Rosario Sarabia

Flow-diverter devices for intracranial aneurysms: systematic review and meta-analysis.

BACKGROUND Although the introduction of flow-diverter devices (FDDs) has aroused great enthusiasm, the level of evidence supporting their use has not been systematically evaluated. OBJECTIVE To report a systematic review of medical literature up to May 2012 on FDDs to assess the morbidity, case fatality rate, and efficacy of FDDs for intracranial aneurysms. METHODS The literature was searched by using MEDLINE, Embase, and all Evidence-Based Medicine in the OVID database. Eligibility criteria were studies including at least 10 patients, reporting duration of follow-up and number of patients lost to follow-up, and documenting the rate of aneurysm occlusion and death and neurological complications. The endpoints were angiographic success, early and late mortality, and neurological morbidity. RESULTS Fifteen studies were analyzed consisting of 897 patients with 1018 aneurysms. The mean value of methodological quality score was 14.4 using the STROBE score. The early mortality rate was 2.8% (95% confidence interval [CI]: 1.7-3.8; I(2) = 93.4%) and the late mortality rate was 1.3% (95% CI: 0.2-2.3; I(2) = 36.9%). The early neurological morbidity rate was 7.3% (95% CI: 5.7-9; I(2) = 91.8%) and the late morbidity rate was 2.6% (95% CI: 1.1-4; I(2) = 81.3%). The Egger test for early and late morbidity and aneurysm occlusion was <0.001. CONCLUSION With the available data from the studies, both heterogeneity and publication biases imply that the current clinical use of FDDs is not supported by high-quality evidence. In the absence of reliable evidence, the use of FDDs in patients eligible for more conventional treatments should be restricted to controlled clinical trials.

Comparison of the Clinical Presentation of Symptomatic Arteriovenous Malformations (Angiographically Visualized) and Occult Vascular Malformations

The authors compared the clinical presentations of angiographically apparent arteriovenous malformations (AVMs) and angiographically occult vascular malformations (AOVMs) of the brain in 188 consecutive patients treated when computed tomography and magnetic resonance were available. There were 133 patients (70.7%) with AVMs and 55 patients (29.2%) with AOVMs. AOVMs tended to occur more frequently in male patients and in the posterior fossa and to present earlier clinically than AVMs, but differences were not significant. One distinctive feature was the greater size of AVMs, as compared with AOVMs. Presentation by hemorrhage occurred in 64.3% of the patients with AVMs and in 61.8% of those with AOVMs. Malformations of both types located in the posterior fossa presented with hemorrhage more frequently (84.2% of AVMs and 78.5% of AOVMs) than similar lesions lying above the tentorium (60.8% of AVMs and 56% of AOVMs). Bleeding was more severe in patients with AVMs than in those with AOVMs, as indicated by the higher mortality associated with hemorrhage (7.5 vs. 3.6% of the cases) and the more frequent and marked decrease in the level of consciousness observed at admission (34 vs. 16.2% of drowsy or comatose patients). Brain hematomas caused by AVMs were on average bigger than those caused by AOVMs (58.8 and 20% of large hematomas, respectively), and intraventricular and subarachnoid hemorrhages were also more common and profuse in patients with AVMs. However, AOVMs bled subsequently more times than AVMs (61.7 vs. 15.6%), before they were diagnosed and treated, leading to a higher nonoperative morbidity (16.3 vs. 13.6%).(ABSTRACT TRUNCATED AT 250 WORDS)

Intraventricular morphine for intractable cancer pain: rationale, methods, clinical results

The experience with the administration of intraventricular morphine for the control of malignant pain in 197 patients is analyzed. Small doses of morphine injected via a ventricular reservoir provided satisfactory control of otherwise intractable pain in terminal cancer patients. Complete analgesia together with a favourable behavioral response was obtained without noticeable neurological changes or side‐effects annoying or severe enough for the patients to discontinue therapy. Tolerance was much less marked than with parenteral opiates. Chronic intraventricular therapy can be safely performed on an outpatient basis by injecting the opiate once or twice a day. The method may be improved by using refillable continuous‐infusion devices and new drugs able to retain the analgesic effects of morphine while eliminating the unwanted ones.

Subarachnoid haemorrhage of unknown aetiology.

SummaryThe authors review the literature on subarachnoid haemorrhage of unknown aetiology (SAHUE) and analyze a personal series of 212 patients diagnosed as SAHUE. These patients represent 30% of all cases of primary SAH admitted over a 14.5 year period.The age, sex, antecedents and initial clinical presentation of patients with SAHUE were indistinguishable from those of patients with subarachnoid haemorrhage due to ruptured aneurysm (SAHRA). However, the present series of SAHUE compare favourably with both a personal and a previously reported series of SAHRA insofar as clinical grade on admission (94% of patients in grades I–II of Botterell), presence of blood on CT (51%), vasospasm (5%), ischaemic deficits (3.3%), persistent hydrocephalus (3.5%), rebleeding (6%) and fatal result (3.9%) are concerned.The amount of blood on CT scan in our patients with SAHUE was associated with a significantly higher incidence of brain ischaemia and hydrocephalus but did not correlate with the Botterell grade on admission or final outcome, which were good in the majority of cases regardless of the presence or not of visible cisternal haemorrhage. The results of the present series confirm that the final prognosis of patients with primary SAH showing normal four-vessel cerebral angiography is essentially favourable.

Changes in systemic blood pressure and cardiac rhythm induced by therapeutic compression of the trigeminal ganglion.

Percutaneous compression of the trigeminal ganglion, which is currently being used for the control of trigeminal neuralgia, induces marked intraoperative elevations of the systemic blood pressure and heart rate changes, which may increase the risk of cardiovascular complications. We have analyzed the characteristics of the arterial hypertensive response and the cardiac rhythm changes induced by percutaneous compression of the trigeminal ganglion in 42 consecutive, unselected patients undergoing operations for essential trigeminal neuralgia under three different regimens of anesthesia. The first 22 patients (Group 1) underwent operations under brief general anesthesia without endotracheal intubation. The following 10 patients (Group 2) had general anesthesia with intubation and mechanical ventilation and received larger doses of hypnotic and analgesic agents. Finally, 10 more patients (Group 3), who had general anesthesia with intubation, underwent local anesthetic blockade of Meckels cave (injection of 1 ml of 1% lidocaine) before ganglion compression. Foramen ovale puncture elicited bradycardia in the majority of the patients of Groups 2 and 3, but only four patients (18%) of Group 1 showed bradycardia. Ganglion compression caused marked tachycardia in all patients of Groups 1 and 2; about one-third of the patients also had extrasystoles. By contrast, patients of Group 3, who had local anesthetic blockade of Meckels cave before ganglion compression, did not develop tachycardia or extrasystoles. Foramen ovale puncture elicited marked elevations of the systemic blood pressure in all patients. Ganglion compression further increased blood pressure, except in patients of Group 3, who had local anesthetic blockade of Meckels cave.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemorragia subaracnoidea aneurismática: guía de tratamiento del Grupo de Patología Vascular de la Sociedad Española de Neurocirugía

Resumen Se realiza una actualizacion sobre los aspectos mas importantes de la hemorragia subaracnoidea aneurismatica respecto a las guias previamente publicadas por el grupo de trabajo de la SENEC. Las recomendaciones propuestas deben considerarse como una guia general de manejo de esta patologia. Sin embargo, pueden ser modificadas, incluso de manera significativa por las circunstancias propias de cada caso clinico, o las variaciones en los recursos diagnosticos y terapeuticos del centro hospitalario que reciba al paciente.

Validation of a prognostic score for early mortality in severe head injury cases

OBJECT Traumatic brain injury (TBI) represents a large health and economic burden. Because of the inability of previous randomized controlled trials (RCTs) on TBI to demonstrate the expected benefit of reducing unfavorable outcomes, the IMPACT (International Mission on Prognosis and Analysis of Clinical Trials in TBI) and CRASH (Corticosteroid Randomisation After Significant Head Injury) studies provided new methods for performing prognostic studies of TBI. This study aimed to develop and externally validate a prognostic model for early death (within 48 hours). The secondary aim was to identify patients who were more likely to succumb to an early death to limit their inclusion in RCTs and to improve the efficiency of RCTs. METHODS The derivation cohort was recruited at 1 center, Hospital 12 de Octubre, Madrid (1990-2003, 925 patients). The validation cohort was recruited in 2004-2006 from 7 study centers (374 patients). The eligible patients had suffered closed severe TBIs. The study outcome was early death (within 48 hours post-TBI). The predictors were selected using logistic regression modeling with bootstrapping techniques, and a penalized reduction was used. A risk score was developed based on the regression coefficients of the variables included in the final model. RESULTS In the validation set, the final model showed a predictive ability of 50% (Nagelkerke R(2)), with an area under the receiver operating characteristic curve of 89% and an acceptable calibration (goodness-of-fit test, p = 0.32). The final model included 7 variables, and it was used to develop a risk score with a range from 0 to 20 points. Age provided 0, 1, 2, or 3 points depending on the age group; motor score provided 0 points, 2 (untestable), or 3 (no response); pupillary reactivity, 0, 2 (1 pupil reacted), or 6 (no pupil reacted); shock, 0 (no) or 2 (yes); subarachnoid hemorrhage, 0 or 1 (severe deposit); cisternal status, 0 or 3 (compressed/absent); and epidural hematoma, 0 (yes) or 2 (no). Based on the risk of early death estimated with the model, 4 risk of early death groups were established: low risk, sum score 0-3 (< 1% predicted mortality); moderate risk, sum score 4-8 (predicted mortality between 1% and 10%); high risk, sum score 9-12 (probability of early death between 10% and 50%); and very high risk, sum score 13-20 (early mortality probability > 50%). This score could be used for selecting patients for clinical studies. For example, if patients with very high risk scores were excluded from our study sample, the patients included (eligibility score < 13) would represent 80% of the original sample and only 23% of the patients who died early. CONCLUSIONS The combination of Glasgow Coma Scale score, CT scanning results, and secondary insult data into a prognostic score improved the prediction of early death and the classification of TBI patients.

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

Resumen Introduccion La hemorragia subaracnoidea (HSA) continua siendo una de las enfermedades de interes neuroquirurgico de mas alta morbilidad y mortalidad. Su estudio es clave a la hora de mejorar la atencion de estos enfermos en nuestro medio. Con este fin el Grupo de Trabajo de Patologia Vascular de la SENEC decidio la creacion de una base de datos multicentrica para su estudio. Material y metodos Se incluyen en esta base de datos todos los casos de hemorragia subaracnoidea espontanea ingresados en los centros participantes de forma prospectiva desde Noviembre del ano 2004 hasta Noviembre del 2007. Se decidieron de forma consensuada los campos a recoger incluyendo edad, antecedentes personales, caracteristicas clinicas, caracteristicas radiologicas y del aneurisma, tipo de tratamiento y complicaciones de la enfermedad, evolucion segun la escala de evolucion de Glasgow (GOS) al alta y a los seis meses asi como el resultado angiografico del tratamiento. Todos los campos se recogieron en un formulario rellenable a traves de una pagina web segura. Resultados En los tres anos en los que ha estado activa la base se han recogido un total de 1149 casos de HSA espontanea 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 caracteristicas generales la serie es similar a otras series hospitalarias no seleccionadas. La edad media de los enfermos incluidos es de unos 55 anos y la relacion mujer:hombre 4:3. En cuanto a la gravedad del sagrado inicial un 32% de los enfermos se encontraba en mal grado clinico (WFNS = 4 o 5). El 5% de los pacientes fallecieron antes de realizarse una angiografia que confirmara el origen aneurismatico del sangrado. Se confirmo el origen aneurismatico en el 76% de los pacientes mientras que en el 19% no se encontro ninguna lesion vascular responsable del sangrado, siendo clasificados como HSA idiopatica. En los pacientes en los que se detecto un aneurisma su tratamiento fue endovascular en el 47% de los casos, quirurgico 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 evolucion, la mortalidad global de la serie se situa en el 22%. Solo el 40% de los enfermos con HSA aneurismatica presentaron una buena evolucion (GOS=5). Conclusiones La HSA espontanea continua siendo una enfermedad con alta morbilidad y mortalidad. Esta base de datos puede ser un instrumento para conocer mejor sus caracteristicas en nuestro medio y mejorar sus resultados, ya que se trata de una serie multicentrica hospitalaria no seleccionada. Seria pues recomendable que esta base constituyera el germen de un registro nacional de HSA espontanea.

Percutaneous compression of the gasserian ganglion for trigeminal neuralgia

The case of a 68 year-old man who developed a fatal intracranial hemorrhagic complication following percutaneous compression of the gasserian ganglion for trigeminal neuralgia is reported. The complication was likely related to improper placement of the Fogarty catheter into the temporal fossa out of the Meckels cave. The anatomical structures at risk of damage by misplaced needle or catheter and some relevant technical details aimed to prevent extratrigeminal complications related with this and other percutaneous trigeminal lesioning procedures are analyzed.

Variabilidad en el manejo de la hemorragia subaracnoidea aneurismática en España: análisis de la base de datos multicéntrica del Grupo de Trabajo de Patología Vascular de la Sociedad Española de Neurocirugía

INTRODUCTION In aneurysmal subarachnoid haemorrhage, endovascular or surgical exclusion of the aneurysm responsible for the bleeding is mandatory to prevent re-bleeding. In Spain there is no data regarding the frequency of usage of the two techniques, the moment treatment is performed, the existence of variability among the different centres treating these patients or the factors that determine the election of the therapeutic modality. OBJECTIVES 1) To describe the variability in the use of endovascular treatment or surgery in the treatment of these patients among the participating centres. 2) To establish which factors are related to the election of treatment and outcome. MATERIALS AND METHODS Of all the patients included in the database, we selected 2,150 cases suffering confirmed aneurysmal subarachnoid haemorrhage from 10 centres that included patients regularly during the period between 2004 and 2012 with a data completeness index over 95%. A descriptive analysis on mode of aneurysm treatment was performed. A multivariate analysis of the factors related to treatment modality of the aneurysm and outcome was performed using logistic regression. RESULTS The ratio endovascular/surgical treatment was 1.32. There was high variability among centres regarding the frequency of endovascular treatment (32-80%). No treatment was given to 17% of the aneurysms, with this percentage being higher in the centres with lower rates of endovascular treatment. Lower volume centres treated aneurysms later. Age and poor clinical grade were factors related to the election of endovascular treatment, while middle cerebral artery location and unfavourable morphological criteria were factors of surgical treatment. The choice of treatment, guideline adherence and centre patient volume were not related to outcome. CONCLUSIONS There is high variability in the election of treatment modality among centres in Spain. Endovascular treatment allows more patients to have their aneurysm treated. Guideline adherence is moderate.