[Influence of armed conflict on mortality due to traumatic brain injury in children and adolescents]. / Influencia del conflicto armado en la mortalidad por trauma craneoencefálico en niños y adolescentes.

BACKGROUND: In the presence an armed conflagration, the mortality behavior of a country is expected to be affected. The aim of this investigation was to assess, in a country with internal warfare, the trend of mortality associated with traumatic brain injury in children and adolescents, which even under social peace conditions, is one of the most common causes of death and disability in this population groups. METHODS: A retrospective, population-based study was conducted, where the trend of mortality due to traumatic brain injury during the 1999 to 2008 period was assessed. A linear regression was performed to establish its correlation with mortality associated with warfare events of the armed conflict. RESULTS: Global mortality rate was 12.7 per 100 000 inhabitants. The temporary analysis showed a -9.67% annual decrease throughout the entire period of study (95 % CI = -9.25 % to -10.1 %; p < 0.001). The mortality rate was increased by 0.28 and 0.62 for each incremental unit in the armed conflict-related violent death rate and in civilian population, respectively. CONCLUSIONS: In an armed conflict scenario, mortality behavior varies according to the intensity of warfare actions. Mortality due to traumatic brain injury in children and adolescents can be used as an indicator of the impact of war on civilian population not involved with the armed conflict.

INTRODUCCIÓN: ante un conflicto bélico es de esperar que el comportamiento de la mortalidad de un país se vea afectado. El objetivo de esta investigación fue evaluar en un país en guerra interna, la tendencia de la mortalidad por trauma craneoencefálico en niños y adolescentes, que aún en condiciones de paz social constituye una de las causas más frecuentes de muerte y discapacidad en esos grupos poblacionales. MÉTODOS: se llevó a cabo un estudio poblacional y retrospectivo en el que se evaluó la tendencia de la mortalidad por trauma craneoencefálico durante el periodo de 1999 a 2008. Se realizó una regresión lineal para determinar su correlación con la mortalidad relacionada con los eventos bélicos del conflicto armado. RESULTADOS: la tasa de mortalidad global fue de 12.7 por 100 000 habitantes. El análisis temporal demostró una disminución anual de ­9.67 % durante todo el periodo de estudio (IC 95 % = ­9.25 % a ­10.1 %, p < 0.001]. La tasa de mortalidad se incrementó 0.28 y 0.62 por cada unidad de incremento en la tasa de muertes violentas relacionadas con el conflicto armado y en población civil, respectivamente. CONCLUSIONES: en un escenario de conflicto armado, el comportamiento de la mortalidad varía en función de la intensidad de las acciones bélicas. La mortalidad por trauma craneoencefálico en niños y adolescentes puede utilizarse como un indicador del impacto de la guerra sobre la población civil ajena al conflicto armado.

Posicionamiento postoperatorio de la cabecera tras drenaje de hematomas subdurales crónicos por trepanación: Revisión sistemática y metaanálisis de estudios controlados aleatorizados / Postoperative bed header position after burr-hole drainage of chronic subdural haematoma: Systematic review and meta-analysis of randomised controlled trials

INTRODUCCIÓN: Algunos estudios han señalado la posible influencia del posicionamiento postoperatorio de la cabecera sobre el riesgo de recurrencias y complicaciones médicas en los pacientes intervenidos por hematomas subdurales crónicos; sin embargo, esta hipótesis aún no se ha evaluado mediante un metaanálisis. MÉTODOS: Se incluyeron todos los estudios prospectivos controlados aleatorizados que analizaron la frecuencia de recurrencias sintomáticas en los pacientes operados por hematomas subdurales crónicos mediante trepanación, con relación al posicionamiento postoperatorio de la cabecera. El desenlace primario fueron las recurrencias sintomáticas y los secundarios, las reintervenciones y las complicaciones médicas postoperatorias. Los resultados se presentaron en riesgos relativos combinados, con sus intervalos de confianza del 95%. RESULTADOS: Fueron incluidos un total de 4 estudios controlados aleatorizados. Los riesgos relativos combinados fueron: recurrencias sintomáticas, 0,51 ([IC 95%: 0,22-1,16]; p = 0,11); reintervenciones, 1,07 ([IC 95%: 0,42-2,69]; p = 0,89) y complicaciones, 1,15 ([IC 95%: 0,7-1,91]; p = 0,58). No se encontró heterogeneidad estadísticamente significativa en ninguno de los análisis. CONCLUSIÓN: No se encontraron diferencias en el riesgo de recurrencias sintomáticas, reintervenciones ni complicaciones médicas en los pacientes que fueron mantenidos con la cabecera plana, en comparación con aquellos en quienes fue elevada en el postoperatorio. Aunque los resultados fueron consistentes entre los estudios incluidos, existe un potencial riesgo de sesgos, lo que proscribe emitir recomendaciones definitivas antes de contarse con estudios de mayor calidad metodológica

INTRODUCTION: Several studies have suggested the possible influence of postoperative bed header position on the risk of symptomatic recurrences and medical complications in patients who have been intervened due chronic subdural haematomas. Nevertheless, this hypothesis has not been assessed by a meta-analysis. METHODS: All randomised controlled trials analysing symptomatic recurrence rates in patients who underwent burr-hole drainage of chronic subdural haematomas, describing postoperative bed header positioning, were included. The primary outcome was risk of recurrence and the secondary outcome were the risks of reoperation and medical complications. Results were presented as pooled relative risks, with 95% confidence intervals. RESULTS: A total of 4 controlled studies were included. Pooled relative risks were: symptomatic recurrences 0.51 ([95% CI: 0.22-1.16]; P = .11), reoperations, 1.07 ([95% CI: 0.42-2.69]; P = .89) and medical complications, 1.15 ([95% CI: 0.7-1.91]; P = .58). No statistically significant heterogeneity was found in any of the analyses. CONCLUSION: There were no differences regarding frequency of symptomatic recurrences, reoperations or medical complications in patients who were maintained in a flat position compared with those whose bed header was elevated during the postoperative course. Despite there being consistency between the results, there is a potential risk of bias; thus proscribing definitive recommendations until studies with higher methodological quality are available

[Postoperative bed header position after burr-hole drainage of chronic subdural haematoma: systematic review and meta-analysis of randomised controlled trials]. / Posicionamiento postoperatorio de la cabecera tras drenaje de hematomas subdurales crónicos por trepanación: Revisión sistemática y metaanálisis de estudios controlados aleatorizados.

INTRODUCTION: Several studies have suggested the possible influence of postoperative bed header position on the risk of symptomatic recurrences and medical complications in patients who have been intervened due chronic subdural haematomas. Nevertheless, this hypothesis has not been assessed by a meta-analysis. METHODS: All randomised controlled trials analysing symptomatic recurrence rates in patients who underwent burr-hole drainage of chronic subdural haematomas, describing postoperative bed header positioning, were included. The primary outcome was risk of recurrence and the secondary outcome were the risks of reoperation and medical complications. Results were presented as pooled relative risks, with 95% confidence intervals. RESULTS: A total of 4 controlled studies were included. Pooled relative risks were: symptomatic recurrences 0.51 ([95% CI: 0.22-1.16]; P=.11), reoperations, 1.07 ([95% CI: 0.42-2.69]; P=.89) and medical complications, 1.15 ([95% CI: 0.7-1.91]; P=.58). No statistically significant heterogeneity was found in any of the analyses. CONCLUSION: There were no differences regarding frequency of symptomatic recurrences, reoperations or medical complications in patients who were maintained in a flat position compared with those whose bed header was elevated during the postoperative course. Despite there being consistency between the results, there is a potential risk of bias; thus proscribing definitive recommendations until studies with higher methodological quality are available.

[The influence of climate on the onset of intracranial hemorrhages]. / Variaciones climáticas y hemorragias intracraneales.

BACKGROUND: there are not studies exploring the potential role of weather conditions in the incidence of intracranial hemorrhages in Latin America. METHODS: a descriptive study was carried out in an emergency room from Cartagena de Indias (Colombia). Data for all adult patients with intracranial hemorrhage and meteorological variables of the days when intracranial hemorrhages occurred were recorded and compared to with those where not a single case. RESULTS: the differences between the average temperature, maximum and minimum temperatures, barometric pressure, relative humidity and wind speed were non statistically significant. However, when comparing the temperature differences day of the event over the previous days, those met the pre-established criteria of statistical significance. Furthermore, differences in barometric pressure, relative humidity, maximum and minimum temperature over the previous day, also reached this criterion. CONCLUSIONS: the results of this study suggest the existence of a climatic profile associated with the onset of intracranial hemorrhages.

Anatomical features and clinical relevance of a persistent trigeminal artery.

BACKGROUND: Although persistent trigeminal artery (PTA) is uncommonly identified, knowledge of this structure is essential for clinicians who interpret cranial imaging, perform invasive studies of the cerebral vasculature, and operate this region. METHODS: A review of the medical literature using standard search engines was performed to locate articles regarding the PTA, with special attention with anatomical descriptions. RESULTS: Although anatomical reports of PTA anatomy are very scarce, those were analyzed to describe in detail the current knowledge about its anatomical relationships and variants. Additionally, the embryology, classification, clinical implications, and imaging modalities of this vessel are extensively discussed. CONCLUSIONS: Through a comprehensive review of isolated reports of the PTA, the clinician can better understand and treat patients with such an anatomical derailment.

Treatment of aneurysmal subarachnoid hemorrhage and unruptured intracranial aneurysms by neurosurgeons in Colombia: A survey.

BACKGROUND: Trends in management of aneurysmal subarachnoid hemorrhage and unruptured intracranial aneurysms among neurosurgeons is very variable and had not been previously described in any Latin American country. This study was conducted to determine the preferences of Colombian neurosurgeons in pharmacologic, surgical, and endovascular management of patients with aneurysmal subarachnoid hemorrhage and unruptured intracranial aneurysms. METHODS: A survey-based descriptive study was performed in a sample of members from the Colombian Association of Neurosurgery. Questions about pharmacologic, surgical, and endovascular management of aneurysmal subarachnoid hemorrhage and unruptured intracranial aneurysm were carried out. We calculated the mean and the standard deviation of the results obtained from the continuous variables. The results of the categorical variables are presented as percentages. RESULTS: The preference of medication with poor clinical evidence, such as magnesium sulfate, aspirin, statins, and anti-fibrinolytics was lower than 10%. The use of intravenous nimodipine and systemic glucocorticoids was as high as 31%. The availability of endovascular therapy was 69%. The indication for treatment of patients with unruptured intracranial aneurysms that required intervention was less than 13.8%. In patients with ruptured or unruptured intracranial aneurysms, coiling was the preferred method for exclusion. CONCLUSIONS: Reported compliance of evidence-based clinical guidelines was similar to that described in developed countries, and even better. However, there is little agreement in treating patients with unruptured intracranial aneurysms. For other issues, the conducts reported by Colombian neurosurgeons are in accordance with the current guidelines.

Non-aneurysmal subarachnoid hemorrhage as presentation of moyamoya disease in an adult.

BACKGROUND: The presentation of moyamoya disease (MMD) as an aneurysmal subarachnoid hemorrhage (SAH) is relatively frequent and in the absence of aneurysms is extremely rare. CASE DESCRIPTION: A 53-year-old male patient suddenly developed severe headache associated with dysarthria and an altered state of consciousness. At the time of admission, he was found drowsy with global aphasia, stiff neck, right hemiparesis and right Babinski's sign. A non-contrast brain computed tomography was performed and a small bleeding in the subarachnoid space over the left frontal and parietal cortex was observed. Four-vessel cerebral angiography showed bilateral stenosis of the internal carotid arteries, with multiple tortuous vessels branching from the anterior and middle cerebral arteries. These abnormal vessels were anastomosing with branches from the posterior cerebral and middle meningeal arteries. With this information, a diagnosis of MMD was made. A three-dimensional reconstruction from digital angiography ruled out aneurysms or vascular malformations. After 4 weeks, another angiography was performed and remained the same as previous one. CONCLUSION: Clinical and radiological characteristics of this case are consistent with previous reports, supporting the theory that non-aneurysmal SAH in MMD is caused by rupture of fragile moyamoya vessels.

Apoplejía postoperatoria de un macroadenoma hipofisiario residual e infarto de la arteria cerebral media / Post-operative apoplexy of a residual pituitary macro-adenoma and middle cerebral artery infarction

La apoplejía postoperatoria de los adenomas hipofisiarios es una complicación rara vez reportada. La presión ejercida por el tumor residular edematoso puede comprometer estructuras nerviosas y vasculares adyacentes a la región selar. Describios el caso de un hombre de 69 años de edad con un tumor selar gigante a quien le fue realizada una resección incompleta a través de un acceso pterional. La cirugía fue detenida por inestabilidad hemodinámica. Cuarenta y ocho horas más tarde, desarrolla oftalmparesias y disminución bilateral de la agudeza visual, deterioro del estado de consciencia, poliuria y hemiparesia izquierda. Una tomografía cerebral simple de emergencia demostró incremento del volumen tumoral con hemorragia y un infarto en el territorio de la arteria cerebral media derecha. El paciente falleció siete días más tarde. Este caso ejemplifica esta rara y catastrófica complicación con alta morbilidad y mortalidad. En la revisión de la literatura, solo fueron encontrados dos casos de ictus isquémico debido a la compresión de arterias intracraneales mayores por apoplejía postoperatoria de macroadenomas residuales.

Postoperative apoplexy of residual pituitary adenomas is a rarely reported complication. Pressure from edematous residual tumor may affect vascular and nervous structures adjacent to sellar region. We described a 69 years old man with a giant sellar tumor who underwent to incomplete resection through pterional approach. Surgery was stopped by hemodynamic instability. Forty-eight hours later, he developed bilateral decreased of visual acuity, bilateral ophthalmoparesis, drowsiness, polyuria and left hemiparesis. An emergency computed tomography scan showed increase in tumor volume with hemorrhage and an infarct of right middle cerebral artery. The patient died seven days later. This case exemplifies this rare and catastrophic complication with high morbidity and mortality. On literature review, only two cases of ischemic strokes due to compression major intracranial arteries by postoperative tumor apoplexy were found.