Coste del dolor: incapacidad temporal y claidad de vida / No disponible

el dolor es una experiencia emocional, subjetiva y compleja, con repercusión física, psicológica, social y laboral. El enfoque multidisciplinar de tratamiento del dolor incluyendo aspectos médicos, psicológicos y físicos ha demostrado ser más eficaz que el tratamiento con una sola modalidad. En Sanidad, la Calidad constituye inicialmente un concepto abstrato que precisa una definición. En un 80% de los pacientes, el dolor no se correlaciona con alteraciones orgánicas, factores emocionales y sociales tienen un peso importante. La CVRS (calidad de vida relacionada con la salud) y de los instrumentos más adecuados par su medición, esta se está revelando como una disciplina de interés teórico y práctico, y con prometedoras aplicaciones en distintos ámbitos de las ciencias de la salud. La medida de la CVRS es de especial utilidad para ofrecer una visión cuantitativa o semicuantitativa del estado de salud, incorporando el carácter subjetivo de la percepción de la enfermedad por el propio paciente (AU)

No disponible

Teoría de la decisión: incorporación de las percepciones del paciente en el procedimiento terapéutico / Decision-making: incorporation of the perceptions of the patient in the therapeutic procedure

Objetivo: Validar que la categorización de las diferentes opciones terapéuticas es esencial en la aplicación clínica de la teoría de la decisión, con la implicación del grado de utilidad, entendido como tal por el paciente implicado en la toma de decisión sobre sus resultados en salud. Método: Este artículo valida y actualiza, revisa el contenido y conocimiento, aplicación y la utilidad de la una determinada opción diagnóstica, clínica, intervencionista o no y terapéutica como primera opción en la hemorragia subaracnoide urgente frente al tratamiento quirúrgico o médico exclusivos. Resultados: Del cálculo de las utilidades de las diferentes opciones terapéuticas ante un caso de colecistitis aguda evolucionada hemos obtenido los siguientes resultados: tratamiento médico exclusivo (0,76), intervención quirúrgica (0,73) y neurorradiología intervencionista (0,93). Ha sido esta última opción, la que ha aportado una buena evolución clínico- radiológica. Conclusiones: Los árboles de decisión representan una herramienta metodológica útil como soporte en la selección de procedimientos terapéuticos quirúrgicos o no quirúrgicos. La valoración e implicación de la percepción del paciente aumenta la eficiencia y sostenibilidad, calidad y excelencia de la toma de decisión. Hay evidencias internacionales que sugieren que las decisiones clínicas serían de mayor calidad en caso de incorporar las preferencias de los pacientes (AU)

Objective: Demonstrate that categorizing different optional treatments is essential for their use in clinical decision-making. To validate that the categorization of the different therapeutic options, it is essential in the clinical application of the theory of the decision, with the implication of the degree of usefulness understood as such by the patient involved in the capture of decision on his results in health. Method: This article validates and updates, checks the content and knowledge, application and the usefulness of one certain diagnostic, clinical option, interventionist or not and therapeutic as the first option with intracerebral hemorrhage opposite to the surgical or medical treatment exclusive. Results: We have analysed the utility of different therapeutic options in a long term acute cholecystitis obtaining the present results: isolate intravenous antibiotic therapy (0.76), surgery (0.73) and arteriography of intracerebral hemorrhage. y (0.93). This last option was performed with good clinical-radiologicalresults. Conclusion: The trees of decision represent a methodological useful tool as support in the selection of therapeutic surgical procedures or not surgically. The valuation and implication of the perception of the patient increases the efficiency and sustainability, quality and excellence of the capture of decision. There are international evidences that suggest that the clinical decisions would be of major quality in case of incorporating the preferences of the patients (AU)

[Aneurysmal subarachnoid hemorrhage: group of study of cerebrovascular pathology of the Spanish society of neurosurgery management guideline]. / Hemorragia subaracnoidea aneurismática: guía de tratamiento del grupo de patología vascular de la sociedad Española de neurocirugía.

An actualized revision of the most important aspects of aneurismal subarachnoid hemorrhage is presented from the guidelines previously published by the group of study of cerebrovascular pathology of the Spanish Society of Neurosurgery. The proposed recommendations should be considered as a general guide for the management of this pathological condition. However, they can be modified, even in a significant manner according to the circumstances relating each clinical case and the variations in the therapeutic and diagnostic procedures available in the center attending each patient.

Hemorragia subaracnoidea aneurismática: guía de tratamiento del Grupo de Patología Vascularde la Sociedad Española de Neurocirugía / Aneurysmal subarachnoid hemorrhage: group of study of Cerebrovascular Pathology of the Spanish Society of Neurosurgery management guideline

Se realiza una actualización sobre los aspectos másimportantes de la hemorragia subaracnoidea aneurismáticarespecto a las guías previamente publicadaspor el grupo de trabajo de la SENEC. Las recomendacionespropuestas deben considerarse como una guíageneral de manejo de esta patología. Sin embargo,pueden ser modificadas, incluso de manera significativapor las circunstancias propias de cada casoclínico, o las variaciones en los recursos diagnósticosy terapéuticos del centro hospitalario que reciba alpaciente (AU)

An actualized revision of the most important aspectsof aneurismal subarachnoid hemorrhage is presentedfrom the guidelines previously published by the groupof study of cerebrovascular pathology of the SpanishSociety of Neurosurgery. The proposed recommendationsshould be considered as a general guide for themanagement of this pathological condition. However,they can be modified, even in a significant manneraccording to the circumstances relating each clinicalcase and the variations in the therapeutic and diagnosticprocedures available in the center attending eachpatient (AU)

Idiopathic subarachnoid hemorrhage: a multicentre series of 220 patients.

BACKGROUND. The Spanish neurosurgical society created a multicentre data base on spontaneous SAH to analyze the real problematic of this disease in our country. This paper focuses on the group of patients with idiopathic SAH (ISAH). METHODS. 16 participant hospitals collect their spontaneous SAH cases in a common data base shared in the internet through a secured web page, considering clinical, radiological, evolution and outcome variables. The 220 ISAH cases collected from November 2004 to November 2007 were statistically analyzed as a whole and divided into 3 subgroups depending on the CT blood pattern (aneurysmal, perimesencephalic, or normal). RESULTS. The 220 ISAH patients constitute 19% of all 1149 spontaneous SAH collected in the study period. In 46,8% of ISAH the blood CT pattern was aneurysmal, which was related to older age, worse clinical condition, higher Fisher grade, more hydrocephalus and worse outcome, compared to perimesencephalic (42.7%) or normal CT (10.4%) pattern. Once surpassed the acute phase, outcome of ISAH patients is similarly good in all 3 ISAH subgroups, significantly better as a whole compared to aneurysmal SAH patients. The only variable related to outcome in ISAH after a logistic regression analysis was the admission clinical grade. CONCLUSIONS. ISAH percentage of spontaneous SAH is diminishing in Spain. Classification of ISAH cases depending on the blood CT pattern is important to differentiate higher risk groups although complications are not negligible in any of the ISAH subgroups. Neurological status on admission is the single most valuable prognostic factor for outcome in ISAH patients.

Idiopathic subarachnoid hemorrhage: a multicentre series of 220 patients

Background. The Spanish neurosurgical society created a multicentre data base on spontaneous SAH to analyze the real problematic of this disease in our country. This paper focuses on the group of patients with idiopathic SAH (ISAH).Methods. 16 participant hospitals collect their spontaneous SAH cases in a common data base shared in the internet through a secured web page, considering clinical, radiological, evolution and outcome variables. The 220 ISAH cases collected from November 2004 to November 2007 were statistically analyzed as a whole and divided into 3 subgroups depending on the CT bloodpattern (aneurysmal, perimesencephalic, or normal).Results. The 220 ISAH patients constitute 19% of all 1149 spontaneous SAH collected in the study period. In 46,8% of ISAH the blood CT pattern was aneurysmal, which was related to older age, worse clinical condition, higher Fisher grade, more hydrocephalus and worse outcome, compared to perimesencephalic (42,7%) or normal CT (10,4%) pattern. Once surpassed the acute phase, outcome of ISAH patients is similarly good in all 3 ISAH subgroups, significantly better as a whole compared to aneurysmal SAH patients. The only variable related to outcome in ISAH after a logistic regression analysis was the admission clinical grade. Conclusions. ISAH percentage of spontaneous SAHis diminishing in Spain. Classification of ISAH cases depending on the blood CT pattern is important to differentiate higher risk groups although complications are not negligible in any of the ISAH subgroups. Neurological status on admission is the single most valuable prognostic factor for outcome in ISAH patients (AU)

Propósito. El grupo de trabajo de Patología Vascular de la SENEC desarrolló y mantiene abierta una base de datos multicéntrica que recoge los casos de hemorragia subaracnoidea espontánea. Con esta base se pretende analizar la problemática real que representa esta patología en nuestro medio. Este trabajo se centra en el estudio del grupo de pacientes de la base que presentaron HSA idiopática o de origen no aclarado (HSAI).Materiales y métodos. La base de datos recoge los casos de HSA espontánea de 16 hospitales españoles a través de una página Web compartida en Internet de forma segura. Se consideran variables epidemiológicas ,clínicas y radiológicas, así como la aparición de complicaciones y la evolución de los pacientes. Entre Noviembre de 2004 y Noviembre de 2007 se recogieron 220 pacientes con HSA idiopática. Este grupo se ha analizado estadísticamente de forma global y subdividido en 3 grupos de acuerdo con el patrón TC de sangrado inicial (de tipo aneurismático, perimesencefálico o TCnormal). Resultados. Los 220 pacientes con HSAI representan el 19% del total de 1.149 pacientes con HSA recogidos en la base de datos en el mismo periodo. El 46,8% de los casos de HSAI presentaron patrón de sangrado aneurismático en TC, hecho que se correlacionó con mayor edad, peor condición clínica al ingreso, mayor grado Fisher de sangrado, más frecuencia de hidrocefalia y peor evolución, comparados con los casos de HSAI con sangrado en TC del tipo perimesencefálico (42,7%) o con TC normal (10,4%).Una vez superada la fase aguda, e independientemente del tipo de sangrado inicial, la evolución de los pacientes con HSAI es globalmente buena y significativamente mejor que la de los pacientes con HSA aneurismática. La única variable con valor pronóstico en los casos de HSAI, tras realizar un análisis de (..) (AU)

Liponeurocitoma: un raro ejemplo de neoplasia cerebelosa / Liponeurocytoma: a unusual cerebellar tumour

Presentamos en nuestro trabajo, un caso de liponeurocitomacerebeloso, tumor poco frecuente, observado en unamujer de 62 años de edad. Dicho tumor mostró una imagenhistológica compatible con un tumor de células pequeñas,de escasa agresividad, positivo para marcadores neuronales(sinaptofisina y enolasa neuronal específica) con áreasfocales de diferenciación lipídica. Tras establecer un diagnósticodiferencial con otras neoplasias, comentamos brevementelas características de esta rara entidad(AU)

We report a case of cerebellar liponeurocytoma in a 62year old woman. Histologically, the tumour was of lowaggressiveness, composed of small cells with areas of lipidisedcells and was positive for neuronal markers (synaptophysinand neuron specific enolase). The principal featuresof this unusual entity are reviewed and the pathologicalaspects of its differential diagnosis are discussed(AU)

[Spontaneous Subarachnoid Haemorrhage multicenter database from the Group for the Study of Vascular Pathology of the Spanish Society for Neurosurgery: presentation, inclusion criteria and development of an internet-based registry]. / Base de datos multicéntrica de hemorragia subaracnoidea espontánea del Grupo de Trabajo de Patología Vascular de la Sociedad Española de Neurocirugía: presentación, criterios de inclusión y desarrollo de una base de datos en internet.

INTRODUCTION: Subarachnoid haemorrhage is one of the most severe neurosurgical diseases. Its study is crucial for improving the care of these patients in our environment. With this goal the Group for the Study of Neurovascular Pathology of the Spanish Society for Neurosurgery (SENEC) decided to create a multicenter registry for the study of this disease. MATERIALS AND METHODS: In this database we have prospectively included all cases with spontaneous subarachnoid haemorrhage admitted to the participant hospitals from November 2004 to November 2007. The fields to be included in the database were selected by consensus, including age, past medical history, clinical characteristics at admission, radiological characteristics including presence or absence of an aneurysm and its size and location, type and complications of the aneurysm treatment, outcome assessed by the Glasgow Outcome Scale (GOS) at discharge and six months after the bleeding as well as the angiographic result of the aneurysm treatment. All fields were collected by means of an electronic form posted in secure web page. RESULTS: During the three years of study a total of 1149 patients have been included by 14 Hospitals. The time needed to fill in a patient in the registry is approximately 3.4 minutes. This series of patients with spontaneous SAH is similar to other non-selected in-hospital series of SAH. The mean age of the patients is 55 years and there is a 4:3 female to male ratio. In relation to the severity of the bleeding 32% of the patients were in poor clinical grade at admission (WFNS 4 or 5). 5% of the patients died before angiography could be performed. An aneurysm was confirmed as the origin of the bleeding in 76% of the patients (aSAH), while in 19% of the patients no lesion was found in the angiographic studies and were thus classified as idiopathic subarachnoid hemorrhage (ISAH). Of those patients with aSAH, 47% were treated endovascularly, 39% surgically, 3% received a combined treatment and 11% did not receive any treatment for their aneurysm because of early death. Regarding outcome, there is a 22% mortality in the series. Only 40% of the patients with aSAH reached a good outcome at discharge (GOS = 5). CONCLUSIONS: Spontaneous SAH continues to be a disease with high morbidity and mortality. This database can be an ideal instrument for improving the knowledge about this disease in our environment and to achieve better results. It would be desirable that this database could in the future be the origin of a national registry of spontaneous SAH.

Base de datos multicéntrica de hemorragia subaracnoidea espontánea del Grupo de Trabajo de Patología Vascular de la Sociedad Española de Neurocirugía: presentación, criterios de inclusión y desarrollo de una base de datos en internet / Spontaneous Subarachnoid Haemorrhage multicenter database from the Group for the Study of Vascular Pathology of the Spanish Society for Neurosurgery: Presentation, inclusion criteria and development of an internet-based registry

Introducción: La hemorragia subaracnoidea (HSA) continúa siendo una de las enfermedades de interés neuroquirúrgico de más alta morbilidad y mortalidad. Su estudio es clave a la hora de mejorar la atención de estos enfermos en nuestro medio. Con este fin el Grupo de Trabajo de Patología Vascular de la SENEC decidió la creación de una base de datos multicéntrica para su estudio. Material y métodos: Se incluyen en esta base de datos todos los casos de hemorragia subaracnoidea espontánea ingresados en los centros participantes de forma prospectiva desde Noviembre del año 2004 hasta Noviembre del 2007. Se decidieron de forma consensuada los campos a recoger incluyendo edad, antecedentes personales, características clínicas, características radiológicas y del aneurisma, tipo de tratamiento y complicaciones de la enfermedad, evolución según la escala de evolución de Glasgow (GOS) al alta y a los seis meses así como el resultado angiográfico del tratamiento. Todos los campos se recogieron en un formulario rellenable a través de una página web segura. Resultados: En los tres años en los que ha estado activa la base se han recogido un total de 1149 casos de HSA espontánea recogidos por 14 centros participantes. Se ha estimado que es necesario aproximadamente un tiempo de 3.4 minutos para rellenar cada caso.En cuanto a sus características generales la serie es similar a otras series hospitalarias no seleccionadas. La edad media de los enfermos incluidos es de unos 55 años y la relación mujer:hombre 4:3. En cuanto a la gravedad del sagrado inicial un 32% de los enfermos se encontraba en mal grado clínico (WFNS = 4 ó 5). El 5% de los pacientes fallecieron antes de realizarse una angiografía que confirmara el origen aneurismático del sangrado. Se confirmó el origen aneurismático en el 76% de los pacientes mientras que en el 19% no se encontró ninguna lesión vascular responsable del sangrado, siendo clasificados como HSA idiopática. En los pacientes en los que se detectó un aneurisma su tratamiento fue endovascular en el 47% de los casos, quirúrgico en el 39, mixto en el 3% y no recibieron tratamiento de su aneurisma el 11% de los pacientes por fallecimiento precoz. En cuanto a su evolución, la mortalidad global de la serie se sitúa en el 22%. Sólo el 40% de los enfermos con HSA aneurismática presentaron una buena evolución (GOS=5). Conclusiones: La HSA espontánea continúa siendo una enfermedad con alta morbilidad y mortalidad. Esta base de datos puede ser un instrumento para conocer mejor sus características en nuestro medio y mejorar sus resultados, ya que se trata de una serie multicéntrica hospitalaria no seleccionada. Sería pues recomendable que esta base constituyera el germen de un registro nacional de HSA espontánea (AU)

Introduction: Subarachnoid haemorrhage is one of the most severe neurosurgical diseases. Its study is crucial for improving the care of these patients in our environment. With this goal the Group for the Study of Neurovascular Pathology of the Spanish Society for Neurosurgery (SENEC) decided to create a multicenter registry for the study of this disease. Materials and methods: In this database we have prospectively included all cases with spontaneous subarachnoid haemorrhage admitted to the participant hospitals from November 2004 to November 2007. The fields to be included in the database were selected by consensus, including age, past medical history, clinical characteristics at admission, radiological characteristics including presence or absence of an aneurysm and its size and location, type and complications of the aneurysm treatment, outcome assessed by the Glasgow Outcome Scale (GOS) at discharge and six months after the bleeding as well as the angiographic result of the aneurysm treatment. All fields were collected by means of an electronic form posted in secure web page. Results:During the three years of study a total of 1149 patients have been included by 14 Hospitals. The time needed to fill in a patient in the registry is approximately 3.4 minutes. This series of patients with spontaneous SAH is similar to other non-selected in-hospital series of SAH. The mean age of the patients is 55 years and there is a 4:3 female to male ratio. In relation to the severity of the bleeding 32% of the patients were in poor clinical grade at admission (WFNS 4 or 5). 5% of the patients died before angiography could be performed. An aneurysm was confirmed as the origin of the bleeding in 76% of the patients (aSAH), while in 19% of the patients no lesion was found in the angiographic studies and were thus classified as idiopathic subarachnoid hemorrhage (ISAH). Of those patients with aSAH, 47% were treated endovascularly, 39% surgically, 3% received a combined treatment and 11% did not receive any treatment for their aneurysm because of early death. Regarding outcome, there is a 22% mortality in the series. Only 40% of the patients with aSAH reached a good outcome at discharge (GOS=5). Conclusions: Spontaneous SAH continues to be a disease with high morbidity and mortality. This database can be an ideal instrument for improving the knowledge about this disease in our environment and to achieve better results. It would be desirable that this database could in the future be the origin of a national registry of spontaneous SAH (AU)

Changes in ventricular size after endoscopic third ventriculostomy.

BACKGROUND: There is general consensus that a successful endoscopic third ventriculostomy is usually followed by a decrease of ventricular size without reaching their normal size. This study was performed to determine how the change related to clinical outcome, how it developed chronologically and whether the change in ventricular size was different in acute and chronic forms of hydrocephalus. METHOD: Fifty-five of 74 patients who had undergone endoscopic third ventriculostomy during the period 1997-2004 were selected by the criterion that they had both pre-operative and post-operative films and no neurosurgical manoeuvre other than a surgically successful endoscopic third ventriculostomy in the time span between both radiological studies. Ventricular size was measured with the Evans index, third ventricle index, cella media index and ventricular score. Median age was 51 years (interquartile range, 27-65 years). RESULTS: The change in ventricular size detected shortly after surgery is related to clinical outcome for all ventricular ratios, except the cella media index (p = 0.08). When third ventriculostomy is clinically successful, there is a gradual decrease of ventricular size over a period of more than three months (p < 0.0001 for all ventricular ratios). The reduction is more prominent in acute hydrocephalus than in chronic forms for all ventricular ratios, except the Evans index (p = 0.12). The third ventricle exhibits the greatest reduction (25% with a 95% confidence interval: 15.4-34.5) and determines a different pattern of change in ventricular size after endoscopic third ventriculostomy between acute and chronic hydrocephalus. CONCLUSIONS: A decrease of the ventricular size detected soon after endoscopic third ventriculostomy is associated with a satisfactory clinical outcome. This response continues during the first few months after surgery. The reduction is more prominent in acute forms of hydrocephalus.

[Skull base meningiomas: a predictive system to know the extent of their surgical resection and patient outcome]. / Meningiomas de la base de cráneo. Un sistema predictivo para canocer las posibilidades de su extirpación y pronóstico

OBJECTIVE: The aim of this study was to build a preoperative predictive system which could provide reliable information about: 1 degrees which skull base meningiomas can be total or partially removed, and 2 degrees their surgical outcome. METHOD: Patient histories and imaging data were reviewed retrospectively from 85 consecutive skull base meningiomas patients who underwent surgery from 1990 and 2002. From the preoperative data, nine variables were selected for conventional statistical analysis as regards their relationship with: 1 degrees total vs partial tumor resection and 2 degrees with patients outcome according to the degree of tumour removal. RESULTS: From the nine variables analysed only two had a statistical association with the type of tumour resection performed (total vs partial) and the patient outcome: 1) arteries encasement and 2) cranial nerves involvement. Upon correlating these two variables with the type of tumour resection performed (total vs partial) and with the Karnofsky'scale to evaluate patients surgical outcome, the following grading groups were identified: Grade I: skull base meningiomas which did not involve cranial nerves or artery or only encased one artery or one cranial nerve. In these cases the incidence of gross tumour resection was 98.3% (p< 0.0001) and the perspective to reach 70 points in the Karnofsky'scale was of 96.5% ( p=0.001). Grade II: skull base meningiomas which involved one cranial nerve and encased, at least, two main cerebral arteries. In these cases, the frequency of total resection, decreased to 83.3% (p<0.0001) and the probability to reach 70 points in the Karnofsky'scale was 70.6% (p=0.001). Grade III: skull base meningiomas which involved two or more cranial nerves and encased several arteries In this group, the frequency of a total resection was of 42.9% (p<0.0001) and the probability of reaching 70 points in the Karnofsky'scale was only 60% (p=0.001). CONCLUSIONS: We propose a preoperative grading system for skull base meningiomas that helps predicting both whether total or partial tumor removal will be achieved during surgery and the immediate postsurgical outcome of the patient. In applying this predictive system we will be able to reduce surgical morbidity, to advance the possibility of a radiosurgical treatment and give a more precise information to the patients and their families about our surgical decision-making process.

Meningiomas de la base de cráneo. Un sistema predictivo para conocer las posibilidades de su extirpación y pronóstico / Skull base meningiomas: a predictive system to know the extent of their surgical resection and patient outcome

Objetivo. Encontrar un sistema predictivo que basándose únicamente en datos preoperatorios nos oriente, con fiabilidad, sobre : 1° qué meningiomas dela base de cráneo pueden ser extirpados total o parcialmente y 2° cuál es su pronóstico postquirúrgico. Métodos. Se ha revisado de forma retrospectiva, las historias clínicas e iconografías de 85 pacientes, con meningiomas de la base de cráneo, intervenidos entre1990 al 2002. De ellas se han tomado nueve variables que han sido tratadas estadísticamente, mediante un test estándar, para correlacionarlas con: 1° resección total o parcial del tumor (Simpson, 5 grados) y 2° conocido el mencionado grado de resección total o parcial, éste se correlacionó con el pronóstico funcional postoperatorio del paciente (Karnofsky).Resultados. De las variables preoperatorios analizadas, solo dos demostraron tener una asociación significativa con la extirpación total o parcial del tumor, así como con el pronóstico postquirúrgico del paciente. Dichas variables fueron: a) las arterias englobadas por el tumor (p = 0.001) y b) la afectación de pares craneales(p< 0.0001). Seguidamente, se conjugaron las diversas posibilidades de cada una de ellas para conocer el grado de extirpación tumoral (total o parcial). Para predecir el pronóstico funcional postoperatorio del enfermo, se relacionó la extirpación total o parcial con la escala de Karnofsky. De ambos análisis, grado de extirpación y pronóstico, se obtuvo el siguiente sistema de gradación: Grado I: meningiomas, de la base de cráneo, que no afectan a pares craneales ni engloban arterias o bien solamente afectan a un par craneal o engloban sólo una arteria. En ellos las posibilidades de extirpación total se encuentran en un 98,3% (p<0.0001) y las perspectivas de alcanzar 70 puntos en la escala de Karnofsky son de un 96,5%.Grado II: meningiomas que afectan a un par craneal e incluyen dos o más arterias. La extirpación total en estos casos disminuye al 83,3% (p< 0.0001) y las perspectivas de alcanzar 70 puntos en la escala de Karnofsky descienden a un 70,6%.Grado III: meningiomas que afectan dos o más pares craneales e incluyen varias arterias. En este grupo, las posibilidades de una extirpación total son de un 42,9% (p<0.0001) con las perspectivas de alcanzarlos 70 puntos en la escala de Karnofsky en sólo el 60%.Conclusiones. El sistema de gradación que se propone permite, en los casos de meningiomas de la base de cráneo: 1° predecir las posibilidades de una extirpación total o parcial y 2° conocer el pronóstico quirúrgico delos pacientes en cada grupo. Aplicando este sistema podremos reducir nuestra morbilidad quirúrgica, anticiparla necesidad de una terapia con radiocirugía y dar una información, más precisa, al paciente y familiares sobre nuestras propuestas quirúrgicas

Objective. The aim of this study was to build a preoperative predictive system which could provide reliable information about: 1° which skull base meningiomas can be total or partially removed, and 2°their surgical outcome. Method. Patient histories and imaging data were reviewed retrospectively from 85 consecutive skull base meningiomas patients who underwent surgery from1990 and 2002. From the preoperative data, nine variables were selected for conventional statistical analysis as regards their relationship with: 1° total vs partial tumor resection and 2° with patients outcome according to the degree of tumour removal. Results. From the nine variables analysed only two had a statistical association with the type of tumour resection performed (total vs partial) and the patient outcome: 1) arteries encasement and 2) cranial nerves involvement. Upon correlating these two variables with the type of tumour resection performed (total vs partial)and with the Karnofsky'scale to evaluate patients surgical outcome, the following grading groups were identified: Grade I: skull base meningiomas which did not involve cranial nerves or artery or only encased one artery or one cranial nerve. In these cases the incidence of gross tumour resection was 98,3% (p<0.0001) and the perspective to reach 70 points in the Karnofsky'scale was of 96,5% ( p= 0.001).Grade II: skull base meningiomas which involved one cranial nerve and encased, at least, two main cerebral arteries. In these cases, the frequency of total resection, decreased to 83,3% (p<0.0001) and the probability to reach 70 points in the Karnofsky'scale was 70,6%(p=0.001).Grade III: skull base meningiomas which involved two or more cranial nerves and encased several arteries In this group, the frequency of a total resection was of42,9% (p<0.0001) and the probability of reaching 70points in the Karnofsky'scale was only 60% (p= 0.001).Conclusions. We propose a preoperative grading system for skull base meningiomas that helps predicting both whether total or partial tumor removal will be achieved during surgery and the immediate postsurgical outcome of the patient. In applying this predictive system we will be able to reduce surgical morbidity, to advance the possibility of a radiosurgical treatment and give a more precise information to the patients and their families about our surgical decision-making process

[Intracerebral hemorrhage following chronic subdural hematoma evacuation: report of two cases and review of the literature]. / Hematoma intracerebral tras la evacuación de hematoma subdural crónico: descripción de dos casos y revisión de la literatura.

Intracerebral hemorrhage ocurring after chronic subdural hematoma evacuation, is a rare and very serious postoperative complication. The sudden increase of cerebral blood flow in the hemisphere beneath the hematoma, is the most likely mechanism responsible for this situation. Two new cases of intracerebral hemorrage after evacuation of chronic subdural hematomas are reported.

Hematoma intracerebral tras la evacuación de hematoma subdural crónico: descripción de dos casos y revisión de la literatura / Intracerebral hemorrhage following chronic subdural hematoma evacuation: Report of two cases and review of the literature

La hemorragia intracerebral que aparece tras la evacuación de un hematoma subdural crónico es una complicación rara y de graves consecuencias. El aumento brusco del flujo sanguíneo cerebral en el hemisferio subyacente al hematoma tras la rápida descompresión, es considerado como el mecanismo más probable causante de este problema. Se presentan dos nuevos casos de hematomas intracerebrales aparecidos tras la evacuación de hematomas subdurales crónicos (AU)

[Analysis of cerebrospinal fluid related complications (hydrocephalus, fistula, pseudomeningocele and infection) following surgery for posterior fossa tumors]. / Análisis de complicaciones licuorales (hidrocefalia, fistula, pseudomeningocele e infeccion) en la cirugía de tumores de fosa posterior.

INTRODUCTION: Hydrocephalus, cerebrospinal fluid (CSF) leak, pseudomeningocele and CSF infection are potential complications related to surgical treatment of posterior fossa tumors. The objectives of this study were to review the incidence of such complications and to identify contributing factors related to them. MATERIAL AND METHODS: This study is based on a retrospective review of the medical records of 71 consecutive patients who underwent posterior fossa surgery for a tumor between the period January 1997 and December 2001. Postoperative hydrocephalus was defined as enlargement of the ventricles and the subsequent clinical worsening requiring surgical treatment. Criteria for CSF leakage were:observed leak of CSF through the wound, rhinorrhea or otorrhea. Pseudomeningocele was determined when there was a large epidural CSF collection diagnosed in the postoperative period or by magnetic resonance imaging performed at least three months after posterior fossa surgery. Finally, CSF infection was defined on clinical ground and positive biochemical examination, but not necessarily positive cultures. RESULTS: The series included 84 operations for resection of posterior fossa tumors on 71 patients. There were CSF related complications in 31% (26/84)with the following detailed incidence: 9.5% (8/84) postoperative hydrocephalus; 14.3% (12/84) CSF leak, 7.1% (6/84) pseudomeningocele; 8.3% (7/84) CSF infection. The mortality rate is 5.9% (5/84). The tumor size was the only statistically significant factor associated with the occurrence of CSF related complications (mean 39.43 mm, SD 18.51 mm vs.29.80 mm, SD 14.12 mm, p=0.015). In the subgroup of patients, in which hydrocephalus was managed preoperatively, the election of an external ventricular drain vs.other strategies (subcutaneous reservoir, definite shunt or endoscopic third ventriculostomy) was associated with a higher occurrence of CSF related complications (p=0.006). The mortality rate was associated with age (mean 63.60 years, SD 5.86 years vs.49.18 years, SD 16.39 years; p=0.002). The occurrence of CSF related complications also influenced mortality (p=0.030), particularly postoperative hydrocephalus (p< 0.001). Inpatient hospital stay was longer in the subgroup of patients who developed CSF related complications (p=0.002). CONCLUSIONS: Tumor size was the only factor associated with the development of CSF related complications after surgery for posterior fossa tumors. In the subgroup of patients in which hydrocephalus was surgically treated preoperatively, the election of an external ventricular drain compared to other surgical modalities was associated with a higher rate of CSF related complications. The development of such complications, particularly hydrocephalus, was related with mortality.

Análisis de complicaciones licuorales (hidrocefalia, fístula, pseudomeningocele e infección) en la cirugía de tumores de fosa posterior / Analysis of cerebrospinal fiuid related complications (hydrocephalus, fistula, pseudomeningocele and infection) following surgery for posterior fossa tumors

Introducción. Hidrocefalia, fístula de líquido cefalorraquídeo (LCR), pseudomeningocele e infección son complicaciones potenciales en la cirugía de los tumores de fosa posterior agrupadas bajo el término complicaciones licuorales. El objetivo de este estudio ha sido identificar variables relacionadas con la aparición de estas complicaciones en la cirugía de los procesos expansivos de fosa posterior.Material y métodos. La población objeto de estudio es una serie de 71 pacientes consecutivos intervenidos de un proceso expansivo de fosa posterior durante el período Enero 1997 - Diciembre 2001. Mediante revisión de historias clínicas se recogió la presencia de dichas complicaciones de acuerdo a los siguientes criterios: hidrocefalia postquirúrgica siempre que un mayor grado de dilatación ventricular respecto a las pruebas de neuroimagen preoperatorias y el cuadro clínico asociado a dicha dilatación condicionara una maniobra quirúrgica; fístula, cuando se detectara fuga de LCR a través de la herida quirúrgica, nariz u oído; pseudomeningocele, ante una colección epidural significativa de LCR detectada en el postoperatorio inmediato o en una resonancia magnética realizada más de tres meses después de la intervención; e infección de LCR, ante un cuadro clínico y un examen bioquímico de LCR compatibles con o sin cultivo positivo de LCR.Resultados. La serie incluye 84 procedimientos quirúrgicos de fosa posterior realizados a 71 pacientes. En el 31 por ciento (26/84) de los procedimientos se detectaron complicaciones licuorales con la siguiente incidencia pormenorizada: 9.5 por ciento (8/84) hidrocefalia postoperatoria; 14.3 por ciento (12/84) fístula de LCR; 7.1 por ciento (6/84) pseudomeningocele; 8.3 por ciento (7/84) infección de LCR. La mortalidad de la serie es del 5.9 por ciento (5/84). La única variable relacionada con la aparición de complicaciones licuorales fue el tamaño de la lesión (media 39.43 mm, DE 1851 mm vs. 29.80 mm, DE 14.12 mm, p=0.015). En el subgrupo de pacientes en que se efectuó una intervención quirúrgica para el control preoperatorio de la hidrocefalia, la elección de un drenaje ventricular externo vs. otras opciones (reservorio subcutáneo, shunt o ventriculostomía endoscópica) se asoció con una mayor tasa de complicaciones licuorales (p=0.006). La mortalidad se relacionó con la edad (media 63.60 años, DE 5.86 años vs. 49.18 años, DE 16.39 años, p=0.002) y con la presencia de complicaciones licuorales (p=0.030), particularmente con el desarrollo de hidrocefalia postoperatoria (p<0.001). La estancia hospitalaria postoperatoria fue más prolongada en el subgrupo de pacientes que desarrolló complicaciones licuorales (p=0.002).Conclusiones. El tamaño del tumor es la única variable relacionada con la aparición de complicaciones licuorales en la cirugía de los tumores de fosa posterior. En el subgrupo de pacientes en que se hace alguna maniobra quirúrgica para el control preoperatorio de la hidrocefalia, la elección de un drenaje ventricular externo comparado a otras opciones se asocia con una tasa mayor de complicaciones licuorales. La mortalidad quirúrgica está relacionada con el desarrollo de complicaciones licuorales, sobre todo con la hidrocefalia postoperatoria (AU)

[Evaluation of microsurgical treatment in a series of 121 intracranial aneurysms]. / Evaluación del tratamiento microquirúrgico de 121 aneurismas intracraneales.

OBJECTIVE: The results obtained with therapy of intracranial aneurysms, in terms of morbidity and mortality, are very important when the patient has to choose between microsurgical techniques or endovascular management. The aim of this paper is to review the information regarding current microsurgical treatment of intracranial aneurysms, and presenting our experience over the last five years. MATERIAL AND METHODS: We studied 101 consecutive patients with 121 intracranial aneurysms admitted between 1996 and 2000 with the initial diagnosis of subarachnoid hemorrhage. We paid special attention to the day of admission from the onset of the symptomatic hemorrhage to the grade of Hunt&Hess scale and the possibility of early or delayed microsurgical treatment. The diagnosis was based on four vessels cerebral angiography and in a few cases with CT-angiography. All patients were treated by microsurgical technique and such treatment was completed by nimodipine, intensive care unit management and in some cases of postoperative suspected vasospasm, induced arterial hypertension was applied. Post surgical angiography was carried out in all patients to confirm the clipping of the cerebral aneurysm. The 12 months assessment was based on the Glasgow Outcome Scale (GOS). RESULTS: The 92.1% of the patients were admitted with a grade equal or below III in the Hunt&Hess scale. A 80% were operated within the 72 hours of admission and in the remaining cases, the surgical treatment was delayed due to a grade IV or V or to a medical contraindication. Four patients died (3.9%). At 12 months follow up, 88.9% presented a score I or II in the GOS. CONCLUSION: According to our results, there are a substantial improvements in the microsurgical treatment of cerebral aneurysms, specially in patients admitted early after the onset of the symptoms of their hemorrhage, who have a grade I to III in the Hunt&Hess scale and showed a good level of consciousness. We think that the improvement of our results are due to: l. the high percentage of patients admitted with grades I to III. 2. the high percentage of patients operated within the first 72 hours from the onset of their symptomatic hemorrhage. 3. surgery was always carried out by the same two experienced vascular neurosurgeons. 4. intraoperative measures taken to prevent the rupture of the aneurysm. 5. early administration of nimodipine, ICU management, doppler studies and in seldom cases, induced hypertension therapy to treat the vasospasm and postoperative hypotension.

Evaluación del tratamiento microquirúrgico de 121 aneurismas intracraneales / Evaluation of microsurgical treatment in a series of 121 intracraneal aneurysms

Objetivo: Los resultados, tanto de morbilidad como de mortalidad, en pacientes con aneurismas intracraneales, son de gran importancia a la hora de presentarle a un enfermo la posibilidad de elegir entre realizar un tratamiento, vía técnica microquirúrgica o endovascular. La idea de este artículo es, fundamentalmente, dar una información reciente sobre el estado actual del tratamiento microquirúrgico de los aneurismas intracraneales, presentando nuestra experiencia y resultados de los últimos cinco años. Material y métodos: Se han estudiado 101 pacientes con 121 aneurismas intracraneales que ingresaron de forma consecutiva entre los años de 1996 al 2000, bajo el diagnóstico de hemorragia subaracnoidea. Especial atención se prestó al día de su ingreso en relación con el comienzo de su hemorragia subaracnoidea, grado de Hunt&Hess y a la posibilidad de una cirugía precoz o demorada. El diagnóstico se realizó mediante examen panagiográfico y en algún caso aislado con Angio-TC. Todos fueron intervenidos mediante téc-nica microquirúrgica y dicho tratamiento fue completado mediante nimodipino, UCI y en algunos casos de sospecha de vaso espasmo postoperatorio, mediante hipervolemia. Su seguimiento fue evaluado mediante angiografía postoperatoria y la GOS. Resultados: 92.1 por ciento de los pacientes ingresaron con un grado igual o menor de III en la escala de Hunt&Hess. 80.8 por ciento fueron intervenidos en las primeras 72 horas y en el resto se demoró este tratamiento, bien por presentar el enfermo un grado IV ó V de Hunt&Hess o por causas médicas. Cuatro enfermos fallecieron (3.9 por ciento). El examen de la GOS a los doce meses de la cirugía mostró que el porcentaje de excelentes o buenos resultados alcanzó un 88.9 por ciento. Conclusión: De acuerdo con los resultados, se puede decir que existe un avance en la mejoría del tratamiento microquirúrgico de los aneurismas intracraneales en Neurocirugía 2003; 14: 5-15 general y sobre todo en aquellos pacientes que ingresan de forma inmediata a su sangrado y con buen nivel de conciencia grado I-III de Hunt&Hess).Por parte de nuestro estudio, la mejoría de los resultados pueden justificarse por: 1° el alto porcentaje de enfermos con HSA ingresados en grado I-III de Hunt&Hess e intervenidos precozmente. 2° la cirugía fue siempre realizada por los mismos dos cirujanos, con larga experiencia en patología vascular cerebral. 3° las medidas tomadas para disminuir la incidencia intra operatoria de rotura aneurismática. 4° el uso de nimodipino, la vigilancia en UCI, la utilidad del doppler y el tratamiento de hipervolemia en casos de sospecha de vaso espasmo o hipotensión postoperatoria (AU)

[Spinal meningeal melanocytoma simulating neurinoma: case report]. / Melanocitoma meníngeo cervical simulando un neurinoma de la raíz C7: caso clínico.

Meningeal melanocytomas are infrequent tumors that when located in the spinal cord and because of their close relationship to the nerve root can resemble a neurinoma. The MRl can help to differentiate them from the neurinomas preoperatively. The case of a female patient harboring a cervical meningeal melanocytoma involving the C7 nerve root, and diagnosed preoperatively as an hourglass neurinoma is presented.

[Middle cerebral artery occlusion after cerebral hydatic embolism in a pediatric patient: case report]. / Oclusión de la arteria cerebral media tras la embolización de material parasitario hidatídico en una paciente en la edad pediátrica: caso clínico.

Stroke is a very uncommon complication of hydatic disease. The case of a pediatric patient who suffered cerebral infarction due to the occlussion of the right middle cerebral artery, and who subsequently developed multiple hydatic cysts in the territory of the occluded vessel, is presented. Even though the diagnostic tests aimed to detect a primary focus of the disease were negative, the existing data support the possibility of a cardiac embolic origin.