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.

Postraumatic frontal sinus obliteration with calvarial bone dust and demineralized bone matrix: a long term prospective study and literature review.

Defining the ideal material for frontal sinus obliteration remains controversial. Autogenous cancellous bone is effective because of its biological properties: it undergoes fast revascularization acting as an active scaffold for bone healing, but is linked to additional donor site morbidity. Bone dust harvesting from the skull surface produces no sequelae but availability is limited. Many efforts have been made to overcome these drawbacks, and an ideal bone substitute sought. Demineralized Bone Matrix (DBX; Musculoskeletal Transplant Foundation, Edison, NJ, USA) is a commercially available product composed of demineralized bone particles reduced after proper processing of human bone in combination with sodium hyaluronate. It generates an osteoconductive surface and it is also a source of osteoinductive factors. Radiological follow-up using computed tomography is a very reliable method of following-up ossification and detecting the early signs of possible complications. The authors present their clinical series of postraumatic frontal sinus obliteration using a mixture of calvarial bone dust and DBX shell, with long-term radiological monitoring. The technique was demonstrated to be effective, reliable, stable in the long term and associated with minimal morbidity.

Intraparenchymal schwannomas: report of two new cases studied with MRI and review of the literature.

Intraparenchymal schwannomas are very rare tumours. We present two young adult patients operated for this type of lesion who show no signs of recurrence 2 years after surgery. These tumours have a bimodal peak of presentation: most occur in young patients under 25 years, and the rest present in the elderly. Characteristically they show both Antoni A and Antoni B areas, intense inmunoreactivity to S-100 and Vimentin protein, and none to EMA or CD34. Electron microscopy is diagnostic when basal membrane is found around the cytoplasmatic processes. MRI spectroscopy depicts increased myoinositol, choline and lipids, and perfusion MR demonstrates high rCBV with a characteristic curve due to the total absence of blood brain barrier. An origin in the Schwann cells of the perivascular nervous plexus in the subarachnoid space is the most accepted theory for the histogenesis of these tumours. We propose to perform the characterization of a series of markers such as SOX-10 in every new case in order to prove that theory.

[Implementation of the Bologna system in medical education. Current status and future prospects]. / El desarrollo del proceso de "Bolonia" y el Grado de Medicina. Situación actual y expectativas para su implantación definitiva.

The implementation of the European Higher Education Area, (EEES in Spanish) inspired in the Bologna Declaration, pursues the introduction of new teaching and learning paradigms which require deep changes in the frame of superior education and university goals. However, in spite that the main purpose of the EEES is convergence and harmonization of curricula contents and titles throughout Europe in order to facilitate circulation of students and professionals, this goal is far from been reached when we are approaching the deadline for its implementation (year 2010). In addition, this process has led to reduce the total duration of the majority of degrees excepting for medicine and few more. In this article we analyze the underdevelopment of the so called Bologna Process in medical education as compared to other careers. Implementation of curricular innovations seems particularly restrained or threatened in Spain because of legal improvisation, lack of funding, and the chronic apathy of national bodies in medical education. As a consequence, and in contrast with other European countries where deep curricular changes have been already arranged, the majority of Spanish Faculties are at risk of introducing little more than cosmetic modifications in their medicine curricula.

El desarrollo del proceso de “Bolonia” y el Grado de Medicina. Situación actual yexpectativas para su implantación definitiva / Implementation of the Bologna system in medical education. Current status and future prospects

La implantación del espacio europeo de educaciónsuperior (EEES) inspirado en la declaración de Boloniaconlleva la introducción de un nuevo paradigma docenteque requiere reestructurar la enseñanza universitaria.Este proceso ha llevado a la reducción de la duración delos anteriores grados con excepción de unos pocos, entrelos que se cuenta el nuevo Grado de Medicina. Aunquees un objetivo prioritario del EEES homogeneizar yarmonizar las enseñanzas y las titulaciones en Europapara favorecer la circulación o intercambio de estudiantesy de profesionales, en el año 2010, cuando deberíahaberse completado el proceso boloñés, está muy lejosde conseguirse la deseada convergencia en la enseñanzasuperior en Europa.En este artículo se comenta cómo el retardo en laarmonización y la convergencia europea es especialmenterelevante en los estudios de Medicina, y se analizael desarrollo del proceso boloñés, tanto en Europacomo en nuestro país, donde se están diseñando losnuevos Planes de Estudio de Medicina en un marcolimitado por la improvisación burocrática y la precipitaciónderivadas de los plazos fijos impuestos porlas autoridades políticas (límite en el 2010), la falta definanciación, y la inercia de sectores profesorales quedesconocen lo esencial del proyecto y muestran indiferencia,o incluso resistencia, a cualquier cambio deparadigma docente. Así, y en contraste con lo ocurridoen otros países vecinos, en los que independientementedel proceso de Bolonia se han conseguido diferentesgrados de modernización curricular, en España existeun alto riesgo de que los nuevos Planes se queden enmeros cambios cosméticos de los utilizados previamenteen la mayoría de las Facultades. De resultar así,la introducción de verdaderas innovaciones docentes,como las preconizadas desde el EEES, se vería seriamentelimitada aumentando más aún la divergenciacon Europa (AU)

The implementation of the European Higher EducationArea, (EEES in Spanish) inspired in the BolognaDeclaration, pursues the introduction of new teachingand learning paradigms which require deep changes inthe frame of superior education and university goals.However, in spite that the main purpose of the EEESis convergence and harmonization of curricula contentsand titles throughout Europe in order to facilitate circulationof students and professionals, this goal is far frombeen reached when we are approaching the deadline forits implementation (year 2010). In addition, this processhas led to reduce the total duration of the majority ofdegrees excepting for medicine and few more.In this article we analyze the underdevelopment ofthe so called Bologna Process in medical education ascompared to other careers. Implementation of curricularinnovations seems particularly restrained or threatenedin Spain because of legal improvisation, lack offunding, and the chronic apathy of national bodies inmedical education. As a consequence, and in contrastwith other European countries where deep curricularchanges have been already arranged, the majority ofSpanish Faculties are at risk of introducing little morethan cosmetic modifications in their medicine curricula (AU)

A case of Hirayama disease treated with laminectomy and duraplasty without spinal fusion.

INTRODUCTION: Juvenile amyotrophy of the distal upper extremity (JADUE) is a rare disease afecting young males. Since neck flexion has been thought to be the cause of the spinal cord damage, cervical orthosis, spinal fusion by an anterior or posterior approach and duraplasty in combination with posterior spinal fusion have been proposed as treatment of JADUE. We are presenting the case of a patient with JADUE who was surgically treated with duraplasty without spinal fusion, thus avoiding the compression of the spinal cord without limitation of cervical movement. CASE: A previously healthy 19-year-old man presented with insidious onset of weakness in the left forearm and hand for the past year. On MRI, during neck flexion, the posterior dura showed anterior displacement that compressed the cervical spinal cord. The dura was opened linearly from C3 to C6, observing the herniation of the spinal cord through the opening. Duraplasty was performed in order to increase the room of the spinal cord. No spinal fusion was performed. DISCUSSION: The postoperative course was uneventful. Clinical deterioration stopped following operation and two years later unchanged as compared to the preoperative one.

Intradural extramedullary spinal hydatidosis: case report.

The parasitic tapeworm Echinococcus granulosis causes hydatid disease, which is rarely encountered in nonendemic regions. It is a progressive disease with serious morbidity risks. Rarely, these cysts are found in the spine. They are mainly found epidurally, originating from direct extension from pulmonary, abdominal or pelvic infestation. Nevertheless, the main mechanism for intradural involvement is not yet clear. Antihelminthic treatment should be administered for a long period following early decompressive surgery. We report a case of recurrent hydatid disease that presented unusual intradural dissemination. Prognosis for spinal hydatid disease remains very poor and comparable to that of a malignant neoplasm.

Intradural extramedullary spinal hydatidosis: case report

The parasitic tapeworm Echinococcus granulosiscauses hydatid disease, which is rarely encountered innonendemic regions. It is a progressive disease withserious morbidity risks. Rarely, these cysts are foundin the spine. They are mainly found epidurally, originatingfrom direct extension from pulmonary, abdominalor pelvic infestation. Nevertheless, the main mechanismfor intradural involvement is not yet clear. Antihelminthictreatment should be administered for a long periodfollowing early decompressive surgery. We report a caseof recurrent hydatid disease that presented unusualintradural dissemination. Prognosis for spinal hydatiddisease remains very poor and comparable to that of amalignant neoplasm (AU)

El Equinococcus granulosis es el parásito causantede la hidatidosis, que se encuentra de forma muy pocofrecuente en regiones no endémicas. Es una enfermedadquística progresiva con riesgo de causar morbilidadimportante, afectando principalmente al hígado y alpulmón. Muy raramente se encuentran quistes a nivelespinal. La hidatidosis espinal afecta sobre todo al espacioepidural por extensión directa de infección existentea nivel pulmonar, abdominal o pélvico. No obstante,el mecanismo para la afectación intradural todavíano está aclarado. El tratamiento antihelmíntico ha deser administrado durante largo tiempo tras la cirugíadescompresiva. Presentamos el caso de una hidatidosisespinal recurrente que presentó una diseminación intradural inusual. El pronóstico de la hidatidosisespinal continúa siendo muy pobre, comparable al deuna enfermedad neoplásica maligna (AU)

[Hyperintensity on T2 MRI and size as predictors of obliteration in radiosurgically treated arteriovenous malformations]. / Hiperintensidad en secuencias T2 y tamaño como factores pronósticos de obliteración en malformaciones arteriovenosas tratadas mediante radiocirugía.

OBJECTIVE: The aim of this study was to determine which factors were statistically related to radiological and clinical outcomes following radiosurgical treatment of arteriovenous malformations (AVMs). METHODS: The data of 59 patients receiving radiosurgical treatment at our department were retrospectivelly reviewed. Different clinical and biological data, including Spetzler-Martin grade, the presentation of symptoms, radiation dose, number of isocenters and both radiological and clinical outcome, were subjected to multivariate analysis. RESULTS: AVM obliteration was achieved in 77% of patients, the majority of them occurring between 3-5 years after treatment. Ten patients (17%) showed either acute or delayed complications. Only one patient died due tor hemorrhage during the follow-up after radiosurgery. A multivariate analysis showed that, hyperintensity on T2 MRI and a nidus smaller than 3 cm were the only factors statistically related to oclusion of the AVM (p=0.03 and p=0.05, respectively). CONCLUSION: The nidus size and the development of hyperintensity on T2 MRI after the treatment were the strongest predictive factors of obliteration in our series of AVMs radiosurgically treated. Moreover, given that many AVMs showed complete obliteration between 3-5 years after treatment, we recommend to wait untill 5 years after treatment before considering a new terapeuthic approach in patients showing small residual nidus at control imaging.

Hiperintensidad en secuencias T2 y tamaño como factores pronósticos de obliteraciónen malformaciones arteriovenosas tratadas mediante radiocirugía / Hyperintensity on T2 MRI and size as predictors of obliteration in radiosurgically treated arteriovenous malformations

Objetivo. Analizar retrospectivamente los factoresimplicados en la obliteración de las malformacionesarteriovenosas (MAVs) tratadas mediante radiocirugía.Métodos. Se revisaron retrospectivamente las historiasclínicas y las pruebas de imagen de 59 pacientescon MAVs tratados consecutivamente mediante tratamientoradioquirúrgico en nuestro Servicio. Se recogenlos datos demográficos y clínicos en el momentodel diagnóstico, así como los referentes al tratamientoempleado y la evolución de dichos pacientes.Resultados. Se consiguió la obliteración en el 77%de las MAVs tratadas. La obliteración completa seobservó en los primeros tres años en sólo el 40% de loscasos, mientras que en el resto, la obliteración ocurrióentre los tres y los cinco años. Diez pacientes (17%)sufrieron complicaciones agudas o crónicas. Sólo unpaciente murió como resultado de una hemorragiaintraparenquimatosa durante el periodo de seguimiento.El análisis multivariable utilizando los diversosfactores y parámetros potencialmente relacionadoscon la obliteración mostró que sólo la hiperintensidadperilesional observada en secuencias T2 de la RM yun tamaño del nidus menor de 3 cm incrementaron demanera estadísticamente significativa la probabilidadde oclusión completa (p=0,03 y p=0,05, respectivamente).Conclusión. Nuestros resultados, son similares a losreportados en otras series. Sin embargo, se obtuvo unamenor tasa de oclusiones en las MAVs >3cm de diámetro,confirmando que el tamaño es un factor determinanteen probabilidad de cierre de las MAVs tratadas (..) (AU)

Objetive. The aim of this study was to determinewhich factors were statistically related to radiologicaland clinical outcomes following radiosurgical treatmentof arteriovenous malformations (AVMs).Methods. The data of 59 patients receiving radiosurgicaltreatment at our department were retrospectivellyreviewed. Different clinical and biological data,including Spetzler-Martin grade, the presentation ofsymptoms, radiation dose, number of isocenters andboth radiological and clinical outcome, were subjectedto multivariate analysis.Results. AVM obliteration was achieved in 77% ofpatients, the majority of them occurring between 3-5years after treatment. Ten patients (17%) showed eitheracute or delayed complications. Only one patient dieddue tor hemorrhage during the follow-up after radiosurgery.A multivariate analysis showed that, hyperintensityon T2 MRI and a nidus smaller than 3 cm werethe only factors statistically related to oclusion of theAVM (p=0,03 and p=0,05, respectively).Conclusion. The nidus size and the development ofhyperintensity on T2 MRI after the treatment were thestrongest predictive factors of obliteration in our seriesof AVMs radiosurgically treated. Moreover, given thatmany AVMs showed complete obliteration between 3-5years after treatment, we recommend to wait untill 5years after treatment before considering a new terapeuthicapproach in patients showing small residual nidusat control imaging. (AU)

La ‘residentalización’ del alumno / The ‘residentialization’ of the student

No disponible

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

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

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

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

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

[The impact of resident work hour limitations on medical student clerkships in Spain]. / La repercusión de la nueva regulación del horario laboral del residente sobre lacalidad de la enseñanza en el pregrado y el postgrado

The influence of new regulations limiting residents work hours on the total time dedicated and the quality of teaching of medical students in university hospitals is analyzed. Though different studies have shown contradictory results on the possible effects of reduced-hour work week on both patients, safety and resident learning, a great concern is arising in Europe and Japan where duty-hour restriction is much more drastic than in USA (48 and 40 hours vs 80 hours, respectively). Deterioration of residents, training could also diminish the total time dedicated to and quality of medical student education.

La repercusión de la nueva regulación del horario laboral del Residente sobre la calidad de la enseñanza en el Pregrado y el Postgrado / The impact of resident work hour limitations on medical student clerkships in Spain

Se considera la posible influencia negativa de la restricción del horario laboral del residente sobre la enseñanza del pregraduado en los hospitales universitarios. Aunque las opiniones de expertos y los resultados de diferentes estudios sobre la repercusión real de la nueva jornada laboral en la calidad del cuidado clínico y la formación del propio residente son contradictorios, parecen ser más los que indican que su efecto puede ser negativo, particularmente en Europa y Japón, donde el horario semanal quedaría reducido a 48 y 40 horas respectivamente, en clara desventaja con el aplicado en USA, que alcanza 80 horas. El problema podría agudizarse más aún en España donde la duración dela residencia es más corta que en otros países europeos. Si la formación del residente empeorara sería también de esperar un deterioro añadido en la enseñanza del pregraduado

The influence of new regulations limiting residents work hours on the total time dedicated and the quality of teaching of medical students in university hospitals is analyzed. Though different studies have shown contradictory results on the possible effects of reduced-hour work week on both patients, safety and resident learning, a great concern is arising in Europe and Japan where duty-hour restriction is much more drastic than in USA (48 and 40 hours vs 80 hours, respectively). Deterioration of residents, training could also diminish the total time dedicated to and quality of medical student education

[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

[Surgical treatment for spontaneous intracerebral haemorrhage. Part I: supratentorial haematomas]. / Tratamiento quirúrgico de la hemorragia intracerebral espontánea. Parte I:Hemorragia supratentorial.

Spontaneous intracerebral haematoma (SICH) represents one the most severe subtypes of ictus. However, and despite a high incidence, medical treatment is almost limited to life support and to control intracranial hypertension and indications of surgical treatment are poorly defined. The aim of this paper was to review the evidence supporting surgical evacuation of SICH. Ten clinical trials and five meta-analyses studying the results of surgical treatment on this pathology were found on English literature. These studies considered all together, failed to show a significant benefit of surgical evacuation in patients with SICH considered as a whole. However, a subgroup of these patients has been considered to potentially present a better outcome after surgical treatment. Current recommendations on supratentorial intra-cerebral haemorrhage state that young patients with lobar haematomas causing deterioration on the level of consciousness should be operated on. Patients suffering from putaminal haematomas and fitting with the same criteria of age and neurological deterioration could also benefit from surgery, at least on terms of survival. Deep neurological deterioration with GCS<5, thalamic location, severe functional deterioration on basal condition or advanced age precluding an adequate functional outcome, have been traditionally considered criteria contraindicating surgery. Given the absence of strong scientific evidence to indicate surgery, this measure should be taken on a tailored manner, and taking into account the social-familiar environment of the patient, that will strongly condition his/her future quality of life.

Tratamiento quirúrgico de la hemorragia intracerebral espontánea. Parte I: Hemorragia supratentorial / Surgical treatment for spontaneous intracerebral haemorrhage. Part I: Supratentorial haematomas

La hemorragia intracerebral espontánea (HIE) constituye uno de los procesos ictales de mayor gravedad. A pesar de esto y de una elevada incidencia, su tratamiento médico no va mucho más allá de un papel de soporte vital y control médico de la hipertensión intracraneal, y las indicaciones del tratamiento quirúrgico están pobremente basadas en evidencia científica. El objetivo del presente trabajo fue revisar las bases de la indicación quirúrgica en la HIE supratentorial. Encontramos 10 ensayos clínicos y 5 meta-análisis en lengua inglesa que analizaban la utilidad del tratamiento quirúrgico en esta patología. Aunque globalmente estos estudios no mostraron un beneficio significativo del tratamiento quirúrgico en el conjunto de pacientes con HIE supratentorial, existe un subgrupo de pacientes en los que parece que dicho tratamiento podría ser beneficioso. En la hemorragia intracerebral espontánea supratentoriallas recomendaciones actuales indican que los pacientes jóvenes, con hematomas lobares cuyo volumen causa un deterioro del nivel de consciencia, deben ser intervenidos. En pacientes con hematomas putaminales que reúnen las mismas condiciones de edad y deterioro neurológico la cirugía podría mejorar la evolución, al menos en términos de supervivencia. Un grave deterioro neurológico con GCS<5, la localización talámica y la presencia de una situación basal o edad que impidan una adecuada recuperación funcional, son criterios considerados tradicionalmente contraindicación del tratamiento quirúrgico. Dada la ausencia de evidencia científica sólida en la que sustentar estas recomendaciones, la decisión terapéutica debe realizarse de manera individualizada y prestando atención al soporte sociofamiliar del paciente, que jugará un papel importante en la evolución del mismo a medio/largo plazo

Spontaneous intracerebral haematoma (SICH)represents one the most severe subtypes of ictus. However, and despite a high incidence, medical treatment is almost limited to life support and to control intracranial hypertension and indications of surgical treatment are poorly defined. The aim of this paper was to review the evidence supporting surgical evacuation of SICH. Ten clinical trials and five meta-analyses studying the results of surgical treatment on this pathology were found on English literature. These studies considered all together, failed to show a significant benefit of surgical evacuation in patients with SICH considered as a whole. However, a subgroup of these patients has been considered to potentially present a better outcome after surgical treatment. Current recommendations on supratentorial intracerebral haemorrhage state that young patients with lobar haematomas causing deterioration on the level of consciousness should be operated on. Patients suffering from putaminal haematomas and fitting with the same criteria of age and neurological deterioration could also benefit from surgery, at least on terms of survival. Deep neurological deterioration with GCS<5, thalamic location, severe functional deterioration on basal condition or advanced age precluding an adequate functional outcome, have been traditionally considered criteria contraindicating surgery. Given the absence of strong scientific evidence to indicate surgery, this measure should be taken on a tailored manner, and taking into account the social-familiar environment of the patient, that will strongly condition his/her future quality of life