Uncommon case of Mycobacterium bovis brain abscess complicated by suppurative fistula, and review of the literature. / Caso insólito de absceso cerebral por Mycobacterium bovis complicado con fístula supurativa y revisión de la bibliografía.

INTRODUCTION: Mycobacterium bovis is an infrequent cause of central nervous system tuberculosis in Spain, with few cases described in the literature. Since compulsory pasteurization of milk and implementation of eradication programs on infected cattle, human sporadic illness with this organism has dramatically declined in developed countries. CASE REPORT: A 71-year-old immunocompromised male, who presented a calvarial lytic lesion. A craniotomy for the total resection of the lesion was performed and the microbiology results were positive for M. bovis, therefore antituberculous therapy was initiated. Despite of the correct treatment, the patient developed a tuberculous abscess that required an aggressive surgical management followed by a suppurative fistula. Based on the treatment of tuberculous lymphadenitis, we decided to perform a conservative management with antituberculous therapy (isoniazid + rifampicin + ethambutol + moxifloxacin + steroids during 12 months) and avoided new surgical cleanings of the surgical bed obtaining a good response and a good clinical evolution. CONCLUSIONS: As far as we know, this is the first case reported of a suppurative fistula after the resection of a cerebral abscess caused by M. bovis, therefore, there is no report in the literature about the treatment of this complication.

TITLE: Caso insólito de absceso cerebral por Mycobacterium bovis complicado con fístula supurativa y revisión de la bibliografía.Introducción. Mycobacterium bovis es una causa infrecuente de tuberculosis del sistema nervioso central en España, del cual existen pocos casos descritos en la bibliografía. Desde la pasteurización obligatoria de la leche y la implementación de programas de erradicación del ganado infectado, la enfermedad esporádica humana con este organismo ha disminuido drásticamente en los países desarrollados. Caso clínico. Varón inmunoafectado de 71 años, que presentaba una lesión lítica esporádica en la calota. Se realizó una craneotomía de la lesión y los resultados de microbiología fueron positivos para M. bovis, por lo que se inició tratamiento con terapia antituberculosa. A pesar del tratamiento correcto, el paciente desarrolló un absceso tuberculoso, que requirió un tratamiento quirúrgico agresivo, seguido de una complicación con una fístula supurativa. Sobre la base del tratamiento descrito para la linfadenitis tuberculosa, se decidió realizar un tratamiento conservador de la fístula supurativa, sin realizar nuevas limpiezas del lecho quirúrgico, y mantener de manera prolongada la terapia antituberculosa (isoniacida + rifampicina + etambutol + moxifloxacino + esteroides durante 12 meses), con lo que presentó una buena evolución clínica. Conclusiones. Hasta la fecha, éste es el primer caso descrito de una fístula supurativa después de la resección de un absceso cerebral causado por M. bovis, por lo que no existe en la bibliografía artículo alguno que describa el tratamiento adecuado de esta complicación.

Spinal cord injury after blunt cervical spine trauma: correlation of soft-tissue damage and extension of lesion.

BACKGROUND AND PURPOSE: In patients with spinal cord injury after blunt trauma, several studies have observed a correlation between neurologic impairment and radiologic findings. Few studies have been performed to correlate spinal cord injury with ligamentous injury. The purpose of this study was to retrospectively evaluate whether ligamentous injury or disk disruption after spinal cord injury correlates with lesion length. MATERIALS AND METHODS: We retrospectively reviewed 108 patients diagnosed with traumatic spinal cord injury after cervical trauma between 1990-2011. Plain films, CT, and MR imaging were performed on patients and then reviewed for this study. MR imaging was performed within 96 hours after cervical trauma for all patients. Data regarding ligamentous injury, disk injury, and the extent of the spinal cord injury were collected from an adequate number of MR images. We evaluated anterior longitudinal ligaments, posterior longitudinal ligaments, and the ligamentum flavum. Length of lesion, disk disruption, and ligamentous injury association, as well as the extent of the spinal cord injury were statistically assessed by means of univariate analysis, with the use of nonparametric tests and multivariate analysis along with linear regression. RESULTS: There were significant differences in lesion length on T2-weighted images for anterior longitudinal ligaments, posterior longitudinal ligaments, and ligamentum flavum in the univariate analysis; however, when this was adjusted by age, level of injury, sex, and disruption of the soft tissue evaluated (disk, anterior longitudinal ligaments, posterior longitudinal ligaments, and ligamentum flavum) in a multivariable analysis, only ligamentum flavum showed a statistically significant association with lesion length. Furthermore, the number of ligaments affected had a positive correlation with the extension of the lesion. CONCLUSIONS: In cervical spine trauma, a specific pattern of ligamentous injury correlates with the length of the spinal cord lesion in MR imaging studies. Ligamentous injury detected by MR imaging is not a dynamic finding; thus it proved to be useful in predicting neurologic outcome in patients for whom the MR imaging examination was delayed.

Severe traumatic head injury: prognostic value of brain stem injuries detected at MRI.

BACKGROUND AND PURPOSE: Traumatic brain injuries represent an important cause of death for young people. The main objectives of this work are to correlate brain stem injuries detected at MR imaging with outcome at 6 months in patients with severe TBI, and to determine which MR imaging findings could be related to a worse prognosis. MATERIALS AND METHODS: One hundred and eight patients with severe TBI were studied by MR imaging in the first 30 days after trauma. Brain stem injury was categorized as anterior or posterior, hemorrhagic or nonhemorrhagic, and unilateral or bilateral. Outcome measures were GOSE and Barthel Index 6 months postinjury. The relationship between MR imaging findings of brain stem injuries, outcome, and disability was explored by univariate analysis. Prognostic capability of MR imaging findings was also explored by calculation of sensitivity, specificity, and area under the ROC curve for poor and good outcome. RESULTS: Brain stem lesions were detected in 51 patients, of whom 66% showed a poor outcome, as expressed by the GOSE scale. Bilateral involvement was strongly associated with poor outcome (P < .05). Posterior location showed the best discriminatory capability in terms of outcome (OR 6.8, P < .05) and disability (OR 4.8, P < .01). The addition of nonhemorrhagic and anterior lesions or unilateral injuries showed the highest odds and best discriminatory capacity for good outcome. CONCLUSIONS: The prognosis worsens in direct relationship to the extent of traumatic injury. Posterior and bilateral brain stem injuries detected at MR imaging are poor prognostic signs. Nonhemorrhagic injuries showed the highest positive predictive value for good outcome.

[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)

[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

Aspiración de secreciones bronquiales con sistema cerrado / Bronchial secretion aspiration with a closed system

La instauración de un nuevo sistema de aspiración de secreciones, que permite de forma simultánea la ventilación ininterrumpida del paciente y la aspiración, creó la necesidad de realizar una praxis estandarizada y establecer las posibles ventajas que derivan de su uso, tanto para el paciente como para el profesional de enfermería(AU)

The discovery of a new system to aspirate secretion which permits simultaneous uninterrupted ventilation by a patient while aspiration takes place, made it necessary to formulate a standardized praxis and to establish the possible advantages derived from its use, both for the patient and for the nursing professional(AU)

[Prognostic models in severe head injury]. / Modelos pronósticos en el traumatismo craneoencefálico grave.

Severe head injury (SHI) is one of the most important health, social, and economic problems in industrialized countries. Most of the recent studies related to this entity still show pessimistic results, with percentages of mortality and unfavourable outcomes very similar than those reported in the last quarter of century. In order to make predictions for patients with SHI, different "prognostic formulas or models" reviewed in this manuscript, have been developed with the main objective of performing reliable predictions for patients with this pathology. These models are constructed by using a group of "prognostic indicators or factors" and different "prognostic scales" useful for measuring the final outcome. The different "statistical techniques or methods" necessary to develop these prognostic models are also analyzed in this paper.

Severe head injury and the risk of early death.

BACKGROUND: Severe head injury (SHI) is one of the most important health, social and economic problems in industrialised countries. Unfortunately, none of the neuroprotection trials for traumatic brain injury have shown efficacy. One of the reasons for this failure could be the inclusion of patients with high probability of early death. A population-based, retrospective study was conducted to develop a prognostic model for identification of these patients. METHODS: Between January 1987 and August 1999, a total of 895 patients (> or = 15 years of age) with non-missile SHI were studied, in whom a computed tomography scan was carried out within the first 6 h of injury. The association between early death (first 48 h after injury) and independent prognostic factors was determined by logistic regression analysis. A scoring system was also constructed. RESULTS: The early-death rate was 20%. Independent predictors of early mortality after SHI were non-evacuated mass (odds ratio (OR) 65, 95% confidence interval (CI) 11 to 379), diffuse injury IV (OR 25, 95% CI 5 to 112), diffuse injury III (OR 8, 95% CI 3 to 22), flaccidity (OR 7, 95% CI 3 to 15), non-reactive bilaterally mydriasis (OR 6, 95% CI 3 to 12), evacuated mass (OR 4, 95% CI 1 to 11), age > or = 65 years (OR 4, 95% CI 1 to 9), decerebration (OR 3, 95% CI 2 to 7) and shock (OR 3, 95% CI 2 to 6). The prognostic model correctly identified 93% of the patients. CONCLUSIONS: This prognostic model is based on simple clinical and radiological data readily available during the first 6 h after injury and is useful for identification of early death after SHI.

Modelos pronósticos en el traumatismo craneoencefálico grave / Prognostic models in severe head injury

El traumatismo craneoencefálico grave (TCEG) es uno de los problemas sanitarios, sociales y económicos más importantes de los países industrializados. Muchos estudios recientes sobre esta entidad arrojan aún resultados pesimistas, presentando cifras de mortalidad y de pronósticos desfavorables muy similares a las publicadas en el último cuarto de siglo. A la hora de predecir el pronóstico de los pacientes con TCEG, se han diseñado diferentes "fórmulas o modelos pronósticos" que nosotros revisamos en este trabajo y cuyo objetivo primordial consiste en realizar predicciones fiables en futuros pacientes que sufran un TCEG. Estos modelos están formados de un lado, por un conjunto de "indicadores o factores pronósticos "y del otro, por unas "escalas pronosticas" que sirven para medir el pronóstico final de estos pacientes. Para la creación de estos modelos se utilizan diversas "técnicas o métodos estadísticos" que también serán analizadas en este artículo

Severe head injury (SHI) is one of the most important health, social, and economic problems in industrialized countries. Most of the recent studies related to this entity still show pessimistic results, with percentages of mortality and unfavourable outcomes very similar than those reported in the last quarter of century. In order to make predictions for patients with SHI, different "prognostic formulas or models" reviewed in this manuscript, have been developed with the main objective of performing reliable predictions for patients with this pathology. These models are constructed by using a group of "prognostic indicators or factors" and different "prognostic scales" useful for measuring the final outcome. The different "statistical techniques or methods "necessary to develop these prognostic models are also analyzed in this paper

[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

Complete surgical resection of high-grade astroblastoma with long time survival: case report and review of the literature.

Astroblastoma is a rare glial neoplasm of unknown origin and uncertain prognosis. It usually presents in young adults as a well circumscribed hemispheric mass, often associated with a cystic component. The histological features of astroblastoma are the presence of typical astroblastic perivascular pseudorosettes and perivascular hyalinization. Two different subtypes of astroblastoma have been defined based upon histological characteristics. Prognosis, however, sometimes is in contradiction with the pathological appearance and seems to be more closely related to the grade of surgical resection. We present a new case of a patient with a high-grade astroblastoma with a long survival time, in whom complete surgical resection was confirmed by an early postoperative MRI.

Complete surgical resection of high-grade astroblastoma with long time survival: case report and review of the literature

El astroblastoma es un tumor glial infrecuente de origen desconocido y pronóstico incierto. Habitualmente se presenta en adultos como una masa hemisférica bien definida, presentando a menudo un componente quístico. Las características histopatológicas de este tumor incluyen la presencia de pseudorrosetas perivasculares astroblásticas típicas y la hialinización perivascular. Se han distinguido dos tipos de astroblastoma en relación a la malignidad histológica. Sin embargo, el pronóstico en ocasiones no guarda relación directa con el tipo histológico y parece más dependiente del grado de resección quirúrgica. Presentamos el caso de una paciente con un astroblastoma de alto grado con supervivencia prolongada, en el cual la resección quirúrgica completa se demostró mediante resonancia magnética postoperatoria precoz

Astroblastoma is a rare glial neoplasm of unknown origin and uncertain prognosis. It usually presents in young adults as a well circumscribed hemispheric mass, often associated with a cystic component. The histological features of astroblastoma are the presence of typical astroblastic perivascular pseudo rosettes and perivascular hyalinization. Two different subtypes of astroblastoma have been defined based upon histological characteristics. Prognosis, however, sometimes is in contradiction with the pathological appearance and seems to be more closely related to the grade of surgical resection. We present a new case of a patient with a high-grade astroblastoma with a long survival time, in whom complete surgical resection was confirmed by an early postoperative MRI

Fasciolosis (liver fluke) of the breast in a male patient: a case report.

Fasciolosis is an uncommon disease in this region, as are parasitic infections of the breast. This report describes a 56-year-old man with a previous history of liver abscess presenting with a painful breast mass. He underwent a mastectomy and is well. The pathological findings revealed chronic granulomatous mastitis with Fasciola spp. ova. The literature on this very rare condition is reviewed.

[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

[Overview of the recent clinical trials in severe head injury and analysis of their therapeutic failure]. / Revisión de los ensayos clínicos sobre prevención del daño neurológico en el traumatismo crancoencefálico grave y análisis de su fracaso terapéutico.

During the past "Decade of the Brain" several neuroprotective agents have been tested in phase III clinical trials for severe head injury (SHI) but unfortunately none of them significantly improved the outcome of these patients. In contrast to the success achieved by these drugs in animal laboratory studies, the results in terms of neuroprotection in the clinical setting have been disappointing. This paper has been divided in three parts: in the first one, we summarize the pathophysiological mechanisms related to SHI, targeted by the neuroprotective agents. In the second part we review the main clinical trials carried out for SHI to date, and in the third one, we analyze the possible reasons that explain why these agents have failed to show efficacy.