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

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

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

La implantación del espacio europeo de educaciónsuperior (EEES) inspirado en la declaración de Boloniaconlleva la introducción de un nuevo paradigma docenteque requiere reestructurar la enseñanza universitaria.Este proceso ha llevado a la reducción de la duración delos anteriores grados con excepción de unos pocos, entrelos que se cuenta el nuevo Grado de Medicina. Aunquees un objetivo prioritario del EEES homogeneizar yarmonizar las enseñanzas y las titulaciones en Europapara favorecer la circulación o intercambio de estudiantesy de profesionales, en el año 2010, cuando deberíahaberse completado el proceso boloñés, está muy lejosde conseguirse la deseada convergencia en la enseñanzasuperior en Europa.En este artículo se comenta cómo el retardo en laarmonización y la convergencia europea es especialmenterelevante en los estudios de Medicina, y se analizael desarrollo del proceso boloñés, tanto en Europacomo en nuestro país, donde se están diseñando losnuevos Planes de Estudio de Medicina en un marcolimitado por la improvisación burocrática y la precipitaciónderivadas de los plazos fijos impuestos porlas autoridades políticas (límite en el 2010), la falta definanciación, y la inercia de sectores profesorales quedesconocen lo esencial del proyecto y muestran indiferencia,o incluso resistencia, a cualquier cambio deparadigma docente. Así, y en contraste con lo ocurridoen otros países vecinos, en los que independientementedel proceso de Bolonia se han conseguido diferentesgrados de modernización curricular, en España existeun alto riesgo de que los nuevos Planes se queden enmeros cambios cosméticos de los utilizados previamenteen la mayoría de las Facultades. De resultar así,la introducción de verdaderas innovaciones docentes,como las preconizadas desde el EEES, se vería seriamentelimitada aumentando más aún la divergenciacon Europa (AU)

The implementation of the European Higher EducationArea, (EEES in Spanish) inspired in the BolognaDeclaration, pursues the introduction of new teachingand learning paradigms which require deep changes inthe frame of superior education and university goals.However, in spite that the main purpose of the EEESis convergence and harmonization of curricula contentsand titles throughout Europe in order to facilitate circulationof students and professionals, this goal is far frombeen reached when we are approaching the deadline forits implementation (year 2010). In addition, this processhas led to reduce the total duration of the majority ofdegrees excepting for medicine and few more.In this article we analyze the underdevelopment ofthe so called Bologna Process in medical education ascompared to other careers. Implementation of curricularinnovations seems particularly restrained or threatenedin Spain because of legal improvisation, lack offunding, and the chronic apathy of national bodies inmedical education. As a consequence, and in contrastwith other European countries where deep curricularchanges have been already arranged, the majority ofSpanish Faculties are at risk of introducing little morethan cosmetic modifications in their medicine curricula (AU)

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

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

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

Objetivo. Analizar retrospectivamente los factoresimplicados en la obliteración de las malformacionesarteriovenosas (MAVs) tratadas mediante radiocirugía.Métodos. Se revisaron retrospectivamente las historiasclínicas y las pruebas de imagen de 59 pacientescon MAVs tratados consecutivamente mediante tratamientoradioquirúrgico en nuestro Servicio. Se recogenlos datos demográficos y clínicos en el momentodel diagnóstico, así como los referentes al tratamientoempleado y la evolución de dichos pacientes.Resultados. Se consiguió la obliteración en el 77%de las MAVs tratadas. La obliteración completa seobservó en los primeros tres años en sólo el 40% de loscasos, mientras que en el resto, la obliteración ocurrióentre los tres y los cinco años. Diez pacientes (17%)sufrieron complicaciones agudas o crónicas. Sólo unpaciente murió como resultado de una hemorragiaintraparenquimatosa durante el periodo de seguimiento.El análisis multivariable utilizando los diversosfactores y parámetros potencialmente relacionadoscon la obliteración mostró que sólo la hiperintensidadperilesional observada en secuencias T2 de la RM yun tamaño del nidus menor de 3 cm incrementaron demanera estadísticamente significativa la probabilidadde oclusión completa (p=0,03 y p=0,05, respectivamente).Conclusión. Nuestros resultados, son similares a losreportados en otras series. Sin embargo, se obtuvo unamenor tasa de oclusiones en las MAVs >3cm de diámetro,confirmando que el tamaño es un factor determinanteen probabilidad de cierre de las MAVs tratadas (..) (AU)

Objetive. The aim of this study was to determinewhich factors were statistically related to radiologicaland clinical outcomes following radiosurgical treatmentof arteriovenous malformations (AVMs).Methods. The data of 59 patients receiving radiosurgicaltreatment at our department were retrospectivellyreviewed. Different clinical and biological data,including Spetzler-Martin grade, the presentation ofsymptoms, radiation dose, number of isocenters andboth radiological and clinical outcome, were subjectedto multivariate analysis.Results. AVM obliteration was achieved in 77% ofpatients, the majority of them occurring between 3-5years after treatment. Ten patients (17%) showed eitheracute or delayed complications. Only one patient dieddue tor hemorrhage during the follow-up after radiosurgery.A multivariate analysis showed that, hyperintensityon T2 MRI and a nidus smaller than 3 cm werethe only factors statistically related to oclusion of theAVM (p=0,03 and p=0,05, respectively).Conclusion. The nidus size and the development ofhyperintensity on T2 MRI after the treatment were thestrongest predictive factors of obliteration in our seriesof AVMs radiosurgically treated. Moreover, given thatmany AVMs showed complete obliteration between 3-5years after treatment, we recommend to wait untill 5years after treatment before considering a new terapeuthicapproach in patients showing small residual nidusat control imaging. (AU)

Acute traumatic central cord syndrome: analysis of clinical and radiological correlations.

AIM: In patients with traumatic spinal cord injury, several studies correlate neurological impairment and radiological findings. However, little information is available about this correspondence in the particular group of acute traumatic central cord syndrome. The object of the present work was to describe the clinical and radiological features of a series of patients presenting with acute traumatic central cord syndrome and to analyze clinical and radiological correlations on admission and at last follow-up. METHODS: Retrospective review of 15 patients diagnosed of acute traumatic central cord syndrome between 1995 and 2005. Global motor score and motor score in upper extremities were determined on admission and at last follow-up (6 months-4 years, mean 16 months). Plain films, cervical computed tomography and magnetic resonance (MR) were performed in every patient and retrieved for the study. In seven patients, serial MR studies were performed during follow-up. Clinical and radiological correlations were statistically analyzed with non-parametric tests. RESULTS: Cervical spondylosis appeared associated with older age, falls, and absence of fracture. Spinal cord edema was the most common finding in MR studies but hemorrhage was also observed. The length of spinal cord edema significantly correlated with initial motor score. The decrease in T2-weighted hyperintensity in serial MR studies correlated with the gain of motor power in upper limbs at last follow-up. CONCLUSION: Elderly patients with more degenerated cervical spines commonly develop acute traumatic central cord syndrome after incidental falls. Length of spinal cord edema correlates with neurological impairment on admission and may provide significant prognostic information.

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

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

La repercusión de la nueva regulación del horario laboral del Residente sobre la calidad de la enseñanza en el Pregrado y el Postgrado / The impact of resident work hour limitations on medical student clerkships in Spain

Se considera la posible influencia negativa de la restricción del horario laboral del residente sobre la enseñanza del pregraduado en los hospitales universitarios. Aunque las opiniones de expertos y los resultados de diferentes estudios sobre la repercusión real de la nueva jornada laboral en la calidad del cuidado clínico y la formación del propio residente son contradictorios, parecen ser más los que indican que su efecto puede ser negativo, particularmente en Europa y Japón, donde el horario semanal quedaría reducido a 48 y 40 horas respectivamente, en clara desventaja con el aplicado en USA, que alcanza 80 horas. El problema podría agudizarse más aún en España donde la duración dela residencia es más corta que en otros países europeos. Si la formación del residente empeorara sería también de esperar un deterioro añadido en la enseñanza del pregraduado

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

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

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

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

El tratamiento quirúrgico juega un papel fundamental en el manejo de algunos pacientes con hematomas de cerebelo, y sin embargo, no existe una guía de tratamiento universalmente aceptada que permita seleccionar a este subgrupo de pacientes. El objetivo del presente trabajo fue revisar la base sobre la que se fundamentan las indicaciones del tratamiento quirúrgico en esta patología. En ausencia de ensayos clínicos que afronten este problema, las series clínicas muestran que los criterios más consistentes para la decisión terapéutica son el nivel de consciencia, el tamaño del hematoma, la presencia de hidrocefalia y los datos radiológicos de compresión de los espacios continentes de LCR en la fosa posterior. El parámetro mejor estudiado como reflejo de este último aspecto posiblemente sea la deformidad del IV ventrículo. La literatura sugiere que los hematomas de 4 o más cm de diámetro, o que causan una oclusión completa del IV ventrículo o de la cisterna prepontina deben ser intervenidos independientemente del nivel de consciencia, al presentar una compresión significativa del tronco del encéfalo (TDE). Por el contrario, es probable que hematomas de menos de 3 cm y que no deforman el IV ventrículo, no causen una compresión importante en la fosa posterior, y puedan ser manejados de forma conservadora o mediante el drenaje dela hidrocefalia si fuera preciso. Para hematomas de tamaño intermedio la decisión terapéutica está menos clara, pudiendo optarse por observación estricta en los pacientes con GCS 14-15 o con drenaje ventricular externo (DVE) aislado en aquellos con GCS<14 que presenten hidrocefalia. En presencia de un bajo nivel de consciencia a pesar del tratamiento de la hidrocefalia, o en ausencia de ésta, se debería realizar una evacuación del hematoma. Finalmente, no parece indicado el tratamiento de pacientes con GCS 3 y ausencia de reflejos de tronco, o aquéllos en los que por su edad avanzada o mala calidad de vida previa presenten un pronóstico funcional malo. Se ha encontrado además que los pacientes en coma y con signos radiológicos de grave compresión del TDE las posibilidades de una buena recuperación son muy escasas. A pesar de todo el tratamiento ha de ser individualizado en cada caso, ya que no existe la evidencia suficiente que permita elaborar una guía de aplicación estricta

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

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

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

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

La hemorragia intracerebral espontánea (HIE) constituye uno de los procesos ictales de mayor gravedad. A pesar de esto y de una elevada incidencia, su tratamiento médico no va mucho más allá de un papel de soporte vital y control médico de la hipertensión intracraneal, y las indicaciones del tratamiento quirúrgico están pobremente basadas en evidencia científica. El objetivo del presente trabajo fue revisar las bases de la indicación quirúrgica en la HIE supratentorial. Encontramos 10 ensayos clínicos y 5 meta-análisis en lengua inglesa que analizaban la utilidad del tratamiento quirúrgico en esta patología. Aunque globalmente estos estudios no mostraron un beneficio significativo del tratamiento quirúrgico en el conjunto de pacientes con HIE supratentorial, existe un subgrupo de pacientes en los que parece que dicho tratamiento podría ser beneficioso. En la hemorragia intracerebral espontánea supratentoriallas recomendaciones actuales indican que los pacientes jóvenes, con hematomas lobares cuyo volumen causa un deterioro del nivel de consciencia, deben ser intervenidos. En pacientes con hematomas putaminales que reúnen las mismas condiciones de edad y deterioro neurológico la cirugía podría mejorar la evolución, al menos en términos de supervivencia. Un grave deterioro neurológico con GCS<5, la localización talámica y la presencia de una situación basal o edad que impidan una adecuada recuperación funcional, son criterios considerados tradicionalmente contraindicación del tratamiento quirúrgico. Dada la ausencia de evidencia científica sólida en la que sustentar estas recomendaciones, la decisión terapéutica debe realizarse de manera individualizada y prestando atención al soporte sociofamiliar del paciente, que jugará un papel importante en la evolución del mismo a medio/largo plazo

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

Dural arteriovenous fistula presenting as brainstem ischaemia.

Dural arteriovenous fistulas presenting with ascending myelopathy are characterised by the presence of an abnormal retrograde drainage through spinal veins. The authors present a case of cranial dural arteriovenous fistula causing brainstem dysfunction secondary to venous hypertension, treated by surgical interruption of the pial venous drainage which resulted in complete clinical and radiological resolution of the brainstem lesion.

[Magnetic resonance in moderate and severe head injury: comparative study of CT and MR findings. Characteristics related to the presence and location of diffuse axonal injury in MR]. / Resonancia magnética en trauma craneal moderado y grave: estudio comparativo de hallazgos en TC y RM. Características relacionadas con la presencia y localización de lesión axonal difusa en RM.

INTRODUCTION: Cranial CT has been the most extended evaluation means for patients suffering head trauma. However, it has low sensitivity in the identification of diffuse axonal injury and posterior fossa lesions. Cranial MR is a potentially more sensitive test but difficult to perform in these patients, a fact that has hampered its generalised use. OBJECTIVE: To compare the identification capability of traumatic intracranial lesions by both diagnostic tests in patients with moderate and severe head injury and to determine which radiological characteristics are associated with the presence of diffuse injury in MR and their clinical severity. MATERIAL AND METHODS: 100 patients suffering moderate or severe head injury to whom a MR had been performed in the first 30 days after trauma were included. All clinical variables related to prognosis were registered, as well as the data from the initial CT following Marshall et al., classification. The MR was blindly evaluated by two neuroradiologists that were not aware of the initial CT results or the clinical situation of the patient. All lesions were registered as well as the classification following the classification of lesions related to DAI described by Adams et al. CT and MR findings were compared evaluating the sensitivities of each test. Factors related to the presence of diffuse injury in MR were studied by univariate analysis using chi2 test and simple correlations. RESULTS: MR is more sensitive than CT for lesions in cerebral white matter, corpus callosum and brainstem. It also detects a greater number of cerebral contussions. The presence of diffuse axonal injury depends on the mechanism of the trauma, being more frequent in higher energy trauma, specially in traffic accidents. Among the radiological characteristics associated to DAI the most clearly related is intraventricular haemorrhage. The presence of a deeper injury and a higher score in the scales of Adams is associated with a lower score in the GCS and motor GCS, and so with a worse level of consciousness and bigger severity of injury, confirming Ommaya's model.

El cambio en el proceso editorial de la revista Neurocirugía / The change in the editorial process of Neurocirugia, the journal of the Spanish Neurosurgical Society

En breve se va a introducir un cambio en el proceso editorial de la revista Neurocirugía, órgano oficial de expresión de la Sociedad Española de Neurocirugía(SENEC). Con tal motivo se hace una breve semblanza del recorrido de la revista desde su aparición en 1991hasta el momento actual. Se consideran algunos cambios ocurridos en los últimos años en el proceso global de la publicación en biomedicina, y más concretamente en la manera de circular los artículos, la metodología dela revisión por pares, y la edición en medios electrónicos, destacando la necesidad de reducir en parte la edición en papel en favor de la electrónica. Se contemplan también otros aspectos relacionados con Neurocirugía, como son la pertinencia y utilidad de disponer de una revista especializada de ámbito nacional, el problema de la lengua a elegir para la presentación de los originales, y la importancia de que los neurocirujanos trasladen a la revista no sólo sus observaciones científicas, sino también opiniones y reflexiones sobre el devenir y la historia de nuestra especialidad

The editorial process of Neurocirugia, which is the official journal of the Spanish Neurosurgical Society, will be changed in the immediate future. Together with the announcement of new instructions to the authors, we analyze some recent trends in the process of publication of biomedical research related to peer review methodology and the controversy of the "authors pays" vs "reader pays" models. The reasons for sustaining a national neurosurgical journal, the advantages for using either Spanish or English to writing the manuscripts, and the importance for Spanish neurosurgeons to reflect some of their scientific contributions and opinions concerning the present and future of our speciality in Neurocirugia are commented

Resonancia magnética en trauma craneal moderado y grave: estudio comparativo de hallazgos en TC y RM. Características relacionadas con la presencia y localización de lesión axonal difusa en RM / Magnetic Resonance in moderate and severe head injury: comparative study of CT and MR findings. Characteristics related to the presence and location of diffuse axonal injury in MR

Introducción. La TC craneal ha sido el método más extendido en la evaluación de enfermos que han sufrido trauma craneal. Sin embargo, es poco sensible en la identificación de lesión axonal difusa y lesiones en fosa posterior. La RM craneal es una prueba potencialmente más sensible pero de difícil realización en estos enfermos, hecho que ha impedido la generalización de su uso. Objetivos. Comparar la capacidad de identificación de lesiones intracraneales postraumáticas por parte de las dos pruebas diagnósticas en enfermos con TCE grave y moderado, y determinar qué características radiológicas en la TC se asocian a la presencia de LAD en RM y su gravedad clínica. Material y métodos. Se incluyen en el estudio 100enfermos con TCE moderado y grave a los que se ha realizado RM craneal dentro de los primeros 30 días tras el trauma craneal. Se recogieron todas las variables clínicas potencialmente relacionadas con el pronóstico de los enfermos, así como los datos del TC inicial según la clasificación de Marshall y cols. La RM fue evaluada de manera ciega por dos neurorradiólogos que ignoraban al resultado de la TC inicial y la situación clínica inicial del paciente. Se recogieron todas las lesiones que presentaban, así como su clasificación según la clasificación de lesiones asociadas con LAD, descrita por Adams. Se compararon los hallazgos en TC y RM, evaluando la sensibilidad de cada prueba con respecto a los diferentes hallazgos. Se estudiaron los hallazgos relacionados con la presencia de LAD en RM, mediante estudio univariable, usando la prueba de χ2 y correlaciones simples. Resultados. La RM es más sensible que la TC para las lesiones en sustancia blanca cerebral, cuerpo calloso y tronco. Además, detecta mayor número de contusiones. La presencia de lesión axonal difusa depende del mecanismo de producción del trauma, siendo más frecuente en traumas de mayor energía, sobre todo en los accidentes de tráfico, bien sea con automóvil o moto/bici. En cuanto a las características radiológicas asociadas a LAD la más claramente relacionada es la hemorragia intraventricular. La presencia de daño cada vez más profundo y mayor puntuación en la escala de Adams se asocia a menor puntuación en la GCS y GCS motora, y por consiguiente peor nivel de conciencia y mayor gravedad del trauma inicial, confirmando el modelo de Ommaya

Introduction. Cranial CT has been the most extended evaluation means for patients suffering head trauma. However, it has low sensitivity in the identification of diffuse axonal injury and posterior fossa lesions. Cranial MR is a potentially more sensitive test but difficult to perform in these patients, a fact that has hampered its generalised use. Objective. To compare the identification capability of traumatic intracranial lesions by both diagnostic tests in patients with moderate and severe head injury and to determine which radiological characteristics are associated with the presence of diffuse injury in MR and their clinical severity. Material and methods. 100 patients suffering moderate or severe head injury to whom a MR had been performed in the first 30 days after trauma were included. All clinical variables related to prognosis were registered, as well as the data from the initial CT following Marshall et al., classification. The MR was blindly evaluated by two neuroradiologists that were not aware of the initial CT results or the clinical situation of the patient. All lesions were registered as well as the classification following the classification of lesions related to DAI described by Adams et al. CT and MR findings were compared evaluating the sensitivities of each test. Factors related to the presence of diffuse injury in MR were studied by univariate analysis using χ2 test and simple correlations. Results. MR is more sensitive than CT for lesions in cerebral white matter, corpus callosum and brainstem. It also detects a greater number of cerebral contussions. The presence of diffuse axonal injury depends on the mechanism of the trauma, being more frequent in higher energy trauma, specially in traffic accidents. Among the radiological characteristics associated to DAI the most clearly related is intraventricular haemorrhage. The presence of a deeper injury and a higher score in the scales of Adams is associated with a lower score in the GCS and motor GCS, and so with a worse level of consciousness and bigger severity of injury, con-firming Ommaya’s model

[Value of serial CT scanning and intracranial pressure monitoring for detecting new intracranial mass effect in severe head injury patients showing lesions type I-II in the initial CT scan]. / Utilidad de la TAC secuencial y la monitorización de la presión intracraneal para detectar nuevo efecto masa intracraneal en pacientes con traumatismo craneal grave y lesión inicial Tipo I-II.

OBJECTIVE: To determine the incidence of pathological and intracranial pressure (ICP) changes during the acute posttraumatic period in severe head injury patients presenting with lesions Types I-II (TCDB classification) in the admission CT scan with the aim of defining the most appropriate strategy of sequential CT scanning and ICP monitoring for detecting new intra-cranial mass effect and improving the final outcome. MATERIAL AND METHODS: 56 patients (ages 15-80 years) consecutively admitted during a 2 years period were included. All had the initial CT scan < 24 hours after injury (mean interval = 150 min), several CT controls within the first days of the course and ICP monitoring after admission. Different epidemiological, clinical and radiological variables were recorded and deterioration defined as the development of sustained ICP over 20 mmHg requiring aggressive medical and/or surgical treatment was considered the dependent variable. Uni and multivariate analyses were made for determining the correlation between different parameters and the occurrence of deterioration and the final outcome as assessed with the GOS. RESULTS: The mean GCS score was 5 and 37% of the patients showed pupillary changes; 52.3% had peritraumatic hypotension-hypoxemia, 16.1% anemia and 12.3% coagulation changes. 50% of the patients showed petechial hemorrhages in the white matter or the brainstem, 66% SAH, 40% HIV, 39.3% brain contusion and 21.4% small extraaxial hematomas. 57.1% of the patients showed CT changes through the acute post-traumatic period consisting of new contusion (26.8% of the cases), growing of previous contusion (68.2%) or previous extraaxial hematoma (10.7%), and generalized brain swelling (10.7%). 64.9% of the patients made a favourable and 35.7% an unfavourable outcome. Overall, 27 (48.9%) patients developed deterioration, 21 (37.5%) with concurrent CT changes and 6 (10.7%) without new pathology as seen by the CT control. The remaining 29 (51.7%) patients in this series did not develop deterioration in spite that 11(19.6%) showed CT changes. The age, the initial score, the occurrence of peritraumatic hypotension-hypoxemia and coagulation disorders did not correlate with the risk of deterioration. By contrast, the presence of contusion at the initial CT scan (p= 0.01) and the occurrence of CT change (only generalized brain swelling, p= 0.003) significantly correlated with the risk of deterioration; in his turn deterioration increased by a factor of 10 (OR = 9.8) the risk of death and 7 out of the 8 patients who died developed intractable intracranial hypertension. The 8 (14.2%) patients requiring surgery showed simultaneous ICP deterioration and CT changes, but another 11 patients in a similar condition could be managed without surgery. With or without ICP deterioration, patients showing CT changes had a worse outcome than those without new pathologies, but the difference did not reach statistical significance, DISCUSSION AND CONCLUSIONS: Over 50% of the patients with initial Type I-II lesions developed new CT changes and nearly 50% showed intracranial hypertension during the acute posttraumatic period. Considering the high incidences of ICP and CT deterioration through the course, along with the absence of strong predictors and the discordances between CT and ICP changes (which were seen in 30.3% of the cases) we recommend ICP monitoring after admission in all patients and serial CT scanning at 2-4, 12, 24, 48 and 72 hours after injury with additional controls as indicated by clinical or ICP changes in all cases. Though it is clear that the presence of severe intra-cranial hypertension significantly increased the risk of death, the small size of the sample in this series prevented to assess to what extent the occurrence of new mass effect and/or raised ICP contributed to the development of moderate and severe disability in the survivors which were mainly due to the occurrence of diffuse axonal injury. Finally, demonstrating that sequential CT scanning and ICP monitoring improve the final outcome in this type of patients would require a prospective randomized trial which is impracticable for different reasons, among them the ethical ones.

Utilidad de la TAC secuencial y la monitorización de la presión intracraneal para detectar nuevo efecto masa intracraneal en pacientes con traumatismo craneal grave y lesión inicial Tipo I-II / Value of serial CT scanning and intracranial pressure monitoring for detecting new intracranial mass effect in severe

Objetivo. Analizar los cambios en la patología y presión intracraneal (PIC) durante el periodo agudo postraumático en una serie de pacientes con trauma craneal grave y lesiones Tipos I-II en la TAC inicial (clasificación del Traumatic Coma Data Bank) con el objetivo de diseñar la pauta mas adecuada de uso de TAC secuencial y monitorización de la PIC para detectar nuevo efecto masa intracraneal y tratar así de mejorar la evolución final de pacientes. Material y métodos. Se analiza una serie de 56 pacientes (edades = 15-80 años) admitidos consecutivamente en un periodo de dos años que fueron sometidos a TAC inicial < 24 horas tras el impacto, (intervalo medio = 150 minutos), TACs control en los primeros días del curso, y monitorización de la PIC. Se recogieron diferentes variables epidemiológicas, clínicas, radiológicas y se consideró como variable dependiente el desarrollo de deterioro definido como elevación mantenida de la PIC por encima de 20 mmHg que requiriera tratamiento agresivo médico y/o quirúrgico. Mediante análisis bi y multivariante se determinaron las correlaciones entre las diferentes variables y la aparición de deterioro. Para estimar la afectación neurológica y el resultado final se emplearon las escalas de coma y evolución de Glasgow, respectivamente. Resultados. El "score " medio en la serie fue de 5, y 37% de los pacientes tuvieron cambios pupilares, 52,3% hipotensión-hipoxemia, 16.1% anemia peritraumáticas y 12,3% alteraciones de la coagulación. 50% de los pacientes mostraron petequias en sustancia blanca y/o tronco cerebral en la TAC inicial, 66% HSA, 40% HIV, 39,3% contusión y 21,4% hematomas extraaxiales. 57,1% de los pacientes mostraron cambios en la TAC de control consistentes en nueva contusión en 26,8% de los casos, crecimiento de contusión previa en 68,2%, crecimiento de hematoma previo en 10,7% y swelling cerebral generalizado en 10,7%. 64% de los pacientes experimentaron una evolución final favorable y 35,7% desfavorable. 27 pacientes (48,9%) desarrollaron deterioro PIC, de los que 21 (37,5%) presentaron cambios concurrentes en la TAC, y 6 (10,7%) no los mostraron. Los restantes 29 (51,7%) pacientes no presentaron deterioro PIC, aunque 11 (19,6%) de ellos mostraron cambio TAC. La edad, el "score", la presencia de hipotension-hipoxemia peritraumáticas y los trastornos de la coagulación no se correlacionaron con riesgo de deterioro. Por el contrario, la presencia de contusión inicial (p=0,01) y el cambio TAC (en forma de desarrollo de swelling cerebral generalizado, p=0,003) se correlacionaron con la aparición de deterioro; a su vez el deterioro multiplicó por 10 (OR = 9,8) el riesgo de muerte y 7 de los 8 pacientes que fallecieron desarrollaron hipertensión intracraneal intratable. Los 8 pacientes (14,2%) que necesitaron cirugía evacuadora o descompresiva presentaron simultáneamente cambio PIC y cambio TAC, si bien otros 13 en situación similar pudieron ser manejados sin cirugía. Mostraran o no deterioro PIC, los pacientes sin cambio TAC evolucionaron mejor que los que desarrollaron nuevas patologías, pero la diferencia no alcanzó diferencia significativa. Discusión y conclusiones. Más de la mitad de los pacientes con lesión inicial Tipo I-II desarrolla cambios patológicos secuenciales, y casi el 50% presenta hipertensión intracraneal. Dada la alta incidencia de cambios TAC y PIC, la escasez y debilidad de los factores predictores de dichos cambios, y la frecuente discordancia entre ambos tipos de cambio (30,3% de los casos), parece recomendable monitorizar la PIC desde el inicio y practicar TACs 2-4, 12, 24, 48 y 72 horas tras el impacto en todos los pacientes, y otros adicionales si la evolución clínica o de la PIC lo requiriera. Si bien parece indudable que el desarrollo de hipertensión intracraneal grave incrementó significativamente el riesgo de muerte, la escasez de la muestra en la serie no permite determinar la contribución del nuevo efecto masa y/o la elevación de la PIC al desarrollo de incapacidad moderada y grave en los pacientes que no fallecieron, causada principalmente por la lesión axonal difusa. Finalmente, demostrar que la practica de TAC secuencial y la monitorización de la PIC mejoran la evolución final de este tipo de pacientes requeriría un estudio prospectivo aleatorizado que no es practicable por diferentes razones, entre ellas las de tipo ético

Objective. To determine the incidence of pathological and intracranial pressure (ICP) changes during the acute posttraumatic period in severe head injury patients presenting with lesions Types I-II (TCDB classification) in the admission CT scan with the aim of defining the most appropriate strategy of sequential CT scanning and ICP monitoring for detecting new intracranial mass effect and improving the final outcome. Material and methods. 56 patients (ages 15-80 years) consecutively admitted during a 2 years period were included. All had the initial CT scan < 24 hours after injury (mean interval = 150 min), several CT controls within the first days of the course and ICP monitoring after admission. Different epidemiological, clinical and radiological variables were recorded and deterioration defined as the development of sustained ICP over 20 mmHg requiring aggressive medical and/or surgical treatment was considered the dependent variable. Uni and multivariate analyses were made for determining the correlation between different parameters and the occurrence of deterioration and the final outcome as assessed with the GOS. Results. The mean GCS score was 5 and 37% of the patients showed pupillary changes; 52.3% had peritraumatic hypotension-hypoxemia, 16.1% anemia and 12.3% coagulation changes. 50% of the patients showed petechial hemorrhages in the white matter or the brainstem, 66% SAH, 40% HIV, 39.3% brain contusion and 21.4% small extraxial hematomas. 57.1% of the patients showed CT changes through the acute post-traumatic period consisting of new contusion (26.8% of the cases), growing of previous contusion (68.2%) or previous extraaxial hematoma (10.7%), and generalized brain swelling (10.7%). 64.9% of the patients made a favourable and 35.7% an unfavourable outcome. Overall, 27 (48.9%) patients developed deterioration, 21 (37.5%) with concurrent CT changes and 6 (10,7%) without new pathology as seen by the CT control. The remaining 29 (51.7%) patients in this series did not develop deterioration in spite that 11(19.6%) showed CT changes. The age, the initial score, the occurrence of peritraumatic hypotension-hypoxemia and coagulation disorders did not correlate with the risk of deterioration. By contrast, the presence of contusion at the initial CT scan (p= 0.01) and the occurrence of CT change (only generalized brain swelling, p= 0.003) significantly correlated with the risk of deterioration; in his turn deterioration increased by a factor of 10 (OR = 9,8) the risk of death and 7 out of the 8 patients who died developed intractable intracranial hypertension. The 8 (14.2%) patients requiring surgery showed simultaneous ICP deterioration and CT changes, but another 11 patients in a similar condition could be managed without surgery. With or without ICP deterioration, patients showing CT changes had a worse outcome than those without new pathologies, but the difference did not reach statistical significance. Discussion and conclusions. Over 50% of the patients with initial Type I-II lesions developed new CT changes and nearly 50% showed intracranial hypertension during the acute posttraumatic period. Considering the high incidences of ICP and CT deterioration through the course, along with the absence of strong predictors and the discordances between CT and ICP changes (which were seen in 30.3% of the cases) we recommend ICP monitoring after admission in all patients and serial CT scanning at 2-4, 12, 24, 48 and 72 hours after injury with additional controls as indicated by clinical or ICP changes in all cases. Though it is clear that the presence of severe intracranial hypertension significantly increased the risk of death, the small size of the sample in this series prevented to assess to what extent the occurrence of new mass effect and/or raised ICP contributed to the development of moderate and severe disability in the survivors which were mainly due to the occurrence of diffuse axonal injury. Finally, demonstrating that sequential CT scanning and ICP monitoring improve the final outcome in this type of patients would require a prospective randomized trial which is impracticable for different reasons, among them the ethical ones

Valor pronóstico de la RM craneal en el traumatismo craneoencefálico moderado y grave / The role of Magnetic Resonance in assessing prognosis after moderate and severe head injury

Introducción: La RM craneal ha demostrado ser una prueba más sensible ala hora de definir anatómicamente el daño cerebral traumático que la TC craneal,prueba que hasta el momento ha sido la más extendida en la evaluaciónde estos enfermos. Por ello, la RM craneal podría ser una prueba determinantea la hora de establecer el pronóstico tras TCE.Objetivos: Establecer la capacidad pronóstica de los hallazgos en RM enenfermos que han sufrido un TCE grave o moderado.Material y métodos: Se incluyen en el estudio 98 enfermos con TCEmoderado y grave a los que se ha realizado RM craneal dentro de los primeros30 días tras el trauma craneal. Se recogieron todas las variables clínicaspotencialmente relacionadas con el pronóstico de los enfermos, así como losdatos del TC inicial según la clasificación de Marshall y cols. La RM fue evaluadade manera ciega por dos neurorradiólogos que ignoraban el resultado de la TCinicial y la situación clínica inicial del paciente. Se recogieron todas las lesionesque presentaban así como su clasificación según Gentry y cols. y Firshing y cols.La evolución fue determinada a los seis meses del TCE mediante la aplicación dela escala de evolución de Glasgow extendida mediante cuestionario normalizadoy aplicando el índice de Barthel y el Mini-Mental State Examination de Folstein.Se estudiaron las relaciones entre los diferentes variables recogidas durante elingreso y la evolución a los seis meses medida mediante las diferentes escalasmediante la aplicación de análisis uni y multivariable (regresión logística). Secomparó asimismo la capacidad pronóstica de los diferentes factoresrelacionados con el pronóstico mediante el análisis de las curvas ROC y el áreadebajo de la curva para cada factor.Resultados: La información obtenida a través de la RM es útil en elestablecimiento del pronóstico de los enfermos con TCE moderado y grave,siendo mayor su contribución en los modelos pronósticos que la informacióndada por la TC. Existe una clara relación entre la profundidad de las lesionestraumáticas demostradas con RM, y su clasificación según las dos escalaspropuestas, y el pronóstico de los enfermos con TCE moderado y grave a los seismeses tras el traumatismo medido mediante diferentes escalas. La clasificaciónde los hallazgos en RM según el modelo de Gentry/Adams establece grupos deenfermos con diferente pronóstico. A mayor profundidad de la lesión peorpronóstico, siendo peor el pronóstico de los enfermos con lesiones en troncocerebral. Sin embargo, no todos los enfermos con lesiones en tronco tienen malaevolución. El GCS motor y la localización de las lesiones son los predictores másimportantes de la evolución de los enfermos con TCE moderado y grave

Introduction: Cranial MR is more sensitive in defining the anatomicsubstrate of traumatic brain injury than cranial CT, which has been, for themoment, the most extended test in the evaluation of these patients. Thereforecranial MR could be a determinant test in order to establish the prognosis ofpatients after head injury.Objective: To establish the role of MR findings in determining prognosisof patients who have suffered moderate or severe head injury.Materials and methods: 98 patients suffering moderate or severe headinjury to whom a MR had been performed in the first 30 days after traumawere included. All clinical variables related to prognosis were registered, aswell as the data from the initial CT following Marshall et al. classification.The MR was blindly evaluated by two neuroradiologists that were not awareof the initial CT results or the clinical situation of the patient. All lesions wereregistered as well as the classification following Gentry et al. and Fishing etal. scales. Outcome was determined six months after head injury by meansof the extended version of the Glasgow outcome scale administered by astructured interview and applying the Barthel index and the Mini-MentalState examination described by Folstein. The relation between the differentfactors recorded during admission and outcome six months after head injurymeasured by different scales was evaluated by means of uni and multivariateanalysis (logistic regression). The prognostic capacity of the different factorsrelated to outcome was compared by the analysis of ROC curves and the areaunder the curve for each factor.Results:The information obtained by cranial MR is most useful indetermining prognosis after moderate and severe head injury, and itscontribution to the prognostic models is superior to the information offeredby cranial CT. There exists a clear relation between the depth of the traumaticlesions shown in MR, and their classification by the two proposed scales, andthe outcome of patients suffering traumatic brain injury determined sixmonths after the injury by different scales. The classification of MR findingsby the scale of Gentry/Adams establishes groups of patients with differentoutcome. The deeper the lesion the worse the prognosis and patients withbrainstem lesions have poor outcome. However, not all patients withbrainstem lesions have a poor outcome. Motor GCS and lesion localizationin MR are the most important predictors of outcome in patients withmoderate and severe head injury

A comparison of different grading scales for predicting outcome after subarachnoid haemorrhage.

BACKGROUND: Most scales used to assess prognosis after subarachnoid haemorrhage (SAH) are based on the level of consciousness of the patient. Based on information from a logistic regression model, Ogilvy et al. developed a new grading scheme (Massachussetts General Hospital (MGH) Scale) which applied a simple scoring method to each prognostic factor considered relevant such as level of consciousness, age, quantity of blood in the first CT scan and size of the aneurysm. The purpose of this study is to introduce a modified version of the MGH scale, built up using factors applicable to every patient suffering SAH, and compare this new scale to the World Federation of Neurological Surgeons scale (WFNS), the Glasgow Coma Scale (GCS) scale for SAH and the MGH scale. METHOD: A series of 442 patients consecutively admitted to Hospital 12 de Octubre between January 1990 and September 2001 with the diagnosis of spontaneous SAH were retrospectively reviewed. Outcome was assessed by means of the Glasgow Outcome Scale measured six months after hospital discharge. Differences between grades of the WFNS, the GCS scale for SAH, the MGH scale and the new scale were computed by chi2 statistics. ROC curves were plotted for the different scales and their areas compared. FINDINGS: Both WFNS and GCS scales fail to present significant differences between most of their grades, while the proposed scale shows a constant inter-grade significant difference in predicting outcome. The proposed scale presents a significantly higher prognostic efficacy in the whole series of patients suffering spontaneous SAH, patients with idiopathic subarachnoid haemorrhage (ISAH) and patients with confirmed aneurysmal SAH. The MGH scale is not applicable to some groups of patients suffering SAH. INTERPRETATION: Grading scales including additional factors to the level of consciousness show higher prognostic efficacy. The proposed modification of the MGH scale makes it applicable to every patient suffering SAH without losing its prediction capability.

Meningiomas of the basal posterior fossa. Surgial experience in 80 cases / Meningiomas basales de la fosa posterior. Experiencia quirúrgica con 80 casos

Introduction. Despite recent imporvements in microsurgical and radiotherpay techniques, treatment of basal posterior fossa meningiomas still carries an elevated risk of morbidity. We present our results in a series of patients with this type of tumor and review the recent literature looking for the results obtained with different approaches and the new tendencies and algorithms proposed for managing these challenging lesions. Material and Methods: We analyzed retrospectively the clinical presentation and outcome of 80 patients consecutively operated between 1979 and 2003 for basal posterior fossa meningioma (foramen magnum tumors excluded). All patients had preoperative CT scans and the majority MRI studies. A total of 114 operations were performed including two-stage operations, reoperation for recurrence, CSF diversion, and XII-VII anastomosis. The most commonly used approaches were lateral suboccipital retrosigmoid, subtemporal-transtentorial, frontotemporal pterional and supra-infratentiorial presigmoid. Thirteen patients received postoperative radiotherapy. Results. There were 50 (73,7%) women and 21 men (mean age = 51,5 years; range = 18-78 yrs). Most common presenting symptoms were ranial nerve dysfunction, gait disturbances and intracranial hypertenseion. The mena duration of symptoms was 2.9 years. 70% of the tumors were over 3 cm in size. Fifty patients (62,5%) had a complete resection, 22 (27,5%) subtotal resection (> 90% tumor volume removed), and 8 (10%) only partial resection. Postoperative complications included hematoma, CSF leak, and infection. Fifty four (67,5%) patients developed new or increased cranial nerve deficits and 12,5% somatomortor, somatosensory or cerebellar deficits immediately after surgery with subsequent improvement in most cases. Following initial surgery 67 patients made a good recovery, 10 developed variable degrees of disability and 3 died (…) (AU)

Introducción: A pesar de la técnica microquirúrgica y la disponibilidad de la radioterapia estereotáxica, el tratamiento de los meningiomas de la base craneal todavía conlleva un riesgo elevado de morbilidad. Se presenta una serie de pacientes con meningiomas básales de la fosa posterior y se revisa la literatura para establecer una comparación de los resultados obtenidos con diferentes tipos de abordaje terapéutico y detectar las nuevas tendencias para el manejo de estos tumores. Material y métodos: Se analizaron de modo retrospectivo la presentación y evolución clínica de 80 pacientes operados consecutivamente entre 1979 y 2003 por vía intradural de meningiomas localizados en la base de la fosa posterior (excluidos los del foramen magno). Se practicó TAC craneal en todos los casos y RM en la mayoría. Se realizaron 114 intervenciones, incluyendo operación en dos estadios, reoperación por recurrencia, derivaciones de LCR y anastomosis VII-XII. Los abordajes más empleados fueron el lateral suboccipital retrosigmoideo, subtemporal-transtentorial, frontotemporal pterional y supra-infratentorial presigmoideo retrolaberíntico. 13 pacientes recibieron además tratamiento radioterápico. Resultados: Se trataron 59 mujeres (73.7%) y 21 hombres (edad media = 51.5 años; rango = 18–78). Los síntomas más frecuentes de presentación (duración media de la historia = 2,9 años) fueron alteraciones de los pares craneales, cefaleas y alteraciones de la marcha. 70% de los tumores tenían un diámetro mayor superior a 3cm. La extirpación fue completa en 50 casos (62.5%), subtotal (resección > 90% del volumen tumoral) en 22 (27.5%) y parcial en 8 (10%). Las complicaciones postoperatorias incluyeron hematoma, fístula LCR, e infección. 54 (67.5%) pacientes desarrollaron incremento, o nueva afectación de pares craneales y un 12.5% déficits de vías largas o cerebelo que mejoraron posteriormente en la gran mayoría. Tras la primera operación 67 pacientes hicieron una buena recuperación, 10 desarrollaron diferentes grados de incapacidad y 3 fallecieron. Once pacientes fallecieron tardíamente durante el curso por recurrencia tumoral con o sin reoperación, meningioma maligno, o causas no relacionadas. Se registraron 9 recurrencias tras resección inicial aparentemente completa (seguimiento medio = 8.6 años). La mayoría de los pacientes con resección subtotal y parcial se han manejado sin reoperación durante un periodo medio de 6.5 años (radiocirugía y/u observación). Discusión y Conclusiones: La técnica microquirúrgica y la radioterapia estereotáxica permiten un control aceptable de estos meningiomas. En los pacientes con invasión del seno cavernoso, extensión extracraneal, transgresión del plano aracnoideo en relación con el tronco cerebral, o adherencia a arterias cerebrales y sus perforantes, la extirpación subtotal parece preferible. En la planificación del tratamiento, se deben considerar además la edad del paciente, la presentación clínica (lesión sintomática o no sintomática), así como el tamaño y la extensión del tumor (AU)