Archivos de la categoría Articulos

Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke

Early decompressive hemicraniectomy reduces mortality without increasing the risk of very severe disability among patients 60 years of age or younger with complete or subtotal space-occupying middle-cerebral-artery infarction. Its benefit in older patients is uncertain.

METHODS:

We randomly assigned 112 patients 61 years of age or older (median, 70 years; range, 61 to 82) with malignant middle-cerebral-artery infarction to either conservative treatment in the intensive care unit (the control group) or hemicraniectomy (the hemicraniectomy group); assignments were made within 48 hours after the onset of symptoms. The primary end point was survival without severe disability (defined by a score of 0 to 4 on the modified Rankin scale, which ranges from 0 [no symptoms] to 6 [death]) 6 months after randomization.

RESULTS:

Hemicraniectomy improved the primary outcome; the proportion of patients who survived without severe disability was 38% in the hemicraniectomy group, as compared with 18% in the control group (odds ratio, 2.91; 95% confidence interval, 1.06 to 7.49; P=0.04). This difference resulted from lower mortality in the surgery group (33% vs. 70%). No patients had a modified Rankin scale score of 0 to 2 (survival with no disability or slight disability); 7% of patients in the surgery group and 3% of patients in the control group had a score of 3 (moderate disability); 32% and 15%, respectively, had a score of 4 (moderately severe disability [requirement for assistance with most bodily needs]); and 28% and 13%, respectively, had a score of 5 (severe disability). Infections were more frequent in the hemicraniectomy group, and herniation was more frequent in the control group.

CONCLUSIONS:

Hemicraniectomy increased survival without severe disability among patients 61 years of age or older with a malignant middle-cerebral-artery infarction. The majority of survivors required assistance with most bodily needs. (Funded by the Deutsche Forschungsgemeinschaft; DESTINY II Current Controlled Trials number, ISRCTN21702227.)1

  1. Jüttler E, Unterberg A, Woitzik J, Bösel J, Amiri H, Sakowitz OW, Gondan M,
    Schiller P, Limprecht R, Luntz S, Schneider H, Pinzer T, Hobohm C, Meixensberger
    J, Hacke W; DESTINY II Investigators. Hemicraniectomy in older patients with
    extensive middle-cerebral-artery stroke. N Engl J Med. 2014 Mar
    20;370(12):1091-100. doi: 10.1056/NEJMoa1311367. PubMed PMID: 24645942. []

We still lack scientific support as a first-tier therapy for the use of therapeutic hypothermia

A literature search for relevant articles in English published from year 2000 up to December 2013 found 19 studies. No signs of improvement in outcome from hypothermia were seen in the five pediatric studies. Varied results were reported in 14 studies on adult patients, 2 of which reported a tendency of higher mortality and worse neurological outcome, 4 reported lower mortality, and 9 reported favorable neurological outcome with hypothermia. The quality of several trials was low. The best-performed randomized studies showed no improvement in outcome by hypothermia-some even indicated worse outcome. TBI patients may suffer from hypothermia-induced pulmonary and coagulation side effects, from side effects of vasopressors when re-establishing the hypothermia-induced lowered blood pressure, and from a rebound increase in intracranial pressure (ICP) during and after rewarming. The difference between body temperature and temperature set by the biological thermostat may cause stress-induced worsening of the circulation and oxygenation in injured areas of the brain. These mechanisms may counteract neuroprotective effects of therapeutic hypothermia.

We still lack scientific support as a first-tier therapy for the use of therapeutic hypothermia in TBI patients for both adults and children, but it may still be an option as a second-tier therapy for refractory intracranial hypertension1

  1.  Sandestig A, Romner B, Grände PO. Therapeutic Hypothermia in Children and Adults with Severe Traumatic Brain Injury. Ther Hypothermia Temp Manag. 2014 Mar 1;4(1):10-20. Review. PubMed PMID: 24660099. []

Journal of Neurosurgery March 2014

Featured Article

Nonfunctioning pituitary adenoma

Nonfunctioning pituitary adenomas (NFAs) are the most common type of pituitary adenoma and, when symptomatic, typically require surgical removal as an initial means of management.
Treatment

Gamma Knife radiosurgery (GKRS) is an alternative therapeutic strategy for patients whose comorbidities substantially increase the risks of resection. In

Lee et al, evaluated the efficacy and safety of initial GKRS for NFAs.

An international group of three academic Gamma Knife centers retrospectively reviewed outcome data in 569 patients with NFAs.

Forty-one patients (7.2%) underwent GKRS as primary management for their NFAs because of an advanced age, multiple comorbidities, or patient preference. The median age at the time of radiosurgery was 69 years. Thirty-seven percent of the patients had hypopituitarism before GKRS. Patients received a median tumor margin dose of 12 Gy (range 6.2-25.0 Gy) at a median isodose of 50%. The overall tumor control rate was 92.7%, and the actuarial tumor control rate was 94% and 85% at 5 and 10 years postradiosurgery, respectively. Three patients with tumor growth or symptom progression underwent resection at 3, 3, and 96 months after GKRS, respectively. New or worsened hypopituitarism developed in 10 patients (24%) at a median interval of 37 months after GKRS. One patient suffered new-onset cranial nerve palsy. No other radiosurgical complications were noted. Delayed hypopituitarism was observed more often in patients who had received a tumor margin dose > 18 Gy (p = 0.038) and a maximum dose > 36 Gy (p = 0.025).

GKRS resulted in long-term control of NFAs in 85% of patients at 10 years. This experience suggests that GKRS provides long-term tumor control with an acceptable risk profile. This approach may be especially valuable in older patients, those with multiple comorbidities, and those who have endocrine-inactive tumors without visual compromise due to mass effect of the adenoma1.

Spine

Three-dimensional motion analysis of the cervical spine for comparison of anterior cervical decompression and fusion versus artificial disc replacement in 17 patients.

Cervical arthroplasty

Cervical arthroplasty with an artificial disc (AD) has emerged as an alternative to anterior cervical discectomy and fusion (ACDF) for the management of cervical spondylosis.

It is an effective, reliable, and safe procedure for the treatment of cervical degenerative disc disease. However, there is no definitive evidence that DCI arthroplasty has better intermediate-term results than anterior cervical discectomy and fusion (ACDF).

3D motion analysis data comparing patients after ACDF and AD replacement in ten patients who underwent C5-6 ACDF and 7 who underwent C5-6 AD replacement were enrolled. Using biplanar fluoroscopy and a model-based track technique (accurate up to 0.6 mm and 0.6°), motion analysis of axial rotation and flexion-extension of the neck was performed. Three nonoperative segments (C3-4, C4-5, and C6-7) were assessed for both intervertebral rotation (coronal, sagittal, and axial planes) and facet shear (anteroposterior and mediolateral). Results There was no difference in total neck motion comparing ACDF and AD replacement for neck extension (43.3° ± 10.2° vs 44.3° ± 12.6°, p = 0.866) and rotation (36.0° ± 6.5° vs 38.2° ± 9.3°, p = 0.576). For extension, when measured as a percentage of total neck motion, there was a greater amount of rotation at the nonoperated segments in the ACDF group than in the AD group (p = 0.003). When comparing specific motion segments, greater normalized rotation was seen in the ACDF group at C3-4 (33.2% ± 4.9% vs 26.8% ± 6.6%, p = 0.036) and C6-7 (28.5% ± 6.7% vs 20.5% ± 5.5%, p = 0.009) but not at C4-5 (33.5% ± 6.4% vs 31.8% ± 4.0%, p = 0.562). For neck rotation, greater rotation was observed at the nonoperative segments in the ACDF group than in the AD group (p = 0.024), but the differences between individual segments did not reach significance (p ≥ 0.146). Increased mediolateral facet shear was seen on neck extension with ACDF versus AD replacement (p = 0.008). Comparing each segment, C3-4 (0.9 ± 0.5 mm vs 0.4 ± 0.1 mm, p = 0.039) and C4-5 (1.0 ± 0.4 mm vs 0.5 ± 0.2 mm, p = 0.022) showed increased shear while C6-7 (1.0 ± 0.4 mm vs 1.0 ± 0.5 mm, p = 0.767) did not.

This study illustrates increased motion at nonoperative segments in patients who have undergone ACDF compared with those who have undergone AD replacement. Further studies will be required to examine whether these changes contribute to adjacent-segment disease 2.

Pediatrics

The comparative effectiveness of ventricular shunt placement versus endoscopic third ventriculostomy for initial treatment of hydrocephalus in infants.

In infants with hydrocephalus, a greater 1-year CSF diversion failure rate may occur after ETV compared with shunt placement. This risk is most significant for procedures performed within the first 90 days of life. Further investigation of the need for multiple reoperations, cost, and impact of surgeon and hospital experience is necessary to distinguish which treatment is more effective in the long term3

  1. Lee CC, Kano H, Yang HC, Xu Z, Yen CP, Chung WY, Pan DH, Lunsford LD, Sheehan JP. Initial Gamma Knife radiosurgery for nonfunctioning pituitary adenomas. J Neurosurg. 2014 Jan 3. [Epub ahead of print] PubMed PMID: 24405068. []
  2. McDonald CP, Chang V, McDonald M, Ramo N, Bey MJ, Bartol S. Three-dimensional motion analysis of the cervical spine for comparison of anterior cervical decompression and fusion versus artificial disc replacement in 17 patients. J Neurosurg Spine. 2013 Dec 20. [Epub ahead of print] PubMed PMID: 24359000. []
  3. Jernigan SC, Berry JG, Graham DA, Goumnerova L. The comparative effectiveness of ventricular shunt placement versus endoscopic third ventriculostomy for initial treatment of hydrocephalus in infants. J Neurosurg Pediatr. 2014 Jan 3. [Epub ahead of print] PubMed PMID: 24404970. []

Neurosurgery March 2014

March 2014 Issue of Neurosurgery is Online

03 March 2014The March 2014 issue of Neurosurgery is now online and full-text access is available for print subscribers. Non-subscribers may access all article abstracts and the full-text of selected articles.

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Artículo especial

Tracking and Sustaining Improvement Initiatives: Leveraging Quality Dashboards to Lead Change in a Neurosurgical Department

Cada vez más, hospitales y  médicos  adquieren conocimiento de estrategias y herramientas para mejorar la calidad empresarial.

En el 2007 el departamento de Neurocirugía de la Universidad de California Los Angeles (UCLA) creó unos indicadores de calidad para ayudar a gestionar las medidas de proceso y resultados con la finalidad de mejorar el rendimiento clínico y la atención al paciente .

En el 2009 , la dirección del departamento y la dirección médica trabajó  para alinear las prioridades de mejora de calidad de inversión. El contenido se ha rediseñado para incluir 3 áreas de prioridades: calidad y seguridad,  satisfacción del paciente , eficiencia y uso de los recursos. A través del tiempo , la calidad de la neurocirugía ha sido reconocida por su claridad y su éxito en las estrategias de gestión.

Se describe la creación, el diseño y  un resumen de la evolución del proceso, e ilustra la forma en que se puede utilizar como una herramienta poderosa de mejora y cambio.

También se discuten los posibles retos y orientaciones futuras de este conjunto de estrategias y llaves enfocadas a la administración y creación de conocimiento sobre el medio, a través del análisis de los datos existentes en un servicio de neurocirugía.