Análisis psicométrico de las preguntas asociadas a imágenes radiológicas en el examen para médico interno residente en España / Psychometric analysis of questions associated with radiological images in the competitive examination for access to residency programs in Spain

ANTECEDENTES Y OBJETIVO: La psicometría es una técnica sencilla e intuitiva que se utiliza en el campo de la docencia y en el de los cuestionarios de respuesta múltiple. El examen MIR incluye desde el año 2009 preguntas asociadas a imagen radiológica. El objetivo de este trabajo es mostrar los resultados del análisis psicométrico de estas preguntas con objeto de comparar el grado de dificultad, la capacidad de discriminación y la estructura interna respecto al resto de preguntas. MATERIAL Y MÉTODOS: Se seleccionaron todas las preguntas del examen desde el año 2009 y se clasificaron en casos clínicos sin y con imagen radiológica, casos clínicos con imagen no radiológica, preguntas test y preguntas negativas. Se utilizó la teoría clásica de test y la teoría de respuesta al ítem para valorar la dificultad y el grado de discriminación de las preguntas. RESULTADOS: Sobre 225 preguntas, los exámenes incluyen entre un 11% y un 15% de preguntas asociadas a imágenes. Las preguntas asociadas a imagen radiológica son más difíciles (grado de dificultad corregida [IDc] 0,51), con una menor capacidad de discriminación. El aumento de la dificultad de la pregunta radiológica se relaciona con una menor discriminación, sobre todo si la información clínica no es adecuada, o es contraria al concepto radiológico, o el concepto nunca ha sido preguntado a lo largo de la historia del MIR. CONCLUSIONES: Para poder igualar los estándares del examen MIR, es necesario mantener una adecuada estructura en la confección de las preguntas de radiología, en términos de entorno clínico, un adecuado uso de distractores y un menor nivel de dificultad, que se puede lograr mediante el uso de imágenes con hallazgos radiológicos típicos

BACKGROUND AND OBJECTIVE: Psychometrics is a simple, intuitive approach used in educational research and in multiple-choice questionnaires. Since 2009, the competitive examination through which access to residency programs in Spain is determined (MIR) has included questions related to radiological images. The objective of this paper is to show the results of the psychometric analysis of these questions with the aim of comparing their degree of difficulty, discriminative capacity, and internal structure with respect to those of the other questions on the examination. MATERIAL AND METHODS: We analyzed all questions on the examination since 2009, classifying them as clinical cases with and without radiological images, clinical cases with and without non-radiological images, multiple choice questions, and negative questions. We used classical test theory and item response theory to assess the difficulty and degree of discrimination of the questions. RESULTS: Of 225 questions, between 11% and 15% of the questions included in the examinations were associated with images. The questions associated with radiological images were more difficult (corrected difficulty index, 0.51) and had worse discriminative capacity. The increased difficulty of radiological questions was associated with worse discriminative capacity, especially if the clinical information provided was inadequate or if the clinical information was contrary to the radiological concept or if there had never been any questions about the concept in previoous MIR examinations. CONCLUSIONS: To equalize the standards of the MIR examination, it is necessary to maintain an appropriate structure in devising radiology questions, with terms from the clinical context, appropriate use of distracters, and a lower level of difficulty, which could be achieved by using radiological images with typical radiological findings

Psychometric analysis of questions associated with radiological images in the competitive examination for access to residency programs in Spain. / Análisis psicométrico de las preguntas asociadas a imágenes radiológicas en el examen para médico interno residente en España.

BACKGROUND AND OBJECTIVE: Psychometrics is a simple, intuitive approach used in educational research and in multiple-choice questionnaires. Since 2009, the competitive examination through which access to residency programs in Spain is determined (MIR) has included questions related to radiological images. The objective of this paper is to show the results of the psychometric analysis of these questions with the aim of comparing their degree of difficulty, discriminative capacity, and internal structure with respect to those of the other questions on the examination. MATERIAL AND METHODS: We analyzed all questions on the examination since 2009, classifying them as clinical cases with and without radiological images, clinical cases with and without non-radiological images, multiple choice questions, and negative questions. We used classical test theory and item response theory to assess the difficulty and degree of discrimination of the questions. RESULTS: Of 225 questions, between 11% and 15% of the questions included in the examinations were associated with images. The questions associated with radiological images were more difficult (corrected difficulty index, 0.51) and had worse discriminative capacity. The increased difficulty of radiological questions was associated with worse discriminative capacity, especially if the clinical information provided was inadequate or if the clinical information was contrary to the radiological concept or if there had never been any questions about the concept in previoous MIR examinations. CONCLUSIONS: To equalize the standards of the MIR examination, it is necessary to maintain an appropriate structure in devising radiology questions, with terms from the clinical context, appropriate use of distracters, and a lower level of difficulty, which could be achieved by using radiological images with typical radiological findings.

Tratamiento combinado, mediante embolización y cirugía, de los aneurismas cerebrales rotos con hematoma cerebral e hipertensión intracraneal: Análisis retrospectivo y revisión de la bibliografía / Combined surgery and embolization to treat ruptured cerebral aneurysms with cerebral hematoma and intracranial hypertension: a retrospective analysis and review of the literature

Objetivo: Valorar si la técnica de embolización urgente del aneurisma cerebral y posterior cirugía del hematoma es segura y eficaz en pacientes con hematoma y signos de hipertensión intracraneal por rotura de aneurisma cerebral. Métodos: Se incluyeron 23 pacientes consecutivos con aneurisma cerebral roto y mal estado clínico debido a un hematoma intracraneal, ambos tratamientos completados en las primeras 4 horas del inicio de la clínica. Todos los pacientes presentaban signos clínicos de hipertensión intracraneal y/o alteración del nivel conciencia, incluido coma por deterioro rostrocaudal. Se valoró la eficacia de la técnica mediante el grado de cierre de los aneurismas y el pronóstico de los pacientes un mes después, y la seguridad, mediante el análisis de las complicaciones de los tratamientos. Resultados: El 91,3% de los pacientes tenía un aneurisma localizado en la arteria cerebral media (ACM). Todos los pacientes presentaban un valor de 4 en la escala de Fisher y de IV-V en la escala de Hunt y Hess. El tiempo medio desde la identificación del aneurisma en la tomografía computarizada hasta la embolización del aneurisma fue de 115 minutos. Se usó balón de remodeling en el 78% de los casos, con el que se logró un cierre adecuado en el 82,6% de los pacientes. Durante la cirugía se colocó un drenaje ventricular en 9 (39,1%) pacientes. Al mes, 13 (56,5%) pacientes eran independientes, con una mortalidad del 13%. No existieron resangrados. Conclusión: En nuestra experiencia, el tratamiento combinado mediante embolización del aneurisma y descompresión quirúrgica con evacuación del hematoma es segura y efectiva, y es una alternativa al tratamiento quirúrgico aislado

Objective: To determine whether the urgent embolization of a cerebral aneurysms and posterior surgery on cerebral hematomas is safe and efficacious in patients with hematomas and signs of intracranial hypertension due to the rupture of cerebral aneurysms. Methods: We included 23 consecutive patients in poor clinical condition due to an intracranial hematoma caused by a ruptured cerebral aneurysm who were treated with both embolization and surgery within 4 hours of the onset of symptoms. All patients had clinical signs of intracranial hypertension and / or altered levels of consciousness, including coma due to rostrocaudal deterioration. We evaluated the efficacy of the combined technique by determining the degree of closure of the aneurysms and the patients' prognosis one month after the procedures; we evaluated safety by analyzing the complications of the treatments. Results: All but two of the patients (21/23; 91.3%) had an aneurysm of the middle cerebral artery. All patients scored 4 on the Fisher scale and were classified as Hunt and Hess IV or V. The mean time from the identification of the aneurysm on computed tomography to embolization was 115minutes. A balloon remodeling technique was used in 18 (78%) patients; embolization achieved adequate closure in 19 (82.6%) patients. During surgery, a ventricular drain was placed in 9 (39.1%) patients. One month after treatment, 13 (56.5%) patients were functionally independent and 3 (13%) had died. No episodes of rebleeding were observed. Conclusion: In our experience, combined treatment including embolization of the aneurysm and surgical decompression with evacuation of the hematoma is a safe and effective alternative to surgical treatment alone

Combined surgery and embolization to treat ruptured cerebral aneurysms with cerebral hematoma and intracranial hypertension: a retrospective analysis and review of the literature. / Tratamiento combinado, mediante embolización y cirugía, de los aneurismas cerebrales rotos con hematoma cerebral e hipertensión intracraneal: Análisis retrospectivo y revisión de la bibliografía.

OBJECTIVE: To determine whether the urgent embolization of a cerebral aneurysms and posterior surgery on cerebral hematomas is safe and efficacious in patients with hematomas and signs of intracranial hypertension due to the rupture of cerebral aneurysms. METHODS: We included 23 consecutive patients in poor clinical condition due to an intracranial hematoma caused by a ruptured cerebral aneurysm who were treated with both embolization and surgery within 4hours of the onset of symptoms. All patients had clinical signs of intracranial hypertension and / or altered levels of consciousness, including coma due to rostrocaudal deterioration. We evaluated the efficacy of the combined technique by determining the degree of closure of the aneurysms and the patients' prognosis one month after the procedures; we evaluated safety by analyzing the complications of the treatments. RESULTS: All but two of the patients (21/23; 91.3%) had an aneurysm of the middle cerebral artery. All patients scored 4 on the Fisher scale and were classified as Hunt and Hess IV or V. The mean time from the identification of the aneurysm on computed tomography to embolization was 115minutes. A balloon remodeling technique was used in 18 (78%) patients; embolization achieved adequate closure in 19 (82.6%) patients. During surgery, a ventricular drain was placed in 9 (39.1%) patients. One month after treatment, 13 (56.5%) patients were functionally independent and 3 (13%) had died. No episodes of rebleeding were observed. CONCLUSION: In our experience, combined treatment including embolization of the aneurysm and surgical decompression with evacuation of the hematoma is a safe and effective alternative to surgical treatment alone.

Resultados y evolución funcional de pacientes críticos con ictus isquémico sometidos a trombectomía mecánica / Results and functional outcomes of acute ischemic stroke patients who underwent mechanical thrombectomy admitted to intensive care unit

OBJETIVO: Estudiar los resultados y las complicaciones del tratamiento endovascular (TEV) en pacientes con ictus isquémico agudo ingresados en una unidad de cuidados intensivos (UCI). Analizar los factores que podrían influir en la mortalidad y en el grado de discapacidad al alta y un año después del ictus. DISEÑO: Estudio prospectivo observacional. Ámbito: UCI polivalente. Hospital de tercer nivel. PACIENTES: Sesenta pacientes adultos. Muestra consecutiva. INTERVENCIONES: Ninguna. Variables de interés: Datos epidemiológicos, tiempo desde la clínica inicial hasta el TEV, resultado angiográfico, tiempo de estancia en UCI, días de ventilación mecánica, complicaciones neurológicas, National Institutes of Health Stroke Scale (NIHSS) al ingreso y al alta de UCI, escala de Rankin modificada (mRS) al año de evolución. RESULTADOS: Edad media 68,90±8,84años. Mediana de tiempo hasta el TEV: 180min. Mediana NIHSS al ingreso: 17,5; al alta: 3. Flujo distal en el 90% de los casos. Mediana estancia en UCI: 3días. Ventilación mecánica: 81,7%. Independencia funcional (mRS≤2) 50% al año del ictus. Fallecimientos: 22 (36,6%); 8 (13,3%) en la UCI y el resto durante el primer año. CONCLUSIONES: Las variables asociadas a un peor estado funcional fueron la transformación hemorrágica sintomática, la ausencia de recanalización y las complicaciones durante el procedimiento. La transformación hemorrágica y la hidrocefalia se asociaron a mayor mortalidad. Se consiguió flujo distal en la mayoría de los casos, con una baja tasa de complicaciones. La mitad de los pacientes alcanza independencia funcional al año del ictus

PURPOSE: To study the results and complications of endovascular treatment (EVT) in acute ischemic stroke patients admitted to Intensive Care Unit (ICU). To analyse the possible factors related to mortality and level of disability at ICU discharge and one year after stroke. DESIGN: Observational prospective study. SETTING: Mixed ICU. Third level hospital. PATIENTS: Sixty adult patients. Consecutive sample. INTERVENTIONS: None. Variables of interest: Epidemiological data, time from symptom onset to EVT, angiographic result, length of stay, days on mechanical ventilation, neurological complications, National Institutes of Health Stroke Scale (NIHSS) at ICU admission and discharge, modified Rankin scale score (mRS) at one year. RESULTS: Mean age 68,90±8,84years. Median time from symptom onset to EVT: 180minutes. Median NIHSS at admission: 17,5; at discharge: 3. Distal flow was achieved in 90% of cases. Median ICU stay: 3 days. Mechanical ventilation: 81,7.%. Functional independence (mRS≤2) 50% at one year. Deaths: 22 (36,6%) of which 8 (13,3%) died during UCI stay and the rest during the first year. CONCLUSIONS: The factors relating to a worse functional outcome were symptomatic hemorrhage transformation, lack of recanalization and complications during EVT. The factors relating to mortality were symptomatic hemorrhage and hydrocephalus. Distal flow was achieve in most cases with a low complication rate. Half of the patients presented functional independence one year after the stroke

Results and functional outcomes of acute ischemic stroke patients who underwent mechanical thrombectomy admitted to intensive care unit. / Resultados y evolución funcional de pacientes críticos con ictus isquémico sometidos a trombectomía mecánica.

PURPOSE: To study the results and complications of endovascular treatment (EVT) in acute ischemic stroke patients admitted to Intensive Care Unit (ICU). To analyse the possible factors related to mortality and level of disability at ICU discharge and one year after stroke. DESIGN: Observational prospective study. SETTING: Mixed ICU. Third level hospital. PATIENTS: Sixty adult patients. Consecutive sample. INTERVENTIONS: None. VARIABLES OF INTEREST: Epidemiological data, time from symptom onset to EVT, angiographic result, length of stay, days on mechanical ventilation, neurological complications, National Institutes of Health Stroke Scale (NIHSS) at ICU admission and discharge, modified Rankin scale score (mRS) at one year. RESULTS: Mean age 68,90±8,84years. Median time from symptom onset to EVT: 180minutes. Median NIHSS at admission: 17,5; at discharge: 3. Distal flow was achieved in 90% of cases. Median ICU stay: 3 days. Mechanical ventilation: 81,7.%. Functional independence (mRS≤2) 50% at one year. Deaths: 22 (36,6%) of which 8 (13,3%) died during UCI stay and the rest during the first year. CONCLUSIONS: The factors relating to a worse functional outcome were symptomatic hemorrhage transformation, lack of recanalization and complications during EVT. The factors relating to mortality were symptomatic hemorrhage and hydrocephalus. Distal flow was achieve in most cases with a low complication rate. Half of the patients presented functional independence one year after the stroke.

[Analysis of the direct costs associated with mechanical thrombectomy and intravenous fibrinolysis in the Hospital Universitario Central de Asturias]. / Analisis de los costes directos asociados a la trombectomia mecanica y a la fibrinolisis intravenosa en el Hospital Universitario Central de Asturias.

INTRODUCTION: The increase in the indications for mechanical thrombectomy and its implementation in Spanish hospitals makes it necessary to determine the costs related to this treatment so as to be able to streamline economic resources and allow them to be distributed in an appropriate manner. AIMS: To analyse the direct costs associated with patients with acute ischaemic stroke who are treated with intravenous fibrinolysis and with mechanical thrombectomy, and to assess the effectiveness and safety of both treatments during the first 90 days of progression in the Hospital Universitario Central de Asturias. PATIENTS AND METHODS: A retrospective analysis was performed that included 44 patients who received intravenous fibrinolysis and 61 patients treated with mechanical thrombectomy, in whom a series of clinical and economic variables were analysed. RESULTS: The mean final total cost per patient was 16,059 euros in treatments with thrombectomy and 8,169 euros in those in which intravenous fibrinolysis was administered. The percentage of patients with a good functional prognosis at 90 days was 63.93% in those treated by endovascular means and 56.82% in those who received intravenous fibrinolysis. Mortality rates were 18.03 and 11.36%, respectively. CONCLUSIONS: The mean cost of treatment with mechanical thrombectomy, as well as the total mean cost per patient during the acute phase of the disease associated with this technique, is higher than in the case of intravenous fibrinolysis. In our setting, both intravenous fibrinolysis and mechanical thrombectomy are considered to be effective and safe.

TITLE: Analisis de los costes directos asociados a la trombectomia mecanica y a la fibrinolisis intravenosa en el Hospital Universitario Central de Asturias.Introduccion. La ampliacion de las indicaciones de la trombectomia mecanica y su implementacion en los hospitales españoles hacen necesario conocer los costes relacionados con este tratamiento para racionalizar los recursos economicos y permitir una adecuada distribucion de estos. Objetivos. Analizar los costes directos asociados a los pacientes con ictus isquemico agudo tratados con fibrinolisis intravenosa y con trombectomia mecanica, y valorar la efectividad y seguridad de ambos tratamientos durante los primeros 90 dias de evolucion en el Hospital Universitario Central de Asturias. Pacientes y metodos. Se realizo un analisis retrospectivo en el que se incluyo a 44 pacientes que recibieron fibrinolisis intravenosa y a 61 pacientes tratados con trombectomia mecanica, en los que se analizaron una serie de variables clinicas y economicas. Resultados. El coste total final medio por paciente fue de 16.059 euros en los tratados con trombectomia y de 8.169 euros en los que se administro fibrinolisis intravenosa. El porcentaje de pacientes con buen pronostico funcional a los 90 dias fue del 63,93% en los tratados de forma endovascular y del 56,82% en los que recibieron fibrinolisis intravenosa. Las tasas de mortalidad fueron del 18,03% y 11,36%, respectivamente. Conclusiones. El coste medio del tratamiento con trombectomia mecanica, asi como el coste medio total por paciente durante la fase aguda de la enfermedad asociado a esta tecnica, es mayor que en el caso de la fibrinolisis intravenosa. Tanto la fibrinolisis intravenosa como la trombectomia mecanica se configuran en nuestro medio como tratamientos efectivos y seguros.

Análisis de la elección de la especialidad de radiodiagnóstico en el examen MIR desde el año 2006 hasta 2015 / Choice of the specialty of diagnostic radiology by results of the competitive examination to assign residency positions from 2006 to 2015

Objetivo. Analizar el perfil del opositor que ha escogido la especialidad de radiodiagnóstico, analizando variables relacionadas con las plazas convocadas a lo largo de la historia. Material y métodos. Se recogen los datos publicados por el Ministerio de Sanidad español en su página web durante los actos de elección de plaza en el examen MIR desde el año 2006 hasta 2015, comparando la especialidad de radiodiagnóstico con el resto de las ofertadas en términos de plaza, preguntas netas, sexo, nacionalidad y lugar de elección de la plaza. Resultados. La especialidad de radiodiagnóstico ocupa la posición número 16 en el ranking de especialidades ordenadas según la mediana de número de orden con la que se escogió cada una de sus plazas desde el año 2006 hasta 2015. La primera plaza se suele escoger por debajo del número de orden 75 y la elección de la especialidad se suele terminar entre los números de orden 3.700 y 4.100. Durante el periodo estudiado, un 58% de los electores de radiodiagnóstico fueron mujeres y un 76%, españoles. Los opositores prefieren los hospitales de la comunidad de Madrid, y el hospital elegido con la mediana más baja (mejor número de orden) es el Hospital Clínic de Barcelona. Conclusiones. Radiodiagnóstico se escoge en el MIR con buenos números de orden, con menor tendencia a ser elegida por mujeres que otras especialidades y escogida en su mayoría por médicos españoles. Se prefieren hospitales grandes en capitales de provincia (AU)

Objective. To analyze the profile of residency candidates choosing the specialty of diagnostic radiology in function of variables related to the positions available in different years. Material and methods. We compiled the data published on the Spanish Ministry of Health's website during the acts celebrated to allow residency candidates to choose positions based on the results of the competitive examinations held from 2006 to 2015, comparing the specialty of diagnostic radiology with the other specialties available in terms of positions available, net questions, sex, nationality, and order of choice of the position. Results. The specialty of diagnostic radiology occupied the 16th position in the ranking of specialties according to the median number of order in the choice for each of the positions offered in the years studied. The first diagnostic radiology residency position was usually assigned after 75 candidates had chosen other specialties, and the last position was usually assigned after 3700 to 4100 candidates had chosen their positions. During the period studied, of those who chose diagnostic radiology 58% were women and 76% were Spanish nationality. Candidates preferred hospitals in the Autonomous Community of Madrid, and the hospital chosen with the lowest median position (highest score on the competitive examination) was the Hospital Clínic de Barcelona. Conclusions. Diagnostic radiology is chosen by candidates with good positioning in the ranking according to official examination results, is less likely than other specialties to be chosen by women, and is chosen mostly by Spanish physicians. Candidates prefer large hospitals in provincial capitals (AU)

Choice of the specialty of diagnostic radiology by results of the competitive examination to assign residency positions from 2006 to 2015. / Análisis de la elección de la especialidad de radiodiagnóstico en el examen MIR desde el año 2006 hasta 2015.

OBJECTIVE: To analyze the profile of residency candidates choosing the specialty of diagnostic radiology in function of variables related to the positions available in different years. MATERIAL AND METHODS: We compiled the data published on the Spanish Ministry of Health's website during the acts celebrated to allow residency candidates to choose positions based on the results of the competitive examinations held from 2006 to 2015, comparing the specialty of diagnostic radiology with the other specialties available in terms of positions available, net questions, sex, nationality, and order of choice of the position. RESULTS: The specialty of diagnostic radiology occupied the 16th position in the ranking of specialties according to the median number of order in the choice for each of the positions offered in the years studied. The first diagnostic radiology residency position was usually assigned after 75 candidates had chosen other specialties, and the last position was usually assigned after 3700 to 4100 candidates had chosen their positions. During the period studied, of those who chose diagnostic radiology 58% were women and 76% were Spanish nationality. Candidates preferred hospitals in the Autonomous Community of Madrid, and the hospital chosen with the lowest median position (highest score on the competitive examination) was the Hospital Clínic de Barcelona. CONCLUSIONS: Diagnostic radiology is chosen by candidates with good positioning in the ranking according to official examination results, is less likely than other specialties to be chosen by women, and is chosen mostly by Spanish physicians. Candidates prefer large hospitals in provincial capitals.

[Description of a series of hospital patients with a spinal fistula]. / Descripcion de una serie hospitalaria de pacientes con fistula espinal.

INTRODUCTION: Although spinal fistulas account for 70% of all spinal arteriovenous malformations, they are an underdiagnosed condition. The arteriovenous shunt produces vascular congestion that gives rise to a progressive myelopathy, sometimes irreversible if it is not treated in the early stages. AIM: To describe the clinicoradiological characteristics of a series of patients with spinal fistulas. PATIENTS AND METHODS: A retrospective search was conducted for patients diagnosed with a spinal fistula who were hospitalised in the neuroscience area of a tertiary care hospital. RESULTS: A total of 19 patients (7 females and 12 males) were identified, with a mean age of 56 years. The spinal fistula was type I in 79% of patients, and a dorsal location was the most frequent. Most of the cases (90%) presented a progressive course. Magnetic resonance imaging was used in the diagnosis in 74% of the patients. In four cases angiography was required to reach a diagnosis, and in one of them it was necessary to perform an intraoperative biopsy. Three lumbar punctures were performed, two of which revealed lymphocytic pleocytosis and high protein levels in cerebrospinal fluid. The average diagnostic delay was nine months. Seventy-nine per cent of the patients were treated and only 10% of them improved. CONCLUSIONS: When faced with a clinical picture suggestive of a spinal fistula, a diagnostic spinal angiography must be carried out, although the patient under study may present atypical cerebrospinal fluid characteristics and normal results in magnetic resonance imaging of the spinal cord.

TITLE: Descripcion de una serie hospitalaria de pacientes con fistula espinal.Introduccion. Aunque las fistulas espinales suponen el 70% de las malformaciones arteriovenosas espinales, son una entidad infradiagnosticada. El shunt arteriovenoso produce una congestion vascular que da lugar a una mielopatia progresiva, en ocasiones irreversible si no se trata de forma precoz. Objetivo. Describir las caracteristicas clinicorradiologicas de una serie de pacientes con fistula espinal. Pacientes y metodos. Se realizo una busqueda retrospectiva de pacientes con diagnostico de fistula espinal ingresados en el area de neurociencias de un hospital de tercer nivel asistencial. Resultados. Se identificaron 19 pacientes (7 mujeres y 12 varones) con una edad media de 56 años. La fistula espinal fue de tipo I en un 79% de los pacientes y la localizacion dorsal fue la mas frecuente. La mayoria de los casos presento un curso progresivo (90%). Un 74% de los pacientes se diagnostico mediante resonancia magnetica. En cuatro casos fue necesaria la realizacion de una angiografia para llegar al diagnostico, y en uno de ellos se preciso una biopsia intraoperatoria. Se realizaron tres punciones lumbares, en dos de las cuales se objetivo pleocitosis linfocitaria e hiperproteinorraquia. El retraso diagnostico medio fue de nueve meses. Se trato a un 79% de los pacientes, y de ellos solo mejoro el 10%. Conclusiones. Ante una clinica sugestiva de fistula espinal, debe realizarse una angiografia espinal diagnostica aunque el paciente estudiado pueda presentar caracteristicas licuorales atipicas y normalidad en la resonancia magnetica medular.

Técnicas asistidas para el tratamiento endovascular de aneurismas cerebrales complejos o atípicos / Assisted techniques for the endovascular treatment of complex or atypical cerebral aneurysms

A lo largo de los últimos 10 años, el abordaje endovascular de los aneurismas cerebrales ha pasado de ser una alternativa a la cirugía a convertirse en la terapia de elección en la inmensa mayoría de los casos. El constante desarrollo de técnicas asistidas y de nuevos materiales de embolización ha multiplicado sus posibilidades terapéuticas, de modo que en la actualidad es posible tratar con eficacia y seguridad aneurismas que hace tan solo unos años hubiesen sido considerados quirúrgicos. Este continuo avance tecnológico exige a los profesionales implicados en el tratamiento de pacientes con aneurismas cerebrales un alto grado de especialización y una actualización formativa permanente. En el presente trabajo repasamos algunas de las técnicas asistidas más empleadas en la actualidad para el tratamiento endovascular de los aneurismas cerebrales, mostramos sus principales indicaciones, las mejoras que suponen respecto a las técnicas de embolización convencional y sus posibles limitaciones(AU)

In the last ten years, the endovascular approach to the management of cerebral aneurysms has gone from being an alternative to surgery to being the first-choice technique in the vast majority of cases. The continuous development of new assisted techniques and of new materials for embolization have multiplied its therapeutic possibilities, so that safe and efficacious endovascular treatment is now possible for aneurysms that would have required surgery only a few years ago. These continuous technological advances require the professionals that treat patients with cerebral aneurysms to achieve a high degree of specialization and to keep up to date through continuous training. In this article, we review some of the most widely used assisted techniques in the endovascular treatment of cerebral aneurysms, discussing their main indications, their advantages over conventional embolization techniques, and their possible limitations(AU)

[Assisted techniques for the endovascular treatment of complex or atypical cerebral aneurysms]. / Técnicas asistidas para el tratamiento endovascular de aneurismas cerebrales complejos o atípicos.

In the last ten years, the endovascular approach to the management of cerebral aneurysms has gone from being an alternative to surgery to being the first-choice technique in the vast majority of cases. The continuous development of new assisted techniques and of new materials for embolization have multiplied its therapeutic possibilities, so that safe and efficacious endovascular treatment is now possible for aneurysms that would have required surgery only a few years ago. These continuous technological advances require the professionals that treat patients with cerebral aneurysms to achieve a high degree of specialization and to keep up to date through continuous training. In this article, we review some of the most widely used assisted techniques in the endovascular treatment of cerebral aneurysms, discussing their main indications, their advantages over conventional embolization techniques, and their possible limitations.

Nuestra experiencia en el diagnóstico y tratamiento de los seudoaneurismas cerebrales / Our experience in the diagnosis and treatment of cerebral pseudoaneurysms

Objetivo. Presentar nuestra experiencia en el diagnóstico y tratamiento intravascular de los seudoaneurismas cerebrales. Material y métodos. Presentamos 11 casos de seudoaneurismas (2 traumáticos, 2 micóticos, 3 iatrogénicos y 4 asociados a otras causas) en otros tantos pacientes y analizamos los métodos y criterios diagnósticos, la evolución radiológica y clínica, los criterios tomados en cuenta para la decisión terapéutica, el método de tratamiento y las complicaciones. Resultados. El método de referencia para el diagnóstico es la angiografía por sustracción digital y los criterios diagnósticos en la literatura médica incluyen: aneurismas con cambios morfológicos precoces, aneurismas distales o aneurismas proximales asociados a otro distal, en el contexto clínico adecuado. En los 9 pacientes tratados mediante técnica intravascular se consiguió el objetivo del tratamiento, evitar el resangrado. Conclusiones. Ante la sospecha clínica de un seudoaneurisma todo paciente debe ser valorado mediante arteriografía, principalmente aquellos que presentan hemorragias cerebrales inexplicables y los pacientes con septicemia. La angiografía mediante TC o mediante RM puede sustituir a la arteriografía con una buena rentabilidad diagnóstica. El tratamiento de elección debe ser el intravascular de primera intención y no demorarse excepto que exista una razón que impida el acceso al seudoaneurisma, normalmente un vasoespasmo cerebral grave (AU)

Objective. To present our experience in the diagnosis and intravascular treatment of cerebral pseudoaneurysms. Material and methods. We present 11 pseudoaneurysms (2 traumatic, 2 mycotic, 3 iatrogenic, and 4 with other causes). We analyze the methods and diagnostic criteria, radiological and clinical outcome, the criteria used in making decisions about treatment, the method of treatment, and the complications. Results. Digital subtraction angiography is the gold standard for the diagnosis of cerebral pseudoaneurysms; the diagnostic criteria in the literature include: aneurysms with early morphological changes and distal aneurysms or proximal aneurysms associated with another distal one, in the context of the right symptoms and signs. In the nine patients treated with endovascular techniques, the treatment objective was achieved and rebleeding did not occur. Conclusions. In cases with clinical suspicion of a pseudoaneurysm, the patient should undergo angiography. This is especially important in patients with inexplicable cerebral hemorrhage and in those with septicemia. CT angiography and MR angiography have good diagnostic accuracy and can replace conventional angiography. However, the treatment of choice is endovascular and treatment should not be delayed unless access to the pseudoaneurysm is impeded, usually due to severe cerebral vasospasm (AU)

Tratamiento endovascular de la estenosis carotídea: experiencia en el Hospital Universitario Central de Asturias / Endovascular treatment of carotid stenosis: an experience in the Hospital Universitario Central de Asturias

Introducción. La estenosis carotídea es responsable de aproximadamente el 25% de los eventos cerebrovasculares isquémicos. La angioplastia-stent carotídeo (ASC) constituye un procedimiento mínimamente invasivo utilizado como alternativa a la endarterectomía carotídea, especialmente en pacientes de alto riesgo quirúrgico. Objetivo. Analizar la eficacia y seguridad del tratamiento endovascular de la estenosis carotídea en el Hospital Universitario Central de Asturias. Pacientes y métodos. Análisis retrospectivo de las estenosis carotídeas tratadas mediante ASC entre febrero de 2005 y abril de 2010, con registro de datos demográficos, diagnóstico clínico, indicación de tratamiento, tiempo entre el inicio de los síntomas y la realización del tratamiento, resultados angiográficos, complicaciones y seguimiento a largo plazo (incluyendo la tasa de reestenosis). Resultados. Se trataron 121 pacientes (77,8% varones y 22,2% mujeres), con una edad media de 70,8 ± 10,7 años. Los principales factores de riesgo vascular fueron hipertensión arterial (65,3%), tabaquismo (61,2%) y dislipidemia (42,1%). En el 86% de los casos se trataba de estenosis sintomáticas y en el 14% de asintomáticas. En un 60,3% de los casos se trataba de estenosis > 70%; en un 30,6%, de estenosis preoclusivas, y en un 9,1%, de recanalizaciones de oclusiones carotídeas inestables. El tiempo medio de tratamiento fue de 17,0 ± 8,3 días tras el evento isquémico. La estenosis residual fue inferior al 30% en todos los casos. La tasa de morbimortalidad a 30 días fue del 4,1% y la tasa de reestenosis a lo largo de un seguimiento medio de 31,2 ± 10,8 meses fue del 2,4%. Conclusiones. La ASC en nuestro hospital se configura como una técnica eficaz y segura, con una tasa de complicaciones dentro de los parámetros que justifican su indicación (AU)

Introduction. Carotid stenosis accounts for about 25% of all ischaemic cerebrovascular events. Carotid angioplasty and stenting (CAS) is a minimally invasive procedure used as an alternative to carotid endarterectomy, especially in high surgical risk patients. Aim. To analyse the effectiveness and safety of the endovascular treatment of carotid stenosis in the Hospital Universitario Central de Asturias. Patients and methods. The study consisted in a retrospective analysis of the carotid stenoses treated by means of CAS between February 2005 and April 2010, and the following information was recorded: demographic data, clinical diagnosis, indication of treatment, time between the onset of symptoms and beginning of treatment, angiographic findings, complications and long-term follow-up (including the rate of restenosis). Results. Altogether 121 patients were treated (77.8% males and 22.2% females), with a mean age of 70.8 ± 10.7 years. The main vascular risk factors were arterial hypertension (65.3%), smoking (61.2%) and dyslipidaemia (42.1%). In 86% of cases the stenoses were symptomatic and in the remaining 14% they were asymptomatic. In 60.3% of cases they were stenoses > 70%, in 30.6% they were preocclusive stenoses and in 9.1% they were recanalisations of unstable carotid occlusions. The mean treatment time was 17.0 ± 8.3 days after the ischaemic event. The residual stenosis was less than 30% in all cases. The morbidity and mortality rate at 30 days was 4.1% and the rate of restenosis throughout a mean follow-up of 31.2 ± 10.8 months was 2.4%. Conclusions. In our hospital CAS is considered an effective and safe technique, with a rate of complications that is within the parameters that justify its indication (AU)

[Our experience in the diagnosis and treatment of cerebral pseudoaneurysms]. / Nuestra experiencia en el diagnóstico y tratamiento de los seudoaneurismas cerebrales.

OBJECTIVE: To present our experience in the diagnosis and intravascular treatment of cerebral pseudoaneurysms. MATERIAL AND METHODS: We present 11 pseudoaneurysms (2 traumatic, 2 mycotic, 3 iatrogenic, and 4 with other causes). We analyze the methods and diagnostic criteria, radiological and clinical outcome, the criteria used in making decisions about treatment, the method of treatment, and the complications. RESULTS: Digital subtraction angiography is the gold standard for the diagnosis of cerebral pseudoaneurysms; the diagnostic criteria in the literature include: aneurysms with early morphological changes and distal aneurysms or proximal aneurysms associated with another distal one, in the context of the right symptoms and signs. In the nine patients treated with endovascular techniques, the treatment objective was achieved and rebleeding did not occur. CONCLUSIONS: In cases with clinical suspicion of a pseudoaneurysm, the patient should undergo angiography. This is especially important in patients with inexplicable cerebral hemorrhage and in those with septicemia. CT angiography and MR angiography have good diagnostic accuracy and can replace conventional angiography. However, the treatment of choice is endovascular and treatment should not be delayed unless access to the pseudoaneurysm is impeded, usually due to severe cerebral vasospasm.

Comparación de la ecografía abdominal con la tomografía computarizada abdominal en el seguimiento del tumor de células germinales testicular / Abdominal ultrasonography versus abdominal CT in the follow-up of testicular germ cell tumors

Introducción. El tumor de células germinales testicular es una neoplasia frecuente que afecta a varones jóvenes. En la literatura médica existe un consenso en los puntos clave que se refieren a su diagnóstico y tratamiento, aunque hay elementos que se encuentran actualmente en revisión, entre ellos los métodos de seguimiento de esta enfermedad. Presentamos un estudio estadístico que analiza, mediante las herramientas de valoración de pruebas diagnósticas, la utilidad de la ecografía abdominal comparada con la tomografía computarizada (TC) abdominal, que tomamos como prueba de referencia para diagnosticar metástasis hepáticas y adenopatías retroperitoneales en el seguimiento de pacientes con neoplasia germinal testicular. Material y métodos. Analizamos 308 pruebas diagnósticas, 154 estudios de TC abdominal y 154 ecografías abdominales, correspondientes a 59 pacientes seguidos durante un período de al menos un año en nuestra institución. Los pacientes se estudiaron mediante una ecografía abdominal que precedía a la TC abdominal, protocolo de seguimiento estándar. Resultados. La ecografía abdominal presenta, respecto a la prueba de referencia, una sensibilidad del 95%, una especificidad del 92%, un VPP del 82% y un VPN del 98%. Conclusión. La ecografía es una prueba con gran sensibilidad que se puede utilizar para descartar la recidiva abdominal en los protocolos de seguimiento de la neoplasia primitiva de testículo (AU)

Introduction. Testicular germ cell tumors are common in young men. There is a wide consensus regarding the key points in their diagnosis and treatment, although some elements, including the best approach to follow-up, are being reviewed and revised. We present a statistical study that uses tools for the evaluation of diagnostic tests to compare the usefulness of abdominal ultrasonography (US) in comparison with that of abdominal CT, taken as the gold standard, in the detection of liver metastases and retroperitoneal adenopathies in patients with testicular germ cell tumors. Material and methods. We analyzed a total of 308 diagnostic tests (154 CT studies and 154 US studies) from 59 patients with at least one year's follow-up at our institution. Patients underwent abdominal US before abdominal CT following a standard protocol. Results. Compared to the gold standard, abdominal US had 95% sensitivity, 92% specificity, 82% PPV, and 98% NPV. Conclusion. US is very sensitive and can be used in protocols for the follow-up of primary testicular tumors to rule out disease (AU)

[Abdominal ultrasonography versus abdominal CT in the follow-up of testicular germ cell tumors]. / Comparación de la ecografía abdominal con la tomografía computarizada abdominal en el seguimiento del tumor de células germinales testicular.

INTRODUCTION: Testicular germ cell tumors are common in young men. There is a wide consensus regarding the key points in their diagnosis and treatment, although some elements, including the best approach to follow-up, are being reviewed and revised. We present a statistical study that uses tools for the evaluation of diagnostic tests to compare the usefulness of abdominal ultrasonography (US) in comparison with that of abdominal CT, taken as the gold standard, in the detection of liver metastases and retroperitoneal adenopathies in patients with testicular germ cell tumors. MATERIAL AND METHODS: We analyzed a total of 308 diagnostic tests (154 CT studies and 154 US studies) from 59 patients with at least one year's follow-up at our institution. Patients underwent abdominal US before abdominal CT following a standard protocol. RESULTS: Compared to the gold standard, abdominal US had 95% sensitivity, 92% specificity, 82% PPV, and 98% NPV. CONCLUSION: US is very sensitive and can be used in protocols for the follow-up of primary testicular tumors to rule out disease.