Resultados clínicos y de costes del tratamiento endovascular frente al quirúrgico en aneurismas incidentales / Clinical results and costs of endovascular treatment in comparison with surgery in non ruptured aneurysms

Objetivo: Evaluar los resultados clínicos y angiográficos, así como los costes del tratamiento quirúrgico frente al endovascular, en el tratamiento de los aneurismas incidentales. Material y métodos: Estudio retrospectivo de una serie consecutiva de 89 pacientes de un solo centro tratados endovascularmente (EV) y quirúrgicamente (SC). Se realiza estudio descriptivo de aspectos demográficos (edad, sexo) y de las características de los aneurismas así como se evalúan resultados clínicos (GOS a 6 meses), angiográficos (grado de oclusión) y de costes económicos tanto globalmente como de cada uno de los grupos. Resultados: Ochenta y nueve pacientes tratados entre 2010 y 2015. Un 74% de los pacientes recibieron tratamiento endovascular y un 26% quirúrgico. No hubo diferencias significativas en cuanto a edad o sexo entre los grupos EV y SC. Un 89% de los pacientes presentaron GOS a los 6 meses favorable (4-5), sin diferencias entre ambos grupos. La oclusión completa del aneurisma fue mayor en el grupo SC (96% versus 55%), así como la estabilidad del tratamiento (24% de retratamientos en el grupo EV versus 0% en el grupo SC). Los retratamientos son más frecuentes en aneurismas de circulación anterior (27%) y de mayor tamaño (un 38,5% de los mayores de 10 mm). El gasto en el grupo SC viene derivado fundamentalmente de la estancia hospitalaria en tanto que en grupo EV tiene más importancia el coste de los materiales de embolización. Las estancias medias son notablemente superiores en el grupo SC pero el coste medio del primer ingreso es un 14% superior en el grupo EV debido al precio de los materiales de embolización. El gasto total es notablemente superior en el grupo EV (un 61%) debido a los gastos derivados del seguimiento y de los retratamientos. Conclusiones: Los resultados clínicos de ambos tipo de tratamiento son comparables. El grado de oclusión aneurismática del grupo SC es superior al del EV, así como la estabilidad del tratamiento, precisando menos retratamientos. A pesar de que el tratamiento quirúrgico genera estancias más largas, los costes del grupo EV son notablemente superiores a los del grupo SC debido al precio de los materiales de embolización, el seguimiento que precisan y la tasa de retratamientos. Una adecuada selección de los casos candidatos a coiling o pinzamiento podría mejorar los resultados angiográficos, reducir la tasa de retratamientos y ahorrar costes

Objective: to evaluate the results and costs of surgical treatment against endovascular in non ruptured aneurysms. Material and methods: retrospective study of a consecutive series non ruptured aneurysms from a single-center treated endovascularly (EV) and surgically (SC). A descriptive study of demographic (age, sex) charqacteristics of the patients and the radiological aspects of the aneurysms have been carried out. Clinical results (GOS at 6 months), angiographic data (occlusion classification) and economic costs have been evaluated in both globally, and in each of the groups. Results: 89 patients treated between 2010 and 2015 were reviewed. Most of them were treated endovascularly (74%). There were no statiscally significant differences between EV and SC groups. 89% of the patients presented favourable GOS (4-5) at six months, being this percentage similar in both groups. Complete occlusion was much higher in SC group (96%) than in EV (55%). Retreatment rate was 24% in EV group and 0% in SC group. The retreatments were more frequent in anterior circulation aneurysms and bigger aneurysms (> 10 mm). The expenses in the SC group come mainly from hospital stay, meanwhile in the EV group is due to embolisation materials. The average length of stay (ALOS) are higher in SC group but costs of first admission are higher in EV group (14% more). When the costs of retreatments and follow up are included the costs of endovascular treatment is much higher than the surgical (61% more expensive). Conclusions: results of both types of treatment are comparable. The grade of aneurysmal occlusion of the SC group was higher than the EV, as well as the stability of the treatment, requiring fewer retreatments. Althoug the ALOS in SC group were longer, the costs of the EV group were significantly higher than the SC group due to the costs of embolisation materials, follow up that they need and the rate of retreatment. Adequate selection of candidates for endovascular coiling could improve angiographic outcomes, reduce retraction rates, and save costs

Clinical results and costs of endovascular treatment in comparison with surgery in non ruptured aneurysms. / Resultados clínicos y de costes del tratamiento endovascular frente al quirúrgico en aneurismas incidentales.

OBJECTIVE: to evaluate the results and costs of surgical treatment against endovascular in non ruptured aneurysms. MATERIAL AND METHODS: retrospective study of a consecutive series non ruptured aneurysms from a single-center treated endovascularly (EV) and surgically (SC). A descriptive study of demographic (age, sex) charqacteristics of the patients and the radiological aspects of the aneurysms have been carried out. Clinical results (GOS at 6 months), angiographic data (occlusion classification) and economic costs have been evaluated in both globally, and in each of the groups. RESULTS: 89 patients treated between 2010 and 2015 were reviewed. Most of them were treated endovascularly (74%). There were no statiscally significant differences between EV and SC groups. 89% of the patients presented favourable GOS (4-5) at six months, being this percentage similar in both groups. Complete occlusion was much higher in SC group (96%) than in EV (55%). Retreatment rate was 24% in EV group and 0% in SC group. The retreatments were more frequent in anterior circulation aneurysms and bigger aneurysms (> 10 mm). The expenses in the SC group come mainly from hospital stay, meanwhile in the EV group is due to embolisation materials. The average length of stay (ALOS) are higher in SC group but costs of first admission are higher in EV group (14% more). When the costs of retreatments and follow up are included the costs of endovascular treatment is much higher than the surgical (61% more expensive). CONCLUSIONS: results of both types of treatment are comparable. The grade of aneurysmal occlusion of the SC group was higher than the EV, as well as the stability of the treatment, requiring fewer retreatments. Althoug the ALOS in SC group were longer, the costs of the EV group were significantly higher than the SC group due to the costs of embolisation materials, follow up that they need and the rate of retreatment. Adequate selection of candidates for endovascular coiling could improve angiographic outcomes, reduce retraction rates, and save costs.

Síndrome de twiddler en paciente con trastorno obsesivo compulsivo tratado mediante estimulación cerebral profunda / Twiddler’s syndrome in a patient with obsessive-compulsive disorder treated with deep brain stimulation

El síndrome de twiddler es una extraña complicación relacionada con los dispositivos implantables de estimulación eléctrica. Descrito por primera vez en un paciente portador de marcapasos, es una complicación conocida en el ámbito de la cardiología, aunque no lo es tanto en el mundo de la neurocirugía, donde se ha descrito en relación con dispositivos de estimulación cerebral profunda. Se caracteriza por la manipulación, ya sea consciente, ya inconsciente, del generador de tales dispositivos, lo que origina el giro de este sobre sí mismo, lo que ocasiona el trenzado del cableado de estos sistemas, pudiendo provocar su rotura o bien el desplazamiento de los electrodos intracraneales. Describimos un caso de síndrome de twiddler en un paciente tratado mediante estimulación cerebral profunda para el trastorno obsesivo compulsivo que, tras una buena respuesta inicial, presenta un deterioro clínico, apreciándose en las radiografías de control del sistema el giro del cableado y el desplazamiento de los electrodos intracraneales

Twiddler's syndrome is a rare complication associated with implantable electrical stimulation devices. First described in a patient with a pacemaker, it is a known complication in the field of cardiology. However, it is not so recognised in the world of neurosurgery, in which it has been described in relation to deep brain stimulation (DBS) devices. Characterised by manipulating either consciously or unconsciously the generator of such devices, which causes it to rotate on itself, the syndrome causes the coiling of the wiring of these systems and can lead to their rupture or the displacement of intracranial electrodes. We describe a case of twiddler's syndrome in a patient treated with DBS for obsessive-compulsive disorder, in which clinical deterioration presented after a good initial response. Control radiographs revealed rotation of the wiring system and displacement of the intracranial electrodes

[Twiddler's syndrome in a patient with obsessive-compulsive disorder treated with deep brain stimulation]. / Síndrome de twiddler en paciente con trastorno obsesivo compulsivo tratado mediante estimulación cerebral profunda.

Twiddler's syndrome is a rare complication associated with implantable electrical stimulation devices. First described in a patient with a pacemaker, it is a known complication in the field of cardiology. However, it is not so recognised in the world of neurosurgery, in which it has been described in relation to deep brain stimulation (DBS) devices. Characterised by manipulating either consciously or unconsciously the generator of such devices, which causes it to rotate on itself, the syndrome causes the coiling of the wiring of these systems and can lead to their rupture or the displacement of intracranial electrodes. We describe a case of twiddler's syndrome in a patient treated with DBS for obsessive-compulsive disorder, in which clinical deterioration presented after a good initial response. Control radiographs revealed rotation of the wiring system and displacement of the intracranial electrodes.

Cognitive effects of subthalamic nucleus stimulation in Parkinson's disease: a controlled study.

BACKGROUND: Subthalamic nucleus deep brain stimulation (STN-DBS) improves motor function in selected patients with Parkinson's disease (PD) but can be associated with variable changes in cognitive functions. METHODS: We studied 21 patients selected for STN-DBS and compared 6-month clinical and neuropsychological outcomes between those who underwent surgery (n = 9) and those who voluntarily refused it (n = 12). RESULTS: Motor and quality of life outcomes were markedly superior in the STN-DBS group versus controls. A wide neuropsychological battery was administered, and the whole sample showed a statistically significant worsening in phonemic verbal fluency, time to perform the Trail Making Test part B, Digit Symbol score of WAIS-III and color-naming score of the Stroop Test. In comparison to controls, a trend to a slightly worse deterioration in phonemic verbal fluency was observed in the STN-DBS patients and was significantly correlated with reductions in the L-dopa-equivalent daily dose (r = 0.850, p = 0.007). CONCLUSION: Our study confirms the safety of STN-DBS from a cognitive standpoint; a reduction in verbal fluency at 6 months after surgery can also be related to PD progression and medication reduction.

Evaluating the recovery of cognitive impairment in subarachnoid hemorrhage taking into consideration the practice effects.

BACKGROUND: It is not completely clear whether there are differences in the evolution of the neuropsychological outcomes between the 2 intervention procedures (surgery and endovascular coiling) used in subarachnoid aneurysmatic hemorrhage. Some studies have investigated this topic but without completely controlling the effect of learning the tests. OBJECTIVE: To analyze our data using 2 different statistical procedures that attempt to solve this problem. METHODS: The sample consists of 70 patients who have suffered a subarachnoid hemorrhage: 40 treated by means of surgery and 30 by means of endovascular coiling. Two cognitive evaluations were performed at 4 and 12 months after the invention. Twenty-seven healthy subjects were also evaluated twice with a delay of 8 months. The data were analyzed using 2 different statistical procedures: one by Samra et al (2007) using z scores and the other by Crawford and Garthwaite (2007) using the regbuild.exe program. RESULTS: The results indicate there are no important differences between the 2 treatment groups in the evolution of the cognitive alterations. Despite an improvement in cognitive scores on repeat testing at 12 months, neither of the 2 treatment groups showed the same level of test-retest learning as healthy control subjects. CONCLUSION: The recovery of neuropsychological functions after a subarachnoid hemorrhage is similar with the 2 interventions. It is important to control the learning effect produced by the repeated administration of tests.

Neuropsychological evaluation of the treatments applied to intracranial aneurysms in a Spanish sample.

Very few studies have examined the neuropsychological differences between the two types of aneurysm treatment, and these studies come from different countries. The purpose of this study is to compare the neuropsychological differences between surgical treatment and endovascular treatment in a Spanish sample of patients who have experienced an aneurysmal subarachnoid hemorrhage. The sample is composed of three groups: 40 patients who underwent surgical intervention, 24 who were treated by means of coiling, and a group of 29 healthy participants. An extensive neuropsychological evaluation was performed. The results presented show that no neuropsychological differences were found between the two types of treatment for aneurysms and that the most affected function was memory. This result coincides with findings from other studies.

Description of quality of life and its predictors in patients with aneurysmal subarachnoid hemorrhage.

BACKGROUND: According to previous studies, the quality of life is usually substantially altered in patients who have suffered a subarachnoid hemorrhage of an aneurysmal origin. Some studies have attempted to find out which factors predict the deterioration in quality of life. Our study will try to describe the quality of life of these patients and discover which variables may predict it in each of its dimensions. METHODS: The participants were 70 patients with aneurysmal subarachnoid hemorrhage between 15 and 85 years of age. The instrument used to measure the quality of life is the SF-36 with its eight dimensions. The predictor variables introduced into the multiple linear regressions are neurological condition on admission [World Federation of Neurological Surgeons (WFNS) scale and Hunt and Hess scale], extension of the hemorrhage (Fisher scale), sex, age, physical handicaps, and the Glasgow Outcome Scale (GOS) on release. RESULTS: The results showed that 42.9% of the patients had a deteriorated quality of life after 4 months, and that the most affected dimension was the Physical Role (60%). The two factors that predict quality of life are sex and physical handicaps. Other factors that intervene are the GOS on release and the WFNS. CONCLUSIONS: The patients who have experienced an aneurysmal subarachnoid hemorrhage show greater difficulty in performing daily activities, and they present more depression and anxiety. The absence of handicaps and being male are predictor factors for an unaffected quality of life.

Carotid body autotransplantation in Parkinson disease: a clinical and positron emission tomography study.

BACKGROUND: Carotid body (CB) glomus cells are highly dopaminergic and express the glial cell line derived neurotrophic factor. The intrastriatal grafting of CB cell aggregates exerts neurotrophic actions on nigrostriatal neurons in animal models of Parkinson disease (PD). OBJECTIVE: We conducted a phase I-II clinical study to assess the feasibility, long term safety, clinical and neurochemical effects of intrastriatal CB autotransplantation in patients with PD. METHODS: Thirteen patients with advanced PD underwent bilateral stereotactic implantation of CB cell aggregates into the striatum. They were assessed before surgery and up to 1-3 years after surgery according to CAPIT (Core Assessment Programme for Intracerebral Transplantation) and CAPSIT-PD (Core Assessment Programme for Surgical Interventional Therapies in Parkinson's Disease) protocols. The primary outcome measure was the change in video blinded Unified Parkinson's Disease Rating Scale III score in the off-medication state. Seven patients had 18F-dopa positron emission tomography scans before and 1 year after transplantation. RESULTS: Clinical amelioration in the primary outcome measure was observed in 10 of 12 blindly analysed patients, which was maximal at 6-12 months after transplantation (5-74%). Overall, mean improvement at 6 months was 23%. In the long term (3 years), 3 of 6 patients still maintained improvement (15-48%). None of the patients developed off-period dyskinesias. The main predictive factors for motor improvement were the histological integrity of the CB and a milder disease severity. We observed a non-significant 5% increase in mean putaminal 18F-dopa uptake but there was an inverse relationship between clinical amelioration and annual decline in putaminal 18F-dopa uptake (r = -0.829; p = 0.042). CONCLUSIONS: CB autotransplantation may induce clinical effects in patients with advanced PD which seem partly related to the biological properties of the implanted glomus cells.

Autotransplantation of human carotid body cell aggregates for treatment of Parkinson's disease.

OBJECTIVE: In this study, we assessed the feasibility of autotransplantation of carotid body (CB) cell aggregates into the striatum for the treatment of patients with Parkinson's disease (PD). METHODS: Six patients with advanced PD underwent bilateral autotransplantation of CB cell aggregates into the striatum. They were evaluated clinically preoperatively and for 18 months after surgery according to the recommendations of the Core Assessment Program for Intracerebral Transplantation. RESULTS: No major complications or adverse events resulted from the cell implantation or surgical procedures. During the course of the study, there was no significant aggravation of dyskinesia or decline in cognitive function in any of the patients. Five of the six patients who underwent transplantation manifested a measurable degree of clinical improvement evidenced by standardized clinical rating scales for PD. A decrease in the blinded Unified Parkinson's Disease Rating Scale Part III in the "off" state, the main measure of transplant efficacy in our study, was found to be maximal (between 26 and 74%) at 6 months after surgery. At 1 year, clear reductions in the blinded Unified Parkinson's Disease Rating Scale Part III were maintained in three patients (24, 38, and 52%, respectively). Modest improvement was seen in two patients (13 and 17%), and the sole patient who showed no improvement had the most fibrosis in the CB. The age of the patient and the state of the CB tissue were adversely correlated with clinical improvement after CB autotransplantation. CONCLUSION: This pilot study indicates that CB autograft transplantation is a relatively simple, safe, and viable therapeutical approach for the treatment of patients with advanced PD. More studies are needed to optimize the procedure and to assess its general applicability for the treatment of patients with PD.