of intubation or death in patients with coronavirus disease 19 (COVID-19) with a hyperinflammatory state according to clinical and laboratory parameters. Methods: A cohort study was performed in 60 Spanish hospitals including 778 patients with COVID-19 and clinical and laboratory data indicative of a hyperinflammatory state. Treatment was mainly with tocilizumab, an intermediate-high dose of corticosteroids (IHDC), a pulse dose of corticosteroids (PDC), combination therapy, or no treatment. Primary outcome was intubation or death; follow-up was 21 days. Propensity score-adjusted estimations using Cox regression (logistic regression if needed) were calculated. Propensity scores were used as confounders, matching variables and for the inverse probability of treatment weights (IPTWs). Results: In all, 88, 117, 78 and 151 patients treated with tocilizumab, IHDC, PDC, and combination therapy, respectively, were compared with 344 untreated patients. The primary endpoint occurred in 10 (11.4%), 27 (23.1%), 12 (15.4%), 40 (25.6%) and 69 (21.1%), respectively. The IPTW-based hazard ratios (odds ratio for combination therapy) for the primary endpoint were 0.32 (95%CI 0.22-0.47; p < 0.001) for tocilizumab, 0.82 (0.71-1.30; p 0.82) for IHDC, 0.61 (0.43-0.86; p 0.006) for PDC, and 1.17 (0.86-1.58; p 0.30) for combination therapy. Other applications of the propensity score provided similar results, but were not significant for PDC. Tocilizumab was also associated with lower hazard of death alone in IPTW analysis (0.07; 0.02-0.17; p < 0.001). Conclusions: Tocilizumab might be useful in COVID-19 patients with a hyperinflammatory state and should be prioritized for randomized trials in this situatio

Role of age and comorbidities in mortality of patients with infective endocarditis

[Purpose]: The aim of this study was to analyse the characteristics of patients with IE in three groups of age and to assess the ability of age and the Charlson Comorbidity Index (CCI) to predict mortality. [Methods]: Prospective cohort study of all patients with IE included in the GAMES Spanish database between 2008 and 2015.Patients were stratified into three age groups:<65 years,65 to 80 years,and ≥ 80 years.The area under the receiver-operating characteristic (AUROC) curve was calculated to quantify the diagnostic accuracy of the CCI to predict mortality risk. [Results]: A total of 3120 patients with IE (1327 < 65 years;1291 65-80 years;502 ≥ 80 years) were enrolled.Fever and heart failure were the most common presentations of IE, with no differences among age groups.Patients ≥80 years who underwent surgery were significantly lower compared with other age groups (14.3%,65 years; 20.5%,65-79 years; 31.3%,≥80 years). In-hospital mortality was lower in the <65-year group (20.3%,<65 years;30.1%,65-79 years;34.7%,≥80 years;p < 0.001) as well as 1-year mortality (3.2%, <65 years; 5.5%, 65-80 years;7.6%,≥80 years; p = 0.003).Independent predictors of mortality were age ≥ 80 years (hazard ratio [HR]:2.78;95% confidence interval [CI]:2.32–3.34), CCI ≥ 3 (HR:1.62; 95% CI:1.39–1.88),and non-performed surgery (HR:1.64;95% CI:11.16–1.58).When the three age groups were compared,the AUROC curve for CCI was significantly larger for patients aged <65 years(p < 0.001) for both in-hospital and 1-year mortality. [Conclusion]: There were no differences in the clinical presentation of IE between the groups. Age ≥ 80 years, high comorbidity (measured by CCI),and non-performance of surgery were independent predictors of mortality in patients with IE.CCI could help to identify those patients with IE and surgical indication who present a lower risk of in-hospital and 1-year mortality after surgery, especially in the <65-year group

Hemorragia intracerebral diferida tras biopsia estereotáctica

El empleo de la biopsia estereotáctica en el manejo de las lesiones intracraneales esta bien establecida en la práctica neuroquirúrgica, al tratarse de una técnica poco invasiva; con frecuencia se minusvaloran sus complicaciones, siendo la más importante la hemorragia intracraneal. Se presenta el caso clínico de un paciente sometido a una biopsia estereotáctica y que presentó una hemorragia intracerebral 17 días después de realizado el procedimiento