Ruptured dissecting cerebral aneurysms in young people: report of three cases.

Intracranial arterial aneurysms in the pediatric population are rare. Among these, dissecting aneurysms are the most frequent, followed by saccular, infectious, and posttraumatic. It is widely known that aneurysmal rupture is uncommon in the first two decades of life. Spontaneous dissecting aneurysms (SDAs) of the middle cerebral artery (MCA) affecting young individuals most frequently present as occlusive syndrome with ischemia, although bleeding and subarachnoid hemorrhage can also occur. Between March 2006 and January 2008, three young patients (20 months, 8 and 20 years old) were surgically treated for MCA SDA in the Neurosurgical Department of "12 de Octubre" Hospital of Madrid. These patients showed hemorrhage as primary radiological finding, and all of them underwent surgical operation. Aneurysms were always treated by trapping, with aneurysmectomy in one case, but no distal extra-intracranial (EC-IC) bypass was performed. In two cases, the histological examination of the aneurysm's wall evidenced signs of subintimal dissection with widespread disruption of the internal elastic lamina and media with neointima formation and intramural hemorrhage. Although bleeding is an uncommon presenting sign of SDAs, they should be suspected in young people showing hemorrhage at CT scan. Early surgical treatment and, if possible, preoperative neuroimaging evaluation of intracranial vessels should be performed to reduce the mortality in these patients despite a higher postoperative morbidity. From a technical point of view, surgical trapping of the aneurysm seems to be a reasonable treatment strategy especially in an emergency basis. However, whenever possible, an EC-IC bypass could help diminish the ischemic morbidity associated with these aneurysms.

Interhemispheric hygroma after decompressive craniectomy: does it predict posttraumatic hydrocephalus?

OBJECT: The aim of this study was to determine the incidence of posttraumatic hydrocephalus in severely head-injured patients who required decompressive craniectomy (DC). Additional objectives were to determine the relationship between hydrocephalus and several clinical and radiological features, with special attention to subdural hygromas as a sign of distortion of the CSF circulation. METHODS: The authors conducted a retrospective study of 73 patients with severe head injury who required DC. The patients were admitted to the authors' department between January 2000 and January 2006. Posttraumatic hydrocephalus was defined as: 1) modified frontal horn index greater than 33%, and 2) the presence of Gudeman CT criteria. Hygromas were diagnosed based on subdural fluid collection and classified according to location of the craniectomy. RESULTS: Hydrocephalus was diagnosed in 20 patients (27.4%). After uni- and multivariate analysis, the presence of interhemispheric hygromas (IHHs) was the only independent prognostic factor for development of posttraumatic hydrocephalus (p<0.0001). More than 80% of patients with IHHs developed hydrocephalus within the first 50 days of undergoing DC. In all cases the presence of hygromas preceded the diagnosis of hydrocephalus. The IHH predicts the development of hydrocephalus after DC with 94% sensitivity and 96% specificity. The presence of an IHH showed an area under the receiver-operator characteristic of 0.951 (95% CI 0.87-1.00; p<0.0001). CONCLUSIONS: Hydrocephalus was observed in 27.4% of the patients with severe traumatic brain injury who required DC. The presence of IHHs was a predictive radiological sign of hydrocephalus development within the first 6 months of DC in patients with severe head injury.

The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury.

BACKGROUND: Since 1999, the Italian guidelines have been used at our department for the management of patients with mild head injury (MHI). According to these guidelines, a computed tomography (CT) scan should be obtained in all patients with coagulopathy and these should routinely undergo strict observation during the first 24 hours after injury; in addition they should have a control CT scan before discharge. With the increased use of anticoagulant therapy in the elderly population, admitting patients in such treatment with a MHI to the emergency rooms has become very common. The aim of our study was to evaluate the need of performing a control CT scan in patients on anticoagulation treatment who showed neither intracranial pathology on the first CT-scan nor neurologic worsening during the observation period. METHODS: We prospectively analyzed the course of all patients on anticoagulation treatment consecutively admitted to our unit between October 2005 and December 2006 who suffered from a MHI and showed a normal initial CT scan. All patients underwent strict observation during the first 24 hours after admission and had a control CT scan performed before discharge. RESULTS: One hundred thirty-seven patients were included in this study. Only two patients (1.4%) showed hemorrhagic changes. However, neither of them developed concomitant neurologic worsening nor needed admitting or surgery. CONCLUSION: According with our data, patients on anticoagulation treatment suffering from MHI could be managed with strict neurologic observation without routinely performing a control CT scan that can be reserved for the rare patients showing new clinical symptoms.

The role of MR imaging in assessing prognosis after severe and moderate head injury.

PURPOSE: The objective of this work is two-fold: to determine the role of MRI findings in establishing the prognosis of patients with moderate and severe traumatic brain injury (TBI) admitted to our centre, measured with different outcome scales; and to determine in which patients the information given by MR findings adds prognostic information to that from traditional prognostic factors. METHODS: One hundred patients suffering moderate or severe head injury in whom MRI had been performed in the first 30 days after trauma were included. The MRI was evaluated by two neuroradiologists who were not aware of the initial CT results or the clinical situation of the patients. Outcome was determined 6 months after head injury by means of the extended version of the Glasgow Outcome Scale. The prognostic capacity of the different factors related to outcome was compared by the analysis of receiver operating characteristic (ROC) curves and the area under the curve (AUC) for each factor. RESULTS: There exists a clear relation between the depth of the traumatic lesions shown on MRI, and their classification by the proposed scale, and the outcome of patients suffering traumatic brain injury determined by different scales 6 months after injury. CONCLUSIONS: The anatomical substrate of TBI depicted by MRI could be a useful prognostic tool in patients suffering moderate and severe head injury. Patients with a score of 4 or less on the motor subscale of the GCS scale are those who could benefit most from the prognostic information provided by MRI.

Typical trigeminal neuralgia associated with brainstem white matter lesions on MRI in patients without criteria of multiple sclerosis.

INTRODUCTION: Although compression of the trigeminal nerve by a vascular loop is thought to be the most common cause of trigeminal neuralgia (TN), other aetiologies, such as multiple sclerosis or brainstem infarction may be associated with this disorder. MRI may detect lesions different from vascular loop compression of the trigeminal nerve that may be related to TN. PATIENTS AND METHODS: The pre-operative MRIs of 68 patients without the diagnosis of multiple sclerosis who were operated for typical TN between 1998 and 2003 were retrospectively reviewed Four of these showed hyperintense lesions in the pons on T2 MRI sequences. No patient had prior surgery. These four patients underwent different operations for the control of pain but in two of them only ablative procedures were effective DISCUSSION: Although it is uncertain whether the occurrence of TN in our patients may be attributed to the brainstem abnormalities seen on MRI, the presence of these lesions appears to be the most convincing explanation for the occurrence of pain. We believe that, in the presence of such imaging changes, a destructive procedure should be regarded as the elective surgical treatment in patients presenting with typical TN with or without apparent vascular loop compression of the trigeminal root.

Brown-Sequard syndrome after blunt cervical spine trauma: clinical and radiological correlations.

The objective of this study was to describe clinical and radiological features of a series of patients presenting with Brown-Sequard syndrome after blunt spinal trauma and to determine whether a correlation exists between cervical plain films, CT, MRI and the clinical presentation and neurological outcome. A retrospective review was done of the medical records and analysis of clinical and radiological features of patients diagnosed of BSS after blunt cervical spine trauma and admitted to our hospital between 1995 and 2005. Ten patients were collected for study, three with upper- and seven with lower-cervical spine fracture. ASIA impairment scale and motor score were determined on admission and at last follow-up (6 months-9 years, mean 30 months). Patients with lower cervical spine fracture presented with laminar fracture ipsilateral to the side of cord injury in five out of six cases. T2-weighted hyperintensity was present in seven patients showing a close correlation with neurological deficit in terms of side and level but not with the severity of motor deficit. Patients with Brown-Sequard syndrome secondary to blunt cervical spine injury commonly presented T2-weighted hyperintensity in the clinically affected hemicord. A close correlation was observed between these signal changes in the MR studies and the neurologic level. Effacement of the anterior cervical subarachnoid space was present in all patients, standing as a highly sensitive but very nonspecific finding. In the present study, craniocaudal extent of T2-weighted hyperintensity of the cord failed to demonstrate a positive correlation with neurological impairment.

Utilidad de la evaluación de la calidad científico técnica en el proceso quirúrgico de la hernia discal lumbar / No disponible

Introducción: El análisis y la evaluación de la calidad de los procesos es un paso imprescindible en la estrategia de mejora continua. La evaluación de la calidad del proceso quirúrgico de la hernia discal lumbar tiene un gran interés si se considera su elevada prevalencia, variabilidad en el manejo y en los resultados obtenidos y la posibilidad de mejora. Objetivos: Realizar la determinación y el análisis descriptivo de la Calidad Científica Técnica (CCT) del proceso quirúrgico de la hernia discal lumbar y su posible relación con determinados resultados como son la efectividad y la calidad de vida de los pacientes. Pacientes y métodos: Ciento setenta y dos pacientes intervenidos de hernia discal lumbar en el período 1996-1999. Para el análisis de la CCT se ha empleado el método PEP (Performance Evaluation Procedure) establecido por la Joint Commission on Accreditation of Hospitals. Los parámetros utilizados para la medida del resultado han sido el estado funcional, mediante los criterios de Spangfort y la calidad de vida, a través del cuestionario SF-12. Los resultados se han registrado a los 12, 24 y 36 meses de la intervención. Resultados: La valoración media de la CCT del proceso ha sido 0,83 (0-1). Se encontró que se había producido el peor registro de la información en la anamnesis (0,57). Los criterios de anamnesis considerados más importantes por los neurocirujanos en el momento de tomar la decisión quirúrgica no siempre han sido los mejor registrados en la historia clínica. Por el contrario, datos considerados poco relevantes se registraron prácticamente en la totalidad de los pacientes. Se observó una correlación significativa entre la puntuación de la CCT y la situación laboral de los pacientes, así como con ciertos parámetros de calidad de vida. Las puntuaciones más altas de CCT las presentaron aquellos pacientes que a los 12 y 24 meses de la intervención no trabajaban a causa del dolor (p<0,02 y p<0,04 respectivamente), así como en pacientes que a los 12 meses de la intervención presentan una menor actividad social y mucho dolor. Se ha definido el perfil de los pacientes con mejor cumplimentación de los datos de la historia clínica, se observaron diferencias significativas con respecto al tipo cualificación y al esfuerzo requeridos en la actividad habitual de los pacientes. Los pacientes que realizaban trabajos poco cualificados (p<0,002) y de gran esfuerzo (p<0,05) tenían un mejor registro de los datos. Los pacientes en los que la recogida de información se ha realizado de forma más exhaustiva presentaban como característica común una indicación quirúrgica no clara, un test de Lasègue negativo, una duración del episodio previo a la intervención de más de 6 meses y pacientes asintomáticos en el momento de la intervención (p<0,01), así como los pacientes que tardaban más de un año en operarse. Conclusiones: El método PEP utilizado ha permitido conocer la calidad científico técnica del proceso quirúrgico en cada fase, proporcionando una valiosa información que ha permitido detectar oportunidades de mejora. Se han establecido correlaciones significativas entre la CCT y aspectos clínicos y laborales preoperatorios, así como entre la CCT y el dolor y actividad postquirúrgica (AU)

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