Nuevo nomenclátor estandarizado de Neurocirugía: criterios e indicadores cuantitativos y cualitativos de baremación de actos médicos / A new standardized nomenclature in neurosurgery: Criteria and quantitative and qualitative evaluation indicators of medical procedures

Objetivos: Actualizar el nomenclátor de actos médicos de la especialidad de Neurocirugía, eliminando actos en desuso y añadiendo las nuevas técnicas quirúrgicas desarrolladas en los últimos años, para que se adapte fielmente a la práctica médica habitual de nuestra especialidad, así como establecer los principios generales y definir los criterios de baremación, indicadores cuantitativos y escalas de valoración. Material y método: La elaboración del nuevo nomenclátor se dividió en 3 fases: 1) identificación y selección de los actos médicos, 2) establecimiento del grado de dificultad de cada uno de ellos basado en la experiencia y el tiempo necesarios para su realización, así como el porcentaje y gravedad de las posibles complicaciones y 3) consenso con los miembros de la SENEC mediante su envío individualizado, realizando los retoques necesarios y posterior aprobación en asamblea de la especialidad. Resultados: El nuevo nomenclátor cuenta con 255 actos médicos agrupados en 4 grupos: consultas y visitas, actos terapéuticos, procedimientos diagnósticos e intervenciones quirúrgicas. Se han eliminado 42 procedimientos recogidos en el nomenclátor de la OMC por obsoletos, no ser propios de la especialidad o resultar demasiado vagos. Se han introducido nuevas técnicas y se han definido de forma más precisa los actos médicos. Conclusiones: Este nomenclátor proporciona una terminología actualizada y servirá para ofertar la cartera de servicios, medir y conocer el valor relativo de nuestra actividad y de los costes aproximados de los procedimientos, y adicionalmente, para realizar estudios comparativos longitudinales. Debe constituir una herramienta para mejorar la atención de los pacientes y minimizar la variabilidad geográfica en todos los ámbitos asistenciales.(AU)

Purpose: Update the list of medical acts in the specialty of neurosurgery, eliminating obsolete acts and adding the new surgical techniques developed in recent years, so that they are faithfully adapted to the usual medical practice of our specialty, as well as establishing the general principles and defining the grading criteria, quantitative indicators and assessment scales. Material and method: The elaboration of the new nomenclator was divided into three phases: (1) identification and selection of medical acts, (2) establishment of the degree of difficulty of each of them based on the experience and the time necessary for their completion, as well as the percentage and severity of the possible complications and (3) consensus with the members of the SENEC through their individualized submission, making the necessary adjustments and subsequent approval in the general assembly of SENEC. Results: The new nomenclator has 255 medical acts grouped into four groups: consultations and visits, therapeutic acts, diagnostic procedures and surgical interventions. Forty-two procedures included in the OMC nomenclator have been eliminated due to being obsolete, not related to the specialty or being too vague. New techniques have been included and medical acts have been more precisely defined. Conclusions: This nomenclator provides up-to-date terminology and will serve to offer the portfolio of services, measure and know the relative value of our activity and the approximate costs of the procedures, and additionally, to carry out longitudinal comparative studies. It should be a tool to improve patient care and minimize geographic variability in all healthcare settings.(AU)

Clinical practice guideline on the management of vestibular schwannoma.

INTRODUCTION: Vestibular schwannoma (VS) is the most common tumour of the cerebellopontine angle. The greater accessibility to radiological tests has increased its diagnosis. Taking into account the characteristics of the tumour, the symptoms and the age of the patient, three therapeutic strategies have been proposed: observation, surgery or radiotherapy. Choosing the most appropriate for each patient is a frequent source of controversy. MATERIAL AND METHODS: This paper includes an exhaustive literature review of issues related to VS that can serve as a clinical guide in the management of patients with these lesions. The presentation has been oriented in the form of questions that the clinician usually asks himself and the answers have been written and/or reviewed by a panel of national and international experts consulted by the Otology Commission of the SEORL-CCC. RESULTS: A list has been compiled containing the 13 most controversial thematic blocks on the management of VS in the form of 50 questions, and answers to all of them have been sought through a systematic literature review (articles published on PubMed and Cochrane Library between 1992 and 2023 related to each thematic area). Thirty-three experts, led by the Otology Committee of SEORL-CCC, have analyzed and discussed all the answers. In Annex 1, 14 additional questions divided into 4 thematic areas can be found. CONCLUSIONS: This clinical practice guideline on the management of VS offers agreed answers to the most common questions that are asked about this tumour. The absence of sufficient prospective studies means that the levels of evidence on the subject are generally medium or low. This fact increases the interest of this type of clinical practice guidelines prepared by experts.

A new standardized nomenclature in neurosurgery: Criteria and quantitative and qualitative evaluation indicators of medical procedures.

PURPOSE: Update the list of medical acts in the specialty of Neurosurgery, eliminating obsolete acts and adding the new surgical techniques developed in recent years, so that they are faithfully adapted to the usual medical practice of our specialty, as well as establishing the general principles and defining the grading criteria, quantitative indicators and assessment scales. METHODS: The elaboration of the new nomenclator was divided into 3 phases: 1) identification and selection of medical acts, 2) establishment of the degree of difficulty of each of them based on the experience and the time necessary for their completion, as well as the percentage and severity of the possible complications and 3) consensus with the members of the SENEC through their individualized submission, making the necessary adjustments and subsequent approval in the general assembly of SENEC. RESULTS: The new nomenclator has 255 medical acts grouped into 4 groups: consultations and visits, therapeutic acts, diagnostic procedures and surgical interventions. 42 procedures included in the OMC nomenclator have been eliminated due to being obsolete, not related to the specialty or being too vague. New techniques have been included and medical acts have been more precisely defined. CONCLUSIONS: This nomenclator provides up-to-date terminology and will serve to offer the portfolio of services, measure and know the relative value of our activity and the approximate costs of the procedures, and additionally, to carry out longitudinal comparative studies. It should be a tool to improve patient care and minimise geographic variability in all healthcare settings.

Patients awaiting surgery for neurosurgical diseases during the first wave of the COVID-19 pandemic in Spain: a multicentre cohort study.

OBJECTIVES: The large number of infected patients requiring mechanical ventilation has led to the postponement of scheduled neurosurgical procedures during the first wave of the COVID-19 pandemic. The aims of this study were to investigate the factors that influence the decision to postpone scheduled neurosurgical procedures and to evaluate the effect of the restriction in scheduled surgery adopted to deal with the first outbreak of the COVID-19 pandemic in Spain on the outcome of patients awaiting surgery. DESIGN: This was an observational retrospective study. SETTINGS: A tertiary-level multicentre study of neurosurgery activity between 1 March and 30 June 2020. PARTICIPANTS: A total of 680 patients awaiting any scheduled neurosurgical procedure were enrolled. 470 patients (69.1%) were awaiting surgery because of spine degenerative disease, 86 patients (12.6%) due to functional disorders, 58 patients (8.5%) due to brain or spine tumours, 25 patients (3.7%) due to cerebrospinal fluid (CSF) disorders and 17 patients (2.5%) due to cerebrovascular disease. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was mortality due to any reason and any deterioration of the specific neurosurgical condition. Second, we analysed the rate of confirmed SARS-CoV-2 infection. RESULTS: More than one-quarter of patients experienced clinical or radiological deterioration. The rate of worsening was higher among patients with functional (39.5%) or CSF disorders (40%). Two patients died (0.4%) during the waiting period, both because of a concurrent disease. We performed a multivariate logistic regression analysis to determine independent covariates associated with maintaining the surgical indication. We found that community SARS-CoV-2 incidence (OR=1.011, p<0.001), degenerative spine (OR=0.296, p=0.027) and expedited indications (OR=6.095, p<0.001) were independent factors for being operated on during the pandemic. CONCLUSIONS: Patients awaiting neurosurgery experienced significant collateral damage even when they were considered for scheduled procedures.

Primary central nervous system angiosarcoma with recurrent acute subdural hematoma.

Angiosarcoma is an infrequent tumor among sarcomas, especially presenting as a primary tumor within the central nervous system, which can lead to a rapid neurological deterioration and death in few months. We present a 41-year old man with a right frontal enhancing hemorrhagic lesion. Surgery was performed with histopathological findings suggesting a primary central nervous system angiosarcoma. He was discharged uneventfully and received adjuvant chemotherapy and radiotherapy. At 5 months, the follow-up MRI showed two lesions with an acute subdural hematoma, suggesting a relapse. Surgery was again conducted finding tumoral membranes attached to the internal layer of the duramater around the right hemisphere. The patient died a few days later due to the recurrence of the subdural hematoma. This case report illustrates a rare and lethal complication of an unusual tumor. The literature reviewed shows that gross-total resection with adjuvant radiotherapy seems to be the best treatment of choice.

Impact of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients: a nationwide study in Spain.

OBJECTIVE: To assess the effect of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients in Spain. SETTINGS: The initial flood of COVID-19 patients overwhelmed an unprepared healthcare system. Different measures were taken to deal with this overburden. The effect of these measures on neurosurgical patients, as well as the effect of COVID-19 itself, has not been thoroughly studied. PARTICIPANTS: This was a multicentre, nationwide, observational retrospective study of patients who underwent any neurosurgical operation from March to July 2020. INTERVENTIONS: An exploratory factorial analysis was performed to select the most relevant variables of the sample. PRIMARY AND SECONDARY OUTCOME MEASURES: Univariate and multivariate analyses were performed to identify independent predictors of mortality and postoperative SARS-CoV-2 infection. RESULTS: Sixteen hospitals registered 1677 operated patients. The overall mortality was 6.4%, and 2.9% (44 patients) suffered a perioperative SARS-CoV-2 infection. Of those infections, 24 were diagnosed postoperatively. Age (OR 1.05), perioperative SARS-CoV-2 infection (OR 4.7), community COVID-19 incidence (cases/105 people/week) (OR 1.006), postoperative neurological worsening (OR 5.9), postoperative need for airway support (OR 5.38), ASA grade ≥3 (OR 2.5) and preoperative GCS 3-8 (OR 2.82) were independently associated with mortality. For SARS-CoV-2 postoperative infection, screening swab test <72 hours preoperatively (OR 0.76), community COVID-19 incidence (cases/105 people/week) (OR 1.011), preoperative cognitive impairment (OR 2.784), postoperative sepsis (OR 3.807) and an absence of postoperative complications (OR 0.188) were independently associated. CONCLUSIONS: Perioperative SARS-CoV-2 infection in neurosurgical patients was associated with an increase in mortality by almost fivefold. Community COVID-19 incidence (cases/105 people/week) was a statistically independent predictor of mortality. TRIAL REGISTRATION NUMBER: CEIM 20/217.

Effectiveness of Automatic Planning of Fronto-orbital Advancement for the Surgical Correction of Metopic Craniosynostosis.

BACKGROUND: The surgical correction of metopic craniosynostosis usually relies on the subjective judgment of surgeons to determine the configuration of the cranial bone fragments and the degree of overcorrection. This study evaluates the effectiveness of a new approach for automatic planning of fronto-orbital advancement based on statistical shape models and including overcorrection. METHODS: This study presents a planning software to automatically estimate osteotomies in the fronto-orbital region and calculate the optimal configuration of the bone fragments required to achieve an optimal postoperative shape. The optimal cranial shape is obtained using a statistical head shape model built from 201 healthy subjects (age 23 ± 20 months; 89 girls). Automatic virtual plans were computed for nine patients (age 10.68 ± 1.73 months; four girls) with different degrees of overcorrection, and compared with manual plans designed by experienced surgeons. RESULTS: Postoperative cranial shapes generated by automatic interventional plans present accurate matching with normative morphology and enable to reduce the malformations in the fronto-orbital region by 82.01 ± 6.07%. The system took on average 19.22 seconds to provide the automatic plan, and allows for personalized levels of overcorrection. The automatic plans with an overcorrection of 7 mm in minimal frontal breadth provided the closest match (no significant difference) to the manual plans. CONCLUSIONS: The automatic software technology effectively achieves correct cranial morphometrics and volumetrics with respect to normative cranial shapes. The automatic approach has the potential to reduce the duration of preoperative planning, reduce inter-surgeon variability, and provide consistent surgical outcomes.

Point-of-care manufacturing: a single university hospital's initial experience.

BACKGROUND: The integration of 3D printing technology in hospitals is evolving toward production models such as point-of-care manufacturing. This study aims to present the results of the integration of 3D printing technology in a manufacturing university hospital. METHODS: Observational, descriptive, retrospective, and monocentric study of 907 instances of 3D printing from November 2015 to March 2020. Variables such as product type, utility, time, or manufacturing materials were analyzed. RESULTS: Orthopedic Surgery and Traumatology, Oral and Maxillofacial Surgery, and Gynecology and Obstetrics are the medical specialties that have manufactured the largest number of processes. Working and printing time, as well as the amount of printing material, is different for different types of products and input data. The most common printing material was polylactic acid, although biocompatible resin was introduced to produce surgical guides. In addition, the hospital has worked on the co-design of custom-made implants with manufacturing companies and has also participated in tissue bio-printing projects. CONCLUSIONS: The integration of 3D printing in a university hospital allows identifying the conceptual evolution to "point-of-care manufacturing."

Primary central nervous system angiosarcoma with recurrent acute subdural hematoma.

Angiosarcoma is an infrequent tumor among sarcomas, especially presenting as a primary tumor within the central nervous system, which can lead to a rapid neurological deterioration and death in few months. We present a 41-year old man with a right frontal enhancing hemorrhagic lesion. Surgery was performed with histopathological findings suggesting a primary central nervous system angiosarcoma. He was discharged uneventfully and received adjuvant chemotherapy and radiotherapy. At 5 months, the follow-up MRI showed two lesions with an acute subdural hematoma, suggesting a relapse. Surgery was again conducted finding tumoral membranes attached to the internal layer of the duramater around the right hemisphere. The patient died a few days later due to the recurrence of the subdural hematoma. This case report illustrates a rare and lethal complication of an unusual tumor. The literature reviewed shows that gross-total resection with adjuvant radiotherapy seems to be the best treatment of choice.

Drezotomía en el tratamiento del dolor por desaferentización: revisión de resultados y análisis de factores predictores de éxito / DREZotomy in the treatment of deafferentation pain: review of results and analysis of predictive factors for success

Antecedentes y objetivos El tratamiento del dolor por desaferentización mediante drezotomía espinal es una opción terapéutica contrastada en la literatura. En los últimos años, la drezotomía ha visto relegado su empleo a un segundo plano debido a la eclosión de las terapias neuromoduladoras. Los objetivos de este estudio son demostrar que la drezotomía continúa siendo un tratamiento efectivo y seguro, y analizar aquellos factores predictores de éxito. Pacientes y métodos Se realizó un estudio retrospectivo de todos los pacientes tratados en nuestro servicio mediante drezotomía espinal desde 1998 hasta 2018. Se excluyeron los casos de drezotomía bulbar. Se emplearon la escala visual analógica (EVA) y la reducción de la medicación habitual como variables resultado, y se analizaron variables demográficas, clínicas y quirúrgicas como factores predictores de éxito. Resultados Un total de 27 pacientes (51,9% mujeres) de 53,7 años de edad media fueron tratados mediante drezotomía. La etiología principal del dolor fue por avulsión de plexo braquial (55,6%) seguida de causa tumoral (18,5%). El tiempo medio de evolución del dolor fue de 8,4 años con una intensidad media de 8,7 según la EVA, pese a que el 63% de los pacientes habían recibido tratamiento neuroestimulador previo. Durante el postoperatorio inmediato un 77,8% de los pacientes presentaron una reducción del 50% o más en la EVA. Tras un seguimiento medio de 22 meses posdrezotomía, permaneció una reducción de al menos el 50% en la EVA en el 59,3% de los pacientes (reducción media de 4,9 puntos) permitiendo una reducción del tratamiento analgésico habitual en el 70,4% de ellos. La drezotomía en la avulsión de plexo braquial presentó una tasa de éxito (93%) superior al resto de patologías (41,7%) de manera significativa (p = 0,001) (AU)

Background and objectives The treatment of deafferentation pain by spinal DREZotomy is a proven therapeutic option in the literature. In recent years, use of DREZotomy has been relegated to second place due to the emergence of neuromodulation therapies. The objectives of this study are to demonstrate that DREZotomy continues to be an effective and safe treatment and to analyse predictive factors for success. Patients and methods A retrospective study was conducted of all patients treated in our department with spinal DREZotomy from 1998 to 2018. Bulbar DREZotomy procedures were excluded. A visual analogue scale (VAS) and the reduction of routine medication were used as outcome variables. Demographic, clinical and operative variables were analysed as predictive factors for success. Results A total of 27 patients (51.9% female) with a mean age of 53.7 years underwent DREZotomy. The main cause of pain was brachial plexus injury (BPI) (55.6%) followed by neoplasms (18.5%). The mean time of pain evolution was 8.4 years with a mean intensity of 8.7 according to the VAS, even though 63% of the patients had previously received neurostimulation therapy. Favourable outcome (≥ 50% pain reduction in the VAS) was observed in 77.8% of patients during the postoperative period and remained in 59.3% of patients after 22 months average follow-up (mean reduction of 4.9 points). This allowed for a reduction in routine analgesic treatment in 70.4% of them. DREZotomy in BPI-related pain presented a significantly higher success rate (93%) than the other pathologies (41.7%) (p = .001). No association was observed between outcome and age, gender, DREZ technique, duration of pain or previous neurostimulation therapies. There were six neurological complications, four post-operative transient neurological deficits and two permanent deficits (AU)

Three-dimensional photography for intraoperative morphometric analysis in metopic craniosynostosis surgery.

PURPOSE: Surgical correction of metopic craniosynostosis typically involves open cranial vault remodeling. Accurate translation of the virtual surgical plan into the operating room is challenging due to the lack of tools for intraoperative analysis of the surgical outcome. This study aimed to evaluate the feasibility of using a hand-held 3D photography device for intraoperative evaluation and guidance during cranial vault surgical reconstruction. METHODS: A hand-held structured light scanner was used for intraoperative 3D photography during five craniosynostosis surgeries, obtaining 3D models of skin and bone surfaces before and after the remodeling. The accuracy of this device for 3D modeling and morphology quantification was evaluated using preoperative computed tomography imaging as gold-standard. In addition, the time required for intraoperative 3D photograph acquisition was measured. RESULTS: The average error of intraoperative 3D photography was 0.30 mm. Moreover, the interfrontal angle and the transverse forehead width were accurately measured in the 3D photographs with an average error of 0.72 degrees and 0.62 mm. Surgeon's feedback indicates that this technology can be integrated into the surgical workflow without substantially increasing surgical time. CONCLUSION: Hand-held 3D photography is an accurate technique for objective quantification of intraoperative cranial vault morphology and guidance during metopic craniosynostosis surgical reconstruction. This noninvasive technique does not substantially increase surgical time and does not require exposure to ionizing radiation, presenting a valuable alternative to computed tomography imaging. The proposed methodology can be integrated into the surgical workflow to assist during cranial vault remodeling and ensure optimal surgical outcomes.

DREZotomy in the treatment of deafferentation pain: review of results and analysis of predictive factors for success. / Drezotomía en el tratamiento del dolor por desaferentización: revisión de resultados y análisis de factores predictores de éxito.

BACKGROUND AND OBJECTIVES: The treatment of deafferentation pain by spinal DREZotomy is a proven therapeutic option in the literature. In recent years, use of DREZotomy has been relegated to second place due to the emergence of neuromodulation therapies. The objectives of this study are to demonstrate that DREZotomy continues to be an effective and safe treatment and to analyse predictive factors for success. PATIENTS AND METHODS: A retrospective study was conducted of all patients treated in our department with spinal DREZotomy from 1998 to 2018. Bulbar DREZotomy procedures were excluded. A visual analogue scale (VAS) and the reduction of routine medication were used as outcome variables. Demographic, clinical and operative variables were analysed as predictive factors for success. RESULTS: A total of 27 patients (51.9% female) with a mean age of 53.7 years underwent DREZotomy. The main cause of pain was brachial plexus injury (BPI) (55.6%) followed by neoplasms (18.5%). The mean time of pain evolution was 8.4 years with a mean intensity of 8.7 according to the VAS, even though 63% of the patients had previously received neurostimulation therapy. Favourable outcome (≥50% pain reduction in the VAS) was observed in 77.8% of patients during the postoperative period and remained in 59.3% of patients after 22 months average follow-up (mean reduction of 4.9 points). This allowed for a reduction in routine analgesic treatment in 70.4% of them. DREZotomy in BPI-related pain presented a significantly higher success rate (93%) than the other pathologies (41.7%) (p=.001). No association was observed between outcome and age, gender, DREZ technique, duration of pain or previous neurostimulation therapies. There were six neurological complications, four post-operative transient neurological deficits and two permanent deficits. CONCLUSION: Dorsal root entry zone surgery is effective and safe for treating patients with deafferentation pain, especially after brachial plexus injury. It can be considered an alternative treatment after failed neurostimulation techniques for pain control. However, its indication should be considered as the first therapeutic option after medical therapy failure due to its good long-term results.

Brain Arteriovenous Malformations: Impact of Neurologic Status, Bleeding, and Type of Treatment on Final Outcome.

BACKGROUND: Well-designed studies assessing the treatment outcome of brain arteriovenous malformations (AVMs) are infrequent and have not consistently included all of the available treatment modalities, making their results not completely generalizable. Moreover, the predictors of poor outcome are not well defined. METHODS: We performed an observational retrospective study of AVM patients. We included patients with clinical, radiologic, and outcome data, with a minimum follow-up of 1 year. Neurologic outcome was documented using the modified Rankin Scale (mRS) at the AVM diagnosis and 30 days after the treatment. RESULTS: There were 117 patients, with equal male/female proportion. The mean follow-up time was 51 months. Treatment distribution in the Spetzler-Martin grades I-III was as follows: 52 (54.6%) surgery, 31 (32.35%) radiosurgery, 2 (0.02%) embolization, and 11 (12%) conservative follow-up. Treatment distribution in Spetzler-Martin grades IV and V was as follows: 4 (20%) surgery, 7 (35%) radiosurgery, and 10 (45%) conservative follow-up. Poor neurologic outcome (mRS ≥ 3) was significantly associated with poor clinical status at diagnosis (Glasgow Coma Scale [GCS] score< 14; odds ratio [OR]: 0.20; 95% confidence interval [CI]: 0.001-0.396; p = 0.010). The rupture of the AVM was associated with poor neurologic outcome. The Lawton-Young Supplementary scale (LYSS) proved to be the most effective in predicting poor outcome. The existence of seizures, treatment-related complications, and conservative treatment was associated with the worsening of the mRS score, whereas the existence of hemorrhage was associated with the likelihood of disability. CONCLUSION: Our results suggest that poor neurologic status at diagnosis, AVM rupture, and conservative treatment were associated with worse outcome. Hemorrhage as initial presentation is related to disability, not with mRS worsening. The LYSS appeared to be the best method to predict outcome.

Atención al ictus agudo durante la pandemia por COVID-19. Recomendaciones Plan Ictus Madrid / Acute stroke care during the COVID-19 pandemic. Ictus Madrid Program

INTRODUCCIÓN: La pandemia por COVID-19 ha obligado a una reorganización de los sistemas sanitarios y una saturación excepcional de sus recursos. En este contexto es vital asegurar la atención al ictus agudo y optimizar los procesos asistenciales del código ictus para reducir el riesgo de contagios y racionalizar el uso de recursos hospitalarios. Para ello desde el Grupo multidisciplinar Ictus Madrid proponemos una serie de recomendaciones. MÉTODOS: Revisión bibliográfica no sistemática de las publicaciones disponibles con los términos "stroke" y "covid-19" o "coronavirus" o "SARS-COV-2", así como otras conocidas por los autores. En base a ésta se redacta un documento de recomendaciones que es sometido a consenso por el Grupo multidisciplinar Ictus Madrid y su Comité de Neurología. RESULTADOS: Las recomendaciones se estructuran en cinco líneas fundamentales: (1) Coordinar la actuación para garantizar el acceso la asistencia hospitalaria de los pacientes con ictus, (2) Reconocer a los pacientes con ictus potencialmente infectados por COVID-19, (3) Organización adecuada para garantizar la protección de los profesionales sanitarios frente al riesgo de contagio por COVID-19, (4) la realización de Neuroimagen y otros procedimientos que conlleven contactos de riesgo de infección COVID-19 hay que procurar reducirlos y asegurar la protección, y (5) alta y seguimiento seguros procurando optimizar la ocupación hospitalaria. Resumimos el procedimiento de forma esquemática con el acrónimo CORONA (COordinar, Reconocer, Organizar, Neuroimagen, Alta). CONCLUSIONES: Estas recomendaciones pueden servir de apoyo para la organización del sistema sanitario en la atención al ictus agudo y la optimización de sus recursos, garantizando la protección de sus profesionales

BACKGROUND: The COVID-19 pandemic has forced a reorganization of healthcare systems and an exceptional saturation of their resources. In this context, it is vital to ensure acute stroke care and optimize the care processes of the stroke code to reduce the risk of contagion and rationalize the use of hospital resources. To do this, the Ictus Madrid multidisciplinary group proposes a series of recommendations. METHODS: Non-systematic bibliographic review of the available publications with the terms "stroke" and "covid-19" or "coronavirus" or "SARS-COV-2", as well as other already known for the authors. We provide a document of recommendations as a result of the consensus of the Ictus Madrid multidisciplinary group and its Neurology Committee. RESULTS: Our recommendations are structured on five lines: (1) Coordinate to guarantee the access to hospital care for stroke patients, (2) Recognize potentially COVID-19 infected stroke patients, (3) Organize to ensure the protection of healthcare professionals from COVID-19 infections, (4) Neuroimaging and other procedures potentially associated to risks for COVID-19 infection should be reduced and secured to avoid contagion, and (5) At home as soon as posible and supported follow-up to optimize hospital occupancy. The procedure is shown summarized under the acronym CORONA (Coordinate, Recognize, Organize, Neuroimaging, At home). CONCLUSIONS: These recommendations can support the organization of healthcare services for acute stroke care and the optimization of their resources, guaranteeing the protection of healthcare professionals

Imaging and Radiologic-Pathologic Correlation in Granular Cell Astrocytomas: Report of 2 Cases.

BACKGROUND: Granular cell astrocytoma is a rare and aggressive subtype of astrocytoma that is histopathologically well defined in the literature. It is formed by polygonal cells with granular cytoplasm mixed with neoplastic astrocytes and usually a perivascular infiltrate of lymphocytes. Despite its unusual histologic appearance, relevant radiologic features have not yet been described. CASE DESCRIPTION: We report 2 middle-aged patients with neurologic symptoms secondary to a newly diagnosed brain tumor. The absence of central tumor necrosis as well as the presence of an atypical pattern of enhancement and areas of intense diffusion restriction on magnetic resonance imaging in both cases led to the diagnosis of primary central nervous system lymphoma. Histopathologic findings in both tumors showed an aggressive astrocytoma with a prominent granular cell population and perivascular lymphocytic cuffing in tissue, corresponding to a granular cell astrocytoma. Despite the favorable prognostic factors, including World Health Organization grades II and III astrocytomas and IDH mutations, the outcome was poor. CONCLUSIONS: Granular cell astrocytomas can show unusual aggressive radiologic features that do not correspond to their histopathologic grade of malignancy. The presence of perivascular lymphocytic infiltrate may alter the typical radiologic appearance of common astrocytomas.

Craniosynostosis surgery: workflow based on virtual surgical planning, intraoperative navigation and 3D printed patient-specific guides and templates.

Craniosynostosis must often be corrected using surgery, by which the affected bone tissue is remodeled. Nowadays, surgical reconstruction relies mostly on the subjective judgement of the surgeon to best restore normal skull shape, since remodeled bone is manually placed and fixed. Slight variations can compromise the cosmetic outcome. The objective of this study was to describe and evaluate a novel workflow for patient-specific correction of craniosynostosis based on intraoperative navigation and 3D printing. The workflow was followed in five patients with craniosynostosis. Virtual surgical planning was performed, and patient-specific cutting guides and templates were designed and manufactured. These guides and templates were used to control osteotomies and bone remodeling. An intraoperative navigation system based on optical tracking made it possible to follow preoperative virtual planning in the operating room through real-time positioning and 3D visualization. Navigation accuracy was estimated using intraoperative surface scanning as the gold-standard. An average error of 0.62 mm and 0.64 mm was obtained in the remodeled frontal region and supraorbital bar, respectively. Intraoperative navigation is an accurate and reproducible technique for correction of craniosynostosis that enables optimal translation of the preoperative plan to the operating room.

Management of congenital midline nasofrontal dermoid cysts in two identical twins: Case report.

Midline dermoid cysts are uncommon lesions that can lead to severe complications when an intracranial extension exists. We report the cases of two twin sisters referred to surgery for removal of the masses and the intracranial extension. They represent an additional example of familial nasal dermoid cysts, providing further support for a genetic basis for the disorder.

Evaluación del impacto del cambio diagnóstico de los gliomas aplicando la nueva clasificación de la OMS de 2016 sobre una serie de casos / Assessment of the impact of glioma diagnostic reclassification following the new 2016 WHO classification on a series of cases

Antecedentes y objetivo: El objetivo de este trabajo es evaluar el cambio del diagnóstico molecular sobre el histológico de una serie de tumores gliales al revisar el diagnóstico con la clasificación de la OMS de 2016. Materiales y métodos: Se realiza un estudio retrospectivo de los tumores gliales (oligodendrogliomas y astrocitomas) tratados en nuestro centro entre enero de 2012 y junio de 2016, y una revisión diagnóstica según su estudio molecular. Se lleva a cabo el análisis estadístico de variables epidemiológicas, histológicas y de genética molecular (mutaciones en IDH y presencia de codeleción 1p19q), variación en el diagnóstico al introducir la nueva clasificación tumoral e impacto clínico de dicha reclasificación. Resultados: De los 147 casos de tumores gliales revisados, se obtuvo el diagnóstico molecular en 74 casos (50,3%). En 23 casos (31%) cambió el diagnóstico, predominando en 20 (87%) el diagnóstico previo de oligodendroglioma (69,6% grado II y 17,4% grado III). Solo 3 de los 23 casos cambiaron de diagnóstico inicial astrocitario al oligodendroglial. Respecto al patrón molecular en estos 23 casos, se detectó IDH mutado en 16 (69,6%) y codeleción 1p19q negativa en 20 (87%). Según la estirpe celular, de los 27 oligodendrogliomas de esta serie, 20 (74%) cambiaron de diagnóstico por tener la codeleción negativa, pasando a ser astrocitomas. Se observó una tendencia a un mayor cambio de diagnóstico en pacientes jóvenes (<40 años), p=0,065, mayoritariamente con diagnóstico previo de oligodendrogliomas, sin relación con el sexo. Además, se detectó una mayor frecuencia de cambio de diagnóstico entre los tumores con IDH mutado (69,6%), p=0,003. Respecto a la supervivencia o el patrón clínico, no se detectaron cambios significativos entre los tumores con o sin cambio diagnóstico, a pesar de no recibir tratamiento de elección, tras un seguimiento medio de 16 meses, en probable relación con el bajo grado lesional. Conclusiones: Dentro del espectro de tumores astrocitarios y oligodendrogliales en nuestro centro, la clasificación diagnóstica con genética molecular evidencia importantes cambios respecto al diagnóstico morfológico. Estos cambios afectan especialmente a los diagnósticos previos de oligodendrogliomas y a los pacientes jóvenes en los casos revisados, y con patrones moleculares de mutación en la IDH y de ausencia de codeleción 1p19q. Si bien se pueden plantear dudas respecto a la clínica, el pronóstico y el tratamiento realizado en estos casos, se requieren estudios específicos en estos aspectos para lograr unas conclusiones apropiadas

Background and objectives: The aim of this project is to assess diagnostic reclassification based on molecular data over morphology in a series of glial tumours since the introduction of the 2016 WHO classification of brain tumours. Materials and methods: Retrospective review of glial tumours (oligodendrogliomas and astrocytomas) treated in our centre between January 2012 and June 2016 in which a review of diagnosis was performed when molecular studies were added. Statistical analysis included evaluation of variables of epidemiology, morphology and molecular data (mainly IDH mutation and 1p19q codeletion), diagnostic changes after new classification was considered, and clinical impact in cases of diagnostic reclassification. Results: From a total of 147 glial tumours reviewed in our centre, molecular diagnosis was obtained in 74 cases (50.3%). Initial diagnosis changed in 23 cases (31%), and 20 (87%) of them had a prior histological diagnosis of oligodendroglioma (69.6% grade II - and 17.4% grade III). Only 3 of these 23 cases diagnosis changed from astrocytoma to oligodendroglioma. Among reclassified tumours, there was a common molecular pattern, as findings showed mutant IDH in 16 cases (69.6%) and no codeletion in 20 cases (87%). According to the cell of origin, of the whole group of 27 oligodendrogliomas in our series (reclassified and non-reclassifed), 20 cases (74%) became astrocytomas, despite typical oligodendroglial morphology, due to absence of 1p19q codeletion. There was a trend for diagnosis reclassification in younger patients (<40 years), P=.065, mainly in those with a prior diagnosis of oligodendroglioma, with no statistical differences based on gender or clinical data. Besides, reclassification was more common among tumours with mutant IDH (69.6%), P=.003, than those with wild type IDH. In terms of survival, despite receiving different treatments, no significant changes were detected between reclassified and non-reclassified tumours after a mean follow-up of 16 months, partly related to lower grade of these lesions. Conclusions: Within the spectrum of the glial tumours treated in our institution, this new classification including molecular genetics over morphological data has provided marked diagnostic changes. These changes appear mainly in tumours previously diagnosed as oligodendrogliomas and in younger patients, with molecular patterns of mutant IDH and 1p19q codeletion. Although diagnosis reclassification may affect clinic, prognosis or therapeutic management of these tumours, deeper and prospective studies on these specific aspects are needed

Neurovascular Relations of the Trigeminal Nerve in Asymptomatic Individuals Studied with High-Resolution Three-Dimensional Magnetic Resonance Imaging.

Neurovascular compression (NVC) is considered the main cause of classic trigeminal neuralgia (TN) and may be surgically addressed with microvascular decompression (MVD). Preoperative high-resolution three-dimensional magnetic resonance has proven a reliable tool to diagnose NVC in patients with refractory TN undergoing MVD. However, there is still scarce data regarding the rate, degree, and characteristics of neurovascular compression in asymptomatic individuals. This article describes the vascular relations of the trigeminal nerve in the cerebellopontine angle (CPA) in 100 subjects without known TN studied with 3.0T FIESTA (Fast Imaging Employing Steady-state Acquisition) MRI sequence. A NVC was observed in 142 (71%) of the 200 nerves with a 75% rate of bilateral NVC. Of the nerves with NVC, 92.3% showed a mere contact (Grade 1) without distortion and 78% occurred at the cisternal segment. This most common vessel causing the NVC was a vein (66%) followed by the superior cerebellar artery (28%). No significant reduction in diameter suggesting atrophy was seen in the nerves with NVC. The results indicate a high rate of mild, distal and predominantly venous vascular contact with the trigeminal nerve at the CPA in asymptomatic individuals. This clearly contrasts with the usual pattern of NVC observed in TN that is generally a severe, proximal, and arterial compression. Knowledge about the frequent NVC in asymptomatic individuals and its features is essential for interpreting preoperative MRI in patients with refractory classical TN considered for surgery. Anat Rec, 302:639-645, 2019. © 2018 Wiley Periodicals, Inc.

Anatomical Variations of the Intrapetrous Portion of the Facial Nerve.

The intrapetrous facial nerve has the second longest intraosseous course of all cranial nerves, after the mandibular nerve. But it is by far the most complex considering the anatomical structures closely related to it. The auditory and vestibular portions of the inner ear, the dura of the middle fossa and posterior fossa, the sigmoid sinus and jugular bulb, and the internal carotid artery are close enough to merit attention. This article includes an anatomical study on 100 temporal bones with anatomical references as seen from the middle fossa and from the transmastoid approaches that may help identifying the facial nerve and protecting surrounding structures. Anatomical variability was present and noteworthy when considering the venous drainage system through the temporal bone and the mastoid pneumatization. The distance from the geniculate ganglion to the hiatus falopii offered the highest variability with a range of 0 to 7.75 mm and a mean of 3.30 mm. The geniculate ganglion was dehiscent in 20.8% of the specimens and the superior semicircular canal was spontaneously blue-lined in 27% of the cases. Through the transmastoid approach, the highest variability was found regarding the distance between the vertical portion of the facial nerve and the jugular bulb (range from 1.5 to 10.0 mm), the sigmoid sinus (range from 0 to 13.25 mm) and the internal carotid artery (range from 6.0 to 15.0 mm). This study highlights the importance of the relative variability of the facial nerve to other surrounding structures within the petrous portion of the temporal bone. Anat Rec, 302:588-598, 2019. © 2018 Wiley Periodicals, Inc.