Extent of resection and survival in patients with glioblastoma multiforme: Systematic review and meta-analysis.

BACKGROUND: Glioblastoma multiforme (GBM) owes an ominous prognosis: its mean overall survival is 14 months. The extent of surgical resection (ESR) highlights among factors in which an association has been found to a somewhat better prognosis. However, the association between greater ESR and prolonged overall (OS) survival is not a constant finding nor a proven cause-and-effect phenomenon. To our objective is to establish the strength of association between ESR and OS in patients with GBM through a systematic review and meta-analysis. METHODS: In accordance with PRISMA-P recommendations, we conducted a systematic literature search; we included studies with adult patients who had undergone craniotomy for GBM. Our primary outcome is overall postoperative survival at 12 and 24 months. We reviewed 180 studies, excluded 158, and eliminated 8; 14 studies that suited our requirements were analyzed. RESULTS: The initial level of evidence of all studies is low, and it may be degraded to very low according to GRADE criteria because of design issues. The definition of different levels of the extent of resection is heterogeneous and poorly defined. We found a great amount of variation in the methodology of the operation and the adjuvant treatment protocol. The combined result for relative risk (RR) for OS for 12 months analysis is 1.25 [95% confidence interval (95% CI) 1.14-1.36, P < .01], absolute risk reduction (ARR) of 15.7% (95% CI 11.9-19.4), relative risk reduction (RRR) of 0.24 (95% CI 0.18-0.31), number needed to treat (NNT) 6; for 24-month analysis RR is 1.59 (95% CI 1.11-2.26, P < .01) ARR of 11.5% (95% CI 7.7-15.1), relative risk reduction (RRR) of 0.53 (95% CI 0.33-0.76), (NNT) 9. In each term analysis, the proportion of alive patients who underwent more extensive resection is significantly higher than those who underwent subtotal resection. CONCLUSION: Our results sustain a weak but statistically significant association between the ESR and OS in patients with GBM obtained from observational studies with a very low level of evidence according to GRADE criteria. As a consequence, any estimate of effect is very uncertain. Current information cannot sustain a cause-and-effect relationship between these variables.

Prevalence of Incidental Clinoid Segment Saccular Aneurysms.

INTRODUCTION: Clinoid segment aneurysms are cerebral vascular lesions recently described in the neurosurgical literature. They arise from the clinoid segment of the internal carotid artery, which is the segment limited rostrally by the dural carotid ring and caudally, by the carotid-oculomotor membrane. Even although clinoid segment aneurysms represent a common incidental finding in magnetic resonance studies, its prevalence has not been yet reported. OBJECTIVE: To determine the prevalence of incidental clinoid segment saccular aneurysms diagnosed by magnetic resonance imaging as well as their anatomic architecture and their association with smoking, arterial hypertension, age, and sex of patients. METHODS: A total of 500 patients were prospectively studied with magnetic resonance imaging time-of-flight sequence and angioresonance with contrast material, to search for incidental saccular intracranial aneurysms. The site of primary interest was the clinoid segment, but the presence of aneurysms in any other location was determined for comparison. The relation among the presence of clinoid segment aneurysms, demographic factors, and secondary diagnosis of arterial hypertension, smoking, and other vascular/neoplastic cerebral lesions was analyzed. RESULTS: We found a global prevalence of incidental aneurysms of 7% (95% confidence interval, 5-9), with a prevalence of clinoid segment aneurysms of 3% (95% confidence interval, 2-4). Univariate logistic regression analysis showed a statistically significant relationship among incidental aneurysms, systemic arterial hypertension (P = 0.000), and smoking (P = 0.004). CONCLUSIONS: In the studied population, incidental clinoid segment aneurysms constitute the variety with highest prevalence.

[Traumatic occipitocervical and atlantoaxial dislocation with clivus fracture in a child. Case report]. / Luxación traumática occipitocervical y atlantoaxial con fractura del clivus en un paciente pediátrico. Reporte de un caso.

BACKGROUND: Cranieovertebral junction lesions in the paediatric population are associated with a low survival rate, which has declined in recent years. Neurological disability is a major concern due to the high economical cost it represents. Paediatric patients are more susceptible to this lesion because of hyperextension capacity, flat articulation, and increased ligamentous laxity. Survival after these kinds of injuries has been more often reported in adults, but are limited in the paediatric population. CLINICAL CASE: A case is reported of an 8-year-old male with occipitocervical and atlantoaxial dislocation associated with clivus fracture, brain oedema, and post-traumatic subarachnoid haemorrhage (SAH). A halo vest system was placed with no traction. One month after the trauma the patient was surgically treated with C1 and C2 trans-articular screws, occipitocervical fixation with plate and screws, and C1- C2 fixation with tricortical bone graft and wires without complication. He has now returned to school and is self-sufficient. CONCLUSIONS: With better pre-hospital medical care and with improved surgical techniques the mortality rate has declined in this kind of lesion.

Pituitary tumor surgery: review of 3004 cases.

OBJECTIVE: To report the efficacy, safety, and outcomes through time of the biggest series to our knowledge of pituitary surgery using transcranial, transsphenoidal, and endoscopic techniques. METHODS: An observational, retrospective, and descriptive review was performed of 3004 patients surgically treated by the senior author from 1973 to June 2011 in Mexico City. A sublabial approach was used in 3000 patients, and a transnasal approach was used in the remaining 4 patients. Tumors were classified according to size as microadenomas or macroadenomas. RESULTS: During the time period of this study, 3004 patients were surgically treated; there were 510 prolactinomas, 822 growth hormone adenomas, 62 adrenocorticotropic hormone-producing adenomas, 8 tumors that produced Nelson syndrome, and 1562 adenomas that were not biologically active. The cure rate of prolactinoma was 82% for microadenomas and 9% for macroadenomas. Gender distribution showed a male predominance of 57.1%. Cure rate for growth hormone adenomas was 87%. Adrenocorticotropic hormone adenomas showed no cure rate; surgery simply aided pharmacologic control. Global mortality rate was 1.6%. The main complications were cerebrospinal fluid fistula, diabetes insipidus, and meningitis. CONCLUSIONS: The sum of this 38-year experience of managing pituitary pathology and its surgical treatment shows the importance of working together with other specialists such as endocrinologists, ophthalmologists, and radiologists. The correct treatment approach for each case must be individually selected. Transsphenoidal surgery is an effective and safe treatment for most patients with pituitary adenoma and could be considered the first-choice therapy in all cases except for prolactinomas that respond to pharmacologic therapy (dopamine agonist).

Hospitales en México / Mexican hospitals

Para conceptuar el hospital actual en México debemos conocer a la perfección nuestro pasado, presente y futuro, la evolución de los hospitales desde la Conquista hasta el México posrevolucionario, la creación de hospitales para pobres y para ricos, que aún continúa; la beneficencia privada, la pública y el cambio de éstas con las Leyes de Reforma. En 1937 nace la Secretaría de Asistencia Pública, dedicada a hospitales, casas de cuna, asilos y orfanato. La fusión en 1943 de la Secretaría de Asistencia Pública con el Departamento de Salubridad, dio origen a la actual Secretaría de Salud. Nacen los seguros privados para enfermedades médicas mayores. Con el surgimiento de la seguridad social hay un cambio radical de la atención hospitalaria. El llamado Seguro Popular y su ley son los pilares en que se sostiene una de las fracciones del artículo IV constitucional, en su capítulo de garantías individuales. Los hospitales públicos en México crecieron lentamente y en ningún momento han logrado satisfacer la demanda de la población. Con la desconcentración y descentralización de los servicios de salud a los estados se inicia, por parte de éstos, la construcción de modernos hospitales. En la actual administración se pretende, aprovechando la infraestructura estatal, crear redes de atención hospitalaria. En las próximas décadas se tendrán que establecer alternativas de los modelos de gestión clínica para sustituir el paradigma actual. El único sincretismoentre el hospital público y privado es que atienden enfermos.

In order to understand current medical and hospital care in Mexico, we need to know first their past and then compare that past to their present situation. We can attempt to glimpse into what their future should be. The evolution of Mexican health services from the time of the Spanish Conquest until the the post-revolutionary period involved the creation of hospitals for both the poor and the rich. This continues to be the present goal. Public and private medical institutions evolved in part along with the legal reforms that were enacted through the passage of the Reform Laws in 1937. The Public Assistance Secretariat was established, which was dedicated to assist hospitals, nurseries, asylums and orphanages. In 1943, this Public Assistance Secretariat joined with the Public Health Department, forming what today is the actual Secretary of Health. The formation of private social health care for major medical needs together with governmental Social Security Health Care brought about a radical improvement in medical and hospital care; however, it is insufficient, overpopulated and outdated. It will be necessary during the coming decades that other alternatives to the models of hospitals and medical care that exist today in Mexico be enacted. The present models have not been able to satisfy the medical and hospital demands for present-day needs of the population.

Mexican hospitals.

In order to understand current medical and hospital care in Mexico, we need to know first their past and then compare that past to their present situation. We can attempt to glimpse into what their future should be. The evolution of Mexican health services from the time of the Spanish Conquest until the the post-revolutionary period involved the creation of hospitals for both the poor and the rich. This continues to be the present goal. Public and private medical institutions evolved in part along with the legal reforms that were enacted through the passage of the Reform Laws in 1937. The Public Assistance Secretariat was established, which was dedicated to assist hospitals, nurseries, asylums and orphanages. In 1943, this Public Assistance Secretariat joined with the Public Health Department, forming what today is the actual Secretary of Health. The formation of private social health care for major medical needs together with governmental Social Security Health Care brought about a radical improvement in medical and hospital care; however, it is insufficient, overpopulated and outdated. It will be necessary during the coming decades that other alternatives to the models of hospitals and medical care that exist today in Mexico be enacted. The present models have not been able to satisfy the medical and hospital demands for present-day needs of the population.

Cerebral salt wasting syndrome in patients with aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Hydroelectrolytic disturbances are part of the complications of subarachnoid hemorrhage. Cerebral salt wasting syndrome (CSWS) must be considered when hyponatremia is associated with a decrease in circulating volume. We performed this study to determine the clinical characteristics and management paradigm of patients with serum sodium concentration abnormalities and aneurysmatic subarachnoid hemorrhage. METHODS: We analyzed retrospectively clinical and laboratory data from eight patients with subarachnoid hemorrhage due to rupture of an intracranial saccular aneurysm and cerebral salt wasting syndrome. Their course, as well as their clinical findings and treatment, are described. RESULTS: In eight patients, hyponatremia that lasted for more than 24 hours was detected (serum sodium under 135 mEq/l). The sodium disturbance occurred between day 3 and day 10 in all cases, in six of them in day 7 or day 8. The specific treatment for CSWS was to increase volume delivery according to the characteristics of the patient. Except for one case, none of the remaining patients required more than 72 hours of treatment to correct hyponatremia. No treatment-related complications were found CONCLUSION: Cerebral salt wasting syndrome, occurring in some patients with subarachnoid hemorrhage, is more commonly related to certain specific anatomic locations of the ruptured aneurysm, responds to sodium replacement therapy and fluids and can be diagnosed and treated based on the clinical, hydroelectrolytic and hemodynamic course of the patient. Further studies are needed to define the underlying mechanism of this condition.

Cirugía de la base del cráneo / Surgical of the skull base

La cirugía de la base del cráneo ha tenido un gran avance en los últimos años debido principalmente a un mejor entendimiento de la anatomía, el desarrollo de nuevas tecnologías en estudios radiológicos y la participación multidisciplinaria de varios expertos en dicho campo; en cada uno de los abordajes, el principal objetivo es lograr la máxima exposición con un mínimo de retracción cerebral. En esta revisión se presentan las diferentes opciones que actualmente existen en el tratamiento de las lesiones en esta área. Se discuten las ventajas y desventajas de cada una de ellas y se incluyen algunos ejemplos clínicos ilustrativos. Para este análisis se dividió la base del cráneo en piso anterior, seno cavernoso, clivus, región petroclival, agujero mango, unión cráneo-vertebral, y foramen yugular

Patología y tratamiento quirúrgico de la luxación atlanto-axoidea: informe de 18 pacientes / Pathology and surgical treatment of atlanto-axial dislocation: report of 18 patients

La articulación atlanto-axoidea puede ser afectada por diversos procesos patológicos, reumáticos, tumorales o traumáticos. La sintomatología es variada dependiendo del grado de compresión. El tratamiento es doble descompresivo y de fijación. En el trabajo se presentan dieciocho enfermos con luxación de esta articulación. Todos tuvieron importantes alteraciones neurológicas. En todos los pacientes se empleó tracción cervical previa a la cirugía que consistió en fijación usando alambre y acrílico en unos casos y en otros alambre y hueso. Los resultados fueron excelentes en nueve casos, cuatro tuvieron buenos resultados, dos malos resultados y tres fallecieron por complicaciones cardiomusculares.(AU)_______________________________________________________