Utilidad de las craniectomías descompresivas

El objetivo de este trabajo consiste en demostrar la utilidad de la craniectomía descompresiva (CD) en el control de la hipertensión intracraneal (HIC) refractaria a tratamiento médico. Desde Enero de 2003 a Marzo de 2008, ambos inclusive, se recogieron 31 pacientes a los que se les realizó una CD bajo las circunstancias previas, tras presentar un traumatismo craneoencefálico (9 pacientes), una patología vascular cerebral (17 casos, 6 de ellos por infarto maligno de la arteria cerebral media derecha) o una patología tumoral cerebral (5 pacientes). Se utilizó la “Glasgow Outcome Scale” para la valoración del pronóstico final a los 6 meses. Además, se relacionaron diferentes variables epidemiológicas, clínicas, radiológicas y terapéuticas con el pronóstico final de los pacientes. Un total de 16 sujetos presentó un buen resultado (sin discapacidad o discapacidad moderada), mientras los restantes 15 pacientes desarrollaron un mal pronóstico (discapacidad grave, estado vegetativo o exitus). Siete pacientes fallecieron (22.6%). Los resultados demostraron que la CD modifica la historia natural de la HIC refractaria a tratamiento médico, es decir, disminuye la mortalidad en estos pacientes pero sin aumentar la morbilidad asociada. Por otro lado, el único factor que se pudo relacionar con el pronóstico final de los pacientes fue la presencia de alteraciones pupilares (midriasis uni o bilateral) previas a la descompresión quirúrgica.The goal of this work consists of demonstrating the utility of the decompressive craniectomy (DC) for the control and treatment of the refractory intracranial hypertension (ICH). From January 2003 to March 2008, both including, we gathered 31 patients to whom a DC under the previous circumstances was performed, after displaying a head injury (9 patients), a cerebral vascular pathology (17 cases, 6 of them secondary to a malignant right middle cerebral artery infarction), or a cerebral tumour (5 patients). The final outcome was graded at 6 months using the Glasgow Outcome Scale. In addition, different variables including epidemiological, clinical, radiological, and therapeutical were related to the final prognosis of these patients. A total of 16 subjects presented a favourable result (without disability or moderate disability), while the remaining 15 patients developed an unfavourable prognosis (severe disability, vegetative state, or death). Mortality rate was 22.6% (7 out of 31). The results demonstrated that DC modifies the natural history of the refractory ICH, that is to say, diminishes the mortality in these patients but without increasing the associate morbidity. On the other hand, the only factor that could be related to the final prognosis of the patients was the presence of pupillary changes (uni or bilateral mydriasis) previous to the surgical decompression

Estudio de las alteraciones genéticas del IDH1 y del VEGF en los tumores cerebrales

Introducción: Múltiples marcadores moleculares se han relacionado recientemente con los tumores cerebrales. Este trabajo estudia la presencia de la mutación del gen de la enzima isocitrato dehidrogenasa 1 (IDH1) y del polimorfismo +936 C/T del factor de crecimiento vascular endotelial (VEGF) en los tumores cerebrales. Además, valora el impacto que estas alteraciones genéticas tienen en la supervivencia. Material y método: La muestra estuvo constituida por 93 pacientes intervenidos en el Hospital Clínico San Carlos de Madrid, entre marzo de 2004 y noviembre de 2012. Como controles para el VEGF se tomaron 325 pacientes ambulatorios de Nefrología. Resultados: La mutación del IDH1 se encontró en 12 pacientes (13,04%), 5 (45,45%) en gliomas benignos y 7 (14,38%) en gliomas malignos. La curva de supervivencia para IDH1 mostró una tendencia hacia un mejor pronóstico de los tumores que exhiben la mutación, con una p de 0,0731 y una Hazard Ratio de 0,35. El polimorfismo del VEGF se encontró en 20 pacientes (21,51%), siendo más frecuente en oligodendrogliomas, meningiomas y ependimomas, sin relación con la supervivencia. Respecto a los controles para VEGF, este polimorfismo se registró en un 23,38%. El estudio de casos y controles no demostró asociación con la supervivencia ni con el riesgo de desarrollar un tumor cerebral. Conclusiones: La mutación en IDH1 es más frecuente en gliomas benignos, con una tendencia a mayor supervivencia de los pacientes que la portan. El polimorfismo +936 C/T del VEGF es más frecuente en tumores benignos aunque sin relación estadística con la supervivencia.Introduction: Multiple molecular markers have recently been related to brain tumors. This study evaluates the presence of gene mutation in isocitrate dehydrogenase enzyme (IDH1) and the vascular endothelial growth factor (VEGF) +936 C/T polymorphism in brain tumors. The impact of these genetic alterations on overall survival was evaluated. Material and Method: A sample of 93 patients operated at Hospital Clínico San Carlos, Madrid, between March 2004 and November 2012, were included. A total of 325 Nephrology outpatients were taken as controls for the VEGF study. Results: IDH1 mutation was found in 12 patients (13.04%), 5 (45.45%) in benign gliomas and 7 (14.38%) in malignant gliomas. The survival curve for IDH1 showed a tendency towards a better prognosis of the tumors exhibited by the mutation, with a p 0.0731 and a Hazard Ratio 0.35. The VEFG +936 C/T polymorphism was found in 20 patients (21.51%), the most common being in oligodendrogliomas, meningiomas and ependymomas, and unrelated to survival. Regarding the controls for VEGF, this polymorphism was recorded in 23.38% of the patients. The case-control study did not show any association with survival or the risk of developing a brain tumor. Conclusions: IDH1 mutation is more frequent in benign gliomas, with a greater survival trend in patients who carry it. The VEGF +936 C/T polymorphism is more common in benign tumors, although there is no statistic relation to survival

Historia de la neurocirugía moderna

The surgery of the nervous system is etymologically known as “Neurosurgery”. Although cranial trepanation is possibly the oldest operation which there are proven traces, from the Paleolithic period (12,000 years BC), Neurosurgery as a discipline of Medicine and Surgery specialty began as such at the end of XIX century. From that time until today can be sentenced to no other medical or surgical speciality that has experienced such a huge development in the span of little over a century. In this paper this historical development of what could be considered “modern” Neurosurgery is exposed. Additional emphasis is placed on what will be the Neurosurgery in the not too distant future, if not already present.La cirugía del sistema nervioso es etimológicamente conocida como “Neurocirugía”. Aunque posiblemente sea la trepanación craneal la operación más antigua de la cual existen huellas comprobadas, ya desde el período Paleolítico (12.000 años a. C.), la Neurocirugía como disciplina de la Medicina y especialidad de la Cirugía se inició como tal a finales del siglo XIX. Desde ese momento hasta nuestros días puede sentenciarse que no hay ninguna otra especialidad médica o quirúrgica que haya experimentado un desarrollo tan ingente en el lapso de poco más de un siglo. En este trabajo se expone este devenir histórico de la que puede considerarse como Neurocirugía “moderna”. Asimismo, se hace hincapié respecto a lo que será la Neurocirugía en un futuro no muy lejano, por no decir ya presente

Flipped classroom applied to Neurosurgery in undergraduate medical education

To compare the academic achievement obtained in Neurosurgery in a class of undergraduate students according to the pedagogical methodology employed: flipped classroom (FC) versus traditional lecture. Students’ satisfaction with the FC model is also analyzed. A quasi-experimental study was designed. The traditional lecture was the pedagogical method employed in teaching units (TUs) 1, 2, and 3 (61, 60, and 66 enrolled students, respectively), whereas TU 4 (69 enrolled students) used the FC methodology. The dropout rate was lower, whereas the academic achievement and the rate of correct answers were higher in TU 4 compared to the rest of the TUs, but these results were not statistically significant. However, the mean score obtained in Neurosurgery was significantly higher in TU 4 compared to the rest of the TUs (p = 0.042). Active learning activities based on clinical cases were positively emphasized. The main weakness was with the time consumed for video-recorded lecture viewing. The FC approach showed better academic results than traditional lectures when comparing students in the same Medical School during the same academic year undergoing the same exam. The students rated the FC approach positively, considering it stimulating and useful for learnin

Neuroprotective efect of indomethacin in normal perfusion pressure breakthrough phenomenon

Loss of cerebral autoregulation in normal perfusion pressure breakthrough (NPPB) phenomenon has been reported in other Central Nervous System diseases such as neonatal intraventricular haemorrhage. Several studies have demonstrated that low-dose indomethacin prevents this latter condition. A previous rat model was used to resemble NPPB phenomenon. Study animals were distributed in 4 groups that received 3 doses of indomethacin at different concentrations prior to fistula occlusion 60 days after its creation. Control animals received saline solution. Intracranial pressure (ICP) increased in all groups following fistula creation, whereas mean arterial pressure (MAP) and cerebral perfusion pressure (CPP) decreased as a manifestation of cerebral hypoperfusion and intracranial hypertension. The administration of indomethacin was associated with raised MAP and CPP, as well as decreased ICP. Sodium fluorescein extravasation was slight in study animals when comparing with control ones. Histological analysis evidenced diffuse ischaemic changes with signs of neuronal apoptosis in all brain layers in control animals. These findings were only focal and slight in study animals. The results suggest the usefulness of indomethacin to revert, at least partially, the haemodynamic effects of NPPB phenomenon in this experimental model, as well as to reduce BBB disruption and histological ischemia observed in absence of indomethacinThis study has been supported by the Spanish Ministries of Economy and Competitiveness in collaboration with the European Regional Development Fund (FEDER) under Grant FIS PI 12/0290

Tunneled antibiotic-impregnated vs. bolt-connected, non-coated external ventricular drainage: a comparison of complications

External ventricular drainage (EVD) is a common emergency neurosurgical procedure, but it is not free of adverse events. The aim of this study is to compare the complication rate of two frequently used EVD types, namely, tunneled antibiotic-impregnated catheters (Bactiseal©) and bolt-connected non-coated devices (Camino©). All EVDs placed between 1 March 2015 and 31 December 2017 were registered. Procedures performed with any catheter different from Bactiseal© or Camino© EVD with incomplete follow-up and those EVDs placed due to infectious disease were excluded. Demographic and clinical variables, as well as the overall complication rate (infection, hemorrhage, obstruction, malposition of the catheter, and involuntary pull-out of the device) and the need for replacement of the EVD, were collected. A total of 77 EVDs were finally considered for analysis (40 Bactiseal® and 37 Camino®). There was a statistically significant difference in diagnosis and also in the location of the procedure, as more bolt-connected EVD was placed outside the operating room (97.3 vs. 23.5%, p < 0.001) due to emergent pathologies such as vascular diseases and spontaneous hemorrhages. In the univariate analysis, a statistically significantly higher rate of catheter involuntary pull-out (29.7 vs. 7.5%, p = 0.012) and the need for EVD replacement (32.4 vs. 12.5%, p = 0.035) was found in the Camino cohort. However, those differences could not be confirmed with multivariable analysis, which showed no association between the type of catheter and any of the studied complications. Ventriculostomy duration was identified as a risk factor for infection (OR 1.09, 95% CI 1.02–1.18). No significant differences were observed regarding infection, hemorrhage, obstruction, malposition, involuntary catheter pull-out, and the need for EVD replacement when comparing non-impregnated bolt-connected EVDs (Camino®) with tunneled antibiotic-impregnated catheters (Bactiseal®). The duration of EVD was associated with an increased risk of infection

Oral extrusion of a vertebral body replacement device after chordoma tumor growth and radiation: case report and review

Screw migration following anterior cervical discectomy and fusion is a very rare complication and it is often related to device failure. Even more exceptional is the extrusion of an intervertebral graft. We report the second case of migration and extrusion through the oral cavity of a cervical vertebral body replacement device (expandable cylinder) in a patient that had undergone cervical corpectomy due to a vertebral chordoma. The antecedent of radiation therapy as well as progressive tumor re-growth may have favored the development of this complication. A literature review is adde

Non-communicating hydrocephalus from pork tapeworm obstructing the foramina of Monro and its endoscopic management; a case report from Europe

Introduction: Taenia solium is the main causative agent of neurocysticercosis. The tapeworm can manifest inside the ventricles, usually in the form of intracranial hypertension. We present a case of hydrocephalus as a result of a neurocysticercosis lesion obstructing both foramina of Monro. Research question: A comprehensive review of the management is provided, as well as video footage (an invaluable resource to compare, critique and learn with other institutions). Material and methods: A 23-year-old female from Honduras presented with a 7-day complaint of headache. On exam, she was hyperreflexic, but otherwise normal. Magnetic resonance imaging (MRI) revealed a non-specific lesion at the level of the foramina of Monro, with associated hydrocephalus. Additional testing was normal. Results: The patient underwent an endoscopic ventriculoscopy with partial excision of the lesion and subsequent implantation of a ventriculoperitoneal shunt. On postoperative MRI, hydrocephalus resolved and pathological analysis identified the parasite as Taenia solium. Albendazole was administered for 14 days. Discussion and conclusion: Neurocysticercosis should be considered in patients presenting with hydrocephalus, especially those from endemic areas. The long-term prognosis of ventricular neurocysticercosis might be favourable, provided that adequate care is given timely. Endoscopic surgery seems to be effective for the removal of parasitic lesions. However, studies comparing open versus endoscopic surgery are lacking. The majority of cases in the literature correspond to America and Asia. This case shows that neurocysticercosis is also present in Europe, and that a high index of suspicion is necessar

Is it feasible a cure of the large brain vascular malformations?

Introducción: el tratamiento definitivo de las malformaciones arteriovenosas (MAVs) supratentoriales complejas (grados III, IV y V en la clasificación de Spetzler & Martin) se ha reservado, clásicamente, para aquellos pacientes con cuadros clínicos progresivos o que habían presentado hemorragia cerebral. Objetivo: publicar nuestra experiencia en el tratamiento de estas MAVs complejas por medio de la embolización en fases con Onyx y la resección microquirúrgica en un segundo tiempo. Pacientes: trece pacientes consecutivos (6 hombres y 7 mujeres) con MAVs supratentoriales, grados III, IV y V en la clasificación de Spetzler & Martin, fueron tratados entre Enero de 2009 y Junio de 2010. La edad media al principio de la terapia fue de 34 años. Todos los pacientes estaban sintomáticos: hemorragia cerebral (5 pacientes), crisis epilépticas (5 casos), cefalea (2 pacientes) y/o déficit neurológico (2 casos). El tamaño medio de las MAVs fue de 48 mm y el volumen medio previo a la embolización de 47 ml. De acuerdo a la clasificación de Spetzler & Martin, 7 pacientes presentaban MAVs grado III, 4 sujetos MAVs grado IV y 2 pacientes MAVs grado V. Resultados: el número medio de procedimientos endovasculares mediante embolización fue de 3 y la obliteración volumétrica media previa a la cirugía del 79,2%. El tiempo medio que transcurrió entre dos procedimientos embolizadores fue de 24 días. Un paciente mostró una complicación no incapacitante tras este tratamiento endovascular. El tiempo medio entre el último procedimiento embolizador y la cirugía fue de 42 días. El volumen medio de transfusión intraoperatorio fue de 471,4 ml. Dos pacientes desarrollaron complicaciones incapacitantes tras la intervención quirúrgica y otro paciente, una complicación no incapacitante. La angiografía de control postquirúrgica demostró la resección completa de las MAVs en todos los pacientes. La puntuación en la Escala de Rankin modificada a los 6 meses de seguimiento fue de 0 en 10 pacientes, 1 en 1 paciente y 2 en 2 pacientes. Por tanto, todos los pacientes son a día de hoy, independientes para sus actividades de la vida diaria. Solo un paciente se encuentra funcionalmente peor tras completar el tratamiento. La angiografía de control al año de seguimiento se ha realizado en 11 pacientes y ha confirmado la ausencia de permeabilidad de las MAVs y por tanto, la curación definitiva de estos pacientes pese a la existencia de material de Onyx intravascular de carácter residual. Conclusión: la embolización con Onyx en diversas fases seguida de la resección microquirúrgica de las MAVs supratentoriales complejas, consigue la curación en el 100% de los pacientes con una mortalidad del 0%, un 15,4% de complicaciones incapacitantes y un 15,4% de complicaciones no incapacitantes. Estos resultados son superiores a la historia natural de la propia enfermedad. Finalmente, hemos demostrado que no es necesaria la resección de la totalidad del Onyx intravascular para lograr la exclusión completa de la MAV y por tanto, la curación del paciente.Introduction: definitive treatment of complex supratentorial arteriovenous malformations (AVMs) (Spetzler-Martin grades III, IV and V) has been classically assigned to ruptured or progressively symptomatic cases. Aim: to report our initial experience in the treatment of complex AVMs by means of staged embolization with Onyx followed by microsurgery. Patients: thirteen consecutive patients (6 males and 7 females) with Spetzler-Martin grades III, IV and V supratentorial AVMs were treated between January 2009 and June 2010. Mean age at the beginning of the therapy was 34. All patients were symptomatic: intracranial haemorrhage (5), seizures (5), headache (2) and/or neurological deficit (2 cases). Mean AVM size was 48 mm and mean volume prior to embolization was 47 ml. According to the Spetzler-Martin grading scale seven patients were classified as grade III, four patients as grade IV and two patients as grade V. Results: mean number of endovascular procedures was 3, and mean volumetric obliteration prior to surgery was 79.2%. Mean time between two embolizations was 24 days. One patient showed a non-disabling complication after endovascular procedures. Mean time between the last embolization and surgery was 42 days. Mean blood transfusion volume was 471.4 ml. Two patients showed disabling complications after surgery and one patient showed a non-disabling complication. Follow-up angiography showed complete removal of permeable AVM in all patients. Modified Rankin Scale score at 6-month follow-up was 0 in 10 patients, 1 in 1 patient and 2 in 2 patients. All patients were, therefore, non-dependent concerning daily life activity. Only one patient was functionally worse after the treatment but also cured. One-year follow-up angiography has been performed in 11 patients so far showing an absence of permeable AVM in spite of the remainder intravascular Onyx. Conclusion: preoperative embolization staging with Onyx followed by microsurgery has made possible 100% cure of complex AVMs with 0% mortality, 15.4% disabling complications and 15.4% non-disabling complications. These results are superior to the natural history of the own disease. Complete onyx resection is not essential in order to achieve the cure of the patient

Base de datos multicéntrica de hemorragia subaracnoidea espontánea del Grupo de Trabajo de Patología Vascular de la Sociedad Española de Neurocirugía: presentación,criterios de inclusión y desarrollo de una base de datos en internet = Spontaneous Subarachnoid Haemorrhage multicenter database from the Group for the Study of Vascular Pathology of the Spanish Society for Neurosurgery: Presentation, inclusion criteria and development of an internet-based registry

Introducción. La hemorragia subaracnoidea (HSA) continúa siendo una de las enfermedades de interés neuroquirúrgico de más alta morbilidad y mortalidad. Su estudio es clave a la hora de mejorar la atención de estos enfermos en nuestro medio. Con este fin el Grupo de Trabajo de Patología Vascular de la SENEC decidió la creación de una base de datos multicéntrica para su estudio. Material y métodos. Se incluyen en esta base de datos todos los casos de hemorragia subaracnoidea espontánea ingresados en los centros participantes de forma prospectiva desde Noviembre del año 2004 hasta Noviembre del 2007. Se decidieron de forma consensuada los campos a recoger incluyendo edad, antecedentes personales, características clínicas, características radiológicas y del aneurisma, tipo de tratamiento y complicaciones de la enfermedad, evolución según la escala de evolución de Glasgow (GOS) al alta y a los seis meses así como el resultado angiográfico del tratamiento. Todos los campos se recogieron en un formulario rellenable a través de una página web segura. Resultados. En los tres años en los que ha estado activa la base se han recogido un total de 1149 casos de HSA espontánea recogidos por 14 centros participantes. Se ha estimado que es necesario aproximadamente un tiempo de 3.4 minutos para rellenar cada caso. En cuanto a sus características generales la serie es similar a otras series hospitalarias no seleccionadas. La edad media de los enfermos incluidos es de unos 55 años y la relación mujer:hombre 4:3. En cuanto a la gravedad del sagrado inicial un 32% de los enfermos se encontraba en mal grado clínico (WFNS = 4 ó 5). El 5% de los pacientes fallecieron antes de realizarse una angiografía que confirmara el origen aneurismático del sangrado. Se confirmó el origen aneurismático en el 76% de los pacientes mientras que en el 19% no se encontró ninguna lesión vascular responsable del sangrado, siendo clasificados como HSA idiopática. En los pacientes en los que se detectó un aneurisma su tratamiento fue endovascular en el 47% de los casos, quirúrgico en el 39, mixto en el 3% y no recibieron tratamiento de su aneurisma el 11% de los pacientes por fallecimiento precoz. En cuanto a su evolución, la mortalidad global de la serie se sitúa en el 22%. Sólo el 40% de los enfermos con HSA aneurismática presentaron una buena evolución (GOS=5). Conclusiones. La HSA espontánea continúa siendo una enfermedad con alta morbilidad y mortalidad. Esta base de datos puede ser un instrumento para conocer mejor sus características en nuestro medio y mejorar sus resultados, ya que se trata de una serie multicéntrica hospitalaria no seleccionada. Sería pues recomendable que esta base constituyera el germen de un registro nacional de HSA espontánea. Introduction. Subarachnoid haemorrhage is one of the most severe neurosurgical diseases. Its study is crucial for improving the care of these patients in our environment. With this goal the Group for the Study of Neurovascular Pathology of the Spanish Society for Neurosurgery (SENEC) decided to create a multicenter registry for the study of this disease. Materials and methods. In this database we have prospectively included all cases with spontaneous subarachnoid haemorrhage admitted to the participant hospitals from November 2004 to November 2007. The fields to be included in the database were selected by consensus, including age, past medical history, clinical characteristics at admission, radiological characteristics including presence or absence of an aneurysm and its size and location, type and complications of the aneurysm treatment, outcome assessed by the Glasgow Outcome Scale (GOS) at discharge and six months after the bleeding as well as the angiographic result of the aneurysm treatment. All fields were collected by means of an electronic form posted in secure web page. Results. During the three years of study a total of 1149 patients have been included by 14 Hospitals. The time needed to fill in a patient in the registry is approximately 3.4 minutes. This series of patients with spontaneous SAH is similar to other non-selected in-hospital series of SAH. The mean age of the patients is 55 years and there is a 4:3 female to male ratio. In relation to the severity of the bleeding 32% of the patients were in poor clinical grade at admission (WFNS 4 or 5). 5% of the patients died before angiography could be performed. An aneurysm was confirmed as the origin of the bleeding in 76% of the patients (aSAH), while in 19% of the patients no lesion was found in the angiographic studies and were thus classified as idiopathic subarachnoid hemorrhage (ISAH). Of those patients with aSAH, 47% were treated endovascularly, 39% surgically, 3% received a combined treatment and 11% did not receive any treatment for their aneurysm because of early death. Regarding outcome, there is a 22% mortality in the series. Only 40% of the patients with aSAH reached a good outcome at discharge (GOS = 5). Conclusions. Spontaneous SAH continues to be a disease with high morbidity and mortality. This database can be an ideal instrument for improving the knowledge about this disease in our environment and to achieve better results. It would be desirable that this database could in the future be the origin of a national registry of spontaneous SAH