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Background: Cerebellar arteriovenous malformations (cAVMs) are rare and challenging lesions with an aggressive natural history. The mechanisms whereby a patient can worsen clinically after a supratentorial AVM resection include an acute alteration in cerebral hemodynamics, which is a known cause of postoperative hyperemia, edema and/or hemorrhage. These phenomena has not been described for cAVMS. Moreover, the underlying pathophysiology of edema and hemorrhage after AVM resection still remains controversial., Methods: We report a patient that presented an abrupt neurological deterioration after cAVM surgical resection. Emergent external ventricular drainage to treat incipient hydrocephalus only partially reverted the patient's deterioration. Consecutive post-surgery CT images revealed fourth ventricle compression secondary to cerebellar swelling that concurred with a new neurological deterioration. Densitometric analysis was performed in these CT images to reveal the nature of these changes as well as their evolution over time., Results: Importantly, we demonstrated a dynamic increase in the cerebellum mean density at the interval of Hounsfield values which correspond to hyperemia values. These changes were dynamic, and when hyperemia resolved and cerebellar density returned to basal levels, the fourth ventricle re-expanded and the patient neurologically recovered., Conclusions: This study demonstrated the utility of quantitative CT image analysis in the context of hemodynamic alterations following cAVM resection. Densitometric CT analysis demonstrated that hyperemic changes, but not ischemic ones, were time-dependent and were responsible for swelling and hemorrhage that conditioned neurological status and patient's evolution., (Copyright © 2021 Sociedad Española de Neurocirugía. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background and Objectives: Traumatic axonal injury is the main cause of the cognitive and neuropsychological situation of patients after head trauma (TBI). Additionally, there are some evidences about the dynamic evolution of traumatic axonal injury. Although the diffusion tensor MRI (DTI) sequence is considered a useful technique for modifying the extent of the traumatic axonal injury, few studies have evaluated the longitudinal changes in the characteristics of the DTI and its relation to evolution of patients., Materials and Methods: We performed a prospective observational study in 118 patients with moderate to severe TBI. The study included clinical outcome assessment based on the Glasgow Outcome Scale Extended and serial DTI studies in the early subacute setting (<60 days) and 6 and 12 months after injury. Fractional anisotropy, axial and radial diffusivities were measured in the 3 portions of corpus callosum (genu, body, splenium) at each time point and compared to normalized values from an age-matched control group. Longitudinal fractional anisotropy analysis and its correlation with patient improvement was also done by non-parametric testing and ordinal regression analysis., Results: Although dynamic changes in DTI characteristics have been detected in the 3 portions of corpus callosum, patients continue to show lower fractional anisotropy and axial diffusivities values and higher radial diffusivities values compared to controls at the end of the period of study. We have also found differences in the pattern of DTI metrics change between subgroups of patients according with their favorable outcome CONCLUSIONS: The temporal profile of the change in DTI characteristics seems to provide important information about the clinical recovery of patients after TBI., (Copyright © 2019 Sociedad Española de Neurocirugía. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background and Objectives: Traumatic axonal injury (TAI) contributes significantly to mortality and morbidity after traumatic brain injury (TBI). Its identification is still a diagnostic challenge because of the limitations of conventional imaging techniques to characterized it. Diffusion tensor imaging (DTI) can indirectly identify areas of damaged white matter integrity by detecting water molecule diffusion alterations. Our main objective is to characterize the TAI using DTI at the early subacute stage in our series of moderate to severe TBI patients and to evaluate if there is a relationship between the information provided by the DTI and patient's outcome., Materials and Methods: We have obtained DTI data from 217 patients with moderate to severe TBI acquired at a median of 19 days after TBI, and patient DTI metrics were compared with data obtained from 58 age-matched healthy controls. Region of interest method was applied to obtain mean fractional anisotropy (FA) value in 28 white matter fiber bundles susceptible to TAI., Results: Our main results were that when we compared patients with controls, patients, regardless of TBI severity, showed significantly reduced mean FA in almost all region of interest measured. We found statistically significant correlation between FA metrics and some clinical characteristics. Additionally, the FA values of the three portions of Corpus callosum, Cingulum and cerebral peduncles measured at the early subacute stage were highly associated with outcome assessed at hospital discharge and at 6 and 12 months after TBI., Conclusions: We conclude that DTI is a useful tool to characterize TAI and the detection of FA reduction in the subacute stage after TBI is associated with long-term unfavorable outcome., (Copyright © 2019 Sociedad Española de Neurocirugía. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background and Objective: The use of histological degeneration scores in surgically-treated herniated lumbar discs is not common in clinical practice and its use has been primarily restricted to research. The objective of this study is to evaluate if there is an association between a higher grade of histological degeneration when compared with clinical or radiological parameters., Patients and Method: Retrospective consecutive analysis of 122 patients who underwent single-segment lumbar disc herniation surgery. Clinical information was available on all patients, while the histological study and preoperative magnetic resonance imaging were also retrieved for 75 patients. Clinical variables included age, duration of symptoms, neurological deficits, or affected deep tendon reflex. The preoperative magnetic resonance imaging was evaluated using Modic and Pfirrmann scores for the affected segment by 2 independent observers. Histological degeneration was evaluated using Weiler's score; the presence of inflammatory infiltrates and neovascularization, not included in the score, were also studied. Correlation and chi-square tests were used to assess the association between histological variables and clinical or radiological variables. Interobserver agreement was also evaluated for the MRI variables using weighted kappa., Results: No statistically significant correlation was found between histological variables (histological degeneration score, inflammatory infiltrates or neovascularization) and clinical or radiological variables. Interobserver agreement for radiological scores resulted in a kappa of 0.79 for the Pfirrmann scale and 0.65 for the Modic scale, both statistically significant., Conclusions: In our series of patients, we could not demonstrate any correlation between the degree of histological degeneration or the presence of inflammatory infiltrates when compared with radiological degeneration scales or clinical variables such as the patient's age or duration of symptoms., (Copyright © 2017 Sociedad Española de Neurocirugía. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background and Objectives: Several studies have shown misconceptions about brain injury in different populations. The aim of this study was to assess the knowledge and perceptions about brain injury of family members of neurosurgical patients in our hospital., Material and Methods: The participants (n=81) were relatives of patients admitted to the neurosurgery department between February and August 2016. They voluntarily completed a 19-item true-false format survey about brain injury based on a translation of other questionnaires used in previous studies from other countries (USA, Canada, UK, Ireland and New Zealand). Also, some sociodemographic data were collected (age, sex, education level and the patient's pathology). Data analysis was developed through graphical modelling with a regularisation parameter plotted on a network representing the association of the items of the questionnaire from the response pattern of participants., Results: Data analysis showed two conceptual areas with a high rate of wrong answers: behaviour and management of patients, and expectations about acquired brain injury recovery., Conclusions: The results obtained in this study would enable us to objectify misconceptions about acquired brain injury in patients' relatives attended in the neurosurgery department. This lack of knowledge could be a great obstacle in patients' recovery process. Therefore, we suggest placing the emphasis on the provision of information on brain injury to patients' families, especially with regard to its symptoms and course of development., (Copyright © 2017 Sociedad Española de Neurocirugía. Publicado por Elsevier España, S.L.U. All rights reserved.)

Chronic traumatic encephalopathy is a neurodegenerative disease produced by accumulated minor traumatic brain injuries; no definitive premortem diagnosis and no treatments are available for chronic traumatic encephalopathy. Risk factors associated with chronic traumatic encephalopathy include playing contact sports, presence of the apolipoprotein E4, and old age. Although it shares certain histopathological findings with Alzheimer disease, chronic traumatic encephalopathy has a more specific presentation (hyperphosphorylated tau protein deposited as neurofibrillary tangles, associated with neuropil threads and sometimes with beta-amyloid plaques). Its clinical presentation is insidious; patients show mild cognitive and emotional symptoms before progressing to parkinsonian motor signs and finally dementia. Results from new experimental diagnostic tools are promising, but these tools are not yet available. The mainstay of managing this disease is prevention and early detection of its first symptoms., (Copyright © 2014 Sociedad Española de Neurología. Publicado por Elsevier España, S.L.U. All rights reserved.)

A programme proposal for competency-based Neurosurgery training adapted to the specialization project is presented. This proposal has been developed by a group of neurosurgeons commissioned by the SENEC (Spanish Society of Neurosurgery) and could be modified to generate a final version that could come into force coinciding with the implementation of the specialization programme. This document aims to facilitate the test of the new programme included in the online version of our journal., Duration of the Programme: Total training period is 6 years; initial 2 years belong to the surgery specialization and remaining 4 years belong to core specialty period., Structure of the Programme: It is a competency-based programmed based on the map used by the US Accreditation Council for Graduate Medical Education (ACGME) including the following domains of clinical competency: Medical knowledge, patient care, communication skills, professionalism, practice-based learning and improvement, health systems, interprofessional collaboration and professional and personal development. Subcompetencies map in the domains of Knowledge and Patient care (including surgical competencies) was adapted to the one proposed by AANS and CNS (annex 1 of the programme). A subcompetency map was also used for the specialization rotations., Instruction Methods: Resident's training is based on personal study (self-learning) supported by efficient use of information sources and supervised clinical practice, including bioethical instruction, clinical management, research and learning techniques., Evaluation Methods: Resident evaluation proposal includes, among other instruments, theoretical knowledge tests, objective and structured evaluation of the level of clinical competency with real or standardised patients, global competency scales, 360-degree evaluation, clinical record audits, milestones for residents progress and self-assessment (annex 2). Besides, residents periodically assess the teaching commitment of the department's neurosurgeons and other professors participating in rotations, and annually assess the overall operation of the programme. Results of evaluations are registered, together with other relevant data, in the Resident's Book., Programme's National Committee: The creation of a Programme Committee directly attached to the SENEC (National Commission) that, aside from generating a final version of the programme, monitors its implementation (level of adherence and operation in the different departments), assumes the creation of test banks and the centralized administration of knowledge tests (in the middle of the residency and/or at the end of it) and centralizes information collected by tutors that could be used for re-accreditation of the services, is proposed., (Copyright © 2016 Sociedad Española de Neurocirugía. Published by Elsevier España. All rights reserved.)

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., (Copyright © 2014 Sociedad Española de Neurocirugía. Published by Elsevier España. All rights reserved.)

Introduction: The design of an appropriate method for the selection of medical graduates for residency posts is extremely important, not only for the efficiency of the method itself (accurate identification of most competent candidates), but also for its influence on the study and teaching methodologies operating in medical schools. Currently, there is a great variation in the criteria used in different countries and there is no definitively appropriate method. The use of isolated or combined criteria, such as the marks obtained by students in medical schools, their performance in tests of theoretical knowledge and evaluations of clinical competence, or personal interviews, have a limited value for identifying those candidates who will perform better during the residency and later on during independent practice., Objectives: To analyse the variability in the methodologies used for the selection of residents employed in different countries, in particular those used in the United Kingdom and USA, where external agencies and medical schools make systematic analyses of curriculum development. The advantages and disadvantages of national or transnational licensing examinations on the process of convergence and harmonization of medical degrees and residency programmes through Europe are discussed. The present analysis is used to design a new and more efficient multi-criteria methodology for resident selection in Spain, which will be published in the next issue of this journal., Conclusions: Since the multi-criteria methods used in UK and USA appear to be most consistent, these have been employed for designing the new methodology that could be applied in Spain. Although many experts in medical education reject national examinations for awarding medical degrees or ranking candidates for residency posts, it seems that, when appropriately designed, they can be used to verify the level of competence of graduating students without necessarily distorting curriculum implementation or improvement., (Copyright © 2014 Sociedad Española de Neurocirugía. Published by Elsevier España. All rights reserved.)

Objectives: To analyse the clinical, radiological and therapeutic variables of intracranial dural arteriovenous fistulae (DAVF) treated at our institution, and to assess the validity of the Borden and Cognard classifications and their correlation with the presenting symptoms., Material and Methods: The DAVF identified were retrospectively analysed. They were classified according to their location, drainage pattern and the Borden and Cognard classifications. We recorded the different treatments, their complications and efficacy., Results: There were 81DAVF identified between 1975 and 2012. The cavernous sinus (CS) location was the most frequent one. The Borden and Cognard classifications showed an interobserver Kappa index of 0.72 and 0.76 respectively. The odds ratio of aggressive presentation in the presence of cortical venous drainage (CVD) was 19.3 (2.8-132.4). No location, once adjusted by venous drainage pattern, showed significant association with an aggressive presentation. Endovascular transarterial treatment of cavernous sinus DAVF achieved symptomatic improvement of 78%, with a complication rate of 5%. The DAVF of non-CS locations, with CVD, treated surgically were angiographically shown cured in 100% of the cases, with no treatment-related complications., Conclusions: The presence of CVD was significantly associated with aggressive presentations. The Borden and Cognard classifications showed little interobserver variability. Endovascular treatment for CS DAVF is safe and relatively effective. Surgical treatment of non-CS DAVF with CVD is safe, effective and the first choice treatment in our environment., (Copyright © 2012 Sociedad Española de Neurocirugía. Published by Elsevier España. All rights reserved.)