Traumatic brain injury in the new millennium: new population and new management.

INTRODUCTION: Traumatic brain injury (TBI) is one of the leading causes of death and disability globally. We present a study describing epidemiological changes in severe TBI and the impact these changes have had on management and analysing alternatives that may improve outcomes in this new population. MATERIALS AND METHODS: We performed a retrospective, descriptive, cross-sectional analysis of patients presenting severe TBI at our hospital in the period of 1992-1996 and 2009-2013. We analysed demographic data, including age, sex, mortality, aetiology, anticoagulation, treatment, and functional outcome. RESULTS: We reviewed data from 220 patients. In the second cohort, there were 40% fewer patients, mean age was 12 years older, patients were more frequently receiving anticoagulation therapy, and the percentage of interventions was halved. Aetiology varied, with traffic accidents being the main cause in the first group, and accidental falls and being hit by cars in the second group. There were no intergroup differences for mortality or functional outcomes. CONCLUSION: The age of patients admitted due to severe TBI has increased. As a result of this, the main cause of severe TBI in our population is accidental falls in elderly, anticoagulated patients. Despite the low-energy nature of trauma, patients in the second cohort presented a poorer baseline status, and were less frequently eligible for surgery, with no improvement in mortality or functional outcomes.

El traumatismo craneoencefálico severo en el nuevo milenio. Nueva población y nuevo manejo / Traumatic brain injury in the new millennium: A new population and new management

Introducción: El TCE es una de las principales causas de muerte y discapacidad a nivel mundial. Presentamos este estudio con el objetivo de detallar el cambio epidemiológico de la población que sufre TCE severo, su influencia en el tipo de tratamiento ofrecido y analizar alternativas que mejoren los resultados ante el nuevo tipo de población que afrontamos. Material y métodos: Se ha realizado un análisis descriptivo, transversal y retrospectivo de los pacientes que sufrieron TCE severo en nuestro hospital en los periodos 1992-1996 y 2009-2013. Se analizaron datos demográficos como edad, sexo, mortalidad, etiología, anticoagulación, tratamiento realizado y resultados funcionales. Resultados: Se revisaron 220 pacientes. En la segunda cohorte el número de pacientes con TCE severo disminuyó un 40%, eran de media 12 años mayores, más frecuentemente anticoagulados y las intervenciones se redujeron a la mitad. Varió la etiología, predominando en el primer grupo los accidentes de tráfico y en el segundo las caídas casuales y los atropellos. No hubo diferencias en la mortalidad de ambos grupos, y sí en su situación funcional. Conclusión: En este estudio encontramos un envejecimiento de la población que ingresa por TCE severo. Ello hace que, en la actualidad, la principal causa de TCE severo en nuestra población sean las caídas casuales en pacientes anticoagulados mayores. A pesar de ser traumatismos de poca energía, los pacientes presentan peores condiciones basales y son menos candidatos a cirugía, sin que mejoren la mortalidad ni la situación funcional. (AU)

Introduction: Traumatic brain injury (TBI) is one of the leading causes of death and disability globally. We present a study describing epidemiological changes in severe TBI and the impact these changes have had on management and analysing alternatives that may improve outcomes in this new population. Materials and methods: We performed a retrospective, descriptive, cross-sectional analysis of patients presenting severe TBI at our hospital in the period of 1992-1996 and 2009-2013. We analysed demographic data, including age, sex, mortality, aetiology, anticoagulation, treatment, and functional outcome. Results: We reviewed data from 220 patients. In the second cohort, there were 40% fewer patients, mean age was 12 years older, patients were more frequently receiving anticoagulation therapy, and the percentage of interventions was halved. Aetiology varied, with traffic accidents being the main cause in the first group, and accidental falls and being hit by cars in the second group. There were no intergroup differences for mortality or functional outcomes. Conclusion: The age of patients admitted due to severe TBI has increased. As a result of this, the main cause of severe TBI in our population is accidental falls in elderly, anticoagulated patients. Despite the low-energy nature of trauma, patients in the second cohort presented a poorer baseline status, and were less frequently eligible for surgery, with no improvement in mortality or functional outcomes. (AU)

Traumatic brain injury in the new millennium: A new population and new management. / El traumatismo craneoencefálico severo en el nuevo milenio. Nueva población y nuevo manejo.

INTRODUCTION: Traumatic brain injury (TBI) is one of the leading causes of death and disability globally. We present a study describing epidemiological changes in severe TBI and the impact these changes have had on management and analysing alternatives that may improve outcomes in this new population. MATERIALS AND METHODS: We performed a retrospective, descriptive, cross-sectional analysis of patients presenting severe TBI at our hospital in the period of 1992-1996 and 2009-2013. We analysed demographic data, including age, sex, mortality, aetiology, anticoagulation, treatment, and functional outcome. RESULTS: We reviewed data from 220 patients. In the second cohort, there were 40% fewer patients, mean age was 12years older, patients were more frequently receiving anticoagulation therapy, and the percentage of interventions was halved. Aetiology varied, with traffic accidents being the main cause in the first group, and accidental falls and being hit by cars in the second group. There were no intergroup differences for mortality or functional outcomes. CONCLUSION: The age of patients admitted due to severe TBI has increased. As a result of this, the main cause of severe TBI in our population is accidental falls in elderly, anticoagulated patients. Despite the low-energy nature of trauma, patients in the second cohort presented a poorer baseline status, and were less frequently eligible for surgery, with no improvement in mortality or functional outcomes.

[Postoperative complications in Chiari I malformation: duroplasty and cerebrospinal fluid leak]. / Complicaciones postquirrgicas de la malformación de Chiari tipo I: duroplastia y fístula de líquido cefalorraquídeo.

UNLABELLED: The surgical treatment of Chiari I malformation is to carry out a suboccipital decompression. It is described that postoperative complications may occur, especially if the dura is open and closed using a graft (duraplasty). Among them, one of the most important events due to its difficult handling is cerebrospinal fluid leak through the suture line. OBJECTIVE: To conduct a postoperative review to analyze the outcome of the patients and the occurrence of complications depending on the dural plasty used. MATERIAL AND METHODS: A retrospective study was carried out between 1997 and 2008, both inclusive, where we assessed 36 patients. All of them were studied with preoperative and postoperative craniospinal magnetic resonance, and by a thorough clinical examination performed before and after the surgery. The surgical procedure consisted of suboccipital decompression and resection of the posterior arch of C1 or C1 and C2 (depending on the extent of the caudal displacement of the tonsils), followed by duraplasty using either an autologous graft (pericranium) or a synthetic graft (Gore-tex). RESULTS: After a mean follow-up of 2 years, the clinical results were: excellent (55%), if there was a great clinical improvement; good (29%), if there was slight improvement; and bad (16%), if there was no improvement or there was worsening. In the 30 patients given a duraplasty (18 with an artificial graft, 12 with an autologous pericranium graft), 6 cases of cerebrospinal fluid leak appeared, although no significant association between the type of dural plasty and the presence of leak was observed. CONCLUSIONS: The best results were obtained for headaches, cervical pain and dizziness. Despite the fact that there were more cases of cerebrospinal fluid leak in patients receiving an artificial graft compared to patients with pericranium graft, there was no significant difference.

Complicaciones postquirúrgicas de la malformación de Chiari tipo I: duroplastia yfístula de líquido cefalorraquídeo / Postoperative complications in Chiari I malformation: duroplasty and cerebrospinal fluid leak

El tratamiento quirúrgico de la malformación deChiari tipo I consiste en realizar una descompresiónósea suboccipital. Está descrito que pueden producirsecomplicaciones derivadas de la cirugía, sobre todo sise realiza apertura dural y posterior cierre con injerto(duroplastia). Una de las más importantes por su difícilmanejo, es la fístula de líquido cefalorraquídeo en lazona quirúrgica.Objetivo. Llevar a cabo una revisión postquirúrgica,donde analizaremos la evolución de los pacientes y lacorrelación de las complicaciones respecto al tipo deplastia dural usada.Material y métodos. Se ha realizado un estudio retrospectivode los pacientes intervenidos en nuestro centroentre el año 1997 y 2008, ambos inclusive, recogiendoun total de 36 pacientes. A todos ellos se les realizó unestudio pre y postoperatorio con resonancia magnéticacraneoespinal, así como un examen neurológico antes ydespués de la intervención. La intervención quirúrgicaconsistió en una descompresión ósea suboccipital, juntocon la extirpación del arco posterior de C1 o C2 (dependiendodel descenso amigdalar), y duroplastia coninjerto autólogo (pericráneo) o con injerto heterólogo(Gore-tex).Resultados. Tras un seguimiento medio de 2 añosobtuvimos los siguientes resultados clínicos: excelente(55%), si hubo gran mejoría clínica; bueno (29%), sihubo leve mejoría; y malo (16%), si no hubo mejoría ohubo empeoramiento. En los 30 pacientes a los que seles realizó duroplastia (18 plastia artificial, 12 plastiaautóloga de pericráneo occipital), (..) (AU)

The surgical treatment of Chiari I malformation is tocarry out a suboccipital decompression. It is describedthat postoperative complications may occur, especiallyif the dura is open and closed using a graft (duraplasty).Among them, one of the most important events due toits difficult handling is cerebrospinal fluid leak throughthe suture line.Objective. To conduct a postoperative review toanalyze the outcome of the patients and the occurrenceof complications depending on the dural plasty used.Material and methods. A retrospective study wascarried out between 1997 and 2008, both inclusive,where we assessed 36 patients. All of them were studiedwith preoperative and postoperative craneoespinalmagnetic resonance, and by a thorough clinical examinationperformed before and after the surgery. Thesurgical procedure consisted of suboccipital decompressionand resection of the posterior arch of C1 or C1 andC2 (depending on the extent of the caudal displacementof the tonsils), followed by duraplasty using either anautologous graft (pericranium) or a synthetic graft(Gore-tex).Results. After a mean follow-up of 2 years, the clinicalresults were: excellent (55%), if there was a great (..) (AU)

Estudio anatómico de la transferencia de los nervios accesorio y toracodorsal al nervio cubital en el gato / Anatomic study of spinal accesory and thoracodorsal nerves transfer to ulnar nerve in cats

Las lesiones del plexo braquial son una de las patologías más graves y con mayor número de secuelas del miembro superior. En el momento actual las transferencias nerviosas se encuentran en primera línea del armamento terapéutico para reconstruir funciones proximales del miembro superior. En el estudio que presentamos se realizaron 20 transferencias nerviosas al nervio cubital del gato común, tomando bien el nervio accesorio del espinal (10 casos) o bien el nervio toracodorsal (10 casos). Como grupo controles utilizó el lado contralateral al intervenido. Durante el año siguiente, se evaluó la reinervación mediante estudios electromiográficos, histológicos de nervio y músculo, así como histoquímicos de médula espinal. Tras el análisis de los resultados encontramos que las motoneuronas de ambos nervios donantes son capaces de conseguir reinervaciones parciales del territorio cubital (AU)

A brachial plexus injury is one of the most severe pathologies of the upper limb, and also has severe sequels. In the actual state of the art, nerve transfers are being used as first line of therapeutic approach in the reconstruction of proximal functions of the upper limb. In this study 20 nerve transfers were made to the ulnar nerve of the cat, using the spinal accessory nerve (10 cases) or the thoracodorsal nerve (10cases). The opposite side was used as control. During next year, reinnervation was assessed by electromyography, nerve and muscle histology and histochemical evaluation of the spinal cord. We found that motoneurons of both donor nerves are able to make partial reinervation of the ulnar nerve territory (AU)

[Solitary fibrous tumors of the meninges: report of three cases and literature review]. / Tumor fibroso solitario meníngeo: descripción de tres casos y revisión de la literatura.

We report 3 patients with fibrous solitary tumor of meningeal location where we described the histological study, as well as evolution after the surgical treatment. The described patients presented ages of 37, 52 and 65 years, after the resection has not appeared an objective sign of recurrence in any case after 4, 6 and 7 years of follow-up respectively. Checking the literature the tumor is indistinguishable clinical and radiolocally of the typical meningioma, doing necessary the use of inmunohistochemistry to do the differential diagnosis, where positiveness for CD34 and the negativeness for EMA define the fibrous solitary tumor. It is about a benign tumor, where total removing is the principal factor in prognosis, nevertheless there are cases of local recurrences and long-distance metastasis. We can find all these characteristics in the showed cases of the present article, having the uncertainty of its local or systemic relapse ability in the future.

[A comparative study of the treatment of high grade gliomas]. / Estudio comparativo en el tratamiento de los gliomas de alto grado.

INTRODUCTION: The influence of surgery, radiotherapy and/or chemotherapy on the outcome on the results in patients with malignant gliomas is controversial. PATIENTS AND METHODS: We studied 44 patients (26, women; 18 men; age 38 72 years) diagnosed with grades III and IV astrocytoma who had been operated and then received adjuvant radiotherapy and either BCNU or temozolamyde chemotherapy. Survival time and adverse effects of the chemotherapy were analysed. CONCLUSION: Aggressive surgery associated with radiotherapy and temozolamyde chemotherapy prolonged survival in our patients with malignant astrocytomas.

Estudio comparativo del tratamiento de los gliomas de alto grado / A comparative study of the treatment of high grade gliomas

Introducción. En los pacientes con astrocitomas malignos se pueden emplear distintos tratamientos, como cirugía, radioterapia y quimioterapia, y es muy controvertida la influencia de estos tratamientos. Pacientes y métodos. Valoramos 44 pacientes diagnosticados de astrocitoma de grado III y IV intervenidos quirúrgicamente, que recibieron como tratamiento adyuvante radioterapia y quimioterapia con BCNU y temozolamida; 26 eran mujeres y 18 hombres, con edades comprendidas entre 38 y 72 años. Valoramos la supervivencia alcanzada por los enfermos y los efectos adversos de los distintos quimioterápicos, y correlacionamos el tratamiento administrado y los resultados. Conclusión. La cirugía agresiva asociada a radioterapia y quimioterapia con temozolamida prolonga la supervivencia de los pacientes con astrocitomas malignos (AU)

Introduction. The influence of surgery, radiotherapy and/or chemotherapy on the outcome on the results in patients with malignant gliomas is controversial. Patients and methods. We studied 44 patients (26, women; 18 men; age 38-72 years) diagnosed with grades III and IV astrocytoma who had been operated and then received adjuvant radiotherapy and either BCNU or temozolamyde chemotherapy. Survival time and adverse effects of the chemotherapy were analysed. Conclusion. Aggressive surgery associated with radiotherapy and temozolamyde chemotherapy prolonged survival in our patients with malignant astrocytomas (AU)

Actualización en el tratamiento de la neurocisticercosis / Update in neurocysticercosis treatment

Introducción. La neurocisticercosis (NCC) es la parasitosis más frecuente del sistema nervioso central, aunque en nuestro país es una enfermedad poco frecuente. La creciente incidencia en nuestro medio se debe al aumento de la inmigración procedente de países en los cuales esta enfermedad es endémica. Objetivos. Actualización de la actitud a tomar ante la sospecha de esta patología. Pacientes y métodos. Se estudian ocho pacientes diagnosticados de NCC: edad, sexo, nacionalidad, sintomatología, pruebas de imagen con TAC y RM (forma clínica, tipo de quiste, localización, estadio evolutivo), pruebas diagnósticas realizadas, tratamiento administrado y duración del mismo en caso de ser médico, y evolución clínica y neurorradiológica. Resultados. Todos los pacientes eran de origen sudamericano, con edades comprendidas entre 25 y 33 años. El síntoma de presentación más frecuente fue la crisis comicial. En dos pacientes existía una lesión única, mientras que en seis era múltiple, y los ocho pacientes presentaban la forma parenquimatosa. Las pruebas serológicas de ELISA sólo fueron positivas en el 50 por ciento de los casos. El tratamiento fue quirúrgico, inicialmente, en un solo caso, mientras que en los siete restantes se inició tratamiento médico con albendazol; en uno de ellos fue inefectivo, por lo que también requirió cirugía. Durante un período medio de seguimiento de 10 meses se ha observado una evolución favorable del 100 por ciento de los pacientes, que se encuentran, todos ellos, asintomáticos en la actualidad. Discusión y conclusiones. La NCC es una infección prevalente entre la población inmigrante en nuestro país. El tratamiento con fármacos antiparasitarios suele ser efectivo, y se reserva la alternativa quirúrgica para casos seleccionados. Consideramos que la duración del tratamiento médico debe individualizarse para cada paciente, en función de la evolución clínica y radiológica (AU)

Introduction. Neurocysticercosis is the most frequent central nervous system parasitosis, although quite infrequent in our country. Its rising incidence can be explained by immigration from regions of the world where this disease is endemic. Objective. This paper reviews treatment options for this condition. Patients and methods. Eight patients have been diagnosed with neurocysticercosis in the last three years in our hospital. Patient age, sex, origin, symptoms, CT and MR images, diagnostic tests, treatment and duration of medical treatment and clinical and neuroradiological evolution are examined. Results. Patient age ranged from 25 to 33 years, all eight came from South America and the most frequent initial symptom was an epileptic crisis. Two patients had a single lesion, six had multiple lesions and all eight showed the lesion in the parenchyma. Only 50% showed a positive serum ELISA test for Taenia solium. Initial treatment was surgical in only one patient and the other seven received albendazol. In one of the latter the drug was ineffective and surgery was undertaken. A ten month follow up period has found a favorable evolution in all the patients, who are all also asymptomatic at the present time. Discussion and conclusions. Neurocysticercosis is more common among immigrants than the local population in Spain. The initial treatment should be medical, with surgery as an option for non-responders. We believe that duration of the medical treatment will depend on the patient and the clinicoradiological evolution of his/her disease (AU)

Derivación de líquido cefalorraquídeo y embarazo / Cerebrospinal fluid shunting and pregnancy

Objetivo. Realizar una revisión bibliográfica y actualización de los pasos a seguir en el manejo de la paciente embarazada portadora de derivación de líquido cefalorraquídeo (LCR).Desarrollo. El riesgo de disfunción valvular (DFV) durante el embarazo es de aproximadamente un 27,5 por ciento, debido, fundamentalmente, a una obstrucción funcional por el aumento de la presión intraabdominal durante la gestación. El riesgo de DFV y de complicaciones es alto hasta 6 meses después del parto. Son de vital importancia tanto el estudio del funcionamiento de la derivación como el consejo genético, previos a la concepción. Se discuten los pasos a s eguir durante el embarazo, durante el parto y después del mismo, así como las implicaciones que supone una derivación de LCR en una paciente embarazada desde un punto de vista neurológico, neuroquirúrgico, obstétrico y anestésico. Aunque la evolución materna es excelente (100 por ciento asintomáticas 6 meses después del parto), existe una proporción muy elevada de abortos (24 por ciento) de causa desconocida. Conclusiones. Se necesitan estudios prospectivos para dilucidar diferentes puntos en los que las series existentes están en desacuerdo (AU)

Aims. The aim of this study is to survey the literature and update the steps to be taken in managing a pregnant patient in whom cerebrospinal fluid (CSF) shunting has been performed. Development. The risk of valve malfunction (VMF) during pregnancy is approximately 27.5% and is mainly produced by a functional obstruction due to an increase in intraabdominal pressure during gestation. The risk of VMF and complications rises until 6 months after childbirth. The study of the functioning of the shunt and genetic counselling prior to conception are of vital importance. We discuss the steps to be taken during pregnancy, and during and after childbirth, as well as the implications of CSF shunting in a pregnant patient from a neurological, neurosurgical, obstetric and anaesthetic point of view. Although maternal progress is excellent (100% were asymptomatic 6 months after childbirth), there is also a very high percentage of miscarriages (24%) of unknown causation. Conclusions. Prospective studies are needed to explain different conflicting points in the series currently available (AU)

[Update in neurocysticercosis treatment]. / Actualizacion en el tratamiento de la neurocisticercosis.

INTRODUCTION: Neurocysticercosis is the most frequent central nervous system parasitosis, although quite infrequent in our country. Its rising incidence can be explained by immigration from regions of the world where this disease is endemic. OBJECTIVE: This paper reviews treatment options for this condition. PATIENTS AND METHODS. Eight patients have been diagnosed with neurocysticercosis in the last three years in our hospital. Patient age, sex, origin, symptoms, CT and MR images, diagnostic tests, treatment and duration of medical treatment and clinical and neuroradiological evolution are examined. RESULTS: Patient age ranged from 25 to 33 years, all eight came from South America and the most frequent initial symptom was an epileptic crisis. Two patients had a single lesion, six had multiple lesions and all eight showed the lesion in the parenchyma. Only 50% showed a positive serum ELISA test for Taenia solium. Initial treatment was surgical in only one patient and the other seven received albendazol. In one of the latter the drug was ineffective and surgery was undertaken. A ten month follow up period has found a favorable evolution in all the patients, who are all also asymptomatic at the present time. DISCUSSION AND CONCLUSIONS: Neurocysticercosis is more common among immigrants than the local population in Spain. The initial treatment should be medical, with surgery as an option for non responders. We believe that duration of the medical treatment will depend on the patient and the clinico radiological evolution of his/her disease.

[Cerebrospinal fluid shunting and pregnancy]. / Derivación de líquido cefalorraquídeo y embarazo.

AIMS: The aim of this study is to survey the literature and update the steps to be taken in managing a pregnant patient in whom cerebrospinal fluid (CSF) shunting has been performed. DEVELOPMENT: The risk of valve malfunction (VMF) during pregnancy is approximately 27.5% and is mainly produced by a functional obstruction due to an increase in intra abdominal pressure during gestation. The risk of VMF and complications rises until 6 months after childbirth. The study of the functioning of the shunt and genetic counselling prior to conception are of vital importance. We discuss the steps to be taken during pregnancy, and during and after childbirth, as well as the implications of CSF shunting in a pregnant patient from a neurological, neurosurgical, obstetric and anaesthetic point of view. Although maternal progress is excellent (100% were asymptomatic 6 months after childbirth), there is also a very high percentage of miscarriages (24%) of unknown causation. CONCLUSIONS: Prospective studies are needed to explain different conflicting points in the series currently available.

Réplica. Cavernomatosis múltiple. Diagnóstico diferencial por eco-gradiente / Reply. Multiple cavernomatosis. Differential diagnosis by gradient-echo

No disponible

No disponible

[Management of multiple cerebral cavernomatosis]. / Tratamiento de la cavernomatosis cerebral multiple.

INTRODUCTION: Cavernous angiomas are angiographically occult vascular malformations that are present in 0.4% of people, and represent 5 13% of all cerebrovascular malformations. They can be alone or multiple, and sporadic or familial. The presence of multiple lesions is more frequent in familial cavernomatosis. OBJECTIVES: Improve our knowledge of the natural history of multiple cavernomatosis in order to improve our diagnostic and therapeutic management of this entity. PATIENTS AND METHODS: We have retrospectively reviewed 18 cases of multiple cerebral cavernomatosis; 4 of them belonged to the same family and 2 belonged to another family. Number, size, characteristics and evolution of the lesions, symptoms, treatment and clinical outcome have been analysed during a follow up period longer than 5 years. RESULTS: 31.5% of the cavernous angiomas reviewed by our department were multiple (at least three lesions). During the 5 year follow up period only four (4/18) patients underwent surgical treatment. 50% of patients suffered at least one hemorrhagic event with clinical impairment, and the most frequent manifestations were headache, focal deficit and seizures. The hemorrhagic rate per lesion per year was under 1%, for the more than 200 lesions and the low frequency of hemorrhagic events with clinical impairment in the time. CONCLUSIONS: Surgical treatment must be considered in patients with accessible lesions that have produced symptoms several or progressive symptoms. The non surgical patients should be followed with yearly MRI. When more than one first degree relative has a cavernous malformation or familial antecedent with cerebral hemorrhage or epilepsy, serial follow up monitoring consisting of physical examinations and MRI should be suggested to family members.

Tratamiento de la cavernomatosis cerebral múltiple / Management of the multiple cerebral cavernomatosis

Introducción. Los angiomas cavernosos son malformaciones vasculares angiográficamente ocultas, presentes en el 0,4 por ciento de los individuos, y que suponen el 5-13 por ciento de las malformaciones vasculares. Pueden ser únicos o múltiples, y esporádicos o familiares. El carácter múltiple de las lesiones es más frecuente en las formas familiares. Objetivos. Un mayor conocimiento de la historia natural de la cavernomatosis múltiple, que nos permita realizar un correcto manejo diagnóstico y terapéutico de esta patología. Pacientes y métodos. Hemos revisado retrospectivamente 18 casos de cavernomatosis cerebral múltiple, cuatro de los cuales pertenecían a una misma familia y dos a otra. Se ha analizado el número, tamaño, características y evolución de las lesiones, sintomatología del paciente, período de seguimiento, tratamiento realizado y evolución clínica a lo largo del tiempo. Resultados. Según los datos de nuestro servicio, en el 31,5 por ciento de los casos de cavernomas, éstos presentan un carácter múltiple (al menos tres lesiones). El seguimiento se ha efectuado durante un período medio de cinco años, durante el cual sólo cuatro pacientes se sometieron a tratamiento quirúrgico. El 50 por ciento de los pacientes presentaron al menos un episodio hemorrágico con repercusión clínica, y las manifestaciones más frecuentes fueron cefalea, focalidad neurológica y crisis comiciales. La incidencia de hemorragia por lesión por año es inferior al 1 por ciento, dado el elevado número de lesiones (más de 200 en total) y la escasa frecuencia de hemorragia con repercusión clínica a lo largo del tiempo. Conclusiones. El tratamiento quirúrgico debe plantearse en casos de lesiones de localización accesible que hayan producido síntomas en repetidas ocasiones o de forma progresiva. En el resto de casos se debe realizar un seguimiento con resonancia magnética (RM) anual. Cuando más de un familiar de primer grado tiene algún cavernoma o existen antecedentes familiares de hemorragias cerebrales o crisis comiciales, se debe ofrecer la posibilidad de seguimiento clínico y radiológico con RM a los miembros de la familia (AU)

[Design, implementation, and results of the clinical pathway for herniated lumbar disk]. / Diseño, implantación y resultados de la vía clínica para la cirugía de la hernia de disco lumbar.

INTRODUCTION: Clinical or critical pathways are a useful tool in the continuous quality improvement. They develop the main characteristics of the quality programs: implementation of the evidence based medicine, increase staff and patient satisfaction and adequacy in hospital costs. This is the application of evidence-based medicine to a process management and it promotes integration of clinical guides, protocols and algorithms. OBJECTIVE: We present our experience in the design, and first nine month's implementation and development of a clinical pathway for lumbar hemilaminectomy. PATIENTS AND METHODS: This clinical pathway consists on four documents: main guide and check sheet, preprinted treatment orders and variation sheet, iconographic information for the patients and patient satisfaction questionnaire. After desing, development and a pilot study, the hemilaminectomy critical pathway was permanently adopted by our Service. A total of 106 patients underwent programmed lumbar disc hemilaminectomy in our Service between April and December-1999. Patients' average age was 44.7 years (SD = 11.2), 55.3% were men and 43.7% women. Twelve were hospitalized in a ward other than Neurosurgery unit and therefore were excluded from the study. This evaluation is based on the initial results obtained from both the pathway documents and the general data collected as usual during hospital care. The impact of the critical pathway on hospital stay has been assessed by comparing the average stay of critical pathway patients to the average of the 70 hemilaminectomies performed at our Service in the period April-December 1998. RESULTS: Clinical pathway coverage has been 68% (standard > 80%). The patients' average stay was 4 days (SD = 1.1), one day more than planned. The pathway establishes a 4 day hospital stay (3 bed-days), a time that was fulfilled by 49% of the patients. The average stay of the 1998 patients was 5.6 days (SD = 2.7), 1.6 days more than the clinical pathway patients (p < 0.0001). Additionally, undesirable variability in the length of hospital stays was also reduced. Analysis of variations identified those corresponding to patient's condition, increases in medication beyond that originally specified due to patient needs, and unjustified prolonged stays. There were no systematic variations. There was a 2.2% incidence of adverse effects. Although satisfaction questionnaire was only returned by 51% of the patients (instead of > 70%), satisfaction index were 93% (vs 90%). CONCLUSIONS: Critical pathways are still under development and changing continuously. Nevertheless their impact on improving patient care and satisfaction, and resource consumption is already evident, and it constitutes a major aim to work in its complete development.

[Antibiotic therapy of infected cerebrospinal fluid in hydrocephalus treated by a shunt]. / Antibioticoterapia del LCR infectado en hidrocefalias tratadas con shunt.

Nine hydrocephalic shunted children with infected cerebrospinal fluid (CSF) were treated. Ages ranged from 0 to 10 years. Diagnosis was made through clinical symptoms, CSF examination, echographic and computed tomography (CT). The microorganism which was seen more frequently, was S. epidermidis. This germ was more often found in young children. Treatment of these patients consisted of a systematic change of the shunt which was externally diverted, implantation of a CSF Ommaya reservoir in the lateral ventricle, and intraventricular and systemic administration of antibiotic, were made. Using this protocol CSF sterilization was obtained in all cases, after 5 to 12 days of treatment. CSF shunt infected with S. epidermidis can be effectively cleaned with daily intra-shunt vancomycin, and shunt infected with gram-negative are also cleaned with daily intra-shunt gentamycin.