Documento de consenso para la monitorización neurofisiológica intraoperatoria multimodal en procedimientos neuroquirúrgicos. Fundamentos básicos / Consensus document for multimodal intraoperatory neurophisiological monitoring in neurosurgical procedures. Basic fundamentals

El presente trabajo pretende establecer una guía de actuación consensuada entre anestesiólogos y neurofisiólogos para realizar una monitorización neurofisiológica intraoperatoria efectiva en procedimientos tanto neuroquirúrgicos, como en aquellos en los que existe un riesgo de lesión neurológica funcional. En la primera parte, se describen las principales técnicas utilizadas en la actualidad para la monitorización neurofisiológica intraoperatoria. En segundo lugar, se describen los factores anestésicos y no anestésicos que pueden afectar al registro eléctrico de las estructuras del sistema nervioso. Posteriormente, se analizan los efectos adversos de las técnicas más comunes derivados de su utilización. Y, por último, se describen las diferentes pautas a seguir tras la aparición de los diferentes eventos clínicos intraoperatorios.(AU)

The present work aims to establish a guide to action, agreed by anaesthesiologists and neurophysiologists alike, to perform effective intraoperative neurophysiological monitoring for procedures presenting a risk of functional neurological injury, and neurosurgical procedures. The first section discusses the main techniques currently used for intraoperative neurophysiological monitoring. The second exposes the anaesthetic and non-anaesthetic factors that are likely to affect the electrical records of the nervous system structures. This section is followed by an analysis detailing the adverse effects associated with the most common techniques and their use. Finally, the last section describes a series of guidelines to be followed upon the various intraoperative clinical events.(AU)

Consensus document for multimodal intraoperatory neurophisiological monitoring in neurosurgical procedures. Basic fundamentals. / Documento de consenso para la monitorización neurofisiológica intraoperatoria multimodal en procedimientos neuroquirúrgicos. Fundamentos básicos.

The present work aims to establish a guide to action, agreed by anaesthesiologists and neurophysiologists alike, to perform effective intraoperative neurophysiological monitoring for procedures presenting a risk of functional neurological injury, and neurosurgical procedures. The first section discusses the main techniques currently used for intraoperative neurophysiological monitoring. The second exposes the anaesthetic and non-anaesthetic factors that are likely to affect the electrical records of the nervous system structures. This section is followed by an analysis detailing the adverse effects associated with the most common techniques and their use. Finally, the last section describes a series of guidelines to be followed upon the various intraoperative clinical events.

Circuitos postoperatorios en los pacientes sometidos a craneotomía programada. Revisión narrativa / Postoperative circuits in patients undergoing elective craniotomy. A narrative review

En 2017 la sección de Neurociencias de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor publicó una encuesta nacional sobre los circuitos de atención y tratamiento postoperatorio en neurocirugía. La encuesta evidenció una gran heterogeneidad de respuestas en función del centro, el anestesiólogo y la afección del paciente. En la actualidad, no disponemos de un estándar de circuito postoperatorio y existe evidencia suficiente para no indicar de forma rutinaria el ingreso en Unidades de Cuidados Críticos Postquirúrgicos a todos los pacientes intervenidos de craneotomía programada. El objetivo de este estudio es hacer una revisión narrativa de los circuitos postoperatorios en la craneotomía programada, para intentar homogeneizar nuestra práctica clínica a la luz de los estudios publicados. Se ha hecho una revisión bibliográfica de los últimos diez años, fecha de actualización noviembre 2019, utilizando las palabras clave neurosurgery and postoperative care y craniotomyand postoperative care en MEDLINE (PubMed)

In 2017, the Neurosciences section of the Spanish Society of Anaesthesiology, Critical Care and Pain Therapy published a national survey on postoperative care and treatment circuits in neurosurgery. The survey showed that practices vary widely, depending on the centre, the anaesthesiologist and the pathology of the patient. There is currently no standard postoperative circuit for cranial neurosurgical procedures in Spanish hospitals, and there is sufficient evidence to show that not all patients undergoing elective craniotomy should be routinely admitted to a postsurgical critical care unit. The aim of this study is to perform a narrative review of postoperative circuits in elective craniotomy in order to standardise clinical practice in the light of published studies. For this purpose, we searched MEDLINE (PubMed) to retrieve studies published in the last ten years, up to November 2019, using the keywords neurosurgery and postoperative care, craniotomyand postoperative care

Postoperative circuits in patients undergoing elective craniotomy. A narrative review. / Circuitos postoperatorios en los pacientes sometidos a craneotomía programada. Revisión narrativa.

In 2017, the Neurosciences section of the Spanish Society of Anaesthesiology, Critical Care and Pain Therapy published a national survey on postoperative care and treatment circuits in neurosurgery. The survey showed that practices vary widely, depending on the centre, the anaesthesiologist and the pathology of the patient. There is currently no standard postoperative circuit for cranial neurosurgical procedures in Spanish hospitals, and there is sufficient evidence to show that not all patients undergoing elective craniotomy should be routinely admitted to a postsurgical critical care unit. The aim of this study is to perform a narrative review of postoperative circuits in elective craniotomy in order to standardise clinical practice in the light of published studies. For this purpose, we searched MEDLINE (PubMed) to retrieve studies published in the last ten years, up to November 2019, using the keywords neurosurgery and postoperative care, craniotomyand postoperative care.

Calidad y seguridad del paciente en el código ictus, en el ámbito neurointervencionista / Quality and safety in endovascular therapy for acute ischemic stroke

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Guía de práctica clínica sobre tromboprofilaxis y manejo de los fármacos anticoagulantes y antiagregantes en pacientes neuroquirúrgicos y neurocríticos / Clinical practice guideline on thromboprophylaxis and management of anticoagulant and antiplatelet drugs in neurosurgical and neurocritical patients

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Encuesta nacional sobre la tromboprofilaxis y el manejo de los anticoagulantes y antiagregantes en pacientes neuroquirúrgicos y neurocríticos / National survey on thromboprophylaxis and anticoagulant or antiplatelet management in neurosurgical and neurocritical patients

Objetivos. Conocer la práctica clínica de los anestesiólogos españoles en la tromboprofilaxis y el manejo de los anticoagulantes y antiagregantes en pacientes neuroquirúrgicos y neurocríticos. Material y métodos. Encuesta diseñada desde la Sección de Neurociencia de la Sociedad Española de Anestesiología y Reanimación, con 22 preguntas, difundida y contestada en formato electrónico, disponible entre junio y octubre de 2012. Resultados. De los 73 centros hospitalarios con servicio de Neurocirugía incluidos en el Catálogo Nacional de Hospitales, se recibió respuesta válida a la encuesta on line por parte de 41 anestesiólogos de 37 centros (tasa de respuesta del 50,7%). Se consideró una respuesta de cada centro. Solo el 27% de los centros respondedores disponían de un protocolo escrito específico para el manejo de estos pacientes. La tromboprofilaxis mecánica se utilizó hasta en un 80%, aunque de forma variable, y la farmacológica en un 75% de los centros. La enoxaparina fue la heparina de bajo peso molecular más utilizada en pacientes sometidos a craneotomía (78%). En la mitad de los centros respondedores se realizaron craneotomías manteniendo el tratamiento con ácido acetilsalicílico en los pacientes con antecedentes de cardiopatía isquémica, stent coronario y antiagregación dual. Conclusiones. La tromboprofilaxis mecánica es más utilizada que la farmacológica en la población neuroquirúrgica de nuestro país. El manejo de los pacientes tratados previamente con anticoagulantes presenta una marcada variabilidad clínica entre los diferentes hospitales, mientras que el tratamiento con antiagregantes se modifica en función de si se trata de profilaxis primaria o secundaria (AU)

Objectives. To determine the protocols used by Spanish anaesthesiologists for thromboprophylaxis and anticoagulant or antiplatelet drugs management in neurosurgical or neurocritical care patients. Material and methods. An online survey with 22 questions, with one or multiple options, launched by the Neuroscience Subcommittee of the Spanish Anaesthesia Society and available between June and October 2012. Results. Of the 73 hospitals included in the National Hospitals Catalogue, a valid response to the online questionnaire was received by 41 anaesthesiologists from 37 sites (response rate 50.7%). Only one response per site was used. A specific protocol was available in 27% of these centres. Mechanical thromboprophylaxis is used, intraoperatively or postoperatively, in 80%, and pharmacological treatment is used by 75% of respondents. Enoxaparin was the most frequent heparin used in craniotomy patients (78%). Craniotomies were performed maintaining acetylsalicylic acid treatment in patients with coronary stents and double anti-platelet treatment in a half of the centres. Conclusions. Mechanical thromboprophylaxis is used more frequently than the pharmacological approach in neurosurgical or neurocritical populations in Spanish hospitals. Management of patients under previous anticoagulant treatment was highly heterogeneous among hospitals included in this survey. Previous antiplatelet treatment is modified depending on primary or secondary prescription (AU)

National survey on thromboprophylaxis and anticoagulant or antiplatelet management in neurosurgical and neurocritical patients.

OBJECTIVES: To determine the protocols used by Spanish anaesthesiologists for thromboprophylaxis and anticoagulant or antiplatelet drugs management in neurosurgical or neurocritical care patients. MATERIAL AND METHODS: An online survey with 22 questions, with one or multiple options, launched by the Neuroscience Subcommittee of the Spanish Anaesthesia Society and available between June and October 2012. RESULTS: Of the 73 hospitals included in the National Hospitals Catalogue, a valid response to the online questionnaire was received by 41 anaesthesiologists from 37 sites (response rate 50.7%). Only one response per site was used. A specific protocol was available in 27% of these centres. Mechanical thromboprophylaxis is used, intraoperatively or postoperatively, in 80%, and pharmacological treatment is used by 75% of respondents. Enoxaparin was the most frequent heparin used in craniotomy patients (78%). Craniotomies were performed maintaining acetylsalicylic acid treatment in patients with coronary stents and double anti-platelet treatment in a half of the centres. CONCLUSIONS: Mechanical thromboprophylaxis is used more frequently than the pharmacological approach in neurosurgical or neurocritical populations in Spanish hospitals. Management of patients under previous anticoagulant treatment was highly heterogeneous among hospitals included in this survey. Previous antiplatelet treatment is modified depending on primary or secondary prescription.

Situación de la monitorización de la profundidad hipnótica durante la anestesia y del despertar intraoperatorio en España. Resultados de la encuesta realizada en 2011 / Spanish anesthesiologists approach on intraoperative awareness with explicit recall. Results of a national survey performed in 2011

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Aplicación de técnicas estereológicas para la cuantificación del tejido adiposo / Quantification of the adipose tissue by stereology

El conocimiento de la estructura y función del tejido adiposo es fundamental no sólo por el papel que desempeña en el metabolismo lipídico y en enfermedades endocrinas como la diabetes, sino también por su importante misión como elemento estructural de soporte mecánico y de modelado del contorno orgánico (facial, por ejemplo); de ahí su relevancia en el campo de la Cirugía Plástica, Reparadora y Estética. La cuantificación es un método que se practica desde los albores de la Histología. En el presente estudio nos referiremos exclusivamente a las metodologías estereológicas, herramientas libres de sesgo que aprovechan propiedades geométricas intrínsecas de las estructuras a cuantificar. En esencia, la estereología consiste en un conjunto de métodos morfométricos que obtienen datos cuantitativos tridimensionales a partir de elementos bidimensionales, utilizando propiedades geométricas intrínsecas a la estructura que se está estudiando. Describimos las metodologías estereológicas que conducen a la estimación no sesgada de la fracción de volumen de tejido adiposo en relación con el espacio de referencia, número relativo de adipocitos, y longitud relativa del lecho microvascular que irriga el tejido adiposo (AU)

The knowledge of the structure and function of the adipose tissue is not only relevant in relation with its role played in the lipidic metabolism or in endocrine disorders as diabetes. The fat tissue plays also an important role as mechanical support and in the modelling of organic contours (facial, for example); therefore its interest in the field of the Plastic Reconstructive and Aesthetic Surgery. The quantitative methodology has been employed from the very beginning of the histological science. The present study deals with the stereology as a set of unbiased tools that employ intrinsic geometrical features of the objects to quantify. In short, the stereology consists in a pool of morphometric methods that obtain tridimensional information from bidimensional elements (the tissue sections) using the geometrical characteristics of the structures of interest. We describe some stereological procedures leading to the unbiased estimate of: volume fraction of the adipose tissue, the relative number of adipocytes, and the relative length of microvessels of the adipose tissue (AU)

Consideraciones preoperatorias y manejo neuroanestesiológico intraoperatorio / Preoperative considerations and intraoperative neuroanesthesiologic management

El manejo anestésico de los pacientes sometidos a procedimientos neuroquirúrgicos de fosa posterior presenta una serie de características particulares que deben ser conocidas por el anestesiólogo. Los cambios fisiopatológicos secundarios a la posición del paciente durante la cirugía, la relevancia del adecuado posicionamiento para facilitar el abordaje quirúrgico, la menor tolerancia a los cambios de elastancia de la región infratentorial, las escasas opciones terapéuticas ante un episodio de edema- hinchazón intraoperatorio y la presencia de complicaciones como la embolia aérea venosa condicionan la actuación intraoperatoria. Este primer apartado de las guías recoge las principales evidencias disponibles en la bibliografía respecto al abordaje preoperatorio e intraoperatorio de estos pacientes (AU)

The anesthesiological management of patients undergoing neurosurgery of the posterior fossa has a series of characteristics that should be known by anesthesiologists. Intraoperative management is guided by a series of factors that include the physiopathological changes secondary to the patient’s position during surgery, the importance of appropriate patient positioning to facilitate the surgical approach, the lower tolerance to changes in the elastance of the infratentorial region, the limited therapeutic options in episodes of intraoperative edema-swelling, and the presence of complications such as a venous air embolism. This first contribution to the guidelines discusses the main evidence available in the literature on the pre- and intraoperative approach to these patients (AU)

Consideraciones y conducta neuroanestesiológica postoperatoria / Postoperative neuroanesthesiologic considerations and management

La cirugía de fosa posterior y/o región craneorraquídea presenta una elevada tasa de morbimortalidad postoperatoria, escasamente descrita en la literatura científica. El propósito de esta revisión es describir las evidencias disponibles en la bibliografía respecto a las complicaciones asociadas y su manejo neuroanestesiológico y/o neurocrítico; así como resaltar los factores predisponentes que pueden influir en el incremento de la tasa de complicaciones.El conocimiento de las complicaciones relacionadas con la patología neuroquirúrgica de la fosa posterior, puede ayudar a su prevención o a la instauración de un tratamiento adecuado que permita minimizar sus consecuencias. Con este objetivo, en las diferentes bases de datos bibliográficos se realizó una búsqueda sistemática, en castellano e inglés, con los artículos comprendidos entre 1966 y 2012. Además se revisaron los manuscritos que se consideraron relevantes en las pesquisas bibliográficas identificadas. La emesis y el dolor postoperatorio son las complicaciones postoperatorias más frecuentemente descritas, seguida por el edema de la lengua y/o vía aérea, la afectación de pares craneales y la aparición de fístula de líquido cefalorraquídeo durante el postoperatorio. El resto de complicaciones fueron referidas como poco frecuentes. La cirugía de fosa posterior y craneorraquídea cervical posterior tiene mayor morbilidad y mortalidad que la cirugía del compartimento supratentorial. Además de las complicaciones de toda craneotomía, la cirugía infratentorial presenta complicaciones específicas. El trabajo en equipo entre todas las especialidades y estamentos implicados en la atención al paciente es fundamental para disminuir la morbimortalidad asociada a estos procedimientos (AU)

Surgery of the posterior fossa and/or craniospinal region has a high rate of postoperative morbidity and mortality, which has rarely been described in the scientific literature. This review aims to describe the available evidence in the literature on the complications associated with this type of surgery and its neuroanesthesiological and/or neurocritical management, as well as to highlight the predisposing factors that can increase the complications rate. Knowledge of the complications related to neurosurgical disorders of the posterior fossa could aid in their prevention or help in the selection of appropriate treatment that would minimize their consequences. A systematic literature search was made in Spanish and English for articles published between 1966 and 2012 in various databases. Articles considered important in the identified literature were reviewed. The most frequently described postoperative complications were vomiting and postoperative pain, followed by edema of the tongue and/or airway, involvement of the cranial nerves, and the development of cerebrospinal fluid fistulas. The remaining complications were reported as being uncommon. Posterior fossa and posterior cervical surgery produces higher morbidity and mortality than surgery of the supratentorial space. In addition to the complications involved in all craniotomies, infratentorial surgery has specific complications. Team work among all the specialties and staff involved in the care of these patients is essential to reduce the morbidity and mortality associated with these procedures (AU)

[Questionnaire on the anaesthesiology treatment of patients subjected to posterior fossa neurosurgery]. / Encuesta sobre el tratamiento anestesiológico de los pacientes sometidos a neurocirugía de fosa posterior.

OBJECTIVES: To find out, by means of a questionnaire, the procedures used by Spanish anaesthetists in peri-operative management of patients subjected to neurosurgery of the posterior cranial fossa. MATERIAL AND METHODS: A closed-question type questionnaire was sent to Anaesthesiology Departments with a Neurosurgery Department on the participation of anaesthetists in the peri-operative treatment of patients subjected posterior fossa surgery. RESULTS: The questionnaire was completed by 42 (57.5%) of the 73 national public hospitals with a Neurosurgery Department. The posterior fossa surgery was performed in the sitting position in 36 hospitals, although it was less frequently used than the lateral decubitus or prone decubitus position. There was little specific neurological monitoring, as well as little use of precordial and/or transcranial Doppler for detecting vascular air embolism. Nitrous oxide was used in less than 10% of the centres, and 15% avoided neuromuscular block when neurophysiological monitoring was used during the surgery. Cardiovascular problems were mentioned as being the most frequent in 29% of the centres, while in the post-operative period the most common complications were, cranial nerve déficit, airway oedema (23%), and post-operative vomiting (47%). CONCLUSIONS: The results obtained from the questionnaire showed that the sitting position was less used than the prone position in posterior fossa surgery, and that neurophysiological monitoring is during surgery is hardly used.

Encuesta sobre el tratamiento anestesiológico de los pacientes sometidos a neurocirugía de fosa posterior / Questionnaire on the anaesthesiology treatment of patients subjected to posterior fossa neurosurgery

Objetivos: Conocer por medio de una encuesta la actuación de los anestesiólogos españoles en el manejo perioperatorio de los pacientes intervenidos neuroquirúrgicamente de enfermedades de fosa posterior del cráneo. Material y métodos: Se remitió a los servicios de anestesiología de hospitales con servicio de neurocirugía un cuestionario con un planteamiento cerrado sobre la participación de los anestesiólogos en el tratamiento perioperatorio de los pacientes sometidos a cirugía de fosa posterior. Resultados: De los 73 hospitales nacionales públicos que disponen de servicio de neurocirugía, completaron el formulario 42 (57,5%). En 36 centros se realiza la cirugía de fosa posterior con el paciente en sedestación, aunque se emplea con menor frecuencia que el decúbito lateral o el decúbito prono. La monitorización neurológica específica es escasa, así como el empleo del Doppler precordial y/o transcraneal para la detección de embolia vascular aérea. La técnica anestésica más empleada en estos procedimientos es la intravenosa. En menos del 10% de los centros se emplea óxido nitroso, y en un 15% se evitan los bloqueadores neuromusculares cuando se usa monitorización neurofisiológica intraoperatoria. Los problemas cardiovasculares durante la cirugía se refieren como muy frecuentes en el 29% de los centros, mientras que en el postoperatorio las complicaciones referidas como más habituales son los déficit de pares craneales, el edema de vía aérea (23%) y los vómitos postoperatorios (47%). Conclusiones: Los resultados obtenidos de la encuesta muestran que en las cirugías de fosa posterior la sedestación se utiliza menos que el decúbito prono y que apenas se usa monitorización neurofisiológica intraoperatoria(AU)

Objectives: To find out, by means of a questionnaire, the procedures used by Spanish anaesthetists in peri-operative management of patients subjected to neurosurgery of the posterior cranial fossa. Material and methods: A closed-question type questionnaire was sent to Anaesthesiology Departments with a Neurosurgery Department on the participation of anaesthetists in the peri-operative treatment of patients subjected posterior fossa surgery. Results: The questionnaire was completed by 42 (57.5%) of the 73 national public hospitals with a Neurosurgery Department. The posterior fossa surgery was performed in the sitting position in 36 hospitals, although it was less frequently used than the lateral decubitus or prone decubitus position. There was little specific neurological monitoring, as well as little use of precordial and/or transcranial Doppler for detecting vascular air embolism. Nitrous oxide was used in less than 10% of the centres, and 15% avoided neuromuscular block when neurophysiological monitoring was used during the surgery. Cardiovascular problems were mentioned as being the most frequent in 29% of the centres, while in the post-operative period the most common complications were, cranial nerve deficit, airway oedema (23%), and post-operative vomiting (47%). Conclusions: The results obtained from the questionnaire showed that the sitting position was less used than the prone position in posterior fossa surgery, and that neurophysiological monitoring is during surgery is hardly used(AU)

[The role of recombinant activated factor VII in neuro- surgical and neurocritical patients]. / Rol del factor VII recombinante activado en pacientes neuroquirúrgicos y neu- rocríticos.

Central nervous system haemorrhage is a severe pathology, as a small amount of bleeding inside the brain can result in devastating consequences. Haemostatic agents might decrease the consequences of intra- cranial bleeding, whichever spontaneous, traumatic, or anticoagulation treatment etiology. Proacogulant recombinant activated factor VII (rFVIIa) has been given after central nervous system bleeding, with an off-label indication. In this update, we go over the drug mechanism of action, its role in the treatment of central nervous system haemorrhage and the published evidences regarding this subject. We carried out a literature review concerning the treatment with rFVIIa in central nervous system haemorrhage, neurocritical pathologies and neurosurgical procedures, searching in MEDLINE and in clinical trials registry: http://clinicaltrials.gov (last review September 2010), as well as performing a manual analysis of collected articles, looking for aditional references. The results of randomized clinical trials do not support the systematic administration of rFVIIa for spontaneous intracranial cerebral haemorrhage. In other central nervous system related haemorrhages, the current available data consist on retrospective studies, expert opinion or isolated case reports.

Study of the distribution of microvessels in normal and pathologic prostate using an information-based similarity analysis.

Categorizing biologic signals by analysis of symbolic sequences was employed in the study of prostate microvessels. The estimates of the volume fraction of the vessels immunostained to Factor-VIII was mapped to binary sequences. The distance between sequences was estimated by comparing the rank and frequency of repetitive elements. These measurements were applied to detect whether there are unique microvascular patterns for each individual, and to search for patterns describing prostate microvessels of different conditions. Normal prostate, benign prostate hyperplasia and prostate carcinoma groups were studied. All the specimens were immunostained to F-VIII and strips formed by adjacent quadrats were explored. At each point of the long axis of the strip, the V(V) F-VIII was calculated. These values were processed with the information-based similarity software to estimate the dissimilarity between two space series. The following comparisons were carried out: intrasubject versus intragroup distances; intragroup distances among the groups studied and intergroup distances. The distance defined between a vessels immunostained to Factor-VIII space series and its randomized surrogate was considered as an index of the nonrandomness of the space series. These indices were compared for all the groups. We conclude that (a) The information-based similarity analysis can be adapted to vessels immunostained to Factor-VIII space series from prostate microvessels. (b) There are no unique microvascular patterns associated with each individual. (c) There are characteristic patterns describing the microvessels from normal prostate, benign prostate hyperplasia and carcinoma. (d) This method is able to account for the differences between prostate cancer and both normal and benign prostate conditions, with respect to the microvessel patterns.

Rol del factor VII recombinante activado en pacientes neuroquirúrgicos y neu- rocríticos / The role of recombinant activated factor VII in neuro- surgical and neurocritical patients

La hemorragia del sistema nervioso central constituye una patología grave, ya que un volumen de sangrado relativamente pequeño en el cerebro puede presentar consecuencias devastadoras. La utilización de agentes hemostáticos pueden reducir las consecuencias de la hemorragia cerebral espontánea, traumática o secundaria a la anticoagulación. El Factor VII recombinante activado (rFVIIa) es un fármaco procoagulante que se ha empleado en diversas patologías hemorrágicas del sistema nervioso central, si bien esta indicación no se recoge en la ficha técnica del fármaco. En esta revisión se repasa el mecanismo de actuación del fármaco, su potencial en el tratamiento de la hemorragia del sistema nervioso central y las evidencias existentes al respecto. Se realizó una revisión de la bibliografía disponible sobre el uso de rFVIIa en el control de la hemorragia relacionada con el sistema nervioso central, la patolo- gía neurocrítica y procedimientos neuroquirúrgicos, mediante búsqueda en MEDLINE y en el registro de ensayos clínicos: http://clinicaltrials.gov (última revi- sión septiembre 2010), además de revisión manual de las publicaciones a partir de la bibliografía de los artí- culos recuperados. En la hemorragia cerebral espontánea, existen ensa- yos clínicos aleatorios, cuyos resultados desaconsejan la utilización sistemática del fármaco en esta indicación. En el resto de hemorragias relacionadas con el sistema nervioso central, los datos existentes se basan en estu- dios retrospectivos, opiniones de expertos o casos clíni- cos aislados (AU)

Central nervous system haemorrhage is a severe pathology, as a small amount of bleeding inside the brain can result in devastating consequences. Haemos- tatic agents might decrease the consequences of intra- cranial bleeding, whichever spontaneous, traumatic, or anticoagulation treatment etiology. Proacogulant recombinant activated factor VII (rFVIIa) has been given after central nervous system bleeding, with an off-label indication. In this update, we go over the drug mechanism of action, its role in the treatment of central nervous system haemorrhage and the published eviden- ces regarding this subject. We carried out a literature review concerning the treatment with rFVIIa in central nervous system hae- morrhage, neurocritical pathologies and neurosurgical procedures, searching in MEDLINE and in clinical trials registry: http://clinicaltrials.gov (last review Sep- tember 2010), as well as performing a manual analysis of collected articles, looking for aditional references. The results of randomized clinical trials do not support the systematic administration of rFVIIa for spontaneous intracranial cerebral haemorrhage. In other central nervous system related haemorrhages, the current available data consist on retrospective studies, expert opinion or isolated case reports (AU)