Early focal electroencephalogram and neuroimaging findings predict epilepsy development after aneurysmal subarachnoid hemorrhage.

INTRODUCTION: Seizures are a common complication of subarachnoid hemorrhage (SAH) in both acute and late stages: 10-20 % acute symptomatic seizures, 12-25 % epilepsy rate at five years. Our aim was to identify early electroencephalogram (EEG) and computed tomography (CT) findings that could predict long-term epilepsy after SAH. MATERIAL AND METHODS: This is a multicenter, retrospective, longitudinal study of adult patients with aneurysmal SAH admitted to two tertiary care hospitals between January 2011 to December 2022. Routine 30-minute EEG recording was performed in all subjects during admission period. Exclusion criteria were the presence of prior structural brain lesions and/or known epilepsy. We documented the presence of SAH-related cortical involvement in brain CT and focal electrographic abnormalities (epileptiform and non-epileptiform). Post-SAH epilepsy was defined as the occurrence of remote unprovoked seizures ≥ 7 days from the bleeding. RESULTS: We included 278 patients with a median follow-up of 2.4 years. The mean age was 57 (+/-12) years, 188 (68 %) were female and 49 (17.6 %) developed epilepsy with a median latency of 174 days (IQR 49-479). Cortical brain lesions were present in 189 (68 %) and focal EEG abnormalities were detected in 158 patients (39 epileptiform discharges, 119 non-epileptiform abnormalities). The median delay to the first EEG recording was 6 days (IQR 2-12). Multiple Cox regression analysis showed higher risk of long-term epilepsy in those patients with CT cortical involvement (HR 2.6 [1.3-5.2], p 0.009), EEG focal non-epileptiform abnormalities (HR 3.7 [1.6-8.2], p 0.002) and epileptiform discharges (HR 6.7 [2.8-15.8], p < 0.001). Concomitant use of anesthetics and/or antiseizure medication during EEG recording had no influence over its predictive capacity. ROC-curve analysis of the model showed good predictive capability at 5 years (AUC 0.80, 95 %CI 0.74-0.87). CONCLUSIONS: Focal electrographic abnormalities (both epileptiform and non-epileptiform abnormalities) and cortical involvement in neuroimaging predict the development of long-term epilepsy. In-patient EEG and CT findings could allow an early risk stratification and facilitate a personalized follow-up and management of SAH patients.

TRPV2 POLYMORPHISMS INCREASE OR REDUCE THE RISK OF TYPE 2 DIABETES - HASHIMOTO THYROIDITIS COMORBIDITY.

CONTEXT: Thyroid disorders are common in diabetics and related to severe diabetic complications. TRPV2 ion channels have crucial functions in insulin secretion and glucose metabolism which have an important role in the pathophysiology of diabetes. Also, they have a significant effect on various immunological events that are involved in the HT pathophysiology. OBJECTIVE: This study aimed to investigate rs14039 and rs4792742 polymorphisms of the TRPV2 ion channels in type 2 diabetes mellitus (T2DM, n=100) Hashimoto thyroiditis (HT, n=70) and comorbid T2DM and HT (T2DM+HT, n=100) patients and control (n=100). DESIGN: Case-control study. SUBJECT AND METHODS: RT-PCR genotyping was used to determine rs14039 and rs4792742 polymorphisms with DNA samples of subjects and appropriate primer and probes. Besides, required biochemical analyses were performed. RESULTS: It was determined that the frequencies of the rs14039 GG homozygote polymorphic genotype and the G allele were significantly higher in T2DM+HT patients compared to the control (p=0.03 and p=0.01, respectively) and that especially the GG genotype increases the risk of T2DM+HT 3.046-fold (p=0.01, OR=3.046). It was detected that the GG genotype increased the risk of HT 2.54-fold (p=0.05, OR=2.541). TRPV2 rs4792742 polymorphisms reduce the risk of HT and T2DM+HT comorbidity almost by half and have a protective effect against HT and T2DM+HT. CONCLUSION: The rs14039 GG genotype of the TRPV2 gene significantly increases the risks of development of T2DM+HT and HT disorders, may have a significant role in the pathophysiology of these diseases, also leading to predisposition for their development. Conversely, rs4792742 polymorphic genotypes have a strong protective effect against the HT and T2DM+HT comorbidity.

[Aneurysmal subarachnoid hemorrhage: group of study of cerebrovascular pathology of the Spanish society of neurosurgery management guideline]. / Hemorragia subaracnoidea aneurismática: guía de tratamiento del grupo de patología vascular de la sociedad Española de neurocirugía.

An actualized revision of the most important aspects of aneurismal subarachnoid hemorrhage is presented from the guidelines previously published by the group of study of cerebrovascular pathology of the Spanish Society of Neurosurgery. The proposed recommendations should be considered as a general guide for the management of this pathological condition. However, they can be modified, even in a significant manner according to the circumstances relating each clinical case and the variations in the therapeutic and diagnostic procedures available in the center attending each patient.

[Primary decompressive craniectomy in patients with aneurysmatic subarachnoid hemorrhage. Results of a pilot study in 11 cases]. / Craniectomía descompresiva primaria en la hemorragia subaracnoidea aneurismática. Resultados deun estudio piloto en 11 casos.

INTRODUCTION: Despite the scientific and technical advances of recent years, aneurysmal subarachnoid hemorrhage (aSAH) continues to present a high morbidity and mortality. This fact, together with the impressive results of the primary decompressive craniotomy (PDC) in the malignant infarction of the middle cerebral artery suggests a possible beneficial effect of decompressive technique in aSAH. We present our experience of a pilot study that PDC was used in patients with poorgrade aSAH with associated intracerebral hematoma. PATIENTS AND METHODS: Between March 1st, 2002 and 31st April, 2008, 342 patients with aneurysmatic subarachnoid hemorrhage (aSAH) were treated at our hospital. Of these, 64 had a poor neurological grade (scores of 4 or 5 of the World Federation of Neurosurgical Societies) at the time of admission. The present study examines 11 of those patients who underwent PDC, which is performed in the same clipping and / or evacuation of an associated hematoma. RESULTS: In three patients PDC was performed after endovascular aneurysm treatment because of the need to evacuate an associated hematoma. In the eight remaining patients, PDC was performed in the same clipping and evacuation of the associated hematoma. Outcome evaluation of these eleven patients was conducted 1 year after the operation assessed by the Glasgow Outcome Scale. Six patients survived, and four of them with good results. The PDC was effective in controlling intracranial pressure in all six surviving patients. However, two of these six patients had unfavorable outcomes. Of the five who didn't survive, one patient died from a delayed epidural-subgaleal hematoma as a complication of the decompressive technique, and the other four patients died because of refractory intracranial hypertension. CONCLUSIONS: Primary DC may be beneficial in selected subgroups of patients with poor-grade aSAH. However, there is a lack of definitive evidence to support a clear recommendation for its use.

Idiopathic subarachnoid hemorrhage: a multicentre series of 220 patients.

BACKGROUND. The Spanish neurosurgical society created a multicentre data base on spontaneous SAH to analyze the real problematic of this disease in our country. This paper focuses on the group of patients with idiopathic SAH (ISAH). METHODS. 16 participant hospitals collect their spontaneous SAH cases in a common data base shared in the internet through a secured web page, considering clinical, radiological, evolution and outcome variables. The 220 ISAH cases collected from November 2004 to November 2007 were statistically analyzed as a whole and divided into 3 subgroups depending on the CT blood pattern (aneurysmal, perimesencephalic, or normal). RESULTS. The 220 ISAH patients constitute 19% of all 1149 spontaneous SAH collected in the study period. In 46,8% of ISAH the blood CT pattern was aneurysmal, which was related to older age, worse clinical condition, higher Fisher grade, more hydrocephalus and worse outcome, compared to perimesencephalic (42.7%) or normal CT (10.4%) pattern. Once surpassed the acute phase, outcome of ISAH patients is similarly good in all 3 ISAH subgroups, significantly better as a whole compared to aneurysmal SAH patients. The only variable related to outcome in ISAH after a logistic regression analysis was the admission clinical grade. CONCLUSIONS. ISAH percentage of spontaneous SAH is diminishing in Spain. Classification of ISAH cases depending on the blood CT pattern is important to differentiate higher risk groups although complications are not negligible in any of the ISAH subgroups. Neurological status on admission is the single most valuable prognostic factor for outcome in ISAH patients.

Influence of high bladder pressure on vesicoureteral reflux and its resolution.

OBJECTIVES: Voiding dysfunction may result in lower urinary tract symptoms in children and is associated with urinary tract infection, renal damage and vesicoureteral reflux (VUR). The aim of this study was to assess the relationship between detrusor pressure, VUR and abnormal renal scintigraphy findings in children with dysfunctional voiding. PATIENTS AND METHODS: Between 2004 and 2007, 30 children with VUR and voiding dysfunction, 22 girls and 8 boys, median age 8.2 years, were evaluated. Urodynamic study, renal scan and voiding cystourethrography were performed in all patients. RESULTS: The degree of the renal scarring was found to be associated with the detrusor pressures (p = 0.018). The highest detrusor pressure was shown in the group of urge syndrome. The degree of the VUR was found to be correlated with the detrusor pressures (p = 0.038). In our study group, VUR had resolved in 11 (37%) patients, had improved in grade in 10 (33%) patients and remained unchanged in 9 (30%) patients after anticholinergic therapy. No significant relationship was found between the duration of therapy and the voiding patterns (p = 0.389). CONCLUSION: Every child with VUR should undergo a careful evaluation of its bladder function. The patients who have high detrusor pressures should be evaluated carefully for the presence of VUR and renal damage.

Acromegaly remission, SIADH and pituitary function recovery after macroadenoma apoplexy

Summary: Pituitary apoplexy is a rare but potentially life-threatening clinical syndrome characterised by ischaemic infarction or haemorrhage into a pituitary tumour that can lead to spontaneous remission of hormonal hypersecretion. We report the case of a 50-year-old man who attended the emergency department for sudden onset of headache. A computed tomography (CT) scan at admission revealed pituitary haemorrhage and the blood test confirmed the clinical suspicion of acromegaly and an associated hypopituitarism. The T1-weighted magnetic resonance imaging (MRI) showed the classic pituitary ring sign on the right side of the pituitary. Following admission, he developed acute-onset hyponatraemia that required hypertonic saline administration, improving progressively. Surprisingly, during the follow-up, IGF1 levels became normal and he progressively recovered pituitary function. Learning Points: Patients with pituitary apoplexy may have spontaneous remission of hormonal hypersecretion. If it is not an emergency, we should delay a decision to undertake surgery following apoplexy and re-evaluate hormone secretion. Hyponatraemia is an acute sign of hypocortisolism in pituitary apoplexy. However, SIADH although uncommon, could appear later as a consequence of direct hypothalamic insult and requires active and individualised treatment. For this reason, closely monitoring sodium at the beginning of the episode and throughout the first week is advisable to guard against SIADH. Despite being less frequent, if pituitary apoplexy is limited to the tumour, the patient can recover pituitary function previously damaged by the undiagnosed macroadenoma.

A randomized trial of endovascular versus surgical management of ruptured intracranial aneurysms: Interim results from ISAT2.

BACKGROUND AND PURPOSE: Appropriate management of ruptured intracranial aneurysm (RIA) in patients eligible for surgical clipping but under-represented in or excluded from previous randomized trials remains undetermined. METHODS: The International Subarachnoid Aneurysm Trial-2 (ISAT-2) is a randomized care trial comparing surgical versus endovascular treatment (EVT) of RIA. All patients considered for surgical clipping but eligible for endovascular treatment can be included. The primary endpoint is death or dependency on modified Rankin score (mRS>2) at 1 year. Secondary endpoints are 1 year angiographic results and length of hospital stay. RESULTS: An interim analysis was performed after 103 patients were treated from November 2012 to July 2017 in 4 active centers. Fifty-two of the 55 patients allocated to surgery were treated by clipping, and 45 of the 48 allocated to EVT were treated by coiling, with 3 crossovers in each arm. The main endpoint (1 year mRS>2), available for 76 patients, was reached in 16/42 patients allocated to clipping (38%; 95%CI: 25%-53%), and 10/34 patients allocated to coiling (29%; 17%-46%). One year imaging results were available in 54 patients: complete aneurysm occlusion was found in 23/27 patients allocated to clipping (85%; 67%-94%), and 18/27 patients allocated to coiling (67%; 47%-81%). Hospital stay exceeding 20 days was more frequent in surgery (26/55 [47%; 34%-60%]) than EVT (9/48 [19%; 10%-31%]). CONCLUSION: Ruptured aneurysm patients for whom surgical clipping may still be best can be managed in a randomized care trial, which is feasible in some centers. More participating centers are needed.

[Detection of episodes of ischemic tissue hypoxia by means of the combined intraoperative neurophysiologic monitoring with the tissue oxygenation monitoring in aneurysm surgery]. / Detección de episodios de hipoxia tisular isquémica mediante la monitorizaciónneurofisiológica intraoperatoria combinada con la monitorización de la oxigenacióntisular en la cirugía aneurismática.

INTRODUCTION: Intraoperative neuromonitoring in aneurysm surgery can be very useful to determine inadequate positions of the vascular clip that cause partial or complete compromise of the cerebral sanguineous flow in the vascular territories irrigated by the arteries related to aneurysm. The direct visualization of these arteries after the application of the surgical clip can be insufficient in detecting this potentially detrimental situation. Knowing this circumstance on the onset would allow the neurosurgeon to correct it and to avoid, therefore, cerebral ischemic tissue hypoxia. We show the utility of the intraoperative monitoring of the oxygen tissue pressure (PtiO2) and the somatosensorial evoked potential (SSEP) for the detection of these situations with the example of a clinical case. CLINICAL CASE: We present the case of a 62 year-old woman, that presented with subarachnoid hemorrhage of aneurysmal origin. The cerebral arteriography demonstrated the existence of an aneurysm of the posterior communicating artery that was treated initially by endovascular procedure with partial exclusion of the aneurysm. For this reason it was decided to complete the treatment with a programmed surgery. The patient was put on an intraoperative monitoring system with a PtiO2 sensor located in the risk area and with SSEP. After positioning the surgical clip the partial oxygen pressure decreased rapidly, as well as the amplitude of the cortical potential of the left posterior tibial nerve. The knowledge of this situation allowed the detection of a trapped posterior communicating artery. After correcting this situation by replacing the surgical clip, both variables recovered to their basal values. CONCLUSIONS: The intraoperative PtiO2 monitoring, combined with neurophysiologic monitoring during aneurysm surgery offers a fast and trustworthy form of early detection of ischemic phenomena caused by bad positioning of the surgical clip.

[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]. / 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.

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.

[Outcomes of surgical treatment in 100 patients with arteriovenous malformations of the brain]. / Resultados del tratamiento quirúrgico en 100 pacientes con malformaciones arteriovenosas cerebrales.

AIM: To conduct a descriptive analysis of a series of patients with arteriovenous malformations (AVM) that had been treated surgically. PATIENTS AND METHODS: Of a total of 189 adult patients with AVM evaluated consecutively in our hospital, 100 patients who had undergone surgical treatment were selected; a number of demographic, clinical and radiological aspects were then analysed, together with data concerning any associated vascular lesions, the type of surgical treatment, angiographic results and clinical outcomes. RESULTS: The mean age was 34 years (range: 15-71 years). The most common presenting symptom was intracranial haemorrhage, which occurred in 60 cases (60%). The AVM were located in the supratentorial convexity in 79% of cases, 8% were deep and 13% were situated in the cerebellum. The most frequent degree, according to the Spetzler and Martin scale, was grade III. Seventeen patients had other associated lesions and it should be noted that eight patients had aneurysms. Most of the patients (78%) underwent elective surgery and, in two cases, post-embolisation. Surgical treatment (salvage surgery) was performed in 13 patients (13%) when other therapeutic options failed and seven patients were submitted to emergency operations because of brain haemorrhages. The postoperative angiographic study showed complete removal of the AVM in 98% of cases. The clinical outcomes were as follows: 75%, good recovery; 20%, moderate incapacity; and 5%, an important degree of incapacity. CONCLUSION: Surgery is the best therapeutic option for patients with AVM, if they are selected in an appropriate manner.

[Causes of hospital mortality due to brain haemorrhage in patients with arteriovenous malformation]. / Causas de la mortalidad hospitalaria por hemorragia cerebral en pacientes con malformacion arteriovenosa.

AIM: To determine the causes of mortality in cases of brain haemorrhage among patients with arteriovenous malformations (AVM) treated in a tertiary hospital. PATIENTS AND METHODS: The patients with AVM who died over the period 1990-2014 were selected from a prospective register of vascular malformations. Demographic aspects, localisation of the AVM, associated aneurysms and previous treatments were reviewed. Three main causes of death were established: initial bleeding/rebleeding, those related with the treatment of the AVM and other causes not related with AVM. RESULTS: A total of 400 patients were treated for AVM, 216 (54%) with a ruptured AVM, of whom 26 (12.1%) died as a result of a brain haemorrhage. The mean age of the group of patients who died was 48.8 years (range: 8-78 years). Twenty (76.9%) were admitted in coma (Glasgow Coma Scale < 9). In five cases (19.2%), bleeding was due to an associated aneurysm. A very high percentage (38.5%) had the AVM in the posterior fossa. Three patients had previously received non-curative treatments for the AVM in other medical centres. Of the total number, six (23.1%) received endovascular/surgical treatment in our hospital, and we have assumed that, due to the indication or owing to the time in which it was carried out, the cause of death was treatment-related, although two young patients underwent surgery with bilateral mydriasis. One patient died due to an associated glioblastoma, and the others, 19 (76%), due to rebleeding or to the initial brain damage. CONCLUSION: Knowing the causes of mortality can help improve the clinical outcome, above all in cases in which an early treatment could be indicated.

TITLE: Causas de la mortalidad hospitalaria por hemorragia cerebral en pacientes con malformacion arteriovenosa.Objetivo. Conocer las causas de la mortalidad en la hemorragia cerebral de los pacientes con malformaciones arteriovenosas (MAV) tratadas en un hospital terciario. Pacientes y metodos. De un registro prospectivo de malformaciones vasculares se han seleccionado los pacientes que fallecieron con MAV en el periodo 1990-2014. Se han revisado aspectos demograficos, localizacion de la MAV, aneurismas asociados y tratamientos previos. Se han establecido tres causas principales de muerte: sangrado inicial/resangrado, relacionadas con el tratamiento de la MAV y otras causas no relacionadas con la MAV. Resultados. Se trato a 400 pacientes de MAV, 216 (54%) con MAV rotas, de los que fallecieron 26 (12,1%) por hemorragia cerebral. La media de edad del grupo de pacientes fallecidos fue de 48,8 años (rango: 8-78 años). Veinte (76,9%) ingresaron en coma (escala de coma de Glasgow < 9). En cinco casos (19,2%), el sangrado se debio a un aneurisma asociado. Un porcentaje muy elevado (38,5%) tenia la MAV en la fosa posterior. Tres pacientes habian recibido previamente en otros centros tratamientos no curativos de la MAV. Del total, seis (23,1%) recibieron tratamiento endovascular/quirurgico en nuestro hospital, y hemos asumido que, por la indicacion o por el momento en que se realizo, la causa de la muerte se relacionaba con el tratamiento, aunque dos pacientes jovenes se operaron con midriasis bilateral. Un paciente fallecio por un glioblastoma asociado, y el resto, 19 (76%), por el resangrado o el daño cerebral inicial. Conclusion. El conocimiento de las causas de mortalidad puede contribuir a mejorar el resultado clinico, sobre todo en los casos en que podria estar indicado un tratamiento precoz.

Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury.

BACKGROUND: High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). High ICP is treated by general maneuvers (normothermia, sedation etc) and a set of first line therapeutic measures (moderate hypocapnia, mannitol etc). When these measures fail to control high ICP, second line therapies are started. Among these, second line therapies such as barbiturates, hyperventilation, moderate hypothermia or removal of a variable amount of skull bone (known as decompressive craniectomy) are used. OBJECTIVES: To assess the effects of secondary decompressive craniectomy (DC) on outcome and quality of life in patients with severe TBI in whom conventional medical therapeutic measures have failed to control raised ICP. SEARCH STRATEGY: We searched the Cochrane Injuries Group's Trial Register, CENTRAL, MEDLINE, EMBASE, Best Evidence, Clinical Practice Guidelines, PubMed, CINAHL, the National Research Register and Google Scholar. We also handsearched relevant conference proceedings and contacted experts in the field and the authors of included studies. SELECTION CRITERIA: Randomized or quasi-randomized studies assessing patients over the age of 12 months with a severe TBI who underwent DC to control ICP refractory to conventional medical treatments. DATA COLLECTION AND ANALYSIS: Two authors independently examined the electronic search results for reports of possibly relevant trials and for retrieval in full. One author applied the selection criteria, performed the data extraction and assessed methodological quality. Study authors were contacted for additional information. MAIN RESULTS: We found one trial with 27 participants conducted in the pediatric population (>18 years). DC was associated with a risk ratio (RR) for death of 0.54 (95% CI 0.17 to 1.72), and RR of 0.54 for death, vegetative status or severe disability 6 to 12 months after injury (95% CI 0.29 to 1.07). AUTHORS' CONCLUSIONS: There is no evidence to support the routine use of secondary DC to reduce unfavourable outcome in adults with severe TBI and refractory high ICP. In the pediatric population DC reduces the risk of death and unfavourable outcome. Despite the wide confidence intervals for death and the small sample size of the only study identified, this treatment maybe justified in patients below the age of 18 when maximal medical treatment has failed to control ICP. To date, there are no results from randomised trials to confirm or refute the effectiveness of DC in adults. However, the results of non-randomized trials and controlled trials with historical controls involving adults, suggest that DC may be a useful option when maximal medical treatment has failed to control ICP. There are two ongoing randomized controlled trials of DC (Rescue ICP and DECRAN) that may allow further conclusions on the efficacy of this procedure in adults.

[Variability in the surgical indications for posttraumatic intradural lesions]. / Variabilidad en las indicaciones quirúrgicas de las lesiones intradurales postraumáticas.

INTRODUCTION: The surgical treatment of focal intradural lesions is still a matter of considerable debate. This is especially important in the decision to evacuate brain contusions. We present the results of a prospective observational study in which the main goal was to analyze intracenter variability in the indication for surgery in focal posttraumatic intradural lesions in a department of Neurosurgery of a University Hospital with a specialized neurotrauma unit. CLINICAL MATERIAL AND METHODS: Between May 1 and December 31, 2001, 32 patients with a closed traumatic brain injury and an intradural posttraumatic focal lesion were included. The patients studied were a subgroup included in the European multicenter observational study of the management of intradural lesions conducted under the aegis of the European Brain Injury Consortium (EBIC). RESULTS: Intradural lesions > 25 cc were immediately evacuated. Nine out of thirteen patients with lesions < 25 cc also underwent surgery due to intracranial hypertension or neuroworsening. In all patients in whom lesions were surgically evacuated, the postoperative CT-scan showed neuroradiological improvement of the signs of mass effect or midline shift. CONCLUSIONS: In our center, we found no evidence of significant variability in the indications for surgery in intradural lesions of more than 25 cc. However, significant differences were detected among neurosurgeons in the surgical indications for lesions below 25 cc. The small sample analyzed precludes generalization of these conclusions. The definitive results of the EBIC study will provide the neurosurgical community with a better understanding of variability in the management of these lesions.

Intracranial hypertension after surgery in patients with Chiari I malformation and normal or moderate increase in ventricular size.

OBJECTIVE: To determine ICP changes in patients with Chiari type I malformation after posterior fossa reconstruction (PFR). PATIENTS AND METHODS: We continuously monitored ICP before and after PFR in 12 patients with Chiari I malformation and with an Evans' Index below or equal to 0.33. Mean ICP (epidural sensor) and percentage of B waves were calculated 24 hours before surgery and during the first 7 days after surgery. RESULTS: Mean ICP and percentage of B waves significantly increased after surgery despite a significant increase in the volume of the posterior fossa. The main finding revealed by control CT scans was compression of the quadrigeminal cistern with a reduction in size of the fourth ventricle. In six patients, a small transitory increase in supratentorial ventricular size was found. CONCLUSIONS: A transitory increase in ICP is common after PFR. This increase could be explained by an initial reperfusion phenomena in the cerebellum that provokes a transitory deterioration in CSF dynamics. The effacement of the quadrigeminal cistern and the reduction in size of the fourth ventricle suggests this hypothesis.

[Arteriovenous malformations of the posterior fossa. Clinical features, treatment and results]. / Malformaciones arteriovenosas de fosa posterior. Clínica, tratamiento y resultados.

OBJECTIVES: We present our experience of 20 cases of arteriovenous malformations (MAV) of the posterior fossa. PATIENTS AND METHODS: During the period 1991 1999 we prospectively collected radiological and therapeutic clinical data and the results obtained in all cases of adults whose arterio venous malformations were treated. We selected 20 of those who had MAV of the posterior fossa. RESULTS: The average age was 39.6 years (15 64). Thirteen (65%) were men. Most patients, 16 cases (80%) presented clinically with cerebellar haemorrhage, subarachnoid and/or intraventricular haemorrhage and 6 (30%) of the patients were admitted in coma. On the Spetzler and Martin scale: grade 1, 1 patient (5%); grade 11, 8 patients (40%); grade 111, 8 patients (40%) and grade 1V, 3 patients (15%). One patient had an associated pedicular aneurysm, another a supratentorial MAV and another patient had several cavernomas. Nine patients required external ventricular drainage, which in 4 cases became a permanent CSF drainage system. Endovascular treatment was used in 8 patients, radiosurgery in 2 and surgery in 9. Complete resection of the MAV was only possible in the patients treated by surgery (two patients had been treated previously by embolizations and radiosurgery). In this series there was a mortality of 20%, in all four cases due to recurrence of bleeding. Good results were obtained in 11 (55%) of the patients, but in the other 5 (25%) there were sequelas. CONCLUSION: The high percentage with haemorrhages as the form of presentation, with a much higher mortality than that of supratentorial MAVs makes more aggressive treatment necessary.

[Use of teleradiology in the evaluation and management of head-injured patients. Results of a pilot study of a link between a district general hospital and a neurosurgical referral center]. / Aplicaciones de la telerradiología al cribaje y manejo de los pacientes con un traumatismo craneoencefálico. Resultados de un estuduo piloto de interconexión entre un hospital comarcal y un centro de referencia neuroquirúrgico.

UNLABELLED: Because of the centralization of neurosurgical services, many head-injured patients who are initially evaluated in district general hospitals need to be transferred to a high technology centre for neurosurgical assessment. However, after assessment, many of these patients are sent back to the original hospital. Establishing a teleradiological system between the two hospitals would eliminate these unnecessary transfers. OBJECTIVES: 1) to describe our initial experience and the results of a pilot study of the teleradiological link between a district general hospital and a tertiary hospital for neurosurgical assessment of head-injured patients, 2) to describe the infrastructure and the technological support required for this project, 3) to analyse the effects of the teleradiological link in both centers (referring and receiving), 4) to evaluate the effectiveness of the system in avoiding unnecessary transfers, and 5) to assess its effectiveness in improving the speed and the quality of transfers in head-injured patients. MATERIAL AND METHODS: In January 1998, the Neurotraumatology Unit of Vall d'Hebron University Hospital established a teleradiological link with the General Hospital of Vic for the neurosurgical evaluation of headinjured patients. The General Hospital of Vic sent the patients' clinical information by fax. CT scan images were digitalized, compressed and prepared for transmission with the StatView program, and were then transmitted by modem to the receiving center. The duty neurosurgeon viewed the images on a PC screen using MutiView software. After evaluating this clinical and radiological information the neurosurgeon sent a report back to the referring center recommending transfer or management (admission, observation, etc.). RESULTS: We analyse the results of our experience 5 years after the implantation of the teleradiological link. CONCLUSIONS: The use of teleradiology in the daily management of head-injured patients provides clear benefits and leads to a more rational use of resources, thus significantly reduces costs. The effectiveness of the system in reducing the interval between the injury and treatment in severe cases depends more on the infrastructure of the health system in each geographical area than on sophisticated telemedicine systems. These methods should be accompanied by other measures designed to hasten the transfer of selected patients.

[Intracerebral pial arteriovenous fistula with giant venous varix]. / Fistula arteriovenosa intracraneal pial con variz gigante.

TITLE: Fistula arteriovenosa intracraneal pial con variz gigante.

Replantation of a vertically fractured maxillary central incisor after repair with adhesive resin.

AIM: To describe the replantation of a vertically fractured root-filled maxillary central incisor after repair with adhesive resin. SUMMARY: Root-filled teeth with vertical root fractures are usually extracted as they generally have a poor prognosis. In this case, an 18-month follow-up of a replanted incisor with vertical root fracture is presented with clinical and radiographic documentation. KEY LEARNING POINTS: * Replantation of root-filled incisors with complete vertical root fracture after resin bonding might be a realistic alternative to extraction. * Practitioners should be aware of the possible disadvantages as well as advantages associated with failure of a replanted incisor with complete vertical root fracture.