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We aim to evaluate the usefulness of preoperative facial nerve tractography in determining the facial nerve position in cerebellopontine angle tumor resection and its value in helping to preserve facial nerve function during surgery.A prospective study was designed to include patients presenting with cerebellopontine angle tumors. Three-dimensional reconstruction of facial nerve tractography was performed and added to the usual preoperative testing in all patients. Facial nerve position was compared between tractography results and surgical findings. Moreover, facial nerve function was evaluated at baseline and during follow-up.Fifteen patients were included for analysis. Complete resection was obtained in 5 patients, near-total resection was achieved in 8 patients, and partial resection in 2 patients. We found a strong statistically significant concordance between the preoperative facial nerve tractography reconstruction and the intraoperative findings (complete concordance in 86.66% of all the cases; κ = 0.784; P0.0001). Facial nerve anatomic structure was preserved in all patients during surgery. At 6 months follow-up, 66.66% of patients had a facial nerve normal function or a mild dysfunction.Preoperative facial nerve tractography reconstruction showed a high correlation with intraoperative findings. Preoperative tractography information regarding facial nerve position and its cisternal course is valuable information and could help the surgeon in increasing the safety of the procedure during cerebellopontine angle tumor surgery.

The clinical manifestations of SARS-CoV-2 infection vary widely, from asymptomatic infection to the development of acute respiratory distress syndrome (ARDS) and death. The host response elicited by SARS-CoV-2 plays a key role in determining the clinical outcome. We hypothesized that determining the dynamic whole blood transcriptomic profile of hospitalized adult COVID-19 patients and characterizing the subgroup that develops severe disease and ARDS would broaden our understanding of the heterogeneity in clinical outcomes. We recruited 60 hospitalized patients with RT-PCR-confirmed SARS-CoV-2 infection, among whom 19 developed ARDS. Peripheral blood was collected using PAXGene RNA tubes within 24 h of admission and on day 7. There were 2572 differently expressed genes in patients with ARDS at baseline and 1149 at day 7. We found a dysregulated inflammatory response in COVID-19 ARDS patients, with an increased expression of genes related to pro-inflammatory molecules and neutrophil and macrophage activation at admission, in addition to an immune regulation loss. This led, in turn, to a higher expression of genes related to reactive oxygen species, protein polyubiquitination, and metalloproteinases in the latter stages. Some of the most significant differences in gene expression found between patients with and without ARDS corresponded to long non-coding RNA involved in epigenetic control.

Becoming aware of one's own states is a fundamental aspect for self-monitoring, allowing us to adjust our beliefs of the world to the changing context. Previous evidence points out to the key role of the anterior insular cortex (aIC) in evaluating the consequences of our own actions, especially whenever an error has occurred. In the present study, we propose a new multimodal protocol combining electrical stimulation mapping (ESM) and functional magnetic resonance imaging (fMRI) to explore the functional role of the aIC for self-monitoring in patients undergoing awake brain surgery. Our results using a modified version of the Stroop task tackling metacognitive abilities revealed new direct evidence of the involvement of the aIC in monitoring our performance, showing increased difficulties in detecting action-outcome mismatches when stimulating a cortical site located at the most posterior part of the aIC as well as significant BOLD activations at this region during outcome incongruences for self-made actions. Based on these preliminary results, we highlight the importance of assessing the aIC's functioning during tumor resection involving this region to evaluate metacognitive awareness of the self in patients undergoing awake brain surgery. In a similar vein, a better understanding of the aIC's role during self-monitoring may help shed light on action/outcome processing abnormalities reported in several neuropsychiatric disorders such as schizophrenia, anosognosia for hemiplegia or major depression.

Radiocirugia estereotàctica; Tractament; Eficàcia Radiocirugía estereotáctica; Tratamiento; Eficacia Stereotactic radiosurgery; Treatment; Effectiveness El objetivo principal del informe es evaluar la seguridad, la eficacia, la efectividad clínica y el costeefectividad de la radiocirugía estereotáctica frente al tratamiento habitual para la epilepsia, el temblor esencial, el temblor asociado a la enfermedad de Parkinson y las neuralgias del glosofaríngeo y del trigémino. Se consideran cuando estas patologías son farmacorresistentes/refractarias. The aim of this report is to evaluate the safety, efficacy, clinical effectiveness and cost-effectiveness of stereotactic radiosurgery versus standard treatment for epilepsy, essential tremor, tremor associated with Parkinson’s disease, and glossopharyngeal and trigeminal neuralgias, when these pathologies are drug-resistant/refractory L’objectiu d’aquest informe és avaluar la seguretat, l’eficàcia, l’efectivitat clínica i el cost-efectivitat de la radiocirurgia estereotàctica davant del tractament habitual per a l’epilèpsia, el tremolor essencial, el tremolor associat a la malaltia de Parkinson i les neuràlgies del glossofaringi i del trigemin, quan aquestes patologies són farmacoresistents/refractàries

Background Burr hole covering in brain surgical procedures can avoid complications and unaesthetic results. The aim of this registry was to assess the safety and performance of a new polymeric burr hole covering device (Cranial COVER, NEOS Surgery). Methods A multicenter, prospective, clinical registry design was used for the study. All the patients who fulfilled the inclusion criteria were included in the study and followed up for 6 months. Baseline clinical parameters, surgical variables (technical success of the implantation, surgeon satisfaction), postoperative variables (aesthetic and functional results, neuroimaging artifacts), and adverse events were evaluated. Results Forty-three Cranial COVER devices were implanted in 30 patients. Most of them were implanted in frontal locations (53.5%). After implantation, 97.7% of the devices completely covered the burr hole, and 100% perfectly adapted to the skull surface. All surgeons ranked their satisfaction with the implantation procedure as very high or high. No artifacts were detected in any of the neuroimaging studies performed and no adverse events related with the device or its implantation were reported during the follow-up. There were significantly more scalp depressions associated with uncovered than with Cranial COVER–covered burr holes (p = 0.040). Patient satisfaction with covered burr holes located in the frontal and parietal areas was 9.0 ± 1.4 over 10. Conclusion Cranial COVER is a safe and reliable burr hole covering system that offers excellent cosmetic results and high satisfaction rates for both surgeons and patients. Cranial COVER is highly adaptable to the skull surface, and it was predominantly used in frontal locations due to their cosmetic importance.

Contains fulltext : 248752.pdf (Publisher’s version ) (Open Access) Background and Purpose: Brain tumors can result in displacement or destruction of important white matter tracts such as the inferior fronto-occipital fascicle (IFOF). Diffusion tensor imaging (DTI) can assess the extent of this effect and potentially provide neurosurgeons with an accurate map to guide tumor resection; analyze IFOF displacement patterns in temporoinsular gliomas based on tumor grading and topography in the temporal lobe; and assess whether these patterns follow a predictable pattern, to assist in maximal tumor resection while preserving IFOF function. Methods: Thirty-four patients with temporal gliomas and available presurgical MRI were recruited. Twenty-two had insula infiltration. DTI deterministic region of interest (ROI)-based tractography was performed using commercial software. Tumor topographic imaging characteristics analyzed were as follows: location in the temporal lobe and extent of extratemporal involvement. Qualitative tractographic data obtained from directional DTI color maps included type of involvement (displaced/edematous-infiltrated/destroyed) and displacement direction. Quantitative tractographic data of ipsi- and contralateral IFOF included whole tract volume, fractional anisotropy, and fractional anisotropy of a 2-dimensional coronal ROI on the tract at the point of maximum tumor involvement. Results: The most common tract involvement pattern was edematous/infiltrative displacement. Displacement patterns depended on main tumor location in the temporal lobe and presence of insular involvement. All tumors showed superior displacement pattern. In lateral tumors, displacement tendency was medial. In medial tumors, displacement tendency was lateral. When we add insular involvement, the tendency was more medial displacement. A qualitative and quantitative assessment supported these results. Conclusions: IFOF displacement patterns are reproducible and suitable for temporoinsular gliomas presurgical planning. 9 p.

Background Surgical site infections after craniotomy (SSI-CRAN) significantly impact patient outcomes and healthcare costs by increasing length of stay and readmission and reoperation rates. However, to our knowledge, no study has yet analysed the economic impact of a surgical care bundle for preventing SSI-CRAN. The aim is to analyse the hospital cost saving after implementation of a care bundle for the prevention of SSI-CRAN. Methods A retrospective cost-analysis was performed, considering two periods: pre-care bundle (2013–2015) and care bundle (2016–2017). A bottom-up approach was used to calculate the costs associated with infection in patients who developed a SSI-CRAN in comparison to those who did not, in both periods and on a patient-by-patient basis. The derived cost of SSI-CRAN was calculated considering: (1) cost of the antibiotic treatment, (2) cost of length of stay in the neurosurgery ward within the 1-year follow up period, (3) cost of the re-intervention, and (4) cost of the implant for cranial reconstruction, when necessary. Results A total of 595 patients were included in the pre-care bundle period and 422 in the care bundle period. Mean cost of a craniotomy procedure was approximately €8000, rising to €24,000 in the case of SSI-CRAN. Mean yearly hospital costs fell by €502,857 in the care bundle period (€714,886 vs. €212,029). Extra costs between periods were mainly due to increased length of hospital stay (€573,555.3 vs. €183,958.9; difference: €389,596.4), followed by the cost of implant for cranial reconstruction (€69,803.4 vs. €9,936; difference: €59,867.4). Overall, implementation of the care bundle saved the hospital €500,844.3/year. Conclusion The implementation of a care bundle for SSI-CRAN had a significant economic impact. Hospitals should consider the deployment of this multimodal preventive strategy to reduce their SSI-CRAN rates, and also their costs.

Introduction Anterior inferior cerebellar artery (AICA) aneurysms are rare, accounting for 0.2%–1.3% of all intracranial aneurysms. The standard treatment is often endovascular embolization or neck clipping; however, sacrifice of the parent vessel is sometimes necessary. Addition of revascularization procedures is a subject of controversy. The occipital artery (OA) has been used as a donor for bypass, but recently there has been a trend toward intracranial-intracranial approaches. The posterior inferior cerebellar artery (PICA)-AICA side-to-side bypass may serve as a safe alternative. Objective To characterize the PICA-AICA side-to-side bypass and the OA-AICA end-to-side bypass and review the literature relevant to AICA revascularization. Methods We performed a far-lateral approach on 12 cadaveric specimens and analyzed the regional anatomy. On this basis, we performed either an OA-AICA or a PICA-AICA bypass and took morphometric measurements relevant to the technique. Results PICA-AICA bypass was successful in 6/12 specimens. The length of the flocculopeduncular segment was 42.6 ± 15.8 mm in the specimens in which the bypass was feasible and 26.2 ± 7.2 mm in those in which the bypass was not feasible (P = 0.04). Mean distance between AICA and PICA was 5.3 ± 4 mm in the specimens in which side-to-side bypass was feasible and 11.6 ± 4.2 mm in the specimens in which it was not (P = 0.02). OA-AICA end-to-side bypass was feasible in all the specimens (75% in the flocculopeduncular segment; 25% in the cortical segment). Conclusions This is the first cadaveric study analyzing the PICA-AICA side-to-side bypass for AICA revascularization. Our analyses provide evidence for the feasibility of this bypass and document the anatomic variations that may indicate its use.

The objective of this study is to determine the role of multimodal intraoperative neurophysiologic monitoring (IONM) in the overall outcome of intracranial aneurysms surgery, and the risk factors associated with ischemic complications. We grouped 268 ruptured and unruptured intracranial aneurysms surgically treated at our institution into 2 cohorts, based on the use of IONM (180; 67.16%) or non-use of IONM (88; 32.84%). The IONM technique used was multimodal: electroencephalogram (EEG), somatosensory evoked potentials (SSEPs), transcranial (TES), and direct cortical (DCS) stimulation motor evoked potentials (MEPs). There was a significant difference, with a reduction in perioperative strokes (p = 0.011) and better motor surgery-related outcome in the IONM group (p = 0.016). Independent risk factors identified for surgery ischemic complications were temporary clipping time ≥ 6'05″ (odds ratio [OR]: 3.03; 95% CI: 1.068-8.601; p = 0.037), aneurysm size ≥ 7.5 mm (OR: 2.65; 95% CI: 1.127-6.235; p = 0.026), and non-use of IONM (OR: 2.79; 95% CI: 1.171-6.636; p = 0.021). Conversely, aneurysm rupture was not detected as an independent risk factor (OR: 2.5; 95% CI: 0.55-4.55; p = 0.4). Longer temporary clipping time, larger aneurysm size, and the non-use of IONM could be considered as risk factors for ischemic complications during microsurgical clipping. A standardized designed protocol including multimodal IONM with DCS provides continuous information about blood supply and allows reduction of treatment-related morbidity. Multimodal IONM is a valuable technique in intracranial aneurysm surgery.

Gross total resection (GTR) is not always possible in acromegalic patients, especially in patients with invasive growth hormone-secreting adenomas. We analyzed the biochemical remission outcome in relation to extent of tumor resection and effectiveness of medical treatment in cases of remnant tumor.Retrospective analysis was performed of acromegalic patients operated on between 2002 and 2017. Preoperative imaging, tumor invasiveness, extent of resection, and biochemical remission were collected. Patients with tumor remnant not amenable to second surgery began medical treatment. The relationship between pituitary adenoma remnant volume and final biochemical outcome was analyzed.Of 120 acromegalic patients operated on, 82 underwent transsphenoidal microsurgery and 38 underwent endonasal endoscopic approach. GTR was achieved in 72 cases (60%); subtotal resection (STR), 21 (17.5%) cases; and partial resection, 27 (22.5%) cases. There was a nonsignificant higher rate of GTR/STR in patients who underwent endonasal endoscopic approach. However, a significantly higher remission rate (89.45% vs. 67.1%) was achieved in these patients (P0.01). Greater tumor volume and invasiveness were associated with a lower remission (P0.05). Patients with tumor remnant who achieved biochemical remission with added medical therapy had a significantly smaller tumor volume (P0.001).The more aggressive surgical resection is, the greater the chance of attaining final biochemical remission, whether or not GTR is achieved. Medical therapy effectiveness is enhanced in cases with STR. Invasive growth hormone-secreting macroadenomas that are not surgically amenable to total resection are best managed with a combination of safe STR and medical treatment.

Additional file 1. Resources and units costs.

In this review, we evaluate the knowledge gained so far about the neural bases of multilingual language processing obtained mainly through imaging and electrical stimulation mapping (ESM). We attempt to answer some key questions about multilingualism in the light of recent literature evidence, such as the degree of anatomical–functional integration of two or more languages in a multilingual brain, how the age of L2-acquisition affects language organization in the human brain, or how the brain controls more than one language. Finally, we highlight the future trends in multilingual language mapping.

Background Although surgical site infections after a craniotomy (SSI-CRANs) are a serious problem that involves significant morbidity and costs, information on their prevention is scarce. We aimed to determine whether the implementation of a care bundle was effective in preventing SSI-CRANs. Methods A historical control study was used to evaluate the care bundle, which included a preoperative shower with 4% chlorhexidine soap, appropriate hair removal, adequate preoperative systemic antibiotic prophylaxis, the administration of 1 g of vancomycin powder into the subgaleal space before closing, and a postoperative dressing of the incisional surgical wound with a sterile absorbent cover. Patients were divided into 2 groups: preintervention (January 2013 to December 2015) and intervention (January 2016 to December 2017). The primary study end point was the incidence of SSI-CRANs within 1 year postsurgery. Propensity score matching was performed, and differences between the 2 study periods were assessed using Cox regression models. Results A total of 595 and 422 patients were included in the preintervention and intervention periods, respectively. The incidence of SSI-CRANs was lower in the intervention period (15.3% vs 3.5%; P < .001). Using a propensity score model, 421 pairs of patients were matched. The care bundle intervention was independently associated with a reduced incidence of SSI-CRANs (adjusted odds ratio, 0.23; 95% confidence interval, .13–.40; P < .001). Conclusions The care bundle intervention was effective in reducing SSI-CRAN rates. The implementation of this multimodal preventive strategy should be considered in centers with high SSI-CRAN incidences.

Contains fulltext : 220228.pdf (Publisher’s version ) (Open Access) Objective; We studied an unusual case of global aphasia (GA) occurring after brain tumor removal and remitting one-month after surgery. After recovering, the patient reported on her experience during the episode, which suggested a partial preservation of language abilities (such as semantic processing) and the presence of inner speech (IS) despite a failure in overt speech production. Thus, we explored the role of IS and preserved language functions in the acute phase and investigated the neuroanatomical underpinnings of this severe breakdown in language processing. Method: A neuropsychological and language assessment tapping into language production, comprehension, attention and working memory was carried out both before and three months after surgery. In the acute stage a simplified protocol was tailored to assess the limited language abilities and further explore patient’s performance on different semantic tasks. The neuroanatomical dimension of these abrupt changes was provided by perioperative structural neuroimaging. Results: Language and neuropsychological performance were normal/close to normal both before and three months after surgery. In the acute stage, the patient presented severe difficulties with comprehension, production and repetition, whereas she was able to correctly perform tasks that requested conceptual analysis and non-verbal operations. After recovering, the patient reported that she had been able to internally formulate her thoughts despite her overt phonological errors during the episode. Structural neuroimaging revealed that an extra-axial blood collection affected the middle frontal areas during the acute stage and that the white matter circuitry was left-lateralized before surgery. Conclusions: We deemed that the global aphasia episode was produced by a combination of the post-operative extra-axial blood collection directly impacting left middle frontal areas and a left-lateralization of the arcuate and/or uncinated fasciculi before surgery. Additionally, we advocate for a comprehensive evaluation of linguistic function that includes the assessment of IS and non-expressive language functions in similar cases. 11 p.

Eloquent area surgery has become safer with the development of intraoperative neurophysiological monitoring and brain mapping techniques. However, the usefulness of intraoperative electric brain stimulation techniques applied to the management and surgical treatment of cavernous malformations in supratentorial eloquent areas is still not proven. With this study, we aim to describe our experience with the use of a tailored functional approach to treat cavernous malformations in supratentorial eloquent areas. Twenty patients harboring cavernous malformations located in supratentorial eloquent areas were surgically treated. Individualized functional approach, using intraoperative brain mapping and/or neurophysiological monitoring, was utilized in each case. Eleven patients underwent surgery under awake conditions; meanwhile, nine patients underwent asleep surgery. Total resection was achieved in 19 cases (95%). In one patient, the resection was not possible due to high motor functional parenchyma surrounding the lesion tested by direct cortical stimulation. Ten (50%) patients presented transient neurological worsening. All of them achieved total neurological recovery within the first year of follow-up. Among the patients who presented seizures, 85% achieved seizure-free status during follow-up. No major complications occurred. Intraoperative electric brain stimulation techniques applied by a trained multidisciplinary team provide a valuable aid for the treatment of certain cavernous malformations. Our results suggest that tailored functional approach could help surgeons in adapting surgical strategies to prevent patients’ permanent neurological damage.

Preoperative radiologic evaluation of pituitary adenomas is essential. Despite the efforts made to determine the achieved resection grade after pituitary adenoma surgery, there is a high level of disagreement among all the available classifications and measurement methods used. Our study aimed to determine pituitary adenoma imaging features, easily obtained from preoperative magnetic resonance, which could be used as resection predictor variables. Second, we analyzed the usefulness of the ellipsoid method in pituitary adenoma volume determination.Two-hundred and ninety-four pituitary adenomas, which were surgically treated in our department, were retrospectively analyzed. Age, gender, surgical approach, hormonal status, greater tumor diameter, volume, cavernous sinus invasion, and extent of resection were evaluated.One-hundred and forty-eight surgical procedures were conducted with a microsurgical transsphenoidal approach whereas 146 were conducted with an endoscopic endonasal approach. Gross total resection was achieved in 54.08% of cases. There were no significant differences in the extent of resection regarding the approach used, age, gender, or hormonal production by the tumor. Only Knosp grade (P0.001) and tumor volume (P0.05) had a statistically and independent significant relationship with the extent of resection. Furthermore, we found a high correlation between the calculated volume, using the ellipsoid method, and the volume measurement obtained with complex planimetry methods.Pituitary adenoma volume and cavernous sinus invasion, graded with the Knosp scale, are 2 pituitary tumor features that, when used in combination, predict the complexity of the surgery and the difficulty of achieving gross total resection in pituitary adenoma surgery.

OBJECTIVE Brain metastases are the most frequent intracranial malignant tumor in adults. Surgical intervention for metastases in eloquent areas remains controversial and challenging. Even when metastases are not infiltrating intra-parenchymal tumors, eloquent areas can be affected. Therefore, this study aimed to describe the role of a functional guided approach for the resection of brain metastases in the central region. METHODS Thirty-three patients (19 men and 14 women) with perirolandic metastases who were treated at the authors' institution were reviewed. All participants underwent resection using a functional guided approach, which consisted of using intraoperative brain mapping and/or neurophysiological monitoring to aid in the resection, depending on the functionality of the brain parenchyma surrounding each metastasis. Motor and sensory functions were monitored in all patients, and supplementary motor and language area functions were assessed in 5 and 4 patients, respectively. Clinical data were analyzed at presentation, discharge, and the 6-month follow-up. RESULTS The most frequent presenting symptom was seizure, followed by paresis. Gross-total removal of the metastasis was achieved in 31 patients (93.9%). There were 6 deaths during the follow-up period. After the removal of the metastasis, 6 patients (18.2%) presented with transient neurological worsening, of whom 4 had worsening of motor function impairment and 2 had acquired new sensory disturbances. Total recovery was achieved before the 3rd month of follow-up in all cases. Excluding those patients who died due to the progression of systemic illness, 88.9% of patients had a Karnofsky Performance Scale score greater than 80% at the 6-month follow-up. The mean survival time was 24.4 months after surgery. CONCLUSIONS The implementation of intraoperative electrical brain stimulation techniques in the resection of central region metastases may improve surgical planning and resection and may spare eloquent areas. This approach also facilitates maximal resection in these and other critical functional areas, thereby helping to avoid new postoperative neurological deficits. Avoiding permanent neurological deficits is critical for a good quality of life, especially in patients with a life expectancy of over a year.

OBJECTIVES: Since the introduction of endovascular treatment for cerebral aneurysms, hospitals in which subarachnoid hemorrhage is treated show different availability and/or preferences towards both treatment modalities. The main aim is to evaluate the clinical and angiographic results according to the hospital's treatment preferences applied. METHODS: This study was conducted based on use of the subarachnoid hemorrhage database of the Vascular Pathology Group of the Spanish Neurosurgery Society. Centers were classified into 3 subtypes according to an index in the relationship between endovascular and surgical treatment as: endovascular preference, high endovascular preference, and elevated surgical preference. The clinical results and angiographic results were evaluated among the 3 treatment strategies. RESULTS: From November 2004 to December 2017, 4282 subarachnoid hemorrhage patients were selected for the study: 630 (14.7%) patients from centers with surgical preference, 2766 (64.6%) from centers with endovascular preference, and 886 (20.7%) from centers with high endovascular preference. The surgical preference group obtained the best angiographic results associated with a greater complete exclusion (odds ratio: 1.359; 95% confidence interval: 1.025-1.801; P = 0.033). The surgical preference subgroup obtained the best outcome at discharge (65.45%), followed by the high endovascular preference group (61.5%) and the endovascular preference group (57.8%) (odds ratio: 1.359; 95% confidence interval: 1.025-1.801; P = 0.033). CONCLUSIONS: In Spain, there is significant variability in aneurysm exclusion treatment in aneurysmal subarachnoid hemorrhage. Surgical centers offer better results for both surgical and endovascular patients. A multidisciplinary approach and the maintenance of an elevated quality of surgical competence could be responsible for these results.

Background Although surgical site infection after craniotomy (SSI-CRAN) is a serious complication, risk factors for its development have not been well defined. We aim to identify the risk factors for developing SSI-CRAN in a large prospective cohort of adult patients undergoing craniotomy. Methods A series of consecutive patients who underwent craniotomy at a university hospital from January 2013 to December 2015 were prospectively assessed. Demographic, epidemiological, surgical, clinical and microbiological data were collected. Patients were followed up in an active post-discharge surveillance programm e for up to one year after surgery. Multivariate analysis was carried out to identify independent risk factors for SSI-CRAN. Results Among the 595 patients who underwent craniotomy, 91 (15.3%) episodes of SSI-CRAN were recorded, 67 (73.6%) of which were organ/space. Baseline demographic characteristics were similar among patients who developed SSI-CRAN and those who did not. The most frequent causative Gram-positive organisms were Cutibacterium acnes (23.1%) and Staphylococcus epidermidis (23.1%), whereas Enterobacter cloacae (12.1%) was the most commonly isolated Gram-negative agent. In the univariate analysis the factors associated with SSI-CRAN were ASA score > 2 (48.4% vs. 35.5% in SSI-CRAN and no SSI-CRAN respectively, p = 0.025), extrinsic tumour (28.6% vs. 19.2%, p = 0.05), and re-intervention (4.4% vs. 1.4%, p = 2 (AOR: 2.26, 95% CI: 1.32–3.87; p = .003) and re-intervention (OR: 8.93, 95% CI: 5.33–14.96; p

Rewiew of large studies assessing SSI-CRAN. (DOCX 18 kb)

STROBE Statement—Checklist of items that should be included in reports of cohort studies. (DOCX 18 kb)

Aneurysms of the anterior pontine segment of the anterior-inferior cerebellar artery (AICA) are uncommon. Their treatment is challenging because critical neurovascular structures are adjacent to it and the available surgical corridors are narrow and deep. Although endoscopic endonasal approaches are accepted for treating midline skull base lesions, their role in the treatment vascular lesions remains undefined. The present study is aimed to assess the anatomic feasibility of the endoscopic endonasal transclival (EET) approach for treating anterior pontine AICA aneurysms and compare it with the subtemporal anterior transpetrosal (SAT) approach.Twelve cadaveric specimens were prepared for surgical simulation. The AICAs were exposed using both EET and SAT approaches. Surgical window area and the length of the exposed artery were measured. The distance from the origin of the artery to the clip applied for proximal control was measured. The number of AICA perforators exposed and the anatomic features of each AICA were recorded.The EET approach provided a wider surgical window area compared with the SAT (P0.001). More AICA perforators were visualized using the EET approach (P0.05). To obtain proximal control of the AICA, an aneurysm clip could be applied closer to the origin of AICA using EET (0.2 ± 0.42 mm) compared with SAT (6.26 ± 3.4 mm) (P0.001).Clipping anterior pontine AICA aneurysms using the EET approach is feasible. Compared with SAT, the EET approach provides advantages in surgical window area, ensuring proximal control before aneurysm dissection, visualization of perforating branches, and better proximal control.

Published: 23 May 2018 The Supplementary Motor Area (SMA)—located in the superior and medial aspects of the superior frontal gyrus—is a preferential site of certain brain tumors and arteriovenous malformations, which often provoke the so-called SMA syndrome. The bulk of the literature studying this syndrome has focused on two of its most apparent symptoms: contralateral motor and speech deficits. Surprisingly, little attention has been given to working memory (WM) even though neuroimaging studies have implicated the SMA in this cognitive process. Given its relevance for higher-order functions, our main goal was to examine whether WM is compromised in SMA lesions. We also asked whether WM deficits might be reducible to processing speed (PS) difficulties. Given the connectivity of the SMA with prefrontal regions related to executive control (EC), as a secondary goal we examined whether SMA lesions also hampered EC. To this end, we tested 12 patients with lesions involving the left (i.e., the dominant) SMA. We also tested 12 healthy controls matched with patients for socio-demographic variables. To ensure that the results of this study can be easily transferred and implemented in clinical practice, we used widely-known clinical neuropsychological tests: WM and PS were measured with their respective Wechsler Adult Intelligence Scale indexes, and EC was tested with phonemic and semantic verbal fluency tasks. Non-parametric statistical methods revealed that patients showed deficits in the executive component of WM: they were able to sustain information temporarily but not to mentally manipulate this information. Such WM deficits were not subject to patients’ marginal PS impairment. Patients also showed reduced phonemic fluency, which disappeared after controlling for the influence of WM. This observation suggests that SMA damage does not seem to affect cognitive processes engaged by verbal fluency other than WM. In conclusion, WM impairment needs to be considered as part of the SMA syndrome. These findings represent the first evidence about the cognitive consequences (other than language) of damage to the SMA. Further research is needed to establish a more specific profile of WM impairment in SMA patients and determine the consequences of SMA damage for other cognitive functions. MH was supported by the Ramón y Cajal (RYC-2016-19477) research program (Spanish Ministry of Economy, Industry, and Competitiveness). MH also acknowledges financial support from the Diputación Foral de Gipuzkoa/Gipuzkoako Foru Aldundia (Programa FellowsGipuzkoa de atracción y retención de talento).

OBJECT Little attention has been given to the functional challenges of the insular approach to the resection of gliomas, despite the potential damage of essential neural networks that underlie the insula. The object of this study is to analyze the subcortical anatomy of the insular region when infiltrated by gliomas, and compare it with the normal anatomy in nontumoral hemispheres. METHODS Ten postmortem human hemispheres were dissected, with isolation of the inferior fronto-occipital fasciculus (IFOF) and the uncinate fasciculus. Probabilistic diffusion tensor imaging (DTI) tractography was used to analyze the subcortical anatomy of the insular region in 10 healthy volunteers and in 22 patients with insular Grade II and Grade III gliomas. The subcortical anatomy of the insular region in these 22 insular gliomas was compared with the normal anatomy in 20 nontumoral hemispheres. RESULTS In tumoral hemispheres, the distances between the peri-insular sulci and the lateral surface of the IFOF and uncinate fasciculus were enlarged (p < 0.05). Also in tumoral hemispheres, the IFOF was identified in 10 (90.9%) of 11 patients with an extent of resection less than 80%, and in 4 (36.4%) of 11 patients with an extent of resection equal to or greater than 80% (multivariate analysis: p = 0.03). CONCLUSIONS Insular gliomas grow in the space between the lateral surface of the IFOF and uncinate fasciculus and the insular surface, displacing and compressing the tracts medially. Moreover, these tracts may be completely infiltrated by the tumor, with a total disruption of the bundles. In the current study, the identification of the IFOF with DTI tractography was significantly associated with the extent of tumor resection. If the IFOF is not identified preoperatively, there is a high probability of achieving a resection greater than 80%.

Resumen Introduccion En la hemorragia subaracnoidea aneurismatica, la exclusion endovascular o quirurgica del aneurisma responsable del sangrado de la circulacion cerebral es mandatoria para prevenir el resangrado. En Espana no existen datos sobre la frecuencia de utilizacion de ambas tecnicas, el momento en el que se realiza el tratamiento, la existencia de variabilidad entre los diferentes centros que tratan estos pacientes o los factores que condicionan la eleccion de una u otra modalidad terapeutica. Objetivos 1) Describir la variabilidad en el uso del tratamiento endovascular o la cirugia en el tratamiento de estos pacientes entre los centros participantes. 2) Establecer que factores se relacionan con la eleccion del tipo de tratamiento y el resultado final. Material y metodos De la totalidad de los pacientes en la base de datos, se seleccionaron los 2150 casos con HSA aneurismatica confirmada provenientes de los 10 centros que incluyeron enfermos de forma regular durante el periodo 2004-2012 con un indice de cumplimentacion de las variables de estudio superior al 95%. Se realizo un analisis descriptivo con respecto al tipo de tratamiento utilizado y un estudio multivariable de regresion logistica para establecer los factores relacionados con la eleccion del tipo de tratamiento y con la evolucion final. Resultados La ratio de tratamiento endovascular/tratamiento quirurgico fue de 1,32. Se observo una elevada variabilidad con respecto al uso del tratamiento endovascular entre centros (32-80%). Un 17% de los aneurismas no recibieron tratamiento siendo este porcentaje mayor en aquellos centros con menor uso del tratamiento endovascular. Los centros con menor volumen de tratamiento trataban los aneurismas mas tardiamente. La edad y el mal grado al ingreso fueron factores que favorecieron el uso del tratamiento endovascular mientras que la localizacion a nivel de la cerebral media y las caracteristicas morfologicas poco favorables de tratamiento quirurgico. La eleccion del tipo de tratamiento o el volumen de pacientes tratados no influyeron en la evolucion final. Conclusiones Hay una elevada variabilidad intercentros en la eleccion del tipo de tratamiento de estos pacientes en Espana. El tratamiento endovascular permite que un mayor numero de pacientes sean tratados. La adherencia a las guias de tratamiento es moderado.

Electric stimulation mapping (ESM) is frequently used during brain surgery to localise higher cognitive functions to avoid post-chirurgical disabilities. Experiments with brain imaging techniques and neuropsychological studies showed differences in the cortical representation and processing of nouns and verbs. The goal of the present study was to investigate whether electric stimulation in specific sites in the frontal cortex disrupted noun and verb production selectively. We found that most of the stimulated areas showed disruption of both verbs and nouns at the inferior frontal gyrus. However, when selective effects were obtained, verbs were more prone to disruption than nouns with important individual differences. The overall results indicate that selective impairments can be observed at inferior and middle frontal regions and the action naming task seems to be more suitable to avoid post-chirurgical language disabilities, as it shows a greater sensitivity to disruption with ESM than the classical object naming task.

Anterior cervical discectomy has a low non-mechanical complication rate. In our literature review, we found 7 cases of delayed surgical site infection. We report a case of cervical prevertebral abscess due to Propionibacterium acnes 2 years after discectomy and arthroplasty, with a beta-2-transferrin false positive test as a complementary highlighted finding. We discuss the diagnosis and etiology of this rare delayed infectious complication.

Background Composite ganglioma and pleomorphic xanthoastrocytoma with anaplastic features in both components is an extremely rare glioneuronal tumor. Five cases of anaplastic progression in the glioma component have been reported. These tumors generally affect young patients who have brain tumor-related epilepsy, which are usually located in the temporal lobe or in the cerebellum and may have associated leptomeningeal spreading. Its current optimal treatment consists of maximal safe surgical resection and adjuvant chemoradiotherapy. Overall survival at 5 years is 33% in anaplastic pleomorphic xanthoastrocytoma and 53% in anaplastic ganglioglioma. Case Description We describe a progression from ganglioglioma to this composite anaplastic entity after 32 months of follow-up, with apparently nontumoral parenchyma separating the 2 components. Polymerase chain reaction showed a wild-type BRAF gene. Seven months after concomitant chemoradiotherapy, radiologic progression led to a second line of chemotherapy, and a third line of chemotherapy was initiated after a subsequent progression at 11 months. Conclusions This case may add some evidence in favor of the glioneuronal maldevelopment hypothesis to explain the oncogenesis of these neuroepithelial tumors.

To assess whether 1H-MRS may be useful to reinforce the radiological suspicion of PCNSL. In this retrospective study, we included 546 patients with untreated brain tumours in which single-voxel spectroscopy at TE 30 ms and 136 ms had been performed. The patients were split into two subgroups: “training set” and “test set.” Differences between PCNSL and five other types of intracranial tumours were assessed in the test set of patients using the Mann-Whitney U nonparametric test and cut-off values for pair-wise comparisons defined by constructing receiver operating characteristic curves. These thresholds were used to construct classifiers for binary comparison between PCNSL and non-PCNSL. The performance of the obtained classifiers was assessed in the independent test set of patients. Significant differences were found between PCNSL and the other groups evaluated. All bilateral comparisons performed in the test set obtained accuracy values above 70 % (71–89 %). Lipids were found to be useful to discriminate between PCNSL and glioblastoma/metastasis at short TE. Myo-inositol resonance was found to be very consistent for discriminating between PCNSL and astrocytomas at short TE. 1H-MRS is useful to reinforce diagnostic suspicion of PCNSL on MRI. • 1 H-MRS can be used to reinforce the diagnostic suspicion of PCNSL. • Lipids can be used to discriminate between PCNSL and GB/MET. • Myo-inositol resonance can be used to discriminate between PCNSL and astrocytomas.

There are no specific recommendations in clinical guidelines about the best time, imaging tests, or intervals for following up patients with intracranial aneurysms treated with endovascular techniques. We reviewed the literature, using the following keywords to search in the main medical databases: cerebral aneurysm, coils, endovascular procedure, and follow-up. Within the Cerebrovascular Disease Group of the Spanish Society of Neuroradiology, we aimed to propose recommendations and an orientative protocol based on the scientific evidence for using neuroimaging to monitor intracranial aneurysms that have been treated with endovascular techniques. We aimed to specify the most appropriate neuroimaging techniques, the interval, the time of follow-up, and the best approach to defining the imaging findings, with the ultimate goal of improving clinical outcomes while optimizing and rationalizing the use of available resources.

Resumen No existen recomendaciones especificas en las guias de practica clinica sobre el tiempo, prueba de imagen ni intervalo para controlar la evolucion de los aneurismas intracraneales tratados por via endovascular. Hemos revisado la bibliografia existente en las principales bases de datos medicas usando como palabras clave: aneurisma cerebral, espirales, procedimiento endovascular y seguimiento. Nuestro objetivo ha sido, dentro del Grupo de Enfermedades Cerebrovasculares de la Sociedad Espanola de Neurorradiologia, proponer unas recomendaciones y un protocolo orientativo, basados en la evidencia cientifica, para monitorizar mediante neuroimagen los aneurismas intracraneales tratados por tecnicas endovasculares, incluyendo las tecnicas de neuroimagen mas adecuadas, el intervalo, el tiempo de seguimiento y la mejor forma de definir los hallazgos radiologicos, con el objetivo de mejorar los resultados clinicos y optimizar y racionalizar los recursos disponibles.

Background Language switching (LS) is an important phenomena usually observed in some bilingual communities. The ability to switch languages is a very fast, efficient and flexible process, being a fundamental aspect of bilingual efficient language communication. The aim of the present study was to characterize the specific role of non-language specific prefrontal regions in the neural network involved in LS in bilingual patients, during awake brain surgery and using electrical stimulation mapping (ESM). Methods In order to identify the neural regions involved in LS we used, a new specific ESM protocol in two patients undergoing awake brain surgery. Besides, functional magnetic resonance imaging (fMRI), neuropsychological testing and the assessment of daily conversational LS patterns post-surgery were used as complementary imaging and behavioral assessments. Results The outcome of the multimodal ESM-fMRI neuroimaging comparison in both patients pointed out to the crucial involvement of the inferior and middle frontal cortices in LS. Conclusions The present results add to previous findings highlighting the important role of non-language specific frontal structures in regulating LS. The new protocol developed here might allow neurosurgeons to plan ahead for surgical intervention in multilingual patients to ensure the preservation of regions involved in LS and therefore the prevention of pathological language mixing after intervention.

Object Descriptions of temporal lobe arteriovenous malformations (AVMs) are inconsistent. To standardize reporting, the authors blended existing descriptions in the literature into an intuitive classification with 5 anatomical subtypes: lateral, medial, basal, sylvian, and ventricular. The authors' surgical experience with temporal lobe AVMs was reviewed according to these subtypes. Methods Eighty-eight patients with temporal lobe AVMs were treated surgically. Results Lateral temporal lobe AVMs were the most common (58 AVMs, 66%). Thirteen AVMs (15%) were medial, 9 (10%) were basal, and 5 (6%) were sylvian. Ventricular AVMs were least common (3 AVMs, 3%). A temporal craniotomy based over the ear was used in 64%. Complete AVM resection was achieved in 82 patients (93%). Four patients (5%) died in the perioperative period (6 in all were lost to follow-up); 71 (87%) of the remaining 82 patients had good outcomes (modified Rankin Scale scores 0–2); and 68 (83%) were unchanged or improved after surgery. Conclusions Categorization of temporal AVMs into subtypes can assist with surgical planning and also standardize reporting. Lateral AVMs are the easiest to expose surgically, with circumferential access to feeding arteries and draining veins at the AVM margins. Basal AVMs require a subtemporal approach, often with some transcortical dissection through the inferior temporal gyrus. Medial AVMs are exposed tangentially with an orbitozygomatic craniotomy and transsylvian dissection of anterior choroidal artery and posterior cerebral artery feeders in the medial cisterns. Medial AVMs posterior to the cerebral peduncle require transcortical approaches through the temporo-occipital gyrus. Sylvian AVMs require a wide sylvian fissure split and differentiation of normal arteries, terminal feeding arteries, and transit arteries. Ventricular AVMs require a transcortical approach through the inferior temporal gyrus that avoids the Meyer loop. Surgical results with temporal lobe AVMs are generally good, and classifying them does not offer any prediction of surgical risk.

Resumen Fundamento y objetivo Los objetivos de este estudio fueron: determinar la prevalencia de la enfermedad renal cronica (ERC) en pacientes con diabetes mellitus tipo 2 (DM2) mediante la estimacion del filtrado glomerular (FGe); comprobar los factores asociados a ERC; y en que medida el filtrado glomerular se relaciona con un riesgo aumentado de enfermedad cardiovascular (ECV). Pacientes y metodo Estudio observacional retrospectivo transversal. Revision de una muestra representativa de 500 historias clinicas seleccionada aleatoriamente del listado de 2.950 pacientes con DM2 de nuestra area. Se registraron datos sociodemograficos, comorbilidades, factores de riesgo cardiovascular, tratamientos farmacologicos y datos analiticos. La ERC se definio como FGe 2 y se clasifico en estadios segun la K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease . Resultados El 51,6% eran mujeres y la media de edad era de 66,2 anos. Se observo una prevalencia de ERC del 23,2%, con 108 casos (21,6%) en estadio 3 y 8 (1,6%) en estadio 4, sin ningun paciente en estadio 5. Un 70,4% eran hipertensos, un 67% tenian dislipidemia, el 17,6% eran fumadores y el 19% tenian antecedente de ECV (46% de ellos, cardiopatia isquemica). La presencia de ERC se relaciono con mas edad, sexo femenino, creatinina plasmatica elevada, presencia de microabuminuria y antecedentes de tabaquismo activo, HTA, dislipidemia y ECV. Al analizar los datos segun las categorias de ERC, desaparecia la relacion significativa con el tabaquismo. En el analisis multivariado existia relacion positiva con edad, sexo femenino, dislipidemia y cardiopatia isquemica. Conclusion En este estudio se confirma la elevada prevalencia de ERC en pacientes con DM2 y su relacion con la presencia de enfermedad cardiovascular.

Background Little is known regarding the optimal treatment of ventriculoperitoneal (VP) shunt infections in adults. Our aim was to assess the efficacy of treatment strategies and to identify factors that predict failure. Methods Retrospective, observational study of patients aged ≥12 years with VP shunt infections (1980 -2014). Therapeutic approaches were classified under 4 headings: only antibiotics (OA), one-stage shunt replacement (OSSR), two-stage shunt replacement (TSSR), and shunt removal without replacement (SR). The primary endpoint was failure of the treatment strategy, defined as the absence of definite cerebrospinal fluid (CSF) sterilization or related mortality. The parameters that predicted failure were analyzed using logistic regression. Results Of 108 episodes (51% male, median age 50 years), 86 were analyzed. Intravenous antibiotics were administered for a median of 19 days. Eighty episodes were treated using strategies that combined antibiotic and surgical treatment (37 TSSR, 24 SR, 19 OSSR) and 6 with OA. Failure occurred in 30% of episodes, mostly due to lack of CSF sterilization in OSSR and OA groups. Twelve percent died of related causes and 10% presented superinfection of the CSF temporary drainage/externalized peritoneal catheter. TSSR was the most effective strategy when VP shunt replacement was attempted. The only independent risk factor that predicted failure was retention of the VP shunt, regardless of the strategy. Conclusions This is the largest series of VP shunt infections in adults reported to date. VP shunt removal, particularly TSSR when the patient is shunt dependent, remains the optimal choice of treatment and does not increase morbidity.

OBJECTIVEMost knowledge regarding the anatomical organization of multilingualism is based on aphasiology and functional imaging studies. However, the results have still to be validated by the gold standard approach, namely electrical stimulation mapping (ESM) during awake neurosurgical procedures. In this ESM study the authors describe language representation in a highly specific group of 13 multilingual individuals, focusing on how age of acquisition may influence the cortical organization of language.METHODSThirteen patients who had a high degree of proficiency in multiple languages and were harboring lesions within the dominant, left hemisphere underwent ESM while being operated on under awake conditions. Demographic and language data were recorded in relation to age of language acquisition (for native languages and early- and late-acquired languages), neuropsychological pre- and postoperative language testing, the number and location of language sites, and overlapping distribution in terms of language acquisition time. Lesion growth patterns and histopathological characteristics, location, and size were also recorded. The distribution of language sites was analyzed with respect to age of acquisition and overlap.RESULTSThe functional language-related sites were distributed in the frontal (55%), temporal (29%), and parietal lobes (16%). The total number of native language sites was 47. Early-acquired languages (including native languages) were represented in 97 sites (55 overlapped) and late-acquired languages in 70 sites (45 overlapped). The overlapping distribution was 20% for early-early, 71% for early-late, and 9% for late-late. The average lesion size (maximum diameter) was 3.3 cm. There were 5 fast-growing and 7 slow-growing lesions.CONCLUSIONSCortical language distribution in multilingual patients is not homogeneous, and it is influenced by age of acquisition. Early-acquired languages have a greater cortical representation than languages acquired later. The prevalent native and early-acquired languages are largely represented within the perisylvian left hemisphere frontoparietotemporal areas, and the less prevalent late-acquired languages are mostly overlapped with them.

We present an extremely infrequent case of brain metastasis of a parotid tumor. To our knowledge, this is the second case reported of a brain metastasis of a malignant parotid tumor, carcinoma ex pleomorphic adenoma. Pleomorphic adenoma represents 60% of tumors of the parotid gland, and although it is a benign tumor, it can transform into carcinoma ex pleomorphic adenoma in 5% of cases, one of the most aggressive neoplasms of the salivary glands. We want to note the need for an accurate diagnostic. Thanks to aggressive surgical management, our patient survived more than 1½ years.

OBJECTIVE Subcortical electrical stimulation during brain surgery may allow localization of functionally crucial white matter fibers and thus tailoring of the tumor resection according to its functional limits. The arcuate fasciculus (AF) is a white matter bundle connecting frontal, temporal, and parietal cortical areas that is often disrupted by left brain lesions. It plays a critical role in several cognitive functions related to phonological processing, but current intraoperative monitoring methods do not yet allow mapping of this tract with sufficient precision. In the present study the authors aimed to test a new paradigm for the intraoperative monitoring of the AF. METHODS In this report, the authors studied 12 patients undergoing awake brain surgery for tumor resection with a related risk of AF damage. To preserve AF integrity and the cognitive processes sustained by this tract in the intraoperative context, the authors used real word repetition (WR) and nonword repetition (NWR) tasks as complements to standard picture naming. RESULTS Compared with the errors identified by WR or picture naming, the NWR task allowed the detection of subtle errors possibly related to AF alterations. Moreover, only 3 patients demonstrated phonological paraphasias in standard picture naming, and in 2 of these patients the paraphasias co-occurred with the total loss of WR and NWR ability. Before surgery, lesion volume predicted a patient's NWR performance. CONCLUSIONS The authors suggest that monitoring NWR intraoperatively may complement the standard naming tasks and could permit better preservation of the important language production functions subserved by the AF.

Biopsies extracted from brain cancer patients often display degraded ribosomal RNA, which makes them unusable in transcriptomic experiments. This has not been properly documented in previous works aimed at refining the molecular classification of brain cancer.To determine RNA integrity in a large cohort of human brain cancer biopsies and to evaluate different factors that may influence RNA integrity in both a murine model of glioblastoma and in additional subsets of patient biopsies.Total RNA was isolated from 255 biopsies of various human brain tumors (HBTs) and processed on a Bioanalyzer. Correct RNA integrity was considered for samples showing either the ribosomal 28S/18S peak ratio ≥ 1.2 or RNA integrity number ≥ 6. The time-dependent effect of ex vivo ischemia was evaluated in a murine model, whose results were tested in a new collection of 27 human biopsies. Multiple biopsy sampling was considered in a further set comprising 32 biopsies.The 255 human biopsies revealed a substantial percentage of samples displaying degraded RNA (27.5%). The murine model confirmed the known relevance of ex vivo ischemia time in increased RNA degradation. Human biopsies extracted immediately after cauterization showed a trend toward less RNA degradation. Combining snap freezing and multiple sampling of biopsies, the percentage of patients with degraded RNA was reduced by twofold (15.6%).We provide a first concise study of factors influencing RNA degradation in HBT biopsies. Immediate biopsy removal after cauterization of the tumor area, snap freezing, and multiple sampling improve RNA quality.

Object There are no specific studies about cranial nerve (CN) injury following mild head trauma (Glasgow Coma Scale Score 14–15) in the literature. The aim of this analysis was to document the incidence of CN injury after mild head trauma and to correlate the initial CT findings with the final outcome 1 year after injury. Methods The authors studied 49 consecutive patients affected by minor head trauma and CN lesions between January 2000 and January 2006. Detailed clinical and neurological examinations as well as CT studies using brain and bone windows were performed in all patients. Based on the CT findings the authors distinguished 3 types of traumatic injury: no lesion, skull base fracture, and other CT abnormalities. Patients were followed up for 1 year after head injury. The authors distinguished 3 grades of clinical recovery from CN palsy: no recovery, partial recovery, and complete recovery. Results Posttraumatic single nerve palsy was observed in 38 patients (77.6%), and multiple nerve injuries were observed in 11 (22.4%). Cranial nerves were affected in 62 cases. The most affected CN was the olfactory nerve (CN I), followed by the facial nerve (CN VII) and the oculomotor nerves (CNs III, IV, and VI). When more than 1 CN was involved, the most frequent association was between CNs VII and VIII. One year after head trauma, a CN deficit was present in 26 (81.2%) of the 32 cases with a skull base fracture, 12 (60%) of 20 cases with other CT abnormalities, and 3 (30%) of 10 cases without CT abnormalities. Conclusions Trivial head trauma that causes a minor head injury (Glasgow Coma Scale Score 14–15) can result in CN palsies with a similar distribution to moderate or severe head injuries. The CNs associated with the highest incidence of palsy in this study were the olfactory, facial, and oculomotor nerves. The trigeminal and lower CNs were rarely damaged. Oculomotor nerve injury can have a good prognosis, with a greater chance of recovery if no lesion is demonstrated on the initial CT scan.

Proposito. El grupo de trabajo de Patologia Vascular de la SENEC desarrollo y mantiene abierta una base de datos multicentrica que recoge los casos de hemorragia subaracnoidea espontanea. Con esta base se pretende analizar la problematica real que representa esta patologia en nuestro medio. Este trabajo se centra en el estudio del grupo de pacientes de la base que presentaron HSA idiopatica o de origen no aclarado (HSAI). Materiales y metodos. La base de datos recoge los casos de HSA espontanea de 16 hospitales espanoles a traves de una pagina Web compartida en Internet de forma segura. Se consideran variables epidemiologicas, clinicas y radiologicas, asi como la aparicion de complicaciones y la evolucion de los pacientes. Entre Noviembre de 2004 y Noviembre de 2007 se recogieron 220 pacientes con HSA idiopatica. Este grupo se ha analizado estadisticamente de forma global y subdividido en 3 grupos de acuerdo con el patron TC de sangrado inicial (de tipo aneurismatico, perimesencefalico o TC normal). 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 patron de sangrado aneurismatico en TC, hecho que se correlaciono con mayor edad, peor condicion clinica al ingreso, mayor grado Fisher de sangrado, mas frecuencia de hidrocefalia y peor evolucion, comparados con los casos de HSAI con sangrado en TC del tipo perimesencefalico (42,7%) o con TC normal (10,4%). Una vez superada la fase aguda, e independientemente del tipo de sangrado inicial, la evolucion de los pacientes con HSAI es globalmente buena y significativamente mejor que la de los pacientes con HSA aneurismatica. La unica variable con valor pronostico en los casos de HSAI, tras realizar un analisis de regresion logistica, es el grado clinico al ingreso. Conclusiones. La proporcion de casos de HSAI entre las HSA espontaneas esta disminuyendo en nuestro pais. Debe mantenerse la clasificacion de los casos de HSAI segun el patron de sangrado inicial en TC porque permite diferenciar grupos de mayor riesgo entre estos pacientes, aunque pueden aparecer complicaciones graves en todos los tipos de HSAI. La situacion clinica al ingreso es el factor individual pronostico mas importante en la evolucion de estos pacientes.

To analyse the association between individual initial computerized tomography (CT) scan characteristics and Glasgow Outcome Scale (GOS) and Extended Glasgow Outcome Scale (GOSE) improvement between 6 months and 1 year.Two hundred and twenty-four adult patients with severe traumatic brain injury and Glasgow Coma Scale (GCS) score of 8 or less who were admitted to an intensive care unit were studied. GOS and GOSE scores were obtained 6 and 12 months after injury in 203 subjects. Patients were predominantly male (84%) and median age was 35 years.Traumatic Coma Data Bank (TCDB) CT classification was associated with GOS/GOSE improvement between 6 months and 1 year, with diffuse injury type I, type II and evacuated mass improving more than diffuse injury type III, type IV and non-evacuated mass; for GOS 43/155 (28%) vs 3/48 (6%) (chi(2) = 9.66, p0.01) and for GOSE 71/155 (46%) vs 7/48 (15%) (chi(2) = 15.1, p0.01). CT individual abnormalities were not associated with GOS/GOSE improvement, with the exception of subarachnoid haemorrhage, which showed a negative association with GOSE improvement (chi(2) = 4.08, p0.05).TCDB CT scan classification and subarachnoid haemorrhage were associated with GOS/GOSE improvement from 6-12 months, but individual CT abnormalities were not associated.

To assess improvements in Glasgow Outcome Scale (GOS) and GOS extended (GOSE) scores between 6 months and 1 year following severe traumatic brain injury (TBI).One studied 214 adult patients with severe TBI with Glasgow Coma Scale (GCS)9 admitted to Intensive Care Unit (ICU). GOS scores were obtained 6 and 12 months after injury in 195 subjects. Patients were predominantly male (84%) and median age was 35 years.Outcome (GOS and GOSE at 6 months and 1 year) was better in the high GCS score at admission (6-8) group than in the low score group (3-5). The improvement in GOS scores between 6 months and 1 year was greater in the high GCS score at admission group than in the low score group. At 6 months, 75 patients had died and 120 survived. None died between the 6-12-month assessments; at 12 months, 36% had improved GOS score.GOS scores improved between 6-12 months after severe TBI in 36% of survivors and it is concluded that the expectancy of improvement is incomplete at 6 months. This improvement was greater in patients with better GCS scores (6-8) at admission than in those with worse GCS scores (3-5).

BACKGROUND Intraoperative identification and preservation of the corticospinal tract is often necessary for glioma resection. OBJECTIVE To make a proposal for intraoperative management with the high-frequency monopolar stimulation technique for monitoring the corticospinal tract. METHODS Ninety-two patients operated on with the assistance of the high-frequency monopolar stimulation. Clinical and neurophysiological data have been related with the motor status at 3 months to establish prognostic factors of motor deterioration. RESULTS Twenty-one patients (22.8%) presented intraoperative alterations in motor-evoked potentials (MEPs). Twelve (13%) presented an increment in the MEP threshold ≥5 mA (no deficit at 3 months). Two (2.2%) presented an MEP amplitude reduction >50% (100% deficit at 3 months). Seven (7.6%) had an intraoperative MEP loss (80% deficit at 3 months). Subcortical stimulation was positive in 75 patients (81.5%). Eighty-five patients were available for the analysis at 3 months. Fourteen presented new deficits (16.5%). Among them, 5 presented a deficit in nonmonitored muscles (5.9%) and 1 presented a new deficit not detected intraoperatively. The combination of patients with preoperative motor deficits, MEP deterioration, or loss and intensity of subcortical stimulation ≤3 mA showed the highest sensitivity and specificity in the prediction of new deficits. CONCLUSIONS Persistent MEP loss or deterioration is associated with a high probability of new deficits. It seems recommendable to stop the subcortical resection before obtaining a subcortical MEP threshold at 3 mA especially in patients with preoperative motor deficits. A careful selection of muscles for the registration of MEPs is mandatory to avoid deficits in nonmonitored muscles.

lenguaje en intervenciones quirúrgicas que incluyan resecciones. La estimulación magnética transcraneana repetitiva (rTMS) a demostrado también su capacidad para inducir alteraciones transitorias. Recientemente el desarrollo del Sistema de Navegación de TMS asegura precisa localización del sitio estimulado. El objetivo del trabajo es estudiar la confiabilidad de la estimulación magnética transcraneal repetitiva navegada (nrTMS) en la localización de los sitios del lenguaje. Métodos: Once pacientes seleccionados para mapeo del lenguaje por DCS fueron evaluados pre-cirugía con nrTMS. Los mapeos de lenguaje prequirúrgicos mediante nrTMS fueron comparados con DCS. Resultados: Un total de 25 nrTMS sitios del lenguaje y 38 DCS fueron localizados. La sensibilidad y la especificidad obtenida fue de 88.4 y 95.6, respectivamente. La distancia media fue evaluada en 4, 5mm. Conclusiones: Los dispositivos de nrTMS permiten la identificación de las áreas corticales del lenguaje. Con un alto grado de concordancia con el mapeo TMS. La nrTMS se muestra como una herramienta de interés en la investigación y aplicación práctica en la función del lenguaje.