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.

[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.

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.

[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.

[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.

[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.

[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.

[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.

[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.