Gabriel Alcalá-Cerra

Efficacy and Safety of Subdural Drains After Burr-Hole Evacuation of Chronic Subdural Hematomas: Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVEnTo determine whether the use of a subdural drain after burr-hole evacuation of a chronic subdural hematoma is safe and effective in preventing recurrence and subsequent operations, and as such improving functional outcomes.nnnMETHODSnThe literature search included the following databases: PubMed, the National Institutes of Health/National Library of Medicine, Clinical Trials Registry, CENTRAL (The Cochrane Library), EMBASE, and LILACS. The search was performed in June 2013, and did not have restrictions or filters with regard to language or year of publication. Methodologic quality was assessed through the Jadads scale. Primary outcomes were recurrence and reoperation rates. Secondary outcomes were functional outcome, mortality, and postoperative complications. Results were presented as pooled Mantel-Haenszel relative risks (RR), with 95% confidence intervals (95% CI).nnnRESULTSnA total of 7 randomized controlled trials were analyzed. Three studies were classified as high methodologic quality and four as low quality. Pooled RR were symptomatic recurrence (RR 0.51; 95% CI 0.36-0.75), reoperation (RR 0.5; 95% CI 0.34-0.74), poor functional outcome (RR 0.61, 95% CI 0.39-0.98), mortality (RR 0.67, 95% CI 0.37-1.22), and postoperative complications (RR 1.28, 95% CI 0.78-2.11). There was no statistically significant heterogeneity within the outcomes.nnnCONCLUSIONSnThe meta-analysis demonstrates that the insertion of a subdural drain was associated with a statistically significant reduction in the risk of symptomatic recurrence and the requirement for further surgical intervention of chronic subdural hematoma after surgical evacuation. Furthermore, it was associated with statistically significant improvements in both short-term and long-term functional outcome.

Cerebral sinus venous thrombosis

Cerebral sinus venous thrombosis (CSVT) is a rare phenomenon that can be seen with some frequency in young patients. CSVT is a multifactorial condition with gender-related specific causes, with a wide clinical presentation, the leading causes differ between developed and developing countries, converting CSVT in a condition characterized by a highly variable clinical spectra, difficult diagnosis, variable etiologies and prognosis that requires fine medical skills and a high suspicious index. Patients who presents with CSVT should underwent to CT-scan venography (CVT) and to the proper inquiry of the generating cause. This disease can affect the cerebral venous drainage and related anatomical structure. The symptoms may appear in relation to increased intracranial pressure imitating a pseudotumorcerebri. Prognosis depends on the early detection. Correcting the cause, generally the complications can be prevented. Mortality trends have diminished, and with the new technologies, surely it will continue. This work aims to review current knowledge about CSVT including its pathogenesis, etiology, clinical manifestations, diagnosis, and treatment.

Orthosis for thoracolumbar burst fractures without neurologic deficit: A systematic review of prospective randomized controlled trials.

Background: Traditionally, conservative treatment of thoracolumbar (TL) burst fractures without neurologic deficit has encompassed the application of an extension brace. However, their effectiveness on maintaining the alignment, preventing posttraumatic deformities, and improving back pain, disability and quality of life is doubtful. Objective: The objective was to identify and summarize the evidence from randomized controlled trials (RCTs) to determine whether bracing patients who suffer TL fractures adds benefices to the conservative manage without bracing. Materials and Methods: Seven databases were searched for relevant RCTs that compared the clinical and radiological outcomes of orthosis versus no-orthosis for TL burst fractures managed conservatively. Primary outcomes were: (1) Loss of kyphotic angle; (2) failure of conservative management requiring subsequent surgery; and (3) disability and pain outcomes. Secondary outcomes were defined by health-related quality of life and in-hospital stay. Results: Based on predefined inclusion criteria, only two eligible high-quality RCTs with a total of 119 patients were included. No significant difference was identified between the two groups regarding loss of kyphotic angle, pain outcome, or in-hospital stay. The pooled data showed higher scores in physical and mental domains of the Short-Form Health Survey 36 in the group treated without orthosis. Conclusion and Recommendation: The current evidence suggests that orthosis could not be necessary when TL burst fractures without neurologic deficit are treated conservatively. However, due to limitations related with number and size of the included studies, more RCTs with high quality are desirable for making recommendations with more certainty.

Management of Craniocerebral Gunshot Injuries: A Review

Craniocerebral gunshot injuries (CGI) are increasingly encountered by neurosurgeons in civilian and urban settings. Unfortunately this is a prevalent condition in developing countries, with major armed conflicts which is not very likely to achieve a high rate of prevention. Management goals should focus on early aggressive, vigorous resuscitation and correction of coagulopathy; those with stable vital signs undergo brain computed tomography scan. Neuroimaging is vital for surgical purposes, especially for determine type surgery, size and location of the approach, route of extraction of the foreign body; however not always surgical management is indicated, there is also the not uncommon decision to choose non-surgical management. The treatment consist of immediate life salvage, through control of persistent bleeding and cerebral decompression; prevention of infection, through extensive debridement of all contaminated, macerated or ischemic tissues; preservation of nervous tissue, through preventing meningocerebral scars; and restoration of anatomic structures through the hermetic seal of dura and scalp. There have been few recent studies involving penetrating craniocerebral injuries, and most studies have been restricted to small numbers of patients; classic studies in military and civil environment have identified that this is a highly lethal or devastating violent condition, able to leave marked consequences for the affected individual, the family and the health system itself. Various measures have been aimed to lower the incidence of CGI, especially in civilians. It is necessarily urgent to promote research in a neurocritical topic such as CGI, looking impact positively the quality of life for those who survive.

Terapia con estimulación del nervio vago en pacientes con epilepsia fármaco-resistente y callosotomía previa.

OBJECTIVEnTo analyse the results of vagus nerve stimulation in patients with drug-resistant epilepsy and previous corpus callosotomy.nnnMATERIALS AND METHODSnWe prospectively reviewed data from patients with drug-resistant epilepsy who showed persistence of disabling seizures after undergoing corpus callosotomy, in whom it was not possible to identify an epileptogenic focus and who were subsequently treated with vagus nerve stimulation. Variables analysed included: age, gender, aetiology of epilepsy, frequency and characteristics of the crises and Engel scale classification, before and after vagal stimulator implant. Furthermore, the percentage differences in seizure frequency changes were also calculated.nnnRESULTSnFour patients were identified: two male and two female. The total seizure frequency had decreased between 20% and 81% after corpus callosotomy in three patients and one of them did not show any favourable response (Engel IVB). Following implantation of the stimulator they became reduced to between 57% and 100% after a mean follow-up period of 8.3 months (range: 3 to 12 months). Generalised seizures decreased between 71.4% and 100%, and focal seizures between 57.7% and 100%.nnnCONCLUSIONSnVagus nerve stimulation therapy proved to be an alternative for the reduction of seizure frequency in patients with drug-resistant epilepsy who suffered disabling seizures despite undergoing corpus callosotomy as primary surgery.

Meningioma de células claras intra-espinal: Presentación de un caso y revisión de la literatura

Resumen El meningioma de celulas claras es una variedad rara de meningioma, que se presenta con particular frecuencia a nivel del angulo ponto-cerebeloso y el canal raquideo. Se describe un caso de un paciente femenino de 28 anos de edad con un sindrome de cauda equina completo. La resonancia magnetica nuclear de columna lumbo-sacra revelo una lesion tumoral que ocupa el canal raquideo desde L3 a S1. Se realizo una reseccion subtotal cuyo examen histopatologico revelo un meningioma de celulas claras. Fue indicada radioterapia complementaria, sin embargo, se descubrio que la paciente estaba embarazada, por lo que debio ser pospuesta La recidiva fue clinicamente evidente a los siete meses, requiriendo nueva reseccion y radioterapia complementaria. Se realizo una revision sistematica de la literatura, exponiendose el comportamiento del meningioma de celulas claras dentro del canal espinal.

Metástasis dural como manifestación inicial de cáncer de próstata

Metastases of prostate cancer to intracranial meninges are rare and often confused with meningiomas or chronic subdural hematomas. These usually occur in patients with a known cancer diagnosis in advanced stages of the disease, and only in some rare cases do its manifestations precede the detection of the primary tumour. The clinical presentation is unspecific. However, due to the affinity of this tumour for the base of the skull, it must be included in the differential diagnosis of men over 70 years of age with cranial nerve palsy. nThe treatment of these lesions has not been standardized. Within the therapeutic options we find surgical resection, chemotherapy, radiotherapy or a combination of these measures, and yet survival is poor. nWe present the case of a 77 year old male patient whose initial symptoms of prostate cancer were caused by a metastatic lesion to the dura, confirmed by histopathology. We also review the epidemiological, clinical and imaging highlights of this condition.

Sacroiliac screw fixation: A mini review of surgical technique

The sacral percutaneous fixation has many advantages but can be associated with a significant exposure to X-ray radiation. Currently, sacroiliac screw fixation represents the only minimally invasive technique to stabilize the posterior pelvic ring. It is a technique that should be used by experienced surgeons. We present a practical review of important aspects of this technique.

Dystrophic thoracic spine dislocation associated with type-1 neurofibromatosis: Case report and rationale for treatment.

The authors report a rare case of spontaneous dystrophic thoracic spine dislocation in a 14-year-old boy with neurofibromatosis type 1 (NF-1). Anteroposterior and lateral standing radiographs showed a dysplastic kyphoscoliotic deformity, with the thoracic kyphosis and scoliosis measuring 75° and 69°, respectively. Three-dimensional reconstruction after computed tomography demonstrated spondyloptosis at T5-T6 with overlapping of T5 over T6 and T7. The patient underwent circumferential fusion with anterior fibular strut grafting mechanically secured between the inferior and superior endplates of T5 and T7 followed by an instrumented posterior fusion from T2 to L1 and thoracoplasty. There was satisfactory resolution of the deformity with stabilization at the last follow-up evaluation.

Tumor papilar del saco endolinfático: presentación catastrófica en un escolar

This was a 9-year-old female patient from a rural area, admitted to emergency service due to rapidly progressing deterioration of the state of consciousness. In the clinical examination, she was comatose, with bilateral nonreflective mydriasis, grade IV (House-Brackmann scale) right facial paralysis, absence of right corneal reflex and bilateral extensor motor responses to pain. When asked, the relatives did not report the presence of symptoms before her admission; in fact, they denied that the patient has any symptoms referring to the vestibular-cochlear system, such as vertigo, hypoacusis, hyperacusis, weakness of the facial muscles or instability in walking. The patient presented no other clinical signs that would suggest von Hippel--Lindau (VHL) disease.