[Implementation of the Bologna system in medical education. Current status and future prospects]. / El desarrollo del proceso de "Bolonia" y el Grado de Medicina. Situación actual y expectativas para su implantación definitiva.

The implementation of the European Higher Education Area, (EEES in Spanish) inspired in the Bologna Declaration, pursues the introduction of new teaching and learning paradigms which require deep changes in the frame of superior education and university goals. However, in spite that the main purpose of the EEES is convergence and harmonization of curricula contents and titles throughout Europe in order to facilitate circulation of students and professionals, this goal is far from been reached when we are approaching the deadline for its implementation (year 2010). In addition, this process has led to reduce the total duration of the majority of degrees excepting for medicine and few more. In this article we analyze the underdevelopment of the so called Bologna Process in medical education as compared to other careers. Implementation of curricular innovations seems particularly restrained or threatened in Spain because of legal improvisation, lack of funding, and the chronic apathy of national bodies in medical education. As a consequence, and in contrast with other European countries where deep curricular changes have been already arranged, the majority of Spanish Faculties are at risk of introducing little more than cosmetic modifications in their medicine curricula.

A case of Hirayama disease treated with laminectomy and duraplasty without spinal fusion.

INTRODUCTION: Juvenile amyotrophy of the distal upper extremity (JADUE) is a rare disease afecting young males. Since neck flexion has been thought to be the cause of the spinal cord damage, cervical orthosis, spinal fusion by an anterior or posterior approach and duraplasty in combination with posterior spinal fusion have been proposed as treatment of JADUE. We are presenting the case of a patient with JADUE who was surgically treated with duraplasty without spinal fusion, thus avoiding the compression of the spinal cord without limitation of cervical movement. CASE: A previously healthy 19-year-old man presented with insidious onset of weakness in the left forearm and hand for the past year. On MRI, during neck flexion, the posterior dura showed anterior displacement that compressed the cervical spinal cord. The dura was opened linearly from C3 to C6, observing the herniation of the spinal cord through the opening. Duraplasty was performed in order to increase the room of the spinal cord. No spinal fusion was performed. DISCUSSION: The postoperative course was uneventful. Clinical deterioration stopped following operation and two years later unchanged as compared to the preoperative one.

Intradural extramedullary spinal hydatidosis: case report.

The parasitic tapeworm Echinococcus granulosis causes hydatid disease, which is rarely encountered in nonendemic regions. It is a progressive disease with serious morbidity risks. Rarely, these cysts are found in the spine. They are mainly found epidurally, originating from direct extension from pulmonary, abdominal or pelvic infestation. Nevertheless, the main mechanism for intradural involvement is not yet clear. Antihelminthic treatment should be administered for a long period following early decompressive surgery. We report a case of recurrent hydatid disease that presented unusual intradural dissemination. Prognosis for spinal hydatid disease remains very poor and comparable to that of a malignant neoplasm.

[Hyperintensity on T2 MRI and size as predictors of obliteration in radiosurgically treated arteriovenous malformations]. / Hiperintensidad en secuencias T2 y tamaño como factores pronósticos de obliteración en malformaciones arteriovenosas tratadas mediante radiocirugía.

OBJECTIVE: The aim of this study was to determine which factors were statistically related to radiological and clinical outcomes following radiosurgical treatment of arteriovenous malformations (AVMs). METHODS: The data of 59 patients receiving radiosurgical treatment at our department were retrospectivelly reviewed. Different clinical and biological data, including Spetzler-Martin grade, the presentation of symptoms, radiation dose, number of isocenters and both radiological and clinical outcome, were subjected to multivariate analysis. RESULTS: AVM obliteration was achieved in 77% of patients, the majority of them occurring between 3-5 years after treatment. Ten patients (17%) showed either acute or delayed complications. Only one patient died due tor hemorrhage during the follow-up after radiosurgery. A multivariate analysis showed that, hyperintensity on T2 MRI and a nidus smaller than 3 cm were the only factors statistically related to oclusion of the AVM (p=0.03 and p=0.05, respectively). CONCLUSION: The nidus size and the development of hyperintensity on T2 MRI after the treatment were the strongest predictive factors of obliteration in our series of AVMs radiosurgically treated. Moreover, given that many AVMs showed complete obliteration between 3-5 years after treatment, we recommend to wait untill 5 years after treatment before considering a new terapeuthic approach in patients showing small residual nidus at control imaging.

[The impact of resident work hour limitations on medical student clerkships in Spain]. / La repercusión de la nueva regulación del horario laboral del residente sobre lacalidad de la enseñanza en el pregrado y el postgrado

The influence of new regulations limiting residents work hours on the total time dedicated and the quality of teaching of medical students in university hospitals is analyzed. Though different studies have shown contradictory results on the possible effects of reduced-hour work week on both patients, safety and resident learning, a great concern is arising in Europe and Japan where duty-hour restriction is much more drastic than in USA (48 and 40 hours vs 80 hours, respectively). Deterioration of residents, training could also diminish the total time dedicated to and quality of medical student education.

[Surgical treatment for spontaneous intracerebral haemorrhage. Part I: supratentorial haematomas]. / Tratamiento quirúrgico de la hemorragia intracerebral espontánea. Parte I:Hemorragia supratentorial.

Spontaneous intracerebral haematoma (SICH) represents one the most severe subtypes of ictus. However, and despite a high incidence, medical treatment is almost limited to life support and to control intracranial hypertension and indications of surgical treatment are poorly defined. The aim of this paper was to review the evidence supporting surgical evacuation of SICH. Ten clinical trials and five meta-analyses studying the results of surgical treatment on this pathology were found on English literature. These studies considered all together, failed to show a significant benefit of surgical evacuation in patients with SICH considered as a whole. However, a subgroup of these patients has been considered to potentially present a better outcome after surgical treatment. Current recommendations on supratentorial intra-cerebral haemorrhage state that young patients with lobar haematomas causing deterioration on the level of consciousness should be operated on. Patients suffering from putaminal haematomas and fitting with the same criteria of age and neurological deterioration could also benefit from surgery, at least on terms of survival. Deep neurological deterioration with GCS<5, thalamic location, severe functional deterioration on basal condition or advanced age precluding an adequate functional outcome, have been traditionally considered criteria contraindicating surgery. Given the absence of strong scientific evidence to indicate surgery, this measure should be taken on a tailored manner, and taking into account the social-familiar environment of the patient, that will strongly condition his/her future quality of life.

[Embolization of indirect carotid-cavernous sinus fistula through the ophthalmic vein]. / Embolización de fístula cavernosa indirecta a través de la vena oftálmica superior.

Indirect or dural carotid cavernous fistulas are abnormal connections between the cavernous sinus and meningeal branches of the external and/or internal carotid arteries. Most of them are idiopathic and occurs spontaneously. Symptoms vary from a tiny episcleral injection to a severe visual loss. Conservative therapy is recomended in cases with few symptoms and no leptomeningeal drainage, as spontaneous resolution is not infrequent. Whenever symptoms worsen, treatment of the fistula should be prescribed. Nowadays, transvenous endovascular treatment consisting of packing the cavernous sinus is the first choice. In most cases, cavernous sinus can be approached through the inferior petrosal sinus. However, sometimes that is not possible, and an approach directly through the superior ophthalmic vein could be necessary. We report a case of a patient with a dural carotid cavernous fistula treated with embolization of the cavernous sinus through the ophthalmic vein.

[Surgical treatment for spontaneous intracerebral haemorrhage. Part II: infratentorial haematomas]. / Tratamiento quirúrgico de la hemorragia intracerebral espontánea. Parte II:Hemorragia infratentorial.

Surgery plays a mayor role in the management of some patients with cerebellar haematomas, although a universally accepted treatment guideline is lacking. The aim of this study was to review the existing evidence supporting surgical evacuation of the haematoma in this pathology. Without any clinical trial on this field, data derived from clinical series suggest that the level of consciousness, the size of the haematoma, the presence of hydrocephalus and the compression of the posterior fossa CSF containing spaces are the main criteria to decide management. Fourth ventricular compression seems to be the best indicator of the last parameter. Existing bibliography shows that haematomas greater than 4 cm or causing complete obliteration of the fourth ventricle or prepontine cistern need surgical evacuation irrespective of the level of consciousness, as they indicate a significant compression of the brainstem. On the other hand, it seems that haematomas of less than 3 cm and without fourth ventricular compression can be managed conservatively or by means of ventricular drainage if hydrocephalus exists and requires treatment. The management of intermediate sized haematomas is less clear although conservative approach could be adopted in presence of adequate neurological status, with EVD in the case of hydrocephalus with low consciousness level. If the level of consciousness is low despite the treatment of hydrocephalus, or in absence of this latter, haematoma evacuation is indicated. Finally, patients with flaccid tetraplejia and absent oculocephalic reflexes, and those whose age or basal condition precludes an adequate functional outcome are not suitable for aggressive treatment. Moreover, some studies have shown that comatose patients with CT scan evidence of severe brainstem compression present a reduced probability of good outcome. Anyway, management should be decided on an individual basis, as there is no enough evidence to support a strict treatment protocol.

[Subarachnoid hemorrhage caused by a dissecting carotid artery aneurysm]. / Hemorragia subaracnoidea como forma de presentación de aneurisma disecante carotídeo.

Dissecting aneurysms of the carotid artery as a cause of subarachnoid hemorrhage are rare. However, the association of arterial dissection with the etiology of some aneurysms of the dorsal or anterior wall of the carotid artery, carotid trunk or "blister-like" aneurysms has increased the interest in the description of dissecting aneurysms, as they are difficult to treat and require non-habitual surgical techniques. We present the case of a patient that presented with a poor grade subarachnoid hemorrhage secondary to a right carotid artery dissecting aneurysm characterised in angiography by a carotid artery stenosis accompanied by a post-stenotic dilatation and the finding of a saccular aneurysm that increased in size in the follow-up study. A carotid occlusion test showed an asymmetry in the opacification of the venous phase indicating the need for a revascularization procedure prior to arterial sacrifice. A high flow EC-IC bypass was performed using a saphenous vein graft prior to right carotid artery occlusion without morbidity. Eight months after the procedure the patient is free of neurological deficit. Control image studies demonstrate the resolution of the carotid lesion and the bypass permeability. We discuss the difficulties in the diagnosis of these aneurysms, their clinical and imaging characteristics and the problems related to their treatment as they often require arterial sacrifice with or without prior cerebral revascularization.

[Spontaneous regression of cerebral arteriovenous malformations: case report and review of the literature]. / Regresión espontánea de las malformaciones arteriovenosas cerebrales: presentación de un caso y revisión de la literatura.

Spontaneous regression of intracranial arteriovenous malformations (AVMs) is a rare phenomenon. Such an event is more likely to occur with small AVMs that present with intracranial hemorrhage, which are fed by a unique artery and drained through a single vein. The factors responsible for AVMs regression remain unclear. Thrombosis of the AVM secondary to intracranial hemorrhage ha been the most commonly associated factor. Other possible causes are the gliosis around the clot secondary to repeated frequent microbleedings or occlusion of the feeding arteries by small emboli. We report a new case of spontaneous regression of a AVM and review the literature related to this entity.