Category Archives: Management

Update: Atorvastatin for chronic subdural hematoma

Atorvastatin for chronic subdural hematoma

It is well known that inflammation influence chronic subdural hematoma (CSDH) formation to a large extent. Atorvastatin has pleiotropic effects on restraining inflammation and promoting angiogenesis besides its cholesterol-lowering function. Hence, atorvastatin may induce anti-inflammation effects and facilitate therapeutic effects for subdural hematoma (SDH).

Atorvastatin treatment may eliminate SDH and improve the neural function of the rats through its anti-inflammatory effects. Hence, it indicated that statin induced inflammatory modulation might play a significant role in rats 1).


Results of a preliminary prospective study showed that oral administration of atorvastatin is safe and effective in treating CSDH, offering a cost-effective alternative to surgery. A prospective randomized clinical trial is required to validate the effect of atorvastatin 2). 3).


Jiang et al. reported a clinical research trial protocol that was designed to evaluate the therapeutic effects of atorvastatin on CSDH 4).

Limited evidence suggests that oral atorvastatin may be beneficial in the management of CSDH. Further high-quality studies focused on dosage, duration, hematoma size are needed to further elucidate the role of atorvastatin in the management of CSDH 5).

A retrospective cohort comparison study has shown that CSDH with Atorvastatin had a lower rate of deterioration and burr-hole drainage 6).

The knowledge of the conservative treatment modalities for cSDH is sparse and based on small case series and low grade evidence. However, some treatment modalities seem promising even in symptomatic patients with large haematomas. Randomised controlled trials are currently underway, and will hopefully provide us with good evidence for or against the conservative treatment of cSDH 7).

Retracted articles

Atorvastatin administration may decrease the risks of recurrence.Patients with severe brain atrophy and bilateral CSDH are prone to the recurrence 8) is a retracted article 9).

Effect of atorvastatin on resolution of chronic subdural hematoma: a prospective observational study [RETRACTED] 10).

1)

Li T, Wang D, Tian Y, Yu H, Wang Y, Quan W, Cui W, Zhou L, Chen J, Jiang R, Zhang J. Effects of atorvastatin on the inflammation regulation and elimination of subdural hematoma in rats. J Neurol Sci. 2014 Jun 15;341(1-2):88-96. doi: 10.1016/j.jns.2014.04.009. Epub 2014 Apr 13. PubMed PMID: 24774750.
2)

Wang D, Li T, Tian Y, Wang S, Jin C, Wei H, Quan W, Wang J, Chen J, Dong J, Jiang R, Zhang J. Effects of atorvastatin on chronic subdural hematoma: a preliminary report from three medical centers. J Neurol Sci. 2014 Jan 15;336(1-2):237-42. doi: 10.1016/j.jns.2013.11.005. Epub 2013 Nov 14. PubMed PMID: 24269089.
3)

Xu M, Chen P, Zhu X, Wang C, Shi X, Yu B. Effects of Atorvastatin on Conservative and Surgical Treatments of Chronic Subdural Hematoma in Patients. World Neurosurg. 2016 Jul;91:23-8. doi: 10.1016/j.wneu.2016.03.067. Epub 2016 Mar 29. PubMed PMID: 27044372.
4)

Jiang R, Wang D, Poon WS, Lu YC, Li XG, Zhao SG, Wang RZ, You C, Yuan XR, Zhang JM, Feng H, Fei Z, Yu XG, Zhao YL, Hu J, Kang DZ, Yu RT, Gao GD, Zhu XD, Sun T, Hao JH, Liu XZ, Su N, Yue SY, Zhang JN. Effect of ATorvastatin On Chronic subdural Hematoma (ATOCH): a study protocol for a randomized controlled trial. Trials. 2015 Nov 18;16:528. doi: 10.1186/s13063-015-1045-y. PubMed PMID: 26581842; PubMed Central PMCID: PMC4652431.
5)

Qiu S, Zhuo W, Sun C, Su Z, Yan A, Shen L. Effects of atorvastatin on chronic subdural hematoma: A systematic review. Medicine (Baltimore). 2017 Jun;96(26):e7290. doi: 10.1097/MD.0000000000007290. Review. PubMed PMID: 28658127; PubMed Central PMCID: PMC5500049.
6)

Chan DY, Chan DT, Sun TF, Ng SC, Wong GK, Poon WS. The use of atorvastatin for chronic subdural haematoma: a retrospective cohort comparison study(). Br J Neurosurg. 2017 Feb;31(1):72-77. doi: 10.1080/02688697.2016.1208806. Epub 2016 Nov 23. PubMed PMID: 27881024.
7)

Soleman J, Noccera F, Mariani L. The conservative and pharmacological management of chronic subdural haematoma. Swiss Med Wkly. 2017 Jan 19;147:w14398. doi: smw.2017.14398. PubMed PMID: 28102879.
8)

Liu H, Luo Z, Liu Z, Yang J, Kan S. Atorvastatin May Attenuate Recurrence of Chronic Subdural Hematoma. Front Neurosci. 2016 Jun 28;10:303. doi: 10.3389/fnins.2016.00303. eCollection 2016. Retraction in: Front Neurosci. 2016 Oct 07;10 :465. PubMed PMID: 27445673; PubMed Central PMCID: PMC4923224.
9)

Frontiers Editorial Office. Retraction: Atorvastatin May Attenuate Recurrence of Chronic Subdural Hematoma. Front Neurosci. 2016 Oct 7;10:465. eCollection 2016. PubMed PMID: 27738420; PubMed Central PMCID: PMC5054353.
10)

Liu H, Liu Z, Liu Y, Kan S, Yang J, Liu H. Effect of atorvastatin on resolution of chronic subdural hematoma: a prospective observational study [RETRACTED]. J Neurosurg. 2016 Jul 29:1-10. doi: 10.3171/2015.12.JNS151991. [Epub ahead of print] Retraction in: J Neurosurg. 2017 Feb;126(2):651. PubMed PMID: 27471887.

Controversies in Spinal and Cranial Surgery, An Issue of Neurosurgery Clinics of North America, 1e (The Clinics: Internal Medicine)

Controversies in Spinal and Cranial Surgery, An Issue of Neurosurgery Clinics of North America, 1e (The Clinics: Internal Medicine)
By Russell R. Lonser, Daniel K. Resnick MD MS

Controversies in Spinal and Cranial Surgery, An Issue of Neurosurgery Clinics of North America, 1e (The Clinics: Internal Medicine)

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This issue of Neurosurgery Clinics focuses on Controversies in Spinal and Cranial Surgery. Article topics will include:Sacro-illiac Fusion; Interspinous Spacers;Bone Morphogenetic Protein, Platelet Concentrates and Other Biologics; MIS decompression; Pipeline flow diversion in subarachnoid hemorrhage; Direct versus indirect bypass for moyamoya disease; Management of prenatally diagnosed myelomeningocele; Management of incidental aneurysm; Surgical management of incidental low-grade glioma; and more!


Product Details

  • Published on: 2017-06-28
  • Original language: English
  • Binding: Hardcover

Editorial Reviews

About the Author
Dr. Russell R. Lonser is professor and chair of the Department of Neurological Surgery at Ohio State University. His research interests include the development of drug delivery paradigms for the central nervous system pathology, as well as investigation of tumor pathogenesis and biology. His clinical and surgical interests are centered on the treatment of brain, skull base, and spinal cord tumors. He is an author on over 250 scientific and clinical publications. He received the Young Investigator Award in 2001 and Mahaley Clinical Research Award in 2013 from the Joint Section on Tumors. He is co-inventor on a patent for imaging delivery of therapeutic agents in the nervous system. He has served the Congress of Neurological Surgeons as past President, a member-at-large of the Executive Committee, scientific meeting chair, Annual Meeting chair, and treasurer. He has been actively involved in the mentoring and training of over 40 neurosurgical fellows. He is on the editorial boards for Neurosurgery, World Neurosurgery and Journal of Neurosurgery. He is an Academic Editor for PLoS One and Science Reports and is consulting editor for Neurosurgery Clinics of North America.

Mannitol for intraoperative brain relaxation

The risk of brain edema after dural opening is high in patients with midline shift undergoing supratentorial tumor surgery. Brain swelling may result in intracranial hypertension, impeded tumor exposure, and adverse outcomes. Mannitol is recommended as a first-line dehydration treatment to reduce brain edema and enable brain relaxation during neurosurgery. Research has indicated that mannitol enhanced brain relaxation in patients undergoing supratentorial tumor surgery; however, these results need further confirmation, and the optimal mannitol dose has not yet been established 1).

Some clinicians 2) 3) advocate high doses (>1.0 g/kg) of mannitol to effectively reduce intracranial pressure, while others recommend lower doses (<1.0 g/kg) 4) 5).

Treatment guidelines for using mannitol in patients with traumatic brain injury and stroke have been published and provide recommendations regarding the dose and timing of mannitol. However, there is still controversy concerning dehydration treatment with mannitol in patients with preoperatively increased intracranial pressure during brain tumor surgery.


Seo et al. sought to determine the dose of mannitol that provides adequate brain relaxation with the fewest adverse effects.

A total of 124 patients were randomized to receive mannitol at 0.25 g/kg (Group A), 0.5 g/kg (Group B), 1.0 g/kg (Group C), and 1.5 g/kg (Group D). The degree of brain relaxation was classified according to a 4-point scale (1, bulging; 2, firm; 3, adequate; and 4, perfectly relaxed) by neurosurgeons; Classes 3 and 4 were considered to indicate satisfactory brain relaxation. The osmolality gap (OG) and serum electrolytes were measured before and after mannitol administration.

The brain relaxation score showed an increasing trend in patients receiving higher doses of mannitol (p = 0.005). The incidence of satisfactory brain relaxation was higher in Groups C and D than in Group A (67.7% and 64.5% vs 32.2%, p = 0.011 and 0.022, respectively). The incidence of OG greater than 10 mOsm/kg was also higher in Groups C and D than in Group A (100.0% in both groups vs 77.4%, p = 0.011 for both). The incidence of moderate hyponatremia (125 mmol/L ≤ Na+ < 130 mmol/L) was significantly higher in Group D than in other groups (38.7% vs 0.0%, 9.7%, and 12.9% in Groups A, B, and C; p < 0.001, p = 0.008, and p = 0.020, respectively). Hyperkalemia (K+ > 5.0 mmol/L) was observed in 12.9% of patients in Group D only.

The higher doses of mannitol provided better brain relaxation but were associated with more adverse effects. Considering the balance between the benefits and risks of mannitol, the authors suggest the use of 1.0 g/kg of intraoperative mannitol for satisfactory brain relaxation with the fewest adverse effects. Clinical trial registration no.: NCT02168075 ( clinicaltrials.gov ) 6).

1)

Peng Y, Liu X, Wang A, Han R. The effect of mannitol on intraoperative brain relaxation in patients undergoing supratentorial tumor surgery: study protocol for a randomized controlled trial. Trials. 2014 May 10;15:165. doi: 10.1186/1745-6215-15-165. PubMed PMID: 24884731; PubMed Central PMCID: PMC4018619.
2)

Wise BL. High-dose mannitol. J Neurosurg. 2004;101:566–567.
3)

Cruz J, Minoja G, Okuchi K, Facco E. Successful use of the new high-dose mannitol treatment in patients with Glasgow Coma Scale scores of 3 and bilateral abnormal pupillary widening: a randomized trial. J Neurosurg. 2004 Mar;100(3):376-83. PubMed PMID: 15035271.
4)

Myburgh JA, Lewis SB. Mannitol for resuscitation in acute head injury: effects on cerebral perfusion and osmolality. Crit Care Resusc. 2000;2:14–18
5)

Sorani MD, Morabito D, Rosenthal G, Giacomini KM, Manley GT. Characterizing the dose–response relationship between mannitol and intracranial pressure in traumatic brain injury patients using a high-frequency physiological data collection system. J Neurotrauma. 2008;25:291–298. doi: 10.1089/neu.2007.0411.
6)

Seo H, Kim E, Jung H, Lim YJ, Kim JW, Park CK, Se YB, Jeon YT, Hwang JW, Park HP. A prospective randomized trial of the optimal dose of mannitol for intraoperative brain relaxation in patients undergoing craniotomy for supratentorial brain tumor resection. J Neurosurg. 2017 Jun;126(6):1839-1846. doi: 10.3171/2016.6.JNS16537. Epub 2016 Aug 19. PubMed PMID: 27540904.

European Training

Training is the acquisition of knowledge, skills, and competencies as a result of the teaching of vocational or practical skills and knowledge that relate to specific useful competencies. Training has specific goals of improving one’s capability, capacity, productivity and performance. It forms the core of apprenticeships and provides the backbone of content at institutes of neurosurgery.

In addition to the basic training required for a trade, occupation or profession, observers of the labor-market recognize as of 2008 the need to continue training beyond initial qualifications: to maintain, upgrade and update skills throughout working life. People within many professions and occupations may refer to this sort of training as professional development.

The introduction of the European Working Time directive 2003/88/EC has led to a reduction of the working hours with distinct impact on the clinical and surgical activity of neurosurgical residents in training.

A survey was performed among European neurosurgical residents between 06/2014 and 03/2015. Multiple logistic regression was used to assess the relationship between responder-specific variables (e.g., age, gender, country, postgraduate year (PGY)) and outcome (e.g., working time).

A total of 652 responses were collected, of which n = 532 responses were taken into consideration. In total, 17.5, 22.1, 29.5, 19.5, 5.9, and 5.5 % of European residents indicated to work <40, 40-50, 51-60, 61-70, 71-80, or >80 h/week, respectively. Residents from France and Turkey (OR 4.72, 95 % CI 1.29-17.17, p = 0.019) and Germany (OR 2.06, 95 % CI 1.15-3.67, p = 0.014) were more likely to work >60 h/week than residents from other European countries. In total, 29 % of European residents were satisfied with their current working time, 11.3 % indicated to prefer reduced working time. More than half (55 %) would prefer to work more hours/week if this would improve their clinical education. Residents that rated their operative exposure as insufficient were 2.3 times as likely as others to be willing to work more hours (OR 2.32, 95 % CI 1.47-3.70, p < 0.001). Less than every fifth European resident spends >50 % of his/her working time in the operating room. By contrast, 77.4 % indicate to devote >25 % of their daily working time to administrative work. For every advanced PGY, the likelihood to spend >50 % of the working time in the OR increases by 19 % (OR 1.19, 95 % CI 1.02-1.40, p = 0.024) and the likelihood to spend >50 % of the working time with administrative work decreases by 18 % (OR 0.84, 95 % CI 0.76-0.94, p = 0.002).

The results of this survey on >500 European neurosurgical residents clearly prove that less than 40 % conform with the 48-h week as claimed by the WTD2003/88/EC. Still, more than half of them would chose to work even more hours/week if their clinical education were to improve; probably due to subjective impression of insufficient training 1).


An electronic survey was sent to European neurosurgical residents between 06/2014 and 03/2015. Multiple logistic regression analysis was used to assess the effect size of the relationship between responder-specific variables (e.g., age, gender, postgraduate year (PGY), country) and the outcomes (e.g., satisfaction).

A total of 652 responses were collected, of which n = 532 were taken into consideration. Eighty-five percent were 26-35 years old, 76 % male, 62 % PGY 4 or higher, and 73.5 % working at a university clinic. Satisfaction rates with theoretical education such as clinical lectures (overall: 50.2 %), anatomical lectures (31.2 %), amongst others, differed largely between the EANS member countries. Likewise, satisfaction rates with practical aspects of training such as hands-on surgical experience (overall: 73.9 %), microsurgical training (52.5 %), simulator training (13.4 %), amongst others, were highly country-dependant. In general, 89.1 % of European residents carried out the first surgical procedure under supervision within the first year of training. Supervised lumbar-/cervical spine surgeries were performed by 78.2 and 17.9 % of European residents within 12 and 24 months of training, respectively, and 54.6 % of European residents operate a cranial case within the first 36 months of training. Logistic regression analysis identified countries where residents were much more or much less likely to operate as primary surgeons compared to the European average. The caseload of craniotomies per trainee (overall: 30.6 % ≥10 craniotomies/month) and spinal procedures (overall: 29.7 % ≥10 spinal surgeries/month) varied throughout the countries and was significantly associated with more advanced residency (craniotomy: OR 1.35, 95 % CI 1.18-1.53, p < 0.001; spinal surgery: OR 1.37, 95 % CI 1.20-1.57, p < 0.001) 2).


1) Stienen MN, Netuka D, Demetriades AK, Ringel F, Gautschi OP, Gempt J, Kuhlen D, Schaller K. Working time of neurosurgical residents in Europe-results of a multinational survey. Acta Neurochir (Wien). 2015 Nov 14. [Epub ahead of print] PubMed PMID: 26566781.
2) Stienen MN, Netuka D, Demetriades AK, Ringel F, Gautschi OP, Gempt J, Kuhlen D, Schaller K. Neurosurgical resident education in Europe-results of a multinational survey. Acta Neurochir (Wien). 2015 Nov 17. [Epub ahead of print] PubMed PMID: 26577637.

El 25% de los pacientes de la UVI son neurocríticos

La atención a paciente neurocrítico afronta una actualización constante que redunda en la mejora de la atención a pacientes en situaciones críticas relacionadas con enfermedades y patologías vinculadas a lesiones cerebrales y de médula espinal. Una actualización necesaria porque, en Burgos por ejemplo, el 25% de los ingresos en la UVI están relacionados con pacientes neurocríticos ya sea por postoperatorios de neurocirugía así como lesiones causadas por traumatismos y hemorragias cerebrales. 300 ingresos de media al año que se derivan a la UVI 1 con ocho camas aunque integrado en una uvi polivalente de 24.

Este área de neurocirugía de Burgos acogió esta semana el III Curso de actualización en el manejo del paciente neurocrítico en el que han participado medio centenar de médicos intensivistas y neurocirujanos de la región. «Se trata de un encuentro de carácter bianual que en sus primeras ediciones se celebró en el Río Ortega de Valladolid y estos días hemos acogido en Burgos, la idea es organizarlo cada dos años en los hospitales donde hay unidades de neurocirugía (Valladolid, Burgos, León y Salamanca)», señala el coordinador de la cita, Arturo Zabalegui.

En el encuentro han participado especialistas de Castilla y León pero también Marilyn Riveiro, intensivista del Hospital Vall d’Hebron de Barcelona, así como Esther Alonso, Marta Arroyo, Pedro David Delgado, Javier Martín del HUBU; Ana Diego del Complejo Asistencial de Salamanca, Ana María Dominguez, del centro de León así como Pedro Enriquez, del Río Hortega de Valladolid y Mario Martinez, Leonor Nogales y Ana María Olmos del Hospital Clínico Universitario de Valladolid.

Entre las temáticas que se han tratado en dos jornadas celebradas en las instalaciones de Burgos figuran las novedades del tratamiento de estas patologías como el estatus epiléptico, el traumatismo craneoencefálico, la lesión medular aguda, la hemorragia cerebral, o la fisiopatología para entender la enfermedad. «Ha habido un avance espectacular a nivel médico en este área y lo que antes eran enfermedades mortales hoy tienen un tratamiento y un pronóstico que va cambiando especialmente en la hemorragia cerebral», señala Zabalegui.

Uno de los aspectos donde más se trabaja en pacientes neurocríticos es lo relacionado con frenar las lesiones secundarias. «Ahora hay muchos medios de tratamiento de diagnóstico que permiten que, si bien en un traumatismo no puedes actuar sobre la lesión primaria, cuando se produce, sí se puede hacer mucho sobre la lesión secundaria». Ésta empieza cuando arranca el tratamiento médico y persigue «salvar el máximo número de nueronas posibles y que el paciente tenga una menor repercusión clínica», señala el neurocirujano burgalés.

BECA DR. D. PEDRO ALBERT 2015

INSTITUTO DE ESPECIALIDADES NEUROLÓGICAS D. PEDRO ALBERT: BECA DR. D. PEDRO ALBERT 2015

Convocatoria dirigida a licenciados en Medicina o Psicología para la financiación de proyectos de investigación con el fin de facilitar a especialistas en neurocirugía, neurología, neurofisiología, psiquiatría o neuropsicología la posibilidad de desarrollar y avanzar en cualquier área de las neurociencias para colaborar en el tratamiento de las enfermedades del Sistema Nervioso tanto central como periférico.

Dotación económica: 10.000€.

Presentación de solicitudes: Hasta el 15 de mayo de 2015.

Más información

El IB-Salut saca a concurso el servicio de neurocirugía por un plazo de dos años

El Área de Salud de Eivissa y Formentera ha publicado, según aparece en el BOIB del pasado sábado, el concurso para la adjudicación del servicio de neurocirugía para Eivissa y Formentera. Según se apunta en el anuncio de la licitación, se establece que el plazo del contrato será de dos años y el presupuesto asciende a  300.000 euros, con la posibilidad de prorrogarlo durante un año más.

Según las bases, los interesados tienes hasta 16 días para la presentación de ofertas ante el Servei de Salut de Balears. La intención, según figura en el pliego de condiciones, es contar con la resolución de las ofertas a finales de este mismo mes de marzo con el fin de iniciar el servicio el 1 de marzo hasta el 31 de marzo de 2017.

El pasado mes de febrero, la Policlínica Nuestra Señora del Rosario rechazaba renovar el convenio para realizar resonancias magnéticas y denunciaba que aún seguían esperando recibir alguna comunicación por parte del IB-Salut respecto al concierto de urgencias de Neurocirugía. En ese comunicado, la Policlínica criticaba que los pacientes en estado crítico eran trasladados a Mallorca, “generándose innecesariamente horas de retraso en su asistencia en casos en los que cada minuto es crucial”.

Ahora publicada ya la licitación habrá que esperar si la Policlínica es uno de los interesados para ofrecer este servicio.