Chronic hyperglycemia and intracranial meningiomas.

Meningiomas are among the most common primary tumors of the central nervous system. Previous research into the meningioma histological appearance, genetic markers, transcriptome and epigenetic landscape has revealed that benign meningiomas significantly differ in their glucose metabolism compared to aggressive lesions. However, a correlation between the systemic glucose metabolism and the metabolism of the tumor hasn't yet been found. We hypothesized that chronic levels of glycaemia (approximated with glycated hemoglobin (HbA1c)) are different in patients with aggressive and benign meningiomas. The study encompassed 71 patients with de novo intracranial meningiomas, operated on in three European hospitals, two in Croatia and one in Spain. Our results show that patients with WHO grade 2 meningiomas had significantly higher HbA1c values compared to patients with grade 1 lesions (P = 0.0290). We also found a significant number of patients (19/71; 26.7%) being hyperglycemic, harboring all the risks that such a condition entails. Finally, we found a significant correlation between our patients' age and their preoperative HbA1c levels (P = 0.0008, ρ(rho) = 0.388), suggesting that older meningioma patients are at a higher risk of having their glycaemia severely dysregulated. These findings are especially important considering the current routine and wide-spread use of corticosteroids as anti-edematous treatment. Further research in this area could lead to better understanding of meningiomas and have immediate clinical impact.

Effects of cranioplasty in cerebral blood perfusion using quantification with 99m-Tc HMPAO SPECT-CT.

BACKGROUND AND PURPOSE: Syndrome of the trephined or sinking skin flap syndrome is an underdiagnosed condition of craniectomized patients that usually improves after cranioplasty. Among the pathophysiological theories proposed, the changes of cerebral blood perfusion (CBP) caused by cranial defects might have a role in the neurological deficiencies observed. We aim to assess the regional cortex changes in CBP after cranioplasty with Technetium 99m hexamethylpropylene-amine oxime (99mTc-HMPAO) SPECT-CT. METHODS: Twenty-eight craniectomized patients subject to cranioplasty were studied with 99mTc-HMPAO SPECT-CT in three different times, before cranioplasty, a week, and 3 months after. The images were processed with quantification software comparing CBP of 24 cortical areas with a reference area, and with a database of controls. A mixed effects model and T-Student were used. RESULTS: CBP increased significantly in both hemispheres after cranioplasty, either using ratio (ß = .019, p-value = .030 first postsurgical SPECT-CT and ß = .021, p-value = .015 in the second study, vs. presurgical) or Z-score (ß = .220, p-value = .026 and ß = .279, p-value = .005, respectively). Nine areas of the damaged side had a significant lower CBP ratio and Z-score than the undamaged. Posterior cingulate showed an increased CBP ratio (p-value = .034) and Z-score (p-value = .028) in the first postsurgical SPECT-CT. These posterior cingulate changes represent a 4.83% increase in ratio and 91.04% in Z-Score (p-value = .035 and .040, respectively). CONCLUSION: CBP changes significantly in specific cortical areas after cranioplasty. Posterior cingulate changes might explain some improvements in attention impairments. SPECT-CT could be a useful tool to assess CBP changes in these patients and might be helpful in their clinical management.

Chronic traumatic encephalopathy: The unknown disease. / Encefalopatía crónica postraumática: aquella gran desconocida.

Chronic traumatic encephalopathy is a neurodegenerative disease produced by accumulated minor traumatic brain injuries; no definitive premortem diagnosis and no treatments are available for chronic traumatic encephalopathy. Risk factors associated with chronic traumatic encephalopathy include playing contact sports, presence of the apolipoprotein E4, and old age. Although it shares certain histopathological findings with Alzheimer disease, chronic traumatic encephalopathy has a more specific presentation (hyperphosphorylated tau protein deposited as neurofibrillary tangles, associated with neuropil threads and sometimes with beta-amyloid plaques). Its clinical presentation is insidious; patients show mild cognitive and emotional symptoms before progressing to parkinsonian motor signs and finally dementia. Results from new experimental diagnostic tools are promising, but these tools are not yet available. The mainstay of managing this disease is prevention and early detection of its first symptoms.

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

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

Hemorragia subaracnoidea aneurismática: guía de tratamiento del Grupo de Patología Vascularde la Sociedad Española de Neurocirugía / Aneurysmal subarachnoid hemorrhage: group of study of Cerebrovascular Pathology of the Spanish Society of Neurosurgery management guideline

Se realiza una actualización sobre los aspectos másimportantes de la hemorragia subaracnoidea aneurismáticarespecto a las guías previamente publicadaspor el grupo de trabajo de la SENEC. Las recomendacionespropuestas deben considerarse como una guíageneral de manejo de esta patología. Sin embargo,pueden ser modificadas, incluso de manera significativapor las circunstancias propias de cada casoclínico, o las variaciones en los recursos diagnósticosy terapéuticos del centro hospitalario que reciba alpaciente (AU)

An actualized revision of the most important aspectsof aneurismal subarachnoid hemorrhage is presentedfrom the guidelines previously published by the groupof study of cerebrovascular pathology of the SpanishSociety of Neurosurgery. The proposed recommendationsshould be considered as a general guide for themanagement of this pathological condition. However,they can be modified, even in a significant manneraccording to the circumstances relating each clinicalcase and the variations in the therapeutic and diagnosticprocedures available in the center attending eachpatient (AU)

[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)

[Embolization of indirect carotid-cavernous sinus fistula through the ophthalmic vein]. / Embolización de fístula cavernosa indirecta a través de la vena oftálmica superior.

Indirect or dural carotid cavernous fistulas are abnormal connections between the cavernous sinus and meningeal branches of the external and/or internal carotid arteries. Most of them are idiopathic and occurs spontaneously. Symptoms vary from a tiny episcleral injection to a severe visual loss. Conservative therapy is recomended in cases with few symptoms and no leptomeningeal drainage, as spontaneous resolution is not infrequent. Whenever symptoms worsen, treatment of the fistula should be prescribed. Nowadays, transvenous endovascular treatment consisting of packing the cavernous sinus is the first choice. In most cases, cavernous sinus can be approached through the inferior petrosal sinus. However, sometimes that is not possible, and an approach directly through the superior ophthalmic vein could be necessary. We report a case of a patient with a dural carotid cavernous fistula treated with embolization of the cavernous sinus through the ophthalmic vein.

Embolización de fístula carótido cavernosa indirecta a través de la vena oftálmica superior / Embolization of indirect carotid-cavernous sinus fistula through the ophthalmic vein

Las fístulas carótido cevernosas (FCC) indirectaso durales son comunicaciones entre el seno cavernoso y ramas extradurales de la arteria carótida interna, la carótida externa o ambas. La mayoría de las FCC indirectas son idiopáticas y aparecen espontáneamente. Los síntomas pueden variar desde una leve inyección conjuntival y escleral hasta la reducción severa de la agudeza visual. En casos poco sintomáticos y sin drenaje leptomeníngeo, el tratamiento conservador estaría indicado inicialmente, pues existe la posibilidad del cierre espontáneo de la fístula. Cuando la sintomatología progresa, requieren algún tipo de tratamiento para cerrarla. Hoy en día, el tratamiento endovascular es el de elección, y la vía transvenosa, con sellado o empaquetado del SC, ha demostrado mayor efectividad que la transarterial. En la mayoría de los casos se puede acceder al SC a través del seno petroso inferior. Sin embargo, en ocasiones no es posible el acceso a la FCC por vía venosa transfemoral, siendo necesario un abordaje directo a la vena oftálmica superior (VOS). Presentamos un caso de FCC indirecta tratada mediante abordaje directo a la VOS y embolización del seno cavernoso

Indirect or dural carotid cavernous fistulas are abnormal connections between the cavernous sinus and meningeal branches of the external and/or internal carotid arteries. Most of them are idiopathic and occurs spontaneously. Symptoms vary from a tiny episcleral injection to a severe visual loss. Conservative therapy is recommended in cases with few symptoms and no leptomeningeal drainage, as spontaneous resolution is not infrequent. Whenever symptoms worsen, treatment of the fistula should be prescribed. Nowadays, transvenousendo vascular treatment consisting of packing the cavernous sinus is the first choice. In most cases, cavernous sinus can be approached through the inferior petrosal sinus. However, sometimes that is not possible, and an approach directly through the superior ophthalmic vein could be necessary. We report a case of a patient with a dural carotid cavernous fistula treated with embolization of the cavernous sinus through the ophthalmic vein

[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

Aneurysm re-rupture during computed tomography angiography.

Re-rupture of cerebral aneurysms during conventional angiography, demonstrated by contrast leakage into the extravascular space, is well known and well documented. However, the occurrence of this complication during computed tomography (CT) angiographic examinations has rarely been published despite its extensive use. We present the clinical and radiological features of a rebleeding event during a CT angiographic study. No hemodynamic or contrast-related factors can be evoked predisposing to he occurrence of this complication during this imaging technique. This, along with the short study time, may explain the rarity of this coincidence.

[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

Acute subdural and intratemporal hematoma as a complication of percutaneous compression of the gasserian ganglion for trigeminal neuralgia.

The case of a 68 year-old man who developed a fatal intracranial hemorrhagic complication following percutaneous compression of the gasserian ganglion for trigeminal neuralgia is reported. The complication was likely related to improper placement of the Fogarty catheter into the temporal fossa out of the Meckel's cave. The anatomical structures at risk of damage by misplaced needle or catheter and some relevant technical details aimed to prevent extratrigeminal complications related with this and other percutaneous trigeminal lesioning procedures are analyzed.

Cerebellar hematoma following transsphenoidal surgery.

Cerebellar hemorrhage after supratentorial surgery is a very infrequent complication. Most cases occur following aneurysm or brain tumor surgery, or evacuation of extracerebral collections. The underlying mechanism of formation of these hematomas is unclear. We present an example of cerebellar hemorrhage following transsphenoidal resection of a pituitary adenoma. To our knowledge, this is the first case reported of hemorrhage in the posterior fossa after a transsphenoidal approach.

Acute subdural and intratemporal hematoma as a complication of percutaneous compression of the gasserian ganglion for trigeminal neuralgia

Se presenta el caso de un paciente de 68 años de edad con neuralgia esencial del trigémino que fue operado mediante compresión percutanea del ganglio de Gasser y desarrolló una hemorragia intracraneal que resultó fatal. La complicación se relacionó probablemente con el emplazamiento erróneo del cateter de Fogarty y el inflado del balón fuera del cavum de Meckel. Se analiza la disposición de las estructuras anatómicas susceptibles de sufrir daño mecánico durante este procedimiento quirúrgico y se comentan algunos aspectos técnicos a tener en cuenta para prevenir el desarrollo de complicaciones como la ocurrida en nuestro paciente

The case of a 68 year-old man who developed a fatal intracranial hemorrhagic complication following percutaneous compression of the gasserian ganglion for trigeminal neuralgia is reported. The complication was likely related to improper placement of the Fogarty catheter into the temporal fossa out of the Mecke1,s cave. The anatomical structures at risk of damage by misplaced needle or catheter and some relevant thecnical details aimed to prevent extratrigeminal complications related with this and other percutaneous trigeminal lesioning procedures are analyzed