Publications by authors named "José F Alen"

30 Publications

  • Page 1 of 1

Transient cortical blindness secondary to contrast-induced encephalopathy following diagnostic cerebral angiography: report of 2 cases.

Acta Neurol Belg 2021 Apr 29;121(2):585-589. Epub 2020 Oct 29.

Department of Neurosurgery, University Hospital, 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain.

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http://dx.doi.org/10.1007/s13760-020-01532-xDOI Listing
April 2021

Craniopharyngiomas: A clinicopathological and molecular study of 52 cases - Experience in the Complejo Hospitalario de Toledo and Hospital Universitario 12 de Octubre (Madrid).

Clin Neuropathol 2021 Jan-Feb;40(1):26-35

Craniopharyngiomas (CPs) are histologically benign tumors that are associated with high levels of morbidity. Two clinicopathological variants - adamantinomatous (ACP) and papillary (PCP) - have been described. They differ in their molecular features, whereby activating mutations in (V600E) and genes characterize PCP and ACP, respectively. Recently, both variants have been shown to express elevated PD-L1 protein expression, but ACP also exhibited tumor cell-intrinsic PD-1 expression. In this study we analyze these molecular alterations in 52 cases with a long follow-up and examine their associations with immunohistochemical and clinical characteristics. ACPs comprise 73.1% of cases, while 21.2% are PCPs. Aberrant nuclear immunoreactivity for β-catenin was observed in all ACPs. p.V600E mutations were observed in 90.9% of PCPs. Only one ACP case featured both alterations. Both types of CP exhibited strong nuclear staining for p63 with diffuse and basal distribution. ACP and PCP consistently expressed PD-L1, most in a substantial percentage of tumor cells, with a distinctive spatial distribution of expression in each subtype; only ACP demonstrated PD-1 expression. There was no evidence of differences in clinical prognosis between ACPs and PCPs. The identification of hallmark molecular signatures in the two CP variants is useful for sub-categorization in routine histopathology reporting. It is also pertinent to personalized therapy and for the development of improved non-invasive therapeutic strategies in this disease.
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http://dx.doi.org/10.5414/NP301268DOI Listing
December 2020

Reliability and accuracy assessment of morphometric measurements obtained with software for three-dimensional reconstruction of brain aneurysms relative to cerebral angiography measures.

Interv Neuroradiol 2021 Apr 30;27(2):191-199. Epub 2020 Sep 30.

Department of Neurosurgery, Hospital Universitario 12 de Octubre, Instituto de Investigación i±12, Madrid, Spain.

Objective: To analyze the reliability and accuracy of morphological measurements of software employed to three-dimensionally reconstruct aneurysms and vessels (VMTKlab, version 1.6.1,) with computed tomography angiography (CTA) as the source of images. Agreement with measurements from three-dimensional digital subtraction angiography (3 D-DSA) was evaluated.

Methods: We evaluated 40 patients presenting with aneurysmal subarachnoid hemorrhage (aSAH). We analyzed four main variables of the aneurysm morphology: absolute height (size), neck (maximum neck width), perpendicular height, and maximum width. The CTA images were uploaded to the software and then segmented to reconstruct the aneurysm. This new method was compared to the current gold standard-3D reconstruction of pretreatment cerebral angiography. We used intraclass correlation coefficient (ICC) and Bland-Altman plot analyses to evaluate the agreement between these methods.

Results: The ICCs obtained for absolute height, neck, perpendicular height, and maximum width were 0.85, 0.57, 0.85, and 0.89, respectively. This implied good agreement except for the neck of the aneurysm (moderate agreement). Bland-Altman plots are presented for the four indexes. The average of the differences was not significant in terms of absolute height, perpendicular height, and maximum width indicating good agreement. However, it was significant for the neck of the aneurysm.

Conclusions: We report good agreement between the values generated using VMTKlab and cerebral angiography for three of the four main variables. Discrepancies in neck diameter are not surprising and its underestimation with a traditional delineation from cerebral angiography has been reported before.
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http://dx.doi.org/10.1177/1591019920961588DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8050538PMC
April 2021

Delayed extensive brain edema caused by the growth of a giant basilar apex aneurysm treated with basilar artery obliteration: a case report.

BMC Neurol 2020 Jun 6;20(1):232. Epub 2020 Jun 6.

Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain.

Background: Partially thrombosed giant aneurysms at the basilar apex (BA) artery are challenging lesions with a poor prognosis if left untreated. Here we describe a rare case of extensive brain edema after growth of a surgically treated and thrombosed giant basilar apex aneurysm.

Case Presentation: We performed a proximal surgical basilar artery occlusion on a 64-year-old female with a partially thrombosed giant BA aneurysm. MRI showed no ischemic lesions but showed marked edema adjacent to the aneurysm. She had a good recovery, but 3 months after surgical occlusion, her gait deteriorated together with urinary incontinence and worsening right hemiparesis. MRI showed that the aneurysm had grown and developed intramural hemorrhage, which caused extensive brain edema and obstructive hydrocephalus. She was treated by a ventriculoperitoneal shunt placement. Follow-up MRI showed progressive brain edema resolution, complete thrombosis of the lumen and shrinkage of the aneurysm. At 5 years follow-up the patient had an excellent functional outcome.

Conclusions: Delayed growth of a surgically treated and thrombosed giant aneurysm from wall dissection demonstrates that discontinuity with the initial parent artery does not always prevent progressive enlargement. The development of transmural vascular connections between the intraluminal thrombus and adventitial neovascularization by the vasa vasorum on the apex of the BA seems to be a key event in delayed aneurysm growth. Extensive brain edema might translate an inflammatory edematous reaction to an abrupt enlargement of the aneurysm.
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http://dx.doi.org/10.1186/s12883-020-01819-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7275367PMC
June 2020

Opening of unusual vascular collaterals leads to early recanalization of a giant intracavernous carotid artery aneurysm following common carotid artery occlusion: A Case report and literature review.

Surg Neurol Int 2020 4;11:62. Epub 2020 Apr 4.

Department of Neurosurgery, Research Institute i+12-CIBERESP, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Avda Cordoba SN, Madrid, Spain.

Background: Parent artery occlusion (PAO) with or without bypass surgery is a feasible treatment for large intracavernous carotid artery (ICCA) aneurysms. The ideal occlusion site (internal or common carotid artery [CCA]) and ischemic complications after PAO have received special attention since the description of the technique. Unfrequently, some patients can also develop unusual external carotid artery-internal carotid artery collateral pathways distal to the ligation site that can explain the failure to aneurysm size reduction.

Case Description: We describe a rare case of delayed refilling of a large ICCA aneurysm partially thrombosed which early recanalized after surgical ligation of the cervical CCA through an unusual collateral pathway.

Conclusion: Based on our experience, we recommend periodic long-term follow-up neuroimaging, especially in those cases where potential collateral branches have not been clearly identified in the preoperative studies.
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http://dx.doi.org/10.25259/SNI_597_2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7193203PMC
April 2020

Endoscopic Transnasal Trans-Sphenoidal Approach for Pituitary Adenomas: A Comparison to the Microscopic Approach Cohort by Propensity Score Analysis.

Neurosurgery 2020 03;86(3):348-356

Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain.

Background: Despite some evidence for the adoption of endoscopic transnasal trans-sphenoidal surgery (ETSS) for pituitary adenomas, the advantages of this technique over the traditional approach have not been robustly confirmed.

Objective: To compare ETSS with the microscopic sublabial trans-septal trans-sphenoidal surgery (MTSS) for pituitary adenomas.

Methods: We retrospectively reviewed 2 cohorts of ETSS and MTSS performed at our institution from 1995 to 2017. Patient characteristics, surgical data, and outcomes were recorded prospectively. We performed a univariate and multivariable analysis to determine the best surgical approach. To improve the quality of the results, we matched the distribution of patient characteristics between groups by propensity score (PS) method.

Results: A total of 187 procedures (90 MTSS, 97 ETSS) were reviewed. We found better results in the ETSS group in terms of gross total resection (P = .002) and hormone-excess secretion control (P = .014). There was also a lower incidence of cerebrospinal fluid leakage (P = .039), transitory diabetes insipidus (P = .028), and postoperative hypopituitarism (P = .045), as well as a shorter hospital length of stay (P < .001). After PS matching, we confirmed by multivariable logistic regression analysis an increased odds ratio of gross total resection for the ETSS (3.910; 95% CI 1.720-8.889; P = .001).

Conclusion: By PS method, our results suggest that the ETSS provides advantages over the traditional MTSS approach for tumor resection. Better control of secreting tumors and a lower rate of most complications also support the selection of the ETSS approach for the treatment of pituitary adenomas.
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http://dx.doi.org/10.1093/neuros/nyz201DOI Listing
March 2020

[Assessment of the correlation between histological degeneration and radiological and clinical parameters in a series of patients who underwent lumbar disc herniation surgery].

Neurocirugia (Astur) 2018 Mar - Apr;29(2):79-85. Epub 2017 Sep 28.

Servicio de Neurocirugía, Hospital Universitario 12 de Octubre, Universidad Complutense, Madrid, España.

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.
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http://dx.doi.org/10.1016/j.neucir.2017.07.003DOI Listing
September 2019

MRI Prognostication Factors in the Setting of Cervical Spinal Cord Injury Secondary to Trauma.

World Neurosurg 2017 May 16;101:623-632. Epub 2017 Feb 16.

Department of Neurosurgery of Hospital 12 de Octubre, Universidad Complutense, Madrid, Spain.

Objective: Several studies have looked for an association between radiologic findings and neurologic outcome after cervical trauma. In the current literature, there is a paucity of evidence proving the prognostic role of soft tissue damage or bony integrity. Our objective is to determine radiologic findings related to neurologic prognosis in patients after incomplete acute traumatic cervical spinal cord injury, regardless of initial neurologic examination results.

Methods: We retrospectively reviewed patients with acute traumatic cervical spinal cord injury who had a magnetic resonance imaging (MRI) performed within the first 96 hours. Clinical and epidemiologic data were recorded from the medical records along with several radiologic findings from the initial computed tomographic scan and MRI. Data were analyzed using a non-parametric test. Significant prognostic factors were analyzed through a stepwise multivariable logistic regression, adjusted by neurologic status at baseline. The receiver-operating characteristic curve was used to test the discriminative capacity of the model.

Results: Eighty-six patients (68 males and 18 females) were included for the analysis. Mean age was 49 years. Ligamentum flavum injury, intramedullary edema larger than 36 mm, and facet dislocation were demonstrated to be associated with a lack of neurologic improvement at follow-up. Multivariable analysis showed that edema larger than 36 mm and facet dislocation were strong predictors of clinical outcome, regardless of the initial neurologic examination result.

Conclusion: Early MRI has an intrinsic prognostic value. Ligamentous injury and larger edema are strong predicting factors of a bad neurologic outcome at long-term follow-up.
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http://dx.doi.org/10.1016/j.wneu.2017.02.034DOI Listing
May 2017

[Competency-based Neurosurgery Residency Programme].

Neurocirugia (Astur) 2016 Mar-Apr;27(2):75-86. Epub 2016 Mar 2.

Servicio de Neurocirugía, Hospital «12 de Octubre», Facultad de Medicina, UCM, Madrid, España.

Unlabelled: 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.
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http://dx.doi.org/10.1016/j.neucir.2016.02.001DOI Listing
July 2016

Prognostic Value of the Amount of Bleeding After Aneurysmal Subarachnoid Hemorrhage: A Quantitative Volumetric Study.

Neurosurgery 2015 Dec;77(6):898-907; discussion 907

Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain.

Background: Quantitative estimation of the hemorrhage volume associated with aneurysm rupture is a new tool of assessing prognosis.

Objective: To determine the prognostic value of the quantitative estimation of the amount of bleeding after aneurysmal subarachnoid hemorrhage, as well the relative importance of this factor related to other prognostic indicators, and to establish a possible cut-off value of volume of bleeding related to poor outcome.

Methods: A prospective cohort of 206 patients consecutively admitted with the diagnosis of aneurysmal subarachnoid hemorrhage to Hospital 12 de Octubre were included in the study. Subarachnoid, intraventricular, intracerebral, and total bleeding volumes were calculated using analytic software. For assessing factors related to prognosis, univariate and multivariate analysis (logistic regression) were performed. The relative importance of factors in determining prognosis was established by calculating their proportion of explained variation. Maximum Youden index was calculated to determine the optimal cut point for subarachnoid and total bleeding volume.

Results: Variables independently related to prognosis were clinical grade at admission, age, and the different bleeding volumes. The proportion of variance explained is higher for subarachnoid bleeding. The optimal cut point related to poor prognosis is a volume of 20 mL both for subarachnoid and total bleeding.

Conclusion: Volumetric measurement of subarachnoid or total bleeding volume are both independent prognostic factors in patients with aneurysmal subarachnoid hemorrhage. A volume of more than 20 mL of blood in the initial noncontrast computed tomography is related to a clear increase in poor outcome risk.

Abbreviation: : aSAH, aneurysmal subarachnoid hemorrhage.
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http://dx.doi.org/10.1227/NEU.0000000000000927DOI Listing
December 2015

[The method of selection of the residents in Spain. Analysis of the examination MIR and offer of a new methodology].

Neurocirugia (Astur) 2015 Mar-Apr;26(2):53-63. Epub 2015 Feb 24.

Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España.

Introduction: The method for selecting medical graduates for residency positions has a strong influence on teaching and learning strategies in medical schools. The methodology currently used in Spain does not seem appropriate for ranking the candidates or improving curriculum development. Thus, and taking into account the most consistent methodologies used in the United Kingdom and USA, we have designed a new method to be used in our country.

Objectives: To analyze the limitations of the methodology used in Spain, and propose a new one aimed to improve the accuracy of selection itself and avoiding the negative influence of the current method on curricular development. In addition, we emphasize the necessity of improving teaching and learning in the clinical context to assure that graduating students reach an adequate level of clinical competence.

Conclusions: The method for selecting candidates to residency post currently used in Spain, which relies mainly on testing theoretical knowledge, should be changed for an alternative methodology taking into account student,s performance through the course and assessing his/her ability for clínical contextualization of knowledge and level of clinical competence.
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http://dx.doi.org/10.1016/j.neucir.2015.02.001DOI Listing
April 2016

[Selection of medical graduates for residency posts. A comparative study of the methodologies used in different countries].

Neurocirugia (Astur) 2015 Jan-Feb;26(1):3-12. Epub 2015 Jan 16.

Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España; Servicio de Neurocirugía, Hospital Universitario 12 de Octubre, Madrid, España.

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.
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http://dx.doi.org/10.1016/j.neucir.2014.12.003DOI Listing
April 2016

Cranioplasty after decompressive craniectomy. A prospective series analyzing complications and clinical improvement.

Neurocirugia (Astur) 2015 May-Jun;26(3):115-25. Epub 2014 Dec 10.

Neurosurgery Department, University Hospital 12 de Octubre, Madrid, Spain.

Background: Cranioplasty is carried out for cosmetic reasons and for protection, but it may also lead to some neurological improvement after the bone flap placement. Complications of cranioplasty are more frequent than expected for a scheduled neurosurgical procedure. We tried to identify factors associated with both complications and improvement after cranioplasty.

Methods: We prospectively studied the cranioplasties performed in our hospital from November 2009 to November 2013. Patients whose initial reason for bone removal was tumor infiltration were excluded. Demographic, clinical and radiological data were collected. The NIH Stroke Scale and Barthel Self-Care Index scores were obtained both before and within 72 h after cranioplasty. The outcome measures were the occurrences of complications and clinical improvement.

Results: Fifty-five cranioplasties were performed. The material used for the cranioplasty was autologous bone in 42 cases, polyetheretherketone (PEEK) in 7 and methacrylate in 6. The average size of the bone defect was 69.5 (19.5-149.5) cm2. The time elapsed between decompressive craniectomy and cranioplasty was 309 (25-1217) days. There were 10 complications (7 severe and 3 mild), an 18.2% complication rate. Statistically significant risk factors of complications were identified as a Barthel≤70 (Odds ratio [OR] 22; 2.5-192; P=0.005), age over 45 years (OR 13.5; 1.5-115; P=0.01) and early surgery (≤85 days; OR 8; 1.69-37.03, P=0.004). After multivariate analysis, Barthel≤70 and age over 45 years remained independent predictors of complications. Twenty-two (40%) of the 55 patients showed objective improvement. Early surgery (<85 days) increased the likelihood of improvement (OR 4.67; 1.05-20.83; P=0.035). Larger bone defects seemed to be related with improvement, but differences in defect size were not statistically significant (75.3 vs 65.6 cm2; P=0.1).

Conclusions: The complication rate of cranioplasty is higher than for other elective neurosurgical procedures. Older age, poorer functional situation (worse Barthel index score) and early surgery (≤85 days) are independent risk factors for complications. However, cranioplasty produces clinical benefits beyond protection and esthetic improvement. Earlier surgery and larger bone defects seem to increase the likelihood of clinical improvement.
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http://dx.doi.org/10.1016/j.neucir.2014.10.001DOI Listing
April 2016

Endovascular treatment of a true posterior communicating artery aneurysm.

Surg Neurol Int 2014 30;5(Suppl 12):S447-50. Epub 2014 Oct 30.

Department of Neurosurgery, "12 de Octubre" University Hospital, Complutense University of Madrid, Madrid, Spain.

Background: Posterior communicating artery (PCoA) aneurysms are most commonly located at the junction of the internal carotid artery and the PCoA. "True" PCoA aneurysms, which originate from the PCoA itself, are rarely encountered. Most previously reported cases were treated surgically mainly before the endovascular option became available.

Case Description: A 53-year-old male presented with sudden onset of right hemiparesis and aphasia. Left middle cerebral artery stroke was diagnosed. Further studies revealed a 3 mm left PCoA aneurysm arising from the PCoA itself, attached to neither the internal carotid artery nor the posterior cerebral artery. Endovascular treatment was performed and the aneurysm was coiled completely.

Conclusion: Technical advances in endovascular interventional technology have permitted an additional approach to these lesions. The possible endovascular significance of the treatment of true PCoA aneurysms is discussed.
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http://dx.doi.org/10.4103/2152-7806.143273DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4235117PMC
November 2014

Microarteriovenous malformations. Response.

J Neurosurg 2013 Sep;119(3):593

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September 2013

[Considerations on the design of a new competency-based resident programme and the need to combine it with the classic teaching-learning model].

Neurocirugia (Astur) 2013 Sep-Oct;24(5):191-6. Epub 2013 Sep 20.

Servicio de Neurocirugía, Hospital 12 de Octubre, Universidad Complutense de Madrid, Madrid, España. Electronic address:

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http://dx.doi.org/10.1016/j.neucir.2013.08.001DOI Listing
March 2014

Coil embolization of ruptured frontopolar artery aneurysm: case report.

Neurocirugia (Astur) 2014 Mar-Apr;25(2):73-6. Epub 2013 May 31.

Departamento de Neurocirugía, Hospital 12 de Octubre, Madrid, Spain.

Distal anterior cerebral artery aneurysms are infrequent. The most common location is at the bifurcation of the pericallosal and callosomarginal arteries. Cerebral artery anomalies can sometimes, at least partially, explain aneurysm formation in less common locations in relation to hemodynamic stress caused on the vascular wall. We report a very rare case of subarachnoid hemorrhage due to a ruptured frontopolar artery aneurysm as a part of an anomalous anterior cerebral artery complex that was, for the first time, treated with endovascular coiling.
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http://dx.doi.org/10.1016/j.neucir.2013.04.002DOI Listing
June 2014

Cerebral microarteriovenous malformations: a series of 28 cases.

J Neurosurg 2013 Sep 10;119(3):594-602. Epub 2013 May 10.

Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid, Spain.

Object: Microarteriovenous malformations (micro-AVMs) are a rare subgroup of brain AVMs characterized by a nidus smaller than 1 cm. The authors' purpose in this study was to assess the clinical presentation, radiological features, therapeutic management, and outcome of these lesions.

Methods: All angiography studies performed at the authors' institution since 2000 for the diagnosis of AVM were retrospectively reviewed. Clinicoradiological findings, therapeutic management, and outcome were evaluated.

Results: Twenty-eight patients had presented with AVMs having a nidus diameter smaller than 1 cm or no clearly identifiable nidus but an early draining vein. All patients, except 2, presented with intracranial hemorrhage, and 12 patients had a focal deficit. Supratentorial hematomas were large (mean volume 25 ml), and in 8 patients hematomas were evacuated urgently. In 6 patients cerebral digital subtraction angiography studies were normal. Magnetic resonance imaging and dynamic MR angiography revealed an AVM in 4 of these 6 patients. Treatment of the AVM consisted of surgery in 16 cases, radiosurgery in 6, and endovascular embolization in 2, and there were no posttreatment deficits. Four patients received no treatment because of their poor condition. The AVM was occluded at the follow-up in all patients treated with surgery or embolization and in 4 of the 6 patients treated with radiosurgery. The Glasgow Outcome Scale (GOS) score was good (GOS 4-5) in 23 patients (82%) and poor (GOS 3-2) in 5 (18%).

Conclusions: Patients with micro-AVMs generally present with large intracranial hemorrhages and neurological deficits. If the initial angiography is negative, then delayed or superselective angiography is recommended. Magnetic resonance imaging may reveal the existence of these lesions. Surgery is the treatment of choice for superficial micro-AVMs, and radiosurgery or embolization can be considered for deep lesions.
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http://dx.doi.org/10.3171/2013.4.JNS121740DOI Listing
September 2013

[Intracranial dural arteriovenous fistulae. Experience after 81 cases and literature review].

Neurocirugia (Astur) 2013 Jul-Aug;24(4):141-51. Epub 2013 Apr 11.

Servicio de Neurocirugía, Hospital Universitario 12 de Octubre, Madrid, España. Electronic address:

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.
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http://dx.doi.org/10.1016/j.neucir.2013.02.006DOI Listing
December 2013

Volumetric analysis of subarachnoid hemorrhage: assessment of the reliability of two computerized methods and their comparison with other radiographic scales.

J Neurosurg 2013 Jan 21;118(1):84-93. Epub 2012 Sep 21.

Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid, Spain.

Object: There were two main purposes to this study: first, to assess the feasibility and reliability of 2 quantitative methods to assess bleeding volume in patients who suffered spontaneous subarachnoid hemorrhage (SAH), and second, to compare these methods to other qualitative and semiquantitative scales in terms of reliability and accuracy in predicting delayed cerebral ischemia (DCI) and outcome.

Methods: A prospective series of 150 patients consecutively admitted to the Hospital 12 de Octubre over a 4-year period were included in the study. All of these patients had a diagnosis of SAH, and diagnostic CT was able to be performed in the first 24 hours after the onset of the symptoms. All CT scans were evaluated by 2 independent observers in a blinded fashion, using 2 different quantitative methods to estimate the aneurysmal bleeding volume: region of interest (ROI) volume and the Cavalieri method. The images were also graded using the Fisher scale, modified Fisher scale, Claasen scale, and the semiquantitative Hijdra scale. Weighted κ coefficients were calculated for assessing the interobserver reliability of qualitative scales and the Hijdra scores. For assessing the intermethod and interrater reliability of volumetric measurements, intraclass correlation coefficients (ICCs) were used as well as the methodology proposed by Bland and Altman. Finally, weighted κ coefficients were calculated for the different quartiles of the volumetric measurements to make comparison with qualitative scales easier. Patients surviving more than 48 hours were included in the analysis of DCI predisposing factors and analyzed using the chi-square or the Mann-Whitney U-tests. Logistic regression analysis was used for predicting DCI and outcome in the different quartiles of bleeding volume to obtain adjusted ORs. The diagnostic accuracy of each scale was obtained by calculating the area under the receiver operating characteristic curve (AUC).

Results: Qualitative scores showed a moderate interobserver reproducibility (weighted κ indexes were always < 0.65), whereas the semiquantitative and quantitative scores had a very strong interobserver reproducibility. Reliability was very high for all quantitative measures as expressed by the ICCs for intermethod and interobserver agreement. Poor outcome and DCI occurred in 49% and 31% of patients, respectively. Larger bleeding volumes were related to a poorer outcome and a higher risk of developing DCI, and the proportion of patients suffering DCI or a poor outcome increased with each quartile, maintaining this relationship after adjusting for the main clinical factors related to outcome. Quantitative analysis of total bleeding volume achieved the highest AUC, and had a greater discriminative ability than the qualitative scales for predicting the development of DCI and outcome.

Conclusions: The use of quantitative measures may reduce interobserver variability in comparison with categorical scales. These measures are feasible using dedicated software and show a better prognostic capability in relation to outcome and DCI than conventional categorical scales.
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http://dx.doi.org/10.3171/2012.8.JNS12100DOI Listing
January 2013

Acute perfusion changes after spontaneous SAH: a perfusion CT study.

Acta Neurochir (Wien) 2012 Mar 12;154(3):405-11; discussion 411-2. Epub 2012 Jan 12.

Department of Neurosurgery, Hospital 12 de Octubre, Crta de Andalucia km 5.4, Madrid, Spain.

Background: Perfusion computed tomography (CT) is a rapid technique that allows the measurement of acute disturbances in local and global cerebral blood flow in patients suffering stroke and spontaneous subarachnoid haemorrhage (SAH). The purpose of this study was to establish the relationship between different measures of brain perfusion made on dynamic-contrast CT reconstructions performed as soon as SAH has been diagnosed and the severity of the bleeding determined by the clinical grade, the extent of the bleeding and the outcome of the patients.

Methods: After the diagnosis of SAH by conventional CT, a perfusion CT was performed before CT angiography. All imaging studies were performed on a six-slice spiral CT scanner. All images were analysed using perfusion software developed by Philips, which produces perfusion CT quantitative data based on temporal changes in signal intensity during the first pass of a bolus of an iodinated contrast agent. Measurements of mean transient time (MTT), time to peak (TTP), cerebral blood volume (CBV) and cerebral blood flow (CBF) in volumes of interest corresponding to territories perfused by the major cerebral arteries were performed. Different data regarding severity of the bleeding-such as level of consciousness, amount of bleeding in conventional CT-were collected. All poor-grade patients received a ventriculostomy catheter so that ICP recordings were obtained. Also, the occurrence of delayed cerebral ischaemia (DCI) was recorded. Outcome was assessed by the Glasgow Outcome Scale 6 months after the bleeding. For statistical analysis, non-parametric correlations between variables were performed.

Findings: Thirty-nine patients have been included in the study since January 2007. In SAH patients there are increasing perfusion abnormalities as the severity of the bleeding increases. The most affected perfusion parameters are TTP and MTT, as they significantly increase with the clinical severity of the bleeding and the total volume of bleeding (P < 0.01, Spearman's Rho). When average MTT time is increased over 5.9 s there is a 20-fold (95% CI = 2.1-182) risk of poor outcome. All patients presenting this MTT time suffered from DCI. This value has a positive predictive value of 100% for DCI and 90% for a poor outcome.

Conclusions: SAH causes cerebral blood flow abnormalities even in the acute phase of the illness, consisting mainly of an increase in circulation times (TTP and MTT), which are correlated with the severity of the bleeding.
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http://dx.doi.org/10.1007/s00701-011-1267-zDOI Listing
March 2012

Ruptured dissecting cerebral aneurysms in young people: report of three cases.

Acta Neurochir (Wien) 2010 Sep 20;152(9):1511-7. Epub 2010 May 20.

Department of Neurosurgery, Di Circolo University Hospital, University of Insubria, Varese, Italy.

Intracranial arterial aneurysms in the pediatric population are rare. Among these, dissecting aneurysms are the most frequent, followed by saccular, infectious, and posttraumatic. It is widely known that aneurysmal rupture is uncommon in the first two decades of life. Spontaneous dissecting aneurysms (SDAs) of the middle cerebral artery (MCA) affecting young individuals most frequently present as occlusive syndrome with ischemia, although bleeding and subarachnoid hemorrhage can also occur. Between March 2006 and January 2008, three young patients (20 months, 8 and 20 years old) were surgically treated for MCA SDA in the Neurosurgical Department of "12 de Octubre" Hospital of Madrid. These patients showed hemorrhage as primary radiological finding, and all of them underwent surgical operation. Aneurysms were always treated by trapping, with aneurysmectomy in one case, but no distal extra-intracranial (EC-IC) bypass was performed. In two cases, the histological examination of the aneurysm's wall evidenced signs of subintimal dissection with widespread disruption of the internal elastic lamina and media with neointima formation and intramural hemorrhage. Although bleeding is an uncommon presenting sign of SDAs, they should be suspected in young people showing hemorrhage at CT scan. Early surgical treatment and, if possible, preoperative neuroimaging evaluation of intracranial vessels should be performed to reduce the mortality in these patients despite a higher postoperative morbidity. From a technical point of view, surgical trapping of the aneurysm seems to be a reasonable treatment strategy especially in an emergency basis. However, whenever possible, an EC-IC bypass could help diminish the ischemic morbidity associated with these aneurysms.
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http://dx.doi.org/10.1007/s00701-010-0688-4DOI Listing
September 2010

Spontaneous hemorrhage into a lumbar synovial cyst.

Eur Spine J 2010 Jul 21;19 Suppl 2:S190-2. Epub 2010 Feb 21.

Departamento de Neurocirugia, Hospital 12 de Octubre, Av Andalucia km 5.4, 28041 Madrid, Spain.

Lumbar synovial cysts frequently present with back pain, chronic radiculopathy and/or progressive symptoms of spinal canal compromise. These cysts generally appear in the context of degenerative lumbar spinal disease. Few cases of spontaneous hemorrhage into synovial cysts have been reported in the literature.
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http://dx.doi.org/10.1007/s00586-010-1332-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899648PMC
July 2010

Predicting the outcome of patients with subarachnoid hemorrhage using machine learning techniques.

IEEE Trans Inf Technol Biomed 2009 Sep 14;13(5):794-801. Epub 2009 Apr 14.

Control, Learning, and Systems Optimization Group, Universidad Carlos III de Madrid, Madrid 28040, Spain.

Background: Outcome prediction for subarachnoid hemorrhage (SAH) helps guide care and compare global management strategies. Logistic regression models for outcome prediction may be cumbersome to apply in clinical practice.

Objective: To use machine learning techniques to build a model of outcome prediction that makes the knowledge discovered from the data explicit and communicable to domain experts.

Material And Methods: A derivation cohort (n = 441) of nonselected SAH cases was analyzed using different classification algorithms to generate decision trees and decision rules. Algorithms used were C4.5, fast decision tree learner, partial decision trees, repeated incremental pruning to produce error reduction, nearest neighbor with generalization, and ripple down rule learner. Outcome was dichotomized in favorable [Glasgow outcome scale (GOS) = I-II] and poor (GOS = III-V). An independent cohort (n = 193) was used for validation. An exploratory questionnaire was given to potential users (specialist doctors) to gather their opinion on the classifier and its usability in clinical routine.

Results: The best classifier was obtained with the C4.5 algorithm. It uses only two attributes [World Federation of Neurological Surgeons (WFNS) and Fisher's scale] and leads to a simple decision tree. The accuracy of the classifier [area under the ROC curve (AUC) = 0.84; confidence interval (CI) = 0.80-0.88] is similar to that obtained by a logistic regression model (AUC = 0.86; CI = 0.83-0.89) derived from the same data and is considered better fit for clinical use.
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http://dx.doi.org/10.1109/TITB.2009.2020434DOI Listing
September 2009

Idiopathic subarachnoid hemorrhage and venous drainage: are they related?

Neurosurgery 2008 Dec;63(6):1106-11; discussion 1111-2

Department of Neurosurgery, 12 de Octubre University Hospital, Madrid, Spain.

Objective: In the past, several possible explanations for idiopathic subarachnoid hemorrhage (ISAH) have been proposed; however, neuroimaging studies have never provided conclusive data about the structural cause of the bleeding. The aim of this study is to determine whether there are anatomic differences in the deep cerebral venous drainage in patients with ISAH compared with those with aneurysmal subarachnoid hemorrhage (ASAH) and those without intracranial hemorrhage.

Methods: We reviewed the venous phase of carotid digital angiograms of 100 consecutive patients who had a final diagnosis of ISAH. We also analyzed the angiograms of a control group of 112 patients with ASAH and the angiograms of a nonhemorrhagic group of 25 patients having incidental aneurysms. The anatomic variants of the basal vein of Rosenthal (BVR) on both sides were classified into the following types: Type A (normal continuous), in which the BVR is continuous with the deep middle cerebral veins and drains mainly into the vein of Galen; Type B (normal discontinuous), in which there is discontinuous venous drainage, anterior to the uncal vein and posterior to the vein of Galen; and Type C (primitive), which drains mainly to veins other than the vein of Galen. We calculated the proportions to analyze the differences in the type of venous drainage between patients with ISAH, patients with ASAH, and patients without hemorrhage. chi2 statistics were used to search for differences.

Results: Types A and C venous drainage were present in 23.8 and 32.3%, respectively, of patients with ISAH compared with 58.7 and 15.4%, respectively, in the ASAH group and 57.5 and 5%, respectively, in the nonhemorrhagic group (P < 0.001). A primitive variant was present in at least 1 hemisphere in 38 patients with ISAH (41.8% of the cases) compared with 24 patients with ASAH (21.4%) and 2 patients (8%) in the nonhemorrhagic group (P < 0.001).

Conclusion: In patients with ISAH, deep cerebral venous drainage more commonly drains directly into dural sinuses instead of via the vein of Galen compared with patients with ASAH and patients without intracranial hemorrhage. The way in which this venous configuration might influence bleeding remains unknown.
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http://dx.doi.org/10.1227/01.NEU.0000335777.14055.71DOI Listing
December 2008

Angiography and aneurysms.

J Neurosurg 2004 May;100(5):982-3; author reply 983-4

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May 2004

Comparison between perimesencephalic nonaneurysmal subarachnoid hemorrhage and subarachnoid hemorrhage caused by posterior circulation aneurysms.

J Neurosurg 2003 Mar;98(3):529-35

Department of Neurosurgery and Division of Neuroradiology, Hospital "12 de Octubre", Facultad de Medicina, Universidad Complutense, Madrid, Spain.

Object: Some authors have questioned the need to perform cerebral angiography in patients presenting with a benign clinical picture and a perimesencephalic pattern of subarachnoid hemorrhage (SAH) on initial computerized tomography (CT) scans, because the low probability of finding an aneurysm does not justify exposing patients to the risks of angiography. It has been stated, however, that ruptured posterior circulation aneurysms may present with a perimesencephalic SAH pattern in up to 10% of cases. The aim of the present study was twofold: to define the frequency of the perimesencephalic SAH pattern in the setting of ruptured posterior fossa aneurysms, and to determine whether this clinical syndrome and pattern of bleeding could be reliably and definitely distinguished from that of aneurysmal SAH.

Methods: Twenty-eight patients with ruptured posterior circulation aneurysms and 44 with nonaneurysmal perimesencephalic SAH were selected from a series of 408 consecutive patients with spontaneous SAH admitted to the authors' institution. The admission unenhanced CT scans were evaluated by a neuroradiologist in a blinded fashion and classified as revealing a perimesencephalic SAH or a nonperimesencephalic pattern of bleeding. Of the 28 patients with posterior circulation aneurysms, five whose grade was I according to the World Federation of Neurosurgical Societies scale were classified as having a perimesencephalic SAH pattern on the initial CT scan. The data show that the likelihood of finding an aneurysm on angiographic studies obtained in a patient with a perimesencephalic SAH pattern is 8.9%. Conversely, ruptured aneurysms of the posterior circulation present with an early perimesencephalic SAH pattern in 16.6% of cases.

Conclusions: This study supports the impression that there is no completely sensitive and specific CT pattern for a nonaneurysmal SAH. In addition, the authors believe that there is no specific clinical syndrome that can differentiate patients who have a perimesencephalic SAH pattern caused by an aneurysm from those without aneurysms. Digital subtraction angiography continues to be the gold standard for the diagnosis of cerebral aneurysms and should be performed even in patients who have the characteristic perimesencephalic SAH pattern on admission CT scans.
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http://dx.doi.org/10.3171/jns.2003.98.3.0529DOI Listing
March 2003