[Endovascular versus surgical treatment in subarachnoid haemorrhage: Cost analysis]. / Costes del tratamiento endovascular frente al quirúrgico en hemorragia subaracnoidea aneurismática.

OBJECTIVES: To analyse costs of endovascular versus surgical treatment in 80 patients with aneurysmal subarachnoid haemorrhage (aSAH). MATERIAL AND METHODS: We analysed data on 80 consecutive patients with aSAH between January 2010 and June 2011. Endovascular treatment was used in 57 patients and surgical in 23 patients. Demographic (gender and age) and clinical data (Hunt-Hess and Fisher scales), length of stay (ICU and ward) and results at 6 months (Glasgow outcome scale,[GOS]) were collected. Costs including stay, follow-up, complications and retreatments were calculated. RESULTS: Age was higher in the endovascular group (statistically significant). There were no differences between the 2 groups in Hunt-Hess and Fisher scales. Results at 6 months were also similar, although slightly better in the surgical group. Length of stay was longer in surgical patients, both in ICU (mean 1.4 days) and ward (1.7 days). Hospitalisation length was also related to age and Hunt-Hess and Fisher scales. Costs from embolisation devices, follow-up and retreatment (12% in this series) made final endovascular treatment 4.1% more expensive than surgical treatment (€35,835 versus €34,404). Endovascular procedure (including retreatments) was 110% more expensive than surgical treatment (€8,015 versus €3,817). CONCLUSIONS: There are no differences between the 2 treatments in terms of morbidity and mortality. Stability of surgical treatment was higher than that of endovascular, with better occlusion and lower retreatment rates. Endovascular treatment is more expensive in ruptured aneurysms, principally due to embolisation device costs, long-term follow-up and retreatments, in retreatments, in spite of shorter hospital stay. In incidental aneurysms, which usually need shorter hospitalisation, differences between the 2 treatments could be even larger.

[Usefulness of continuous intracranial pressure monitoring in long-standing overt ventriculomegaly in adults]. / Utilidad de la monitorización de la presión intracraneal en pacientes con ventriculomegalia marcada de larga evolución.

OBJECTIVES: To analyze the usefulness of intracranial pressure (ICP) monitoring in overt long-standing ventriculomegaly patients. MATERIAL AND METHODS: There were 22 patients with ventriculomegaly and neurological symptoms. Demographic, clinical and radiological data were collected, as well as ICP monitoring data and complications related to the procedure. Results were evaluated 6 months after surgery. RESULTS: Mean age was 44 years (22-70). Mean Evans index was 0.47 (0.35-0.66). Aqueductal stenosis was present in more than half of the patients (55%). Mean ICP was higher than 12 mmHg in only 9% of patients. Morphological analysis of ICP recordings was abnormal in 64% of patients. "Pre-plateau" A waves were seen in 7 patients, with B waves seen in 20 patients (high amplitude B waves in 14). Twelve patients were operated on the basis of ICP recordings (CSF shunt or ventriculostomy). Seventy per cent of treated patients had improved at 6 months. There were no complications related to the monitoring technique. CONCLUSIONS: ICP monitoring is a valuable, safe tool, very useful in these cases. Selection of surgical candidates on the basis of ICP monitoring seems to be advisable. Mean ICP may be normal even with pathological recordings. Morphological analysis is essential to establish a correct diagnosis. The presence of A and B waves in the recording is highly related to good shunt response.

[Usefulness of intracranial pressure continuous monitoring in pseudotumor cerebri]. / Utilidad de la monitorización de la presión intracraneal en pacientes con sospecha de hipertensión intracraneal benigna.

OBJECTIVES: To analyse the usefulness of intracranial pressure (ICP) monitoring in pseudotumor cerebri (PTC). MATERIAL AND METHODS: Ten patients with suspected PTC, but having incomplete criteria for the syndrome, on whom ICP monitoring was performed. Demographic, clinical and radiological data were collected, as well as ICP monitoring data and related complications. Results were evaluated 6 months after surgery. RESULTS: In relation to demographics, all patients were young females. Mean ICP was less than 250 mmH2O in 5 of 8 patients with pathological monitoring. Most patients (62.5%) showed A waves; these were related with higher mean ICP, but not always with papilloedema. All recordings showed high amplitude B waves. Most pathological recordings showed wave amplitudes superior to 5 mmHg. There were no complications related to the monitoring technique. CONCLUSIONS: Clinical and lumbar opening pressure data are not enough to establish PTC diagnosis correctly, especially if patient has been treated previously. Monitoring using ICP is a valuable, safe tool, and very useful in this syndrome. Mean ICP could be normal even with pathological recordings. Morphological analysis is necessary to establish diagnosis. A and B waves are highly related to shunt response. Wave amplitude is related to brain compliance and to shunt response as well.

[Adult chronic idiopathic hydrocephalus-diagnosis, treatment and evolution. Prospective study]. / Hidrocefalia crónica del adulto: diagnóstico, tratamiento y evolución. Estudio prospectivo.

INTRODUCTION: At present, chronic hydrocephalus or normal pressure hydrocephalus (NPH) has a controversial diagnosis in which multiple diagnostic and therapeutic techniques have been used with variable degrees of postoperative success. The aim of our study is to evaluate a number of patients diagnosed with adult chronic idiopathic hydrocephalus who were treated with a CSF shunt at our centre between 2006 and 2009 through clinical scales and radiological controls pre- and postoperatively. MATERIAL AND METHODS: We prospectively analysed 40 patients. The diagnosis of idiopathic NPH was established when patients met 3 criteria: (i)clinical; (ii)radiological (Evans >0.3), and (iii)hydrodynamic (Katzman infusion test with Rout >12) or pathological ICP monitoring (B waves in over 20% of a nocturnal registration). We used a low-pressure DVP 5/35 GAV in all cases. Clinical assessments were conducted at 3, 6 and 12 months and radiological assessments at 6 months postoperatively. The clinical improvement of patients was assessed with the NPH, modified RANKIN and modified PFEIFFER rating scales. RESULTS: The study of risk factors (age, gender, smoking, drinking, arterial hypertension, diabetes mellitus, dyslipidemia) did not establish statistically significant relationships. A statistically significant improvement was observed (P<.01) in the NPH and RANKIN tests at 3, 6 and 12 months. Clinical improvement values obtained were: NPH 73%, 74% and 64%, and RANKIN 54%, 72% and 56%, respectively. The PFEIFFER scale only showed a significant improvement at 12 months. These improvements were classified into various levels (high, moderate, mild and no improvement). The initial mean Evans index was 0.385, and 0.3675 postoperatively. There was only one infection of the valvular system (2%) without further complications. Morbidity and mortality related to the procedure were 0%. CONCLUSION: An appropriate selection of patients through clinical, radiological, hydrodynamic and ICP monitoring criteria enables us to obtain good results and a low complication rate.

Cerebellopontine angle meningiomas: LINAC stereotactic radiosurgery treatment.

OBJECTIVES: To evaluate the efficacy of treatment with linear accelerator-based stereotactic radiosurgery (LINAC) in cerebellopontine angle meningiomas. METHODS: We analyzed 80 patients diagnosed with cerebellopontine angle meningiomas between 2001 and 2014, treated with stereotactic radiosurgery (SRS), of whom 81.9% (n=68) were women, with an average age of 59.1 years (32-79). SRS was applied as primary treatment in 83.7% (n=67) and in 16.3% (n=13) as an adjuvant treatment to surgery. SRS treatment was provided using LINAC (Varian 600, 6MeV) with M3 micromultilamines (brainLab) and stereotactic frame. The average tumor volume was 3.12cm3 (0.34-10.36cm3) and the coverage dose was 14Gy (12-16Gy). We performed a retrospective descriptive analysis and survival analysis was performed with the Kaplan-Meier method and multivariate analysis to determine those factors predictive of tumor progression or clinical improvement. RESULTS: After an average follow-up period of 86.9 months (12-184), the tumor control rate was 92.8% (n=77). At the end of the study, there was an overall reduction in tumor volume of 32.8%, with an average final volume of 2.11cm3 (0-10.35cm3). The progression-free survival rate at 5, 10 and 12 years was 98%, 95% and 83.3% respectively. The higher tumor volume (p=0.047) was associated with progression. There was clinical improvement in 26.5% (n=21) of cases and clinical worsening in 16.2% (n=13). Worsening is related to the radiation dose received by the brainstem (p=0.02). Complications were 8.7% (7 cases) of hearing loss, 5% (4 cases) of brain radionecrosis, and 3.7% (3 cases) of cranial nerve V neuropathy. Hearing loss was related to initial tumor size (p=0.033) and maximum dose (p=0.037). The occurrence of radionecrosis with the maximum dose (p=0.037). CONCLUSIONS: Treatment of cerebellopontine angle meningiomas with single-dose SRS using LINAC is effective in the long term. Better tumor control rates were obtained in patients with small lesions.

Long-term Experience of LINAC Single-Dose Radiosurgery for Skull Base Meningiomas: A Retrospective Single-Center Study of 241 Cases.

BACKGROUND AND OBJECTIVES: Stereotactic radiosurgery (SRS) is increasingly applied to treat meningiomas, attributable to their increased incidence in older individuals at greater surgical risk. To evaluate the effectiveness of treatment with linear accelerator (LINAC)-based stereotactic radiosurgery in skull base meningiomas as either primary treatment or postresection adjuvant therapy. METHODS: This study included 241 patients diagnosed with skull base meningiomas treated by single-dose SRS, with a median age of 59 years. SRS was primary treatment in 68.1% (n = 164) and adjuvant treatment in 31.9% (n = 77), using LINAC (Varian 600, 6 MeV). The median tumor volume was 3.2 cm 3 , and the median coverage dose was 14 Gy. Bivariate and multivariate analyses were performed to determine predictive factors for tumor progression, clinical deterioration, and complications. Kaplan-Meier analysis was used for survival analysis. RESULTS: After the median follow-up of 102 months, the tumor control rate was 91.2% (n = 220). Progression-free survival rates were 97.07%, 90.1%, and 85.7% at 5, 10, and 14 years, respectively. Clinical improvement was observed in 56 patients (23.2%). In multivariate analysis, previous surgery (hazard ratio 3.8 [95%CI 1.136-12.71], P = .030) and selectivity (hazard ratio .21 [95%CI 0.066-0.677], P = .009) were associated with tumor progression and increased maximum dose (odds ratio [OR] 4.19 [95% CI 1.287-13.653], P = .017) with clinical deterioration. The permanent adverse radiation effect rate was 6.2% (n = 15) and associated with maximum brainstem dose >12.5 Gy (OR 3.36 [95% CI .866-13.03], P = .08) and cerebellopontine angle localization (OR 3.93 [95% CI 1.29-11.98], P = .016). CONCLUSION: Treatment of skull base meningiomas with single-dose SRS using LINAC is effective over the long term. Superior tumor control is obtained in patients without previous surgery. Adverse effects are related to localization in the cerebellopontine angle, and maximum brainstem radiation dose was >12.5 Gy.

Development of an integrated solution for patients with neurostimulator for chronic pain in times of COVID-19: A mobile application with a support center.

INTRODUCTION: Chronic pain is one of the most prevalent pathologies in the world. Treatment with neurostimulators is carried out in the most extreme cases and requires a large investment of resources. In these times of the COVID19 pandemic, we present a comprehensive solution for monitoring this kind of patient, this solution includes the development of a mobile application and a support center for remote monitoring (SCRM). MATERIAL AND METHODOLOGY: The project was developed according to the scientific evidence in the following phases: (1) Approval in a multidisciplinary clinical committee of implants for chronic pain, (2) Setting up a group of experts, (3) Protocol adaptation for the follow-up of patients with chronic pain to the Smartphone environment, (4) Technology platform adaptation to the clinical protocol (technological environment and workflow between the hospital and the SCRM), and (5) Quality evaluation by survey (quantitative and qualitative) of a small series of patients. RESULTS: The application was evaluated by asking for user opinions about design and usefulness with the first implanted patients. Some minor adjustments were made concerning downloadable material and screen color and text. CONCLUSIONS: Developing a comprehensive solution should be based on scientific principles and in accordance with established protocols. A support center ensures greater adherence for follow-up and better patient care.

[Development of an integrated solution for patients with neurostimulator for chronic pain in times of COVID-19: A mobile application with a support center]. / Desarrollo de una solución integrada para pacientes con dolor crónico portadores de neuroestimulador en tiempos del COVID-19: una aplicación para móvil con centro de soporte.

Introduction: Chronic pain is one of the most prevalent pathologies in the world. Treatment with neurostimulators is carried out in the most extreme cases and requires a large investment of resources. In these times of COVID-19 pandemic, we present a comprehensive solution for monitoring this kind of patient, this solution includes the development of a mobile application and a support center for remote monitoring (SCRM). MMaterial and methodology: The project was developed according to the scientific evidence in the following phases: (1) approval in a multidisciplinary clinical committee of implants for chronic pain, (2) setting up a group of experts, (3) protocol adaptation for the follow-up of patients with chronic pain to the Smartphone environment, (4) technology platform adaptation to the clinical protocol (technological environment and workflow between the hospital and the SCRM), and (5) quality evaluation by survey (quantitative and qualitative) of a small series of patients. Results: The application was evaluated by asking for user opinions about design and usefulness with the first implanted patients. Some minor adjustments were made concerning downloadable material and screen color and text. Conclusions: Developing a comprehensive solution should be based on scientific principles and in accordance with established protocols. A support center ensures greater adherence for follow-up and better patient care.

High-frequency spinal cord stimulation as rescue therapy for chronic pain patients with failure of conventional spinal cord stimulation.

BACKGROUND: This study aims to evaluate the efficacy of 10-kHz high-frequency (HF10) devices as a rescue treatment in patients with failure of conventional spinal cord stimulation (SCS) therapy for chronic pain without the need to change the spinal hardware. METHODS: In this real-world prospective study, patients with neuropathic pain treated with conventional tonic SCS in whom the therapy had failed, either during the trial phase or after a period of optimal functioning, were recruited throughout 2 years for HF10-SCS therapy. Data on analgesia, functionality, analgesics use and treatment safety were collected 12 months after treatment. RESULTS: Eleven of the 18 (61%) patients included in the study were successfully rescued with HF10-SCS. Of them, 5 out of 12 (45%) were in the trial phase and six out of six (100%) had previously functioning implants. A significant improvement in low-back and limb pain was obtained (p = 0.003 and p = 0.0001, respectively). Treatment success was significantly associated with gender (p = 0.037), weight (p = 0.014), body mass index (BMI) (p = 0.007) and time of rescue (p = 0.015). A linear regression test confirmed a significant association between treatment failure and BMI and gender (p = 0.004). CONCLUSIONS: Our results suggest that analgesic rescue with HF10-SCS is an effective therapeutic option for non-responders to conventional SCS, although obesity might be a limiting factor for treatment success. Nevertheless, more comprehensive studies are needed to corroborate our findings. SIGNIFICANCE: This study shows that high-frequency stimulation may be useful in patients with failure of conventional tonic stimulation for chronic pain, both in the trial phase and in previously implanted subjects. The novelty of this study lies in the use of the implanted epidural electrodes, which avoids the need for further surgery. The results in terms of pain control and recovery of functionality are satisfactory. In addition, variables such as male gender and high body mass index could be predictors of therapy failure.

Angiographic characteristics of epileptogenic arteriovenous malformations and effectiveness in the seizure control after treatment with radiosurgery.

OBJETIVE: Define the angiographic characteristics of epileptogenic arteriovenous malformations (AVM) and assess symptom control of the seizure after treatment with radiosurgery. MATERIAL AND METHODS: Between 1996 and 2006, a total of 237 adults patients were diagnosed with AVM and were treated in our center by radiosurgery with linear accelerator. We analyzed demographics, clinicals, angiographics and radiosurgicals characteristics and the complications of the procedure in each of them. The first symptom was a seizure in 68 of them and the subsequent analysis of the treatment effectiveness for the seizure control was done, and the possible predictive factors of AVM nidus evolution were assessed. RESULT: The average volume of the epileptogenic AVMs was 7.17 cc, compared ot the non-epileptogenic AVM 5.06 cc (p<0.03). Other differentiating factors were surface blood supply (p<0.003), venous ectasia (p<0.064), angiogenesis (p<0.078), and the presence of unrelated aneurysms (p<0.08). For 68 patients (28.7%) with seizures a clinical control (Seizure Frequency Scoring System SFSS ≤2) was obtained in 70% of patients and there was an excellent control (SFSS ≤1) in 25% of them. The percent occlusion of their AVMs was 50%. There was statistical significance with SFSS ≤1 (p<0.01), but was not any significance with SFSS ≤2. Age (p<0.003) and diffuse nidus morphology (p<0.05) were predictors of good AVM nidus evolution. CONCLUSIONS: The stereotactic radiosurgery seems to be an effective method for control of symptomatic seizures for intracranial AVMs. Certain angiographic characteristics, such as the volume, surface blood supply, angiogenesis, venous ectasia, and unrelated aneurysms to the AVMs, seem to influence the appearance of epileptic seizures.