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

Objetivos. El objetivo principal del estudio es conseguir la identificación intraoperatoria de la función del área motora suplementaria (AMS) implicada en tareas motoras complejas. El objetivo secundario es valorar el pronóstico funcional tras la preservación quirúrgica de este área. Método. Se han seleccionado 15 pacientes con tumores cerebrales localizados en área premotora. Todos los pacientes fueron intervenidos despiertos. El córtex motor primario fue identificado mediante estimulación cerebral directa. Para identificar el AMS, el paciente realizó una tarea motora de oposición de dedos con la mano contralateral a la lesión que se bloqueaba mediante la estimulación eléctrica del córtex cerebral premotor. Resultados. El AMS pudo ser identificada en todos los pacientes mediante este método. La resección fue macroscópicamente completa en 13 pacientes (86.6%) y subtotal en 2 (13.3%). La función encontrada en el AMS se ha podido preservar en 14 pacientes (93,3%). Sólo en una paciente se resecó parcialmente el AMS funcional junto a la lesión por infiltración de la misma (6.6%). En el postoperatorio inmediato 8 pacientes (53.3%) presentaron empeoramiento de los déficits, cinco pacientes (33.3%) no mostraron cambios respecto a su exploración preoperatoria y 2 pacientes mejoraron. A los 6 meses de la intervención 5 pacientes (33.3%) se encuentran asintomáticos y 10 pacientes presentan déficits permanentes. En este último grupo, 5 pacientes (33.3%) muestran un déficit muy leve que no interfiere en su vida normal. En los otros 5 pacientes (33.3%) los déficits permanentes interfieren con la vida del paciente: dos pacientes presentan hemiparesia severa 3/5 (igual estado preoperatorio que no mejora), uno afasia de expresión y otros dos (13.3%) presentan un síndrome del AMS izquierda permanente. En los 2 pacientes con hemiparesia severa postoperatoria se objetivó intraoperatoriamente una infiltración tumoral del córtex motor primario y de la vía motora; el déficit motor severo preoperatorio (KPS

BACKGROUND: Microsurgical resection of arteriovenous malformations (AVMs) located in the language and motor cortex is associated with the risk of neurological deterioration, yet electrocortical stimulation mapping has not been widely used. OBJECTIVE: To demonstrate the usefulness of intraoperative mapping with language/ motor AVMs. METHODS: During an 11-year period, mapping was used in 12 of 431 patients (2.8%) undergoing AVM resection (5 patients with language and 7 patients with motor AVMs). Language mapping was performed under awake anesthesia and motor mapping under general anesthesia. RESULTS: Identification of a functional cortex enabled its preservation in 11 patients (92%), guided dissection through overlying sulci down to the nidus in 3 patients (25%), and influenced the extent of resection in 4 patients (33%). Eight patients (67%) had complete resections. Four patients (33%) had incomplete resections, with circumferentially dissected and subtotally disconnected AVMs left in situ, attached to areas of eloquence and with preserved venous drainage. All were subsequently treated with radiosurgery. At follow-up, 6 patients recovered completely, 3 patients were neurologically improved, and 3 patients had new neurological deficits. CONCLUSION: Indications for intraoperative mapping include preoperative functional imaging that identifies the language/motor cortex adjacent to the AVM; larger AVMs with higher Spetzler-Martin grades; and patients presenting with unruptured AVMs without deficits. Mapping identified the functional cortex, promoted careful tissue handling, and preserved function. Mapping may guide dissection to AVMs beneath the cortical surface, and it may impact the decision to resect the AVM completely. More conservative, subtotal circumdissections followed by radiosurgery may be an alternative to observation or radiosurgery alone in patients with larger language/motor cortex AVMs.

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.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.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.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.

Object Olfactory dysfunction has an important impact on quality of life. In patients with subarachnoid hemorrhage (SAH), anosmia has mainly been reported after surgery for aneurysms of the anterior communicating artery (ACoA). The authors studied whether and how frequently patients with ACoA aneurysms present with smell identification deficits in 2 treatment groups (endovascular and surgical treatment). Methods A prospective study was conducted of patients with SAH caused by ruptured ACoAs and who had a Glasgow Outcome Scale score of 1 or 2, in comparison with a control group matched by age and sex. Olfactory function was assessed using the University of Pennsylvania Smell Identification Test (UPSIT). Results A total of 39 patients were enrolled. A marked olfactory impairment was observed in patients with ruptured ACoAs compared with the control group (p < 0.001). Seventeen patients with ruptured ACoAs (44%) compared with 1 patient in the control group (3%) showed a smell identification deficit according to performance on the UPSIT (p < 0.001). Both groups that underwent treatment presented with olfactory impairment. Ten (59%) of 17 patients who underwent aneurysmal clip placement versus 6 (28.5%) of 21 patients who underwent coil embolization scored below the 25th percentile on the UPSIT, and surgical patients also performed worse than endovascular patients (p = 0.048). The authors observed a worse performance on the olfactory test in patients subjected to endovascular coil embolization when cerebral vasospasm (p = 0.037) or frontal cerebral lesions (p = 0.009) were present. This difference was not observed in patients who underwent surgery. Conclusions Olfactory disorders after SAH caused by rupture of the ACoA are very frequent and were present in both treatment groups. Cerebral vasospasm and frontal lobe lesions are related to worse performance on an olfactory test in patients undergoing endovascular coil embolization.

Introducción. La hemorragia subaracnoidea (HSA) continúa siendo una de las enfermedades de interés neuroquirúrgico de más alta morbilidad y mortalidad. Su estudio es clave a la hora de mejorar la atención de estos enfermos en nuestro medio. Con este fin el Grupo de Trabajo de Patología Vascular de la SENEC decidió la creación de una base de datos multicéntrica para su estudio. Material y métodos. Se incluyen en esta base de datos todos los casos de hemorragia subaracnoidea espontánea ingresados en los centros participantes de forma prospectiva desde Noviembre del año 2004 hasta Noviembre del 2007. Se decidieron de forma consensuada los campos a recoger incluyendo edad, antecedentes personales, características clínicas, características radiológicas y del aneurisma, tipo de tratamiento y complicaciones de la enfermedad, evolución según la escala de evolución de Glasgow (GOS) al alta y a los seis meses así como el resultado angiográfico del tratamiento. Todos los campos se recogieron en un formulario rellenable a través de una página web segura. Resultados. En los tres años en los que ha estado activa la base se han recogido un total de 1149 casos de HSA espontánea recogidos por 14 centros participantes. Se ha estimado que es necesario aproximadamente un tiempo de 3.4 minutos para rellenar cada caso. En cuanto a sus características generales la serie es similar a otras series hospitalarias no seleccionadas. La edad media de los enfermos incluidos es de unos 55 años y la relación mujer:hombre 4:3. En cuanto a la gravedad del sagrado inicial un 32% de los enfermos se encontraba en mal grado clínico (WFNS = 4 ó 5). El 5% de los pacientes fallecieron antes de realizarse una angiografía que confirmara el origen aneurismático del sangrado. Se confirmó el origen aneurismático en el 76% de los pacientes mientras que en el 19% no se encontró ninguna lesión vascular responsable del sangrado, siendo clasificados como HSA idiopática. En los pacientes en los que se detectó un aneurisma su tratamiento fue endovascular en el 47% de los casos, quirúrgico en el 39, mixto en el 3% y no recibieron tratamiento de su aneurisma el 11% de los pacientes por fallecimiento precoz. En cuanto a su evolución, la mortalidad global de la serie se sitúa en el 22%. Sólo el 40% de los enfermos con HSA aneurismática presentaron una buena evolución (GOS=5). Conclusiones. La HSA espontánea continúa siendo una enfermedad con alta morbilidad y mortalidad. Esta base de datos puede ser un instrumento para conocer mejor sus características en nuestro medio y mejorar sus resultados, ya que se trata de una serie multicéntrica hospitalaria no seleccionada. Sería pues recomendable que esta base constituyera el germen de un registro nacional de HSA espontánea. Introduction. Subarachnoid haemorrhage is one of the most severe neurosurgical diseases. Its study is crucial for improving the care of these patients in our environment. With this goal the Group for the Study of Neurovascular Pathology of the Spanish Society for Neurosurgery (SENEC) decided to create a multicenter registry for the study of this disease. Materials and methods. In this database we have prospectively included all cases with spontaneous subarachnoid haemorrhage admitted to the participant hospitals from November 2004 to November 2007. The fields to be included in the database were selected by consensus, including age, past medical history, clinical characteristics at admission, radiological characteristics including presence or absence of an aneurysm and its size and location, type and complications of the aneurysm treatment, outcome assessed by the Glasgow Outcome Scale (GOS) at discharge and six months after the bleeding as well as the angiographic result of the aneurysm treatment. All fields were collected by means of an electronic form posted in secure web page. Results. During the three years of study a total of 1149 patients have been included by 14 Hospitals. The time needed to fill in a patient in the registry is approximately 3.4 minutes. This series of patients with spontaneous SAH is similar to other non-selected in-hospital series of SAH. The mean age of the patients is 55 years and there is a 4:3 female to male ratio. In relation to the severity of the bleeding 32% of the patients were in poor clinical grade at admission (WFNS 4 or 5). 5% of the patients died before angiography could be performed. An aneurysm was confirmed as the origin of the bleeding in 76% of the patients (aSAH), while in 19% of the patients no lesion was found in the angiographic studies and were thus classified as idiopathic subarachnoid hemorrhage (ISAH). Of those patients with aSAH, 47% were treated endovascularly, 39% surgically, 3% received a combined treatment and 11% did not receive any treatment for their aneurysm because of early death. Regarding outcome, there is a 22% mortality in the series. Only 40% of the patients with aSAH reached a good outcome at discharge (GOS = 5). Conclusions. Spontaneous SAH continues to be a disease with high morbidity and mortality. This database can be an ideal instrument for improving the knowledge about this disease in our environment and to achieve better results. It would be desirable that this database could in the future be the origin of a national registry of spontaneous SAH.

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.

Surgical site infections (SSI) after neurosurgery have serious clinical consequences and increase costs. Surveillance of SSI after craniotomy is not carried out enough.

Spontaneous and non-spontaneous spinal epidural hematoma (SEH) is a rare condition in neurosurgical practice. It presents as an acute spinal cord compression and usually requires emergent surgical decompression. Recently non-surgical treatment (corticoid therapy) has been proposed in selected cases of SEH with good neurological recovery.To identify the prognostic factors of this condition. A treatment management based upon our results is proposed.Between 1985 and 2001, 22 patients suffering SEH were treated at our Department. Age, sex, initial neurological condition (evaluated using the Frankel grading scale), surgical timing, radiological data such as location, extension and degree of radiological cord compression, anticoagulation or antiplatelet therapy, epidural anesthesia and previous spinal surgery were analyzed in order to find prognostic factors. Finally, conservative or surgical treatment as well as final neurological condition were also considered for the analysis.The average age was 69 years with a male preponderance (72.7%). Surgical decompression was done in 17 cases, most of them (11 cases) presenting with high neurological deficit (Frankel A-B). Conservative treatment was used on 5 patients. Operated patients showed a larger degree of neurological recovery. The incidence of post-operative complications was of 13%.This study shows the efficiency of SEH surgical evacuation performed within the first 24 hours, particularly when the patient presents a severe neurological deficit (Frankel A-B). Patients presenting minimal neurological involvement (Frankel D-E) can be managed successfully with conservative treatment.

A 69-year-old man with rectal adenocarcinoma and no relevant medical history was scheduled for anterior resection of the tumor under combined anesthesia. The epidural catheter was removed 48 h after surgery. A clinical picture consistent with a diagnosis of epidural hematoma developed gradually and was confirmed by magnetic resonance imaging. The last dose of low molecular weight heparin had been administered 8 h before catheter removal and blood analyses were normal. Recovery was complete following laminectomy and evacuation of the hematoma 31 h after the onset of symptoms. Our analysis of the literature on conditions leading to epidural hematoma after catheter insertion revealed that complications may appear for unknown reasons even when catheter management and thrombolytic prophylaxis are appropriate. Nevertheless, the maneuver for removing an epidural catheter is clearly not risk-free and can cause complications. Monitoring after removal is therefore important if complications are to be detected early.

Introduction In 2009, Deletis et al. were the first to describe a method for eliciting the R1 component of BR in patients under general anaesthesia. The R1 includes trigeminal afferents, brainstem connections between trigeminal and facial nuclei and facial nerve. Therefore this technique might be considered a tool to intraoperatively monitor the involved structures in the reflex arc. In this work we compare the neurophysiologic behaviour of R1 component of BR and facial and/or trigeminal CoMEPs in 21 patients. Material and methods The study includes 21 patients diagnosed of skull base tumours that underwent surgery by the retrosigmoidal approach. Multimodal intraoperative monitoring was performed including: BR, lower facial and trigeminal CoMEPs, SEPs, MEPs and cranial nerve mapping. We used the published methodology by Deletis et al. to elicit BR and CoMEPs. Results Of the 21 patients, two patients with previous facial paresis did not have a BR. Of the 19 who had a BR; nine did not show changes in BR or CoMEPs during surgery. None of those had facial or trigeminal deficit postoperatively. Eight patients lost BR and presented significant decrement in amplitude of CoMEPs. Of these eight, five recovered all responses after stopping surgery momentarily, the other three didn’t recover responses and presented postoperative facial paresis. The last two patients lost BR during the surgery while CoMEPs didn’t show any change. We assumed that these changes in BR were due to changes in depth of anaesthesia. Conclusion There is a strong correlation between BR and CoMEPs changes during skull base surgery. BR and CoMEPs help to predict the clinical outcome of facial and trigeminal nerve function. BR should be included in the routine methodology for intraoperative monitoring skull base surgeries since is a reliable tool to monitor the structures involved in the reflex arc.

Since 1932 when Cushing's disease has been described, several important advances have been made in diagnosis and management. However several points remain obscure and there is no general agreement among authors. An accurate biological diagnosis is one of the difficulties found when we face a patient with hypercortisolism. In addition, corticotropin dependent syndrome should be distinguished from the independent one, as well as identifying the source of ACTH hypersecretion. The main problem in Cushing's disease is to localise the secreting adenoma and at the moment there is not any diagnostic method with absolute sensibility and specificity. Magnetic Resonance Imaging shows a sensibility of 77% and 87% especificity; inferior petrosal sinus sampling may help in localising the side, where the adenoma lies, although an appropriate technique is mandatory. New developing techniques, such as intraoperative doppler and assessment of ACTH levels in the peripituitary veins may help us in localising the source of ACTH hypersecretion. Sometimes the adenoma cannot be identified and a surgical exploration of the pituitary is required. If an adenoma is found, a 89% probility of curation has been reported; on the contrary, incomplete tumor removal, no tumor found at surgery, or the presence of the so-called corticotrop hyperplasia where followed of bad results and may explain the failed surgery. Then, hypofisectomy, hemi-hypofisectomy, radiotherapy, photon knife or gamma knife, may be of help in the control of this condition. We reviewed the recent literature and analysed the diagnostic strategies and teatments currently available for this illness. In addition we propose an algohritm for diagnosis and treatment and analyze our results in a consecutive series of 38 patients.

La evolucion radiologica de los aneurismas cerebrales tratados mediante coils GDC puede presentarse como repermeabilizacion de aneurismas completamente ocluidos, falta de oclusion y/o crecimiento de restos aneurismaticos. El riesgo potencial de esta evolucion es el sangrado. Las opciones terapeuticas en estos casos incluyen la reembolizacion o el tratamiento quirurgico. Entre los 1997–2000 hemos intervenido doce pacientes portadores de aneurismas cerebrales que habian sido embolizados con coils GDC como terapia inicial. Una tercera parte de ellos fueron remitidos desde Unidades de Terapia Endovascular distintas a la de nuestro centro. La serie se compone de 9 mujeres y tres hombres con edades entre 19 y 73 anos. Diez de 105 debutaron con HSA; la comunicante posterior fue la localizacion mas frecuente. Angiograficamente diez tenian cuello ancho (superior a 4 mm) y la embolizacion consiguio la oclusion del 100% en dos casos, mientras que en el resto fue inferior al 95%. Durante el periodo de seguimiento se observo resangrado en dos casos, falta de trombosis del resto aneurismatico en 7 y compactacion de coils en 5. La cirugia se llevo a cabo entre 6 meses y 5 anos desde el tratamiento inicial, consiguiendo la oclusion completa en 9 casos, y un resto de cuello en 1 caso. Dos pacientes fallecieron en el postoperatorio, siendo ambos aneurismas del territorio posterior. La morbilidad fue del 33%, transitoria en la mitad de los casos. Se analizan las dificultades quirurgicas, en terminos dificultad en la diseccion del cuello, manejo intraoperatorio de los coils y del material trombotico intraaneurismatico y presentacion de las estructuras vasculonerviosas adyacentes, proponiendo estrategias de manejo intraoperatorio.

Es convida a Ferrater a col·laborar en un número especial de la revista dedicat al pensament en el Quixot Cervantes Saavedra, Miguel de