Documento descargado de http://www.revistaneurocirugia.com el 21/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato. )UDFWXUDHYROXWLYDGHFUiQHRHQODLQIDQFLD3UHVHQWDFLyQGHFDVRV 50LHUH]$*XLOOpQ0%UHOO(&DUGRQD(&ODUDPXQW\-0&RVWD 6HUYLFLRGH1HXURFLUXJtD+RVSLWDO6DQW-RDQGH'pX8QLYHUVLGDGGH%DUFHORQD 5HVXPHQ /DIUDFWXUDHYROXWLYDGHFUiQHR)(&HVXQDFRP SOLFDFLyQ SRFR IUHFXHQWH GHO WUDXPDWLVPR FUDQHRHQFH IiOLFR 7&( HQ OD LQIDQFLD &RQVLVWH HQ XQD IUDFWXUD FRQ XQ GHVJDUUR GXUDO VXE\DFHQWH TXH VH HQVDQFKD SURJUHVLYDPHQWH KDVWD FRQVWLWXLU XQ GHIHFWR FUDQHDO 6X¿VLRSDWRORJtDDVtFRPRDOJXQRVDVSHFWRVGHOPDQHMR WHUDSpXWLFR VRQ WRGDYtD FRQWURYHUWLGRV 6H SUHVHQWD XQD UHYLVLyQ UHWURVSHFWLYD GH FDVRV GLDJQRVWLFDGRV \ WUDWDGRV HQWUH ORV DxRV \ HQ QXHVWUD LQV WLWXFLyQ2QFHSDFLHQWHVHUDQPHQRUHVGHDxRV\XQR WHQtDDxRVHQHOPRPHQWRGHOWUDXPDWLVPR/DFDXVD PiV IUHFXHQWH GH7&( IXH OD FDtGD (Q OD UDGLRJUDItD LQLFLDO SDFLHQWHV WHQtDQ IUDFWXUDV FRQ GLDVWDVLV \ VRODPHQWHXQSDFLHQWHWHQtDIUDFWXUDOLQHDO(OKDOOD]JR WRPRJUi¿FR FRP~Q D WRGRV ORV FDVRV IXH FRQWXVLyQ FRUWLFDOVXE\DFHQWHDODIUDFWXUD(OLQWHUYDORSURPHGLR HQWUH WUDXPDWLVPR \ SUHVHQWDFLyQ GH ODV )(& IXH GH VHPDQDV/DORFDOL]DFLyQSUHIHUHQWHGHODV)(&IXH HQODUHJLyQSDULHWDO(OGLDJQyVWLFRVHKL]RSRUSDOSD FLyQGHXQGHIHFWRFUDQHDO\VHFRQ¿UPyFRQUDGLRJUD ItD6HHQFRQWUDURQOHVLRQHVDVRFLDGDVHQOD7$&\501 SUHRSHUDWRULDFRPRKLGURFHIDOLDHQFHIDORPDODFLDTXLV WHV OHSWRPHQtQJHRV KHUQLDFLyQ GH WHMLGR HQFHIiOLFR \ GLODWDFLyQ YHQWULFXODU LSVLODWHUDO 7RGRV ORV SDFLHQWHV IXHURQVRPHWLGRVDUHSDUDFLyQSOiVWLFDGHODGXUDPDGUH \HOGHIHFWRFUDQHDOVHFXEULyFRQIUDJPHQWRVyVHRV6yOR XQSDFLHQWHSUHFLVyFUDQHRSODVWLDFRQPDOODGHWLWDQLR 7RGDV ODV IUDFWXUDV GH FUiQHR HQ HGDG SHGLiWULFD GHEHQ FRQWURODUVH KDVWD FRQVWDWDU VX UHSDUDFLyQ /RV SDFLHQWHVPHQRUHVGHDxRVFRQIUDFWXUDVLQLFLDOPHQWH GLDVWDVDGDV\FRQHYLGHQFLDHQOD7$&R501GHODFH UDFLyQGXUDOWLHQHQPD\RUSUREDELOLGDGGHGHVDUUROODU XQD)(&(QHVWRVFDVRVVHUHFRPLHQGDHOWUDWDPLHQWR SUHFR]SDUDHYLWDUXQGDxRFHUHEUDOSURJUHVLYR 3$/$%5$6&/$9(7UDXPDWLVPRFUDQHRHQFHIiOLFR)UDF WXUDGHFUiQHR)UDFWXUDHYROXWLYDGHFUiQHR 1HXURFLUXJtD 5HFLELGR$FHSWDGR *URZLQJ VNXOO IUDFWXUH LQ FKLOGKRRG 3UHVHQWDWLRQ RI FDVHV 6XPPDU\ *URZLQJVNXOOIUDFWXUHV*6)DUHUDUHFRPSOLFDWLRQV RIKHDGLQMXU\+,LQFKLOGKRRG7KLVHQWLW\FRQVLVWVRID VNXOOIUDFWXUHZLWKDQXQGHUO\LQJGXUDOWHDUWKDWFRXUVHV ZLWK D SURJUHVVLYH HQODUJHPHQW RI WKH IUDFWXUH WR SUR GXFH D FUDQLDO GHIHFW 7KH SDWKRSK\VLRORJ\ DQG VRPH DVSHFWVRILWVPDQDJHPHQWDUHVWLOOFRQWURYHUVLDO ,QWKLVUHYLHZZHSUHVHQWSDWLHQWVGLDJQRVHGGDQG WUHDWHGIRUD*6)DWRXULQVWLWXWLRQEHWZHHQDQG SDWLHQWVZHUHXQGHUWKHDJHRI\HDUVDQGRQH SDWLHQWZDV\HDUVROGDWWKHPRPHQWRI+,7KHPRVW FRPPRQFDXVHRILQMXU\ZDVIDOODIURPKHLJKW,QWKH LQLWLDO SODLQ [UD\¿OPV SDWLHQWV VKRZHG D GLDVWDWLF VNXOOIUDFWXUHDQGRQHSDWLHQWRQO\KDGDOLQHDUIUDF WXUH$WWKLVWLPH&7VFDQVKRZHGFRUWLFDOFRQWXVVLRQ XQGHUO\LQJ WKH IUDFWXUH LQ HYHU\ FDVH 7KH PHDQ WLPH EHWZHHQLQMXU\DQGSUHVHQWDWLRQRI*6)ZDVZHHNV 'LDJQRVLVZDVPDGHE\SDOSDWLRQRIWKHFUDQLDOGHIHFW DQGFRQ¿UPHGZLWKVNXOO[UD\¿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ocumento descargado de http://www.revistaneurocirugia.com el 21/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato. 1HXURFLUXJtD )UDFWXUDHYROXWLYDGHFUiQHRHQODLQIDQFLD3UHVHQWDFLyQGHFDVRV ,QWURGXFFLyQ /DIUDFWXUDHYROXWLYDGHFUiQHR)(&HVXQDFRPSOL FDFLyQFRQRFLGDDXQTXHSRFRIUHFXHQWHGHOWUDXPDWLVPR FUDQHRHQFHIiOLFR 7&( HQ HGDG SHGLiWULFD 2FXUUH FDVL H[FOXVLYDPHQWHHQQLxRVPHQRUHVGHDxRV\VHORFDOL]D SUHIHUHQWHPHQWHHQODUHJLyQSDULHWDO&RQVLVWHWtSLFDPHQWH HQXQDIUDFWXUDFRQODFHUDFLyQGHODGXUDPDGUHVXE\DFHQWH TXH WLHQGH D HQVDQFKDUVH SURJUHVLYDPHQWH SURGXFLHQGR XQ GHIHFWR FUDQHDO 6L ELHQ VX ¿VLRSDWRJHQHVLD HV WRGDYtD FRQWURYHUWLGDVHFRQVLGHUDTXHHOKHFKRSULQFLSDO\SRU ORWDQWRUHTXLVLWRLQGLVSHQVDEOHSDUDTXHODPLVPDVHSUR GX]FDHVHOGHVJDUURGXUDODVRFLDGR (O VLJXLHQWH HVWXGLR UHWURVSHFWLYR GH SDFLHQWHV FRQ )(&GLDJQRVWLFDGRV\WUDWDGRVHQQXHVWUDLQVWLWXFLyQSUH WHQGH UHYLVDU ODV FDUDFWHUtVWLFDV FOtQLFDV \ SURYHHU JXtDV SDUDHOFRUUHFWRGLDJQyVWLFRDVLFRPRSDUDHOWUDWDPLHQWR GHHVWDHQWLGDG $ % )LJ $ 5; FRQ IUDFWXUD H[WHQVD ELSDULHWDO % 5; GHO PLVPR SDFLHQWH D ODV VHPDQDV GHO 7&( TXH PXHVWUD IUDFWXUDHYROXWLYDELODWHUDO 0DWHULDO\0pWRGRV (QWUHORVDxRV\SDFLHQWHVFRQHOGLDJ QyVWLFRGH)(&IXHURQWUDWDGRVTXLU~UJLFDPHQWHGHXQWRWDO DSUR[LPDGRGHIUDFWXUDVGHFUiQHRHQHO+RVSLWDO 6DQW-RDQGH'pXGH%DUFHORQD 6HUHYLVDURQODVKLVWRULDVFOtQLFDVGHWRGRVORVSDFLHQWHV 6HUHJLVWUDURQGDWRVHSLGHPLROyJLFRVFRPRHGDGDOPRPHQWR GHOWUDXPDWLVPRVH[RFDXVDGHO7&(\ORFDOL]DFLyQGHOD IUDFWXUD 6H DQDOL]y HO FXDGUR FOtQLFR TXH SUHVHQWDEDQ ORV SDFLHQWHVLQPHGLDWDPHQWHGHVSXpVGHO7&((QODUDGLRORJtD LQLFLDOVHPLGLyHODQFKRGHODIUDFWXUDHQOD]RQDGHPD\RU GLDVWDVLV\VHHYDOXyODSUHVHQFLDGHOHVLRQHVWRPRJUi¿FDV VXJHVWLYDV GH GHVJDUUR GXUDO FRPR FRQWXVLyQ FRUWLFDO \ KHPRUUDJLD VXEDUDFQRLGHD IRFDO 6H PLGLy HO LQWHUYDOR GH WLHPSR HQWUH HO WUDXPDWLVPR \ HO GLDJQyVWLFR GH )(& 6H UHJLVWUDURQORVVLJQRVORFDOHVDOPRPHQWRGHODSUHVHQWDFLyQ DVtFRPRORVFDPELRVHQOD5;'HORVSURWRFRORVTXLU~UJL FRVVHKDQYDORUDGRGDWRVUHIHUHQWHVDODWpFQLFDHPSOHDGD\ DORVKDOOD]JRVLQWUDRSHUDWRULRV/RVGDWRVHYROXWLYRVDODUJR SOD]R UHVXOWDGR TXLU~UJLFR VHFXHODV \ WLHPSR GH VHJXL PLHQWRVHREWXYLHURQGHORVUHJLVWURVGHFRQVXOWDVH[WHUQDV 5HVXOWDGRV (SLGHPLRORJtD 'HORVSDFLHQWHVFRQ)(&HUDQYDURQHV8QSDFLHQWH WHQtD DxRV HQ HO PRPHQWR GHO WUDXPD ORV UHVWDQWHV HUDQPHQRUHVGHDxRVLQFOXtGRXQRFRQWUDXPDWLVPRSUH QDWDO(QFXDQWRDODFDXVDGHO7&(VHGHELHURQDFDtGD DDFFLGHQWHVGHWUi¿FR\DWUDXPDREVWpWULFR(QHOFDVR SUHQDWDOVHWUDWyGHXQDFFLGHQWHGHFLUFXODFLyQVXIULGRSRU ODPDGUHDODVVHPDQDVGHHPEDUD]R7RGRVORVFDVRV VDOYR HO WUDXPD REVWpWULFR IXHURQ DWHQGLGRV LQLFLDOPHQWH HQQXHVWUDLQVWLWXFLyQ /DORFDOL]DFLyQPiVIUHFXHQWHIXHSDULHWDOQ 2WUDV ORFDOL]DFLRQHVIXHURQWHPSRUDOQ \IURQWDOQ 8QR GHORVSDFLHQWHVSUHVHQWy)(&SDULHWDOELODWHUDODSDUWLUGH XQDIUDFWXUDSDQSDULHWDO)LJ (OLQWHUYDORHQWUHHOWUDXPDWLVPR\HOGLDJQyVWLFRGH)(& IXHGHDVHPDQDVFRQXQDPHGLDGHVHPDQDV &OtQLFD\QHXURLPiJHQHV ,QLFLDOPHQWHSDFLHQWHVVHSUHVHQWDURQFRQ7&(JUDYH \*&6PHQRUGH8QRGHHOORVWXYRTXHVHULQWHUYHQLGR GH XUJHQFLD SDUD UHSDUDFLyQ GH XQD JUDQ iUHD GH KXQGL PLHQWR GLVWDQWH GH OD IUDFWXUD TXH SRVWHULRUPHQWH RULJL QDUtD OD )(& 2WURV SDFLHQWHV WXYLHURQ VLJQRV IRFDOHV FRQ GHSUHVLyQ PRGHUDGD GH OD FRQFLHQFLD /RV FDVRV GH WUDXPD SUHQDWDO \ REVWpWULFR IXHURQ UHFLpQ QDFLGRV FRQ LPSRUWDQWH GHWHULRUR QHRQDWDO \ HO ~OWLPR UHTXLULy GHUL YDFLyQYHQWULFXODUH[WHUQDSDUDWUDWDPLHQWRGHKHPRUUDJLD LQWUDYHQWULFXODUDVRFLDGDDSUHPDWXULGDG6yORXQSDFLHQWH GHVDUUROOyXQD)(&DSDUWLUGHXQWUDXPDWLVPREDQDO /RFDOPHQWH SDFLHQWHV WHQtDQ WXPHIDFFLyQ GH FXHUR FDEHOOXGR HQ HO VLWLR GH IUDFWXUD HGHPD GLIXVR \ HQ XQ FDVRFHIDORKHPDWRPDGHJUDQWDPDxR(QHOPRPHQWRGHO GLDJQyVWLFRWRGRVORVSDFLHQWHVSUHVHQWDEDQXQGHIHFWRFUD QHDOIiFLOPHQWHSDOSDEOH 7RGRV ORV SDFLHQWHV WHQtDQ IUDFWXUDV HQ OD UDGLRJUDItD LQLFLDO FRQ GLDVWDVLV GH D PP \ FRQ XQ WUD]R OLQHDO VLQ GLDVWDVLV (O KDOOD]JR FRP~Q D ORV SDFLHQ WHVHQOD7$&LQLFLDOIXHFRQWXVLyQFRUWLFDOVXE\DFHQWHDOD IUDFWXUD \ GLYHUVRV JUDGRV GH HGHPD VXEJDOHDO (O VHJXL PLHQWRPHGLDQWHUDGLRJUDItDVVHULDGDVHYLGHQFLyHQWRGRV ORVSDFLHQWHVODHYROXFLyQKDFLDHOHQVDQFKDPLHQWRGHORV GHIHFWRV TXH WHQtDQ IRUPD RYDO FRQ HVFOHURVLV \ OLJHUD Documento descargado de http://www.revistaneurocirugia.com el 21/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato. 1HXURFLUXJtD 0LHUH]\FRO 7DEOD +DOOD]JRVHQ7$&501SUHRSHUDWRULD +DOOD]JR 1GHSDFLHQWHV +LGURFHIDOLD 4XLVWHOHSWRPHQtQJHR (QFHIDORPDODFLD +HUQLDFLyQGHWHMLGRHQFHIiOLFR 'LODWDFLyQYHQWULFXODULSVLODWHUDO HYHUVLyQGHORVERUGHV&XDWURSDFLHQWHVIXHURQHVWXGLDGRV PHGLDQWH501SUHRSHUDWRULD\FRQ7$&/RVKDOOD]JRV GHQHXURLPiJHQHVVHUHVXPHQHQODWDEOD ,QWHUYHQFLyQTXLU~UJLFD 'RV SDFLHQWHV SUHFLVDURQ GHULYDFLyQ YHQWUtFXORSHUL WRQHDO FRPR WUDWDPLHQWR GH KLGURFHIDOLD DVRFLDGD DQWHV GHWUDWDUOD)(&(QDPERVFDVRVODWXPRUDFLyQGHOVFDOS GLVPLQX\ySHURHOGHIHFWRyVHRSHUPDQHFLyFRQHOPLVPR WDPDxRHQODUDGLRJUDItD (OKDOOD]JRTXLU~UJLFRFRP~QIXHHOGHXQGHIHFWRyVHR \XQGHIHFWRGXUDOVXE\DFHQWHPiVH[WHQVR/RVERUGHVGH ODGXUDPDGUHHVWDEDQDGKHULGRVHQPD\RURPHQRUJUDGR DXQiUHDGHJOLRVLV6RODPHQWHHQFDVRVVHHQFRQWUyXQD OHVLyQTXtVWLFD /D WpFQLFD SDUD UHSDUDFLyQ GH )(& FRQVLVWLy HQ XQD FUDQHRWRPtDDPSOLDFHQWUDGDHQHOGHIHFWRyVHRGHVEULGD PLHQWRGHORVERUGHVGXUDOHV\UHSDUDFLyQSOiVWLFDFRQDSR QHXURVLV SHULFUDQHDO R IDVFLD ODWD VDOYR HQ SDFLHQWHV HQ TXHVHXWLOL]yPDWHULDOKHWHUyORJRSDUDUHSDUDUODGXUDPDGUH /DVOHVLRQHVTXtVWLFDVIXHURQHYDFXDGDVUHVHFDQGRVXSDUHG \FRPXQLFDGDVFRQHOHVSDFLRVXEDUDFQRLGHR 3RVWHULRUPHQWH VH FRORFDURQ IUDJPHQWRV yVHRV SURYH QLHQWHVGHODFUDQHRWRPtDSDUDFXEULUHOGHIHFWR 6HJXLPLHQWR 1RKXERFRPSOLFDFLRQHVUHODFLRQDGDVFRQODFLUXJtD(O UDQJRGHVHJXLPLHQWRIXHGHPHVHVDDxRV (Q FDVRV HO GHIHFWR FHUUy VDWLVIDFWRULDPHQWH \ QR UHTXLULHQGRPDVLQWHUYHQFLyQTXHODGHVFULWD 6yORHQXQSDFLHQWHGHODVHULHODUHSDUDFLyQyVHDQR IXH VX¿FLHQWH SUHFLVDQGR OD FRORFDFLyQ GH XQD PDOOD GH WLWDQLRDOFDERGHVLHWHPHVHV 'RV SDFLHQWHV TXHGDURQ FRQ XQD KHPLSDUHVLD OHYH \ XQRVHHQFXHQWUDDFWXDOPHQWHHQWUDWDPLHQWRSRUHSLOHSVLD SRVWUDXPiWLFD/RVGRVFDVRVFRQKLGURFHIDOLDLQLFLDOWLHQHQ DFWXDOPHQWHUHWUDVRSVLFRPRWUL] 'LVFXVLyQ /D PD\RUtD GH ODV IUDFWXUDV GH FUiQHR HQ OD LQIDQFLD FRQVROLGDQ HQ HO ODSVR GH D PHVHV$OJXQDV YHFHV OD EUHFKD VH HQVDQFKD SURJUHVLYDPHQWH KDVWD FRQVWLWXLU XQ GHIHFWR FUDQHDO $ HVWD FRPSOLFDFLyQ SRFR IUHFXHQWH OD GHQRPLQDPRV IUDFWXUD HYROXWLYD GH FUiQHR &RQRFLGD \D GHVGH HO VLJOR GLHFLQXHYH VH OH GLR GHVGH HQWRQFHV GLV WLQWRVQRPEUHVFRPRSRUHMHPSORFHIDORKLGURFHOHTXLVWH YHQWULFXODU WUDXPiWLFR HURVLyQ FUDQHRFHUHEUDO IUDFWXUD H[SDQVLYDHWF'HWRGRVHVWRVHOPiVXWLOL]DGRIXHHOGH ³TXLVWH OHSWRPHQtQJHR´ SRUTXH VH SHQVDED TXH OD OHVLyQ TXtVWLFD TXH D YHFHV VH DVRFLD DO GHIHFWR FUDQHDO HUD OD FDXVD SULQFLSDO GH WRGR HO SURFHVR$FWXDOPHQWH SUHIH ULPRVGHQRPLQDUODIUDFWXUDHYROXWLYDGHFUiQHR\DTXHHV PiVDGHFXDGRGHVGHHOSXQWRGHYLVWD¿VLRSDWROyJLFR (SLGHPLRORJtD /DLQFLGHQFLDGHVFULWDHQODOLWHUDWXUDSDUDHVWDHQWLGDG YDUtDHQWUHHO\HO6LQHPEDUJRHOULHVJRGH TXHXQDIUDFWXUDVHKDJDHYROXWLYDSXHGHVHUPD\RUVLVyOR VH FRQVLGHUDQ ODV IUDFWXUDV HQ OD LQIDQFLD WHPSUDQD /RV GDWRVHSLGHPLROyJLFRVREWHQLGRVHQQXHVWUDVHULHVRQVLPL ODUHVDORVGHRWUDVSXEOLFDFLRQHV&OiVLFDPHQWHVHGLFH TXHPiVGHODPLWDGGHORVFDVRVRFXUUHQDQWHVGHOSULPHU DxRGHYLGD\HODQWHVGHOWHUFHUR(VSRVLEOHTXH XQDIUDFWXUDHQHGDGDGXOWDVHDJUDQGHSHURHVWRHVH[FHS FLRQDO\FDVLWRGRVORVFDVRVGLDJQRVWLFDGRVHQHODGXOWR VRQGHELGRVDWUDXPDWLVPRVRFXUULGRVHQODLQIDQFLD 1XHVWUR HVWXGLR LQFOX\H XQ SDFLHQWH FRQ WUDXPD SUHQDWDO TXHGHVDUUROOy)(&)LJVyORVDEHPRVTXHH[LVWHXQD GHVFULSFLyQGHXQFDVRVLPLODUDpVWHHQODELEOLRJUDItD /DVGRVFDXVDVPDVIUHFXHQWHVGH7&(VRQODVFDtGDV\ ORVDFFLGHQWHVGHWUi¿FR /D )(& WDPELpQ KD VLGR GHVFULWD FRPR FRPSOLFDFLyQ GH OD FLUXJtD GH FUDQHRVLQRVWRVLV \ GH ORV WUDXPDWLVPRV REVWpWULFRV 1XHVWUD VHULH UHFRJH XQ SDFLHQWH FRQ )(& GHELGDDHVWD~OWLPDFDXVD /DORFDOL]DFLyQPiVIUHFXHQWHGHOD)(&HVHQODUHJLyQ SDULHWDO7DPELpQVHPHQFLRQDQHQODOLWHUDWXUDORFD OL]DFLRQHVSRFRKDELWXDOHVFRPRHOWHFKRRUELWDULR\OD IRVDSRVWHULRU )LVLRSDWRORJtD (OFUiQHRFUHFHUiSLGDPHQWHHQORVSULPHURVDxRVGH YLGDSDUDDFRPRGDUVHDOFUHFLPLHQWRFHUHEUDO6HVDEHTXH XQD IUDFWXUD FRQ ODFHUDFLyQ GXUDO HQ HVWH SHULRGR SXHGH SURGXFLUXQD)(&SHURODVHFXHQFLDH[DFWDGHHYHQ WRV TXH FRQGXFHQ D VX IRUPDFLyQ HV D~Q FRQWURYHUWLGD ,QLFLDOPHQWHVHSHQVDEDTXHDSDUWLUGHO/&5DWUDSDGR HQHOVLWLRGHIUDFWXUDVHIRUPDEDXQTXLVWHTXHHURVLRQDED SURJUHVLYDPHQWH ORV ERUGHV yVHRV KDVWD FRQVWLWXLU HO GHIHFWR(VWDWHRUtDIXHUHIXWDGDSRUHVWXGLRVH[SHULPHQ WDOHV \ SRU OD REVHUYDFLyQ FOtQLFD GH TXH HO TXLVWH QR VLHPSUHHVWiSUHVHQWHFRPRWDPSRFRORHVWiODHURVLyQGH ORVERUGHV7DPELpQODKLSHUWHQVLyQLQWUDFUDQHDOKDVLGR LPSOLFDGDHQHOPHFDQLVPR¿VLRSDWROyJLFR3HURHVWXGLRV Documento descargado de http://www.revistaneurocirugia.com el 21/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato. 1HXURFLUXJtD )UDFWXUDHYROXWLYDGHFUiQHRHQODLQIDQFLD3UHVHQWDFLyQGHFDVRV $ $ % % )LJXUD$5[GHFUiQHRFRQ)(&WHPSRUDO%501GHO PLVPR SDFLHQWH GRQGH VH REVHUYD KHUQLDFLRQ GHO WHMLGR FHUHEUDODWUDYHVGHOGHIHFWRyVHR & )LJXUD 3DFLHQWH FRQ WUDXPDWLVPR SUHQDWDO $ 7$& DO PRPHQWR GHO QDFLPLHQWR TXH PXHVWUD IUDFWXUD SDULHWDO FRQDUHDFHUHEUDOFRQWXVDVXE\DFHQWH\HGHPDVXEJDOHDO %5;DODVVHPDQDVGHYLGDFRQGHIHFWRRVHRH[WHQVR HQHOVLWLRGHODIUDFWXUD&501GHODPLVPDpSRFDTXH HYLGHQFLDPDUFDGDKLGURFHIDOLD\XQTXLVWHOHSWRPHQtQJHR GHJUDQWDPDxR UHFLHQWHVFRQ501QRHQFXHQWUDQHYLGHQFLDGHKLSHUWHQVLyQ HQORVSDFLHQWHVFRQ)(& $FWXDOPHQWHVHFUHHTXHODODFHUDFLyQGXUDOLPSLGHOD FRQVROLGDFLyQyVHD(QWRQFHVDPHGLGDTXHHOFUiQHR\HO FHUHEURFUHFHQODIUDFWXUDDOVHUXQSXQWRGHPHQRUUHVLV WHQFLDVHHQVDQFKD /DIDOWDGHGXUDPDGUH\KXHVRDQLYHOGHOGHIHFWRKDFHQ TXHHVWHVLWLRWHQJDPHQRUUHVLVWHQFLDDODKHUQLDFLyQFHUH EUDO¿J(VWR~OWLPRH[SOLFDUtDWDPELpQODWHQGHQFLDDOD GLODWDFLyQYHQWULFXODULSVLODWHUDOTXHDYHFHVVHREVHUYD 2EVHUYDFLRQHV FOtQLFDV \ HVWXGLRV QHXURSDWROy JLFRV VXJLHUHQ TXH HO WHMLGR FHUHEUDO KHUQLDGR VXIUH XQ GDxR SURJUHVLYR 'H HVWD PDQHUD ODV PDQLIHVWDFLRQHV QHXUROyJLFDV WDPELpQ SXHGHQ VHU SURJUHVLYDV \ QR HVWDU VRODPHQWHUHODFLRQDGDVFRQHOWUDXPDLQLFLDO 'LDJQyVWLFR /DV )(& SXHGHQ GHVDUUROODUVH GHVSXpV GH 7&( WDQWR JUDYHVFRPREDQDOHV(QQXHVWUDVHULHWRGRVORVSDFLHQWHV VDOYR XQR SUHVHQWDEDQ VLJQRV GH JUDYHGDG \D VHD SRU GHSUHVLyQ GH OD FRQFLHQFLD R SRU OD SUHVHQFLD GH Gp¿FLW QHXUROyJLFRIRFDO/RVVLJQRVORFDOHVFRQVLVWHQHQWXPHIDFFLyQ Documento descargado de http://www.revistaneurocirugia.com el 21/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato. 1HXURFLUXJtD 0LHUH]\FRO SRU HGHPD R FHIDORKHPDWRPD \ WDUGDQ PiV WLHPSR TXH OR KDELWXDO HQ UHVROYHUVH /D UDGLRORJtD HQ HVWD HWDSD LQL FLDOPXHVWUDIUDFWXUDVFRQGLDVWDVLVPD\RUHVGHPP \ HQ HO 7$& VH REVHUYD FRQWXVLyQ FRUWLFDO R KHPRUUDJLD VXEDUDFQRLGHD IRFDO FRPR VLJQRV LQGLUHFWRV GH ODFHUDFLyQ GXUDO 'HVSXpVGHOWUDXPDWLVPRODHYROXFLyQGHOGHIHFWRyVHR VXHOH VHU UiSLGD SURGXFLpQGRVH HO FUHFLPLHQWR Pi[LPR HQWUHODV\VHPDQDV(QQXHVWURVSDFLHQWHVHOWLHPSR PHGLRIXHGHVHPDQDV6HJ~Q7DYHUDV\FROHOLQWHU YDORHQWUHHO7&(\ODSUHVHQWDFLyQFOtQLFDHVWtSLFDPHQWH PHQRU GH DxRV 6LQ HPEDUJR KD\ TXH WHQHU HQ FXHQWD TXH HVWH LQWHUYDOR SXHGH VHU H[FHSFLRQDOPHQWH ODUJR LQFOXVRPD\RUGHDxRV(QHOPRPHQWRGHODFRQVXOWD VHREVHUYDXQGHIHFWRFUDQHDOKDELWXDOPHQWHSXOViWLOTXH SXHGHDEXOWDURHVWDUOLJHUDPHQWHGHSULPLGR /DUDGLRORJtDHVFDUDFWHUtVWLFD\GLDJQyVWLFDSRQLHQGR HQ HYLGHQFLD XQ GHIHFWR yVHR RYDO FRQ ERUGHV HVFOH UyWLFRV (Q OD 7$& R HQ OD 501 SXHGHQ REVHUYDUVH OHVLRQHV DVRFLDGDV FRPR KLGURFHIDOLD HQFHIDORPDODFLD TXLVWHV OHSWRPHQtQJHRV KHUQLDFLyQ FHUHEUDO \ GLODWDFLyQ YHQWULFXODUDVLPpWULFDSHURHVWRVKDOOD]JRVQRVRQ FRQVWDQWHVQLLQGLVSHQVDEOHVSDUDHOGLDJQyVWLFR 'HODQiOLVLVGHODELEOLRJUDItD\GHQXHVWUDSURSLD FDVXtVWLFD VXUJHQ IDFWRUHV TXH SXHGHQ FRQVLGHUDUVH FRPR SUHGLFWLYRVGHOGHVDUUROORGH)(&/RVSDFLHQWHVFRQPD\RU ULHVJRSDUHFHQVHUORVPHQRUHVGHDxRVFRQWXPHIDFFLyQ ORFDOSHUVLVWHQWHFRPSURPLVRQHXUROyJLFR\IUDFWXUDVFRQ GLDVWDVLV LQLFLDO 6HNKDU \ FRO PHQFLRQDQ XQ WLSR GH IUDFWXUDTXHHQXQSULPHUPRPHQWRFUHFH\DOFDERGHSRFDV VHPDQDVLQYROXFLRQD/DGHQRPLQDQIUDFWXUDSVHXGRHYROX WLYD \ VH DVRFLD WtSLFDPHQWH D XQ WUDXPDWLVPR EDQDO VLQ Gp¿FLWQHXUROyJLFR\FRQGLDVWDVLVPHQRUGHPP(VLQWH UHVDQWHTXHQXHVWUDVHULHLQFOX\DXQFDVRFRQFDUDFWHUtVWLFDV VLPLODUHV SHUR TXH OHMRV GH LQYROXFLRQDU GHVDUUROOy XQD YHUGDGHUD)(&¿J(VWRDQXHVWURHQWHQGHUGHPXHVWUD TXHWRGDVODVIUDFWXUDVGHFUiQHRHQHGDGSHGLiWULFDGHEHQ VHUFRQWURODGDVKDVWDFRQVWDWDUVXFRQVROLGDFLyQ 7UDWDPLHQWR (O REMHWLYR GHO WUDWDPLHQWR TXLU~UJLFR HV UHSDUDU HO GHIHFWRFUDQHDOSDUDHYLWDUTXHVHSURGX]FDXQGDxRFHUH EUDOSURJUHVLYR/DWpFQLFDHVWDQGDUFRQVLVWHHQH[SRQHU ORVERUGHVGXUDOHVPHGLDQWHXQDFUDQHRWRPtDDPSOLDFHQ WUDGDHQHOGHIHFWRyVHR3RVWHULRUPHQWHODGXUDPDGUHGHEH VHUVHSDUDGDGHOWHMLGRJOLyWLFRDOFXDOHVWiKDELWXDOPHQWH DGKHULGD (Q HVWH PRPHQWR VL H[LVWH XQD OHVLyQ TXtVWLFD GHEH UHVHFDUVH VX SDUHG \ FRPXQLFDUVH FRQ HO HVSDFLR VXEDUDFQRLGHR /D GXUDPDGUH VH UHSDUD SUHIHUHQWHPHQWH FRQ SODVWLD KRPyORJD GH DSRQHXURVLV HSLFUiQHD R IDVFLD ODWD)LQDOPHQWHHOGHIHFWRVHFXEUHFRQIUDJPHQWRVyVHRV SURYHQLHQWHVGHODFUDQHRWRPtD (VWH WUDWDPLHQWR WLHQH H[FHOHQWHV UHVXOWDGRV HQ QLxRV $ % )LJXUD3DFLHQWHFRQWUDXPDWLVPREDQDOGHELGRDSUHFL SLWDFLyQGHEDMDDOWXUD$5[LQLFLDOTXHPXHVWUDIUDFWXUD OLQHDOQRGLDVWDVDGD%5[DODVVHPDQDVHQODTXHVH REVHUYDHYROXFLRQKDFLDXQGHIHFWRFUDQHDO SHTXHxRV \ SXHGH UHDOL]DUVH HQ FXDOTXLHU PRPHQWR GH OD HYROXFLyQ 6RODPHQWH HQ XQ SDFLHQWH GH QXHVWUD UHYLVLyQ OD UHJHQHUDFLyQ yVHD QR IXH VX¿FLHQWH \ GHELy FRORFDUVH SRVWHULRUPHQWH XQD PDOOD GH WLWDQLR (Q DGROHVFHQWHV R DGXOWRVHOWUDWDPLHQWRHVPiVFRPSOHMR\GHEHSUDFWLFDUVH FUDQHRSODVWLDGHSULPHUDLQWHQFLyQ $OJXQRVDXWRUHVSURSRQHQODFRORFDFLyQGH³VKXQW´FRPR ~QLFR WUDWDPLHQWR 3DUD QRVRWURV HVWR QR HV FRUUHFWR \D TXHQRVROXFLRQDODFDXVDEiVLFDTXHHVHOGHVJDUURGXUDO $GHPiV REVHUYDPRV TXH HQ ORV GRV SDFLHQWHV RSHUDGRV GHKLGURFHIDOLDPHGLDQWHGHULYDFLyQYHQWULFXORSHULWRQHDO HOGHIHFWRQRVHUHGXMRKHFKRTXHWDPELpQKDVLGRQRWDGR SRURWURVDXWRUHV (V HYLGHQWH TXH OD )(& XQD YH] GLDJQRVWLFDGD GHEH VHUWUDWDGDLQPHGLDWDPHQWH/RTXHD~QHVFRQWURYHUWLGRHV HOWUDWDPLHQWRSUR¿OiFWLFRGHODVIUDFWXUDVGLDVWDVDGDVSDUD HYLWDUVXHYROXFLyQ &UHHPRV TXH XQ HQIRTXH UDFLRQDO VHUtD RSHUDU SUHFR]PHQWH D ORV ODFWDQWHV FRQ GLDVWDVLV WUDXPiWLFD WXPHIDFFLyQ VXEJDOHDO SHUVLVWHQWH \ VLJQRV LQGLUHFWRV GH ODFHUDFLyQGXUDOVXE\DFHQWHHQOD501 Documento descargado de http://www.revistaneurocirugia.com el 21/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato. 1HXURFLUXJtD )UDFWXUDHYROXWLYDGHFUiQHRHQODLQIDQFLD3UHVHQWDFLyQGHFDVRV 'HHVWDPDQHUDVHHYLWDUtDODSRVLELOLGDGGHGDxRFHUH EUDO SURJUHVLYR 7DPELpQ OD WpFQLFD TXLU~UJLFD VHUtD PiV VHQFLOOD \D TXH HO GHIHFWR HV PHQRU \ OD GXUDPDGUH HVWi PHQRVDGKHULGDDOWHMLGRFHUHEUDO &RQFOXVLyQ 7RGDIUDFWXUDGHFUiQHRHQHGDGSHGLiWULFDGHEHVHUFRQ WURODGDKDVWDFRPSUREDUVXFLHUUH/RVSDFLHQWHVPHQRUHV GH DxRV FRQ GLDVWDVLV WUDXPiWLFD LQLFLDO \ HYLGHQFLD GH GHVJDUURGXUDOHQOD7$&R501WLHQHQDOWDSUREDELOLGDG GHGHVDUUROODUXQD)(&(QHVWRVFDVRVGHEHFRQVLGHUDUVH ODUHSDUDFLyQTXLU~UJLFDSUHFR]SDUDHYLWDUTXHVHSURGX]FD XQGDxRFHUHEUDOSURJUHVLYR %LEOLRJUDItD dRODN $ $NEDVDND $ %LOLFLOHU % (UWHQ 6) .RoDF$$QXQXVXDOYDULDQWRIDJURZLQJVNXOOIUDFWXUHLQ DQDGROHVFHQW3HGLDWU1HXURVXUJ 'RQDKXH -' 6DQIRUG 5$ 0XKOEDXHU 06 &KDGGXFN :0 &UDQLDO EXUVW IUDFWXUH LQ LQIDQWV DFXWH UHFRJQLWLRQ DQG PDQDJHPHQW &KLOG¶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¶V1HUY6\VW .DVKLZDJL6$ELNR6$RNL+*URZLQJVNXOOIUDF WXUH LQ FKLOGUHQ D UHFXUUHQW FDVH WUHDWHG E\ VKXQW RSHUDWLRQ 6XUJ1HXURO .Ro 5. .XUWVR\ $ 2NWHP 6 $NGHPLU + *URZLQJVNXOOIUDFWXUHRIWKHRUELWDOURRIFDVHUHSRUW3HGLD WULF1HXURVXUJ /HQGH5$(ULNVRQ7&*URZLQJVNXOOIUDFWXUHLQ FKLOGKRRG-1HXURVXUJ 0RVV6':DONHU0/2VWHUJDUG6*ROHPEHVNL ' ,QWUDXWHULQH JURZLQJ VNXOO IUDFWXUH &KLOG¶V 1HUY 6\VW 0XKRQHQ 0* 3LSHU -* 0HQH]HV$+ 3DWKR JHQHVLVDQGWUHDWPHQWRIJURZLQJVNXOOIUDFWXUH6XUJ1HXURO 0XUDW . 'HPLUFDQ 1 $NLQ 21 %DVHNLP & 8QWUHDWHGJURZLQJVNXOOIUDFWXUHGHWHFWHGLQODWHVWDJH1HXUR VXUJHU\ 1HPRWR6+RIIPDQ+-/HSWRPHQLQJHDOF\VWRIWKH SRVWHULRUIRVVD-1HXURVXUJ 3DSDHIWK\PLRX*2EHUEDXHU53HQGO*&UDQLR FHUHEUDOELUWKWUDXPDFDXVHGE\YDFXXPH[WUDFWLRQ$FDVHRI JURZLQJ VNXOO IUDFWXUH DV D 3HULQDWDO FRPSOLFDWLRQ &KLOG¶V 1HUY6\VW 5DPDPXUWKL%.DO\DUDPDQ65DWLRQDOHIRUVXUJHU\ LQJURZLQJIUDFWXUHRIWKHVNXOO-1HXURVXUJ 5RVHQWKDO 6$ *ULHVKRS - )UHHPDQ /0 ([SH ULPHQWDOREVHUYDWLRQRQHQODUJLQJVNXOOIUDFWXUH-1HXURVXUJ 5R\66DUNDU&7DQGRQ31%DQHUML$.&UD QLRFHUHEUDOHURVLRQJURZLQJIUDFWXUHRIWKHVNXOOLQFKLOGUHQ SDUW3DWKRORJ\$FWD1HXURFKLU:LHQ 6FDUIR *% 0DULRWWLQL $ 7RPDFFLQL ' 3DUPD , *URZLQJ VNXOO IUDFWXUH 3URJUHVVLYH HYROXWLRQ RI EUDLQ GDPDJHDQGHIIHFWLYHQHVVRIVXUJLFDOWUHDWPHQW&KLOG¶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pQ$%UHOO0&DUGRQD(&ODUDPXQW (&RVWD-0)UDFWXUDHYROXWLYDGHFUiQHRHQODLQIDQFLD 3UHVHQWDFLyQGHFDVRV1HXURFLUXJtD &RUUHVSRQGHQFLD SRVWDO -RVp 0DUtD &RVWD 6HUYLFLR GH 1HXUR FLUXJtD +RVSLWDO 6DQW -RDQ GH 'pX 8QLYHUVLGDG GH %DUFHORQD 3DVVHLJ6DQW-RDQGH'pX(63/8*(6%DUFHORQD (PDLOMFRVWD#KVMGEFQRUJ