Factores pronósticos en el traumatismo

Anuncio
Documento descargado de http://www.revistaneurocirugia.com el 17/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
)DFWRUHVSURQyVWLFRVHQHOWUDXPDWLVPRFUDQHRHQFHIiOLFRJUDYH
*5%RWR3$*yPH]-'HOD&UX]\5'/REDWR
6HUYLFLRGH1HXURFLUXJtD\8QLGDGGH(SLGHPLRORJtD&OtQLFD+RVSLWDOGH2FWXEUH0DGULG
5HVXPHQ
(O FRQRFLPLHQWR GH ORV OODPDGRV IDFWRUHV R
LQGLFDGRUHV SURQyVWLFRV LPSOLFDGRV HQ HO WUDXPDWLVPR
FUDQHRHQFHIiOLFRJUDYH7&(*UHVXOWDIXQGDPHQWDOD
ODKRUDGHSURQRVWLFDUHOIXWXURGHORVSDFLHQWHVDIHFWRV
GHHVWDSDWRORJtD(VRVLQGLFDGRUHVFRQVWLWX\HQORVSLOD
UHV EiVLFRV GH ODV GLIHUHQWHV IyUPXODV R PRGHORV SUR
QyVWLFRVTXHVHXWLOL]DQSDUDUHDOL]DUSUHGLFFLRQHVHQHO
7&(* 'LFKRV PRGHORV SRU WDQWR HVWDUiQ IRUPDGRV
SRUHOFRQMXQWRGHXQDVHULHGHYDULDEOHVLQGLFDGRUHV
R IDFWRUHV SURQyVWLFRV \ GH XQDV HVFDODV HVFDODV
SURQyVWLFDV TXH VLUYHQ SDUD PHGLU HO SURQyVWLFR ¿QDO
GHHVWRVSDFLHQWHV
(Q HVWH WUDEDMR VH UHVXPHQ WUDV DQDOL]DU H[KDXV
WLYDPHQWH OD ELEOLRJUDItD ORV SULQFLSDOHV FRQRFLPLHQ
WRV VREUH ORV IDFWRUHV SURQyVWLFRV UHODFLRQDGRV FRQ HO
7&(* (VWRV LQGLFDGRUHV VH KDQ FODVL¿FDGR HQ FXDWUR
JUXSRVSULQFLSDOHVGHtQGROHFOtQLFRUDGLROyJLFR¿VLR
OyJLFR \ ELRTXtPLFR$GHPiV VH GHVFULEHQ EUHYHPHQWH
ODVHVFDODVSURQyVWLFDVPiVXWLOL]DGDVHQHO7&(*
,QWKLVSDSHUZHUHVXPHDIWHUDQH[KDXVWLYHUHYLHZ
RI WKH OLWHUDWXUH WKH NQRZOHGJH DERXW WKH SURJQRVWLF
IDFWRUVUHODWHGWR6+,7KHVHLQGLFDWRUVKDYHEHHQFODV
VL¿HG DV IROORZV FOLQLFDO UDGLRORJLFDO SK\VLRORJLFDO
DQG ELRFKHPLFDO 0RUHRYHU ZH KDYH EULHÀ\ GHVFULEHG
WKHSURJQRVWLFVFDOHVPRUHFRPPRQO\XVHGLQ6+,
.(< :25'6 3URJQRVWLF IDFWRUV 3URJQRVWLF LQGLFDWRUV
6HYHUHKHDGLQMXU\
)DFWRUHVSURQyVWLFRVHQHOWUDXPDWLVPRFUDQHRHQFH
IiOLFRJUDYH7&(*
3URJQRVWLFIDFWRUVLQVHYHUHKHDGLQMXU\
$OJXQRVLQGLFDGRUHVFRPRODSXQWXDFLyQHQOD*ODVJRZ
&RPD6FDOH*&6ODHGDG\ODUHDFWLYLGDGSXSLODUGHEH
UtDQHPSOHDUVHVLHPSUHTXHVHUHDOLFHQSUHGLFFLRQHVHQHO
7&(*\DTXHKDQGHPRVWUDGRHQP~OWLSOHVHVWXGLRVTXH
VRQ LQGLFDGRUHV SURQyVWLFRV FRQVLVWHQWHV 2WUDV FRPR OD
LQIRUPDFLyQGHODWRPRJUDItDFRPSXWDUL]DGD7&FUDQHDO
\ ORV UHÀHMRV WURQFRHQFHIiOLFRV SUREDEOHPHQWH VHDQ WDP
ELpQGHXWLOLGDG/RVQLYHOHVGHSUHVLyQLQWUDFUDQHDO3,&
ODV PHGLFLRQHV GH ÀXMR VDQJXtQHR FHUHEUDO )6& FRQ
GLYHUVDVWpFQLFDV\ORVSRWHQFLDOHVHYRFDGRV3(VSXHGHQ
VHUYLUSDUDDxDGLUVHJXULGDGDODVSUHGLFFLRQHV$FRQWLQXD
FLyQSDVDPRVDUHYLVDUORVGLIHUHQWHVIDFWRUHVSURQyVWLFRV
LPSOLFDGRVHQHO7&(*
6XPPDU\
'HWLSRFOtQLFR
7KHNQRZOHGJHRIWKHVRFDOOHGSURJQRVWLFIDFWRUVRU
LQGLFDWRUVLQYROYHGLQVHYHUHKHDGLQMXU\6+,LVDQLVVXH
RIJUHDWLQWHUHVWWRPDNHSUHGLFWLRQVDERXWWKHIXWXUHRI
SDWLHQWVZLWKWKLVSDWKRORJ\7KRVHLQGLFDWRUVFRQVWLWXWH
WKHEDVLFHOHPHQWVRIWKHGLIIHUHQWSURJQRVWLFIRUPXODVRU
PRGHOVFDUULHGRXWLQRUGHUWRPDNHSUHGLFWLRQVLQ6+,
7KHPHQWLRQHGPRGHOVWKHUHIRUHZLOOEHFRQVWUXFWHGE\
D JURXS RI YDULDEOHV SURJQRVWLF LQGLFDWRUV RU IDFWRUV
DQGVHYHUDOVFDOHVSURJQRVWLFVFDOHVWKDWDUHXVHIXOIRU
PHDVXULQJWKH¿QDORXWFRPHRIWKHVHSDWLHQWV
*&6
/D *&6 GHVDUUROODGD HQ HV OD HVFDOD PiV XWLOL
3$/$%5$6 &/$9( )DFWRUHV SURQyVWLFRV ,QGLFDGRUHV
SURQyVWLFRV7UDXPDWLVPRFUDQHRHQFHIiOLFRJUDYH
1HXURFLUXJtD5HFLELGR$FHSWDGR
$EUHYLDWXUDV$DGUHQDOLQD%5EXHQDUHFXSHUDFLyQ&3.%%
FUHDWLQD IRVIRTXLQDVD LVRHQ]LPD %% ((* HOHFWURHQFHIDOR
JUDPD (9 HVWDGR YHJHWDWLYR )6& ÀXMR VDQJXtQHR FHUHEUDO
*&6 *ODVJRZ FRPD VFDOH *26 *ODJRZ RXWFRPH VFDOH ,*
LQFDSDFLGDG JUDYH /$' OHVLyQ D[RQDO GLIXVD /&5 OtTXLGR
FHIDORUUDTXtGHR1$QRUDGUHQDOLQD3(VSRWHQFLDOHVHYRFDGRV
33& SUHVLyQ GH SHUIXVLyQ FHUHEUDO 50 UHVRQDQFLD PDJQp
WLFD 6MY2 VDWXUDFLyQ \XJXODU GHO R[tJHQR 7&( WUDXPDWLVPR
FUDQHRHQFHIiOLFR7&(*WUDXPDWLVPRFUDQHRHQFHIiOLFRJUDYH
Documento descargado de http://www.revistaneurocirugia.com el 17/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
1HXURFLUXJtD
%RWR\FRO
]DGDDODKRUDGHGHWHUPLQDUODJUDYHGDGGHOWUDXPDWLVPR
FUDQHRHQFHIiOLFR7&(\DPHQXGRFRQVWLWX\HHOSULPHUR
VHJXQGRLQGLFDGRUSURQyVWLFRPiVVLJQL¿FDWLYRFXDQGRVH
FRQVLGHUDHQXQPRGHORPXOWLYDULDEOH
(PSOHDODSXQWXDFLyQWRWDOTXHYDGHDDGMXGLFDGD
DWUHVSDUiPHWURVWUDVUHVXFLWDFLyQQRTXLU~UJLFDDSHUWXUD
RFXODUUHVSXHVWDYHUEDO\UHVSXHVWDPRWRUD([LVWHXQD
HVWUHFKDDVRFLDFLyQHQWUHEDMDSXQWXDFLyQHQOD*&6\PDO
SURQyVWLFR WDQWR QHXUROyJLFR FRPR QHXURSVLFROyJLFR GH
WDOPDQHUDTXHODPRUWDOLGDGHQORVSDFLHQWHVFRQXQDSXQ
WXDFLyQHQWUH\HVWUHVYHFHVPD\RUTXHODGHORVSDFLHQ
WHV FRQ XQD SXQWXDFLyQ HQWUH \ $GHPiV VH HVWLPD
TXHDOUHGHGRUGHODOGHSDFLHQWHVFRQXQ7&(*
FHUUDGR\XQDSXQWXDFLyQGHHQOD*&6PRULUiQ
/D UHVSXHVWD PRWRUD DLVODGDPHQWH FRQVLGHUDGD FRQV
WLWX\H SRU Vt PLVPD XQR GH ORV IDFWRUHV SURQyVWLFRV PiV
LPSRUWDQWHVHQHO7&(*\DTXHFDUHFHGHODYDULDELOLGDG
LQKHUHQWH SURSLD GH OD DSHUWXUD RFXODU R GH OD UHVSXHVWD
YHUEDO (O SURQyVWLFR HPSHRUD D PHGLGD TXH OD UHVSXHVWD
PRWRUDYDGHODQRUPDOLGDGDODÀDFFLGH]DXQTXHHVWDUHOD
FLyQ SXHGH VHU PHQRV DFXVDGD HQ SDFLHQWHV FRQ OHVLRQHV
TXLU~UJLFDVGHELGRDODPD\RUPRUWDOLGDGGHHVWHJUXSRGH
SDFLHQWHVDXQFXDQGRSUHVHQWHQUHVSXHVWDVPRWRUDVORFD
OL]DGRUDVRGHUHWLUDGD/DÀDFFLGH]DOLQJUHVRFRQOOHYDOD
PRUWDOLGDGPiVDOWDFHUFDQDDO\ODFRPELQDFLyQGH
ÀDFFLGH]\HGDGVXSHULRUDORVDxRVHVDVLPLVPRH[WUH
PDGDPHQWHOHWD
/D XWLOL]DFLyQ GH OD *&6 SXHGH YHUVH LQWHUIHULGD SRU
GLYHUVDV FLUFXQVWDQFLDV HQWUH ODV TXH HVWiQ HO DOFRKRO ODV
GURJDVODKLSRWHQVLyQODKLSR[LDODVFULVLVFRPLFLDOHVORV
HVWDGRVSRVWLFWDOHV\ODPHGLFDFLyQVHGRUHODMDQWH$GHPiV
ORVLPSDFWRVIDFLDOHV\ODLQWXEDFLyQRURWUDTXHDOOLPLWDQOD
H[SORUDFLyQGHODDSHUWXUDRFXODU\GHODUHVSXHVWDYHUEDO
UHVSHFWLYDPHQWH 3RU RWUD SDUWH VH FDOFXOD TXH DOUHGHGRU
GH OD FXDUWD SDUWH GH ORV SDFLHQWHV FRQ 7&(* PHMRUDUiQ
VX SXQWXDFLyQ HQ OD *&6 WUDV UHVXFLWDFLyQ QR TXLU~UJLFD
\WUDWDPLHQWRGHVXVOHVLRQHVH[WUDFUDQHDOHV3RUWDQWROD
SXQWXDFLyQ HQ OD *&6 HVWLPDGD PX\ SUHFR]PHQWH R VLQ
WHQHUHQFXHQWDHVWDVFLUFXQVWDQFLDVQRSXHGHVHUHPSOHDGD
FRPRLQGLFDGRUSURQyVWLFRHQHO7&(*
$XQTXH VH KDQ SURSXHVWR YDULDV PRGL¿FDFLRQHV GH
OD *&6 LQFRUSRUDQGR SRU HMHPSOR D pVWD ORV UHÀHMRV
WURQFRHQFHIiOLFRV OD *ODVJRZ/LHJH 6FDOH R DVR
FLDQGR DPERV D OD ODWHUDOL]DFLyQ PRWRUD OD 0DU\ODQG
&RPD 6FDOH OD *&6 SHUPDQHFH FRPR HO JROG VWDQ
GDUG SDUD HYDOXDU OD JUDYHGDG GHO 7&(* IXQGDPHQWDO
PHQWHSRUVXHVFDVDYDULDELOLGDGLQWHUREVHUYDGRU
(GDG
3HVHDODH[LVWHQFLDGHXQPD\RUQ~PHURGHFRPSOLFD
FLRQHVVLVWpPLFDVHQORVDQFLDQRVVHKDGHPRVWUDGRTXHOD
HGDG HV XQ IDFWRU SURQyVWLFR LQGHSHQGLHQWH TXH LQÀXHQFLD
WDQWRODPRUWDOLGDGFRPRHOJUDGRGHLQFDSDFLGDGORTXH
ODFRQYLHUWHHQODYDULDEOHPiVLPSRUWDQWHUHODFLRQDGDFRQ
HOSURQyVWLFRHQDOJXQRVHVWXGLRVGH7&(*/D
UHVSXHVWD¿VLRSDWROyJLFDGHOFHUHEURDOWUDXPDWLVPRYDUtD
FRQODHGDGGHWDOPDQHUDTXHHOFHUHEURGHODQFLDQRSDUHFH
UHVXOWDU PiV YXOQHUDEOH D ORV LQVXOWRV \D TXH WLHQH XQD
UHVHUYDQHXURQDOPHQRU\XQDFDSDFLGDGSDUDODUHFXSHUD
FLyQ SRVLEOHPHQWH GLVPLQXLGD FRPSDUDGR FRQ HO FHUHEUR
GHOMRYHQ
([LVWH XQD IXHUWH DVRFLDFLyQ HQWUH HGDG DYDQ]DGD \
SURQyVWLFR GHVIDYRUDEOH (Q JHQHUDO OD SURSRUFLyQ GH
SURQyVWLFRVGHVIDYRUDEOHVVHLQFUHPHQWDGHPDQHUDFRQV
WDQWH FRQ OD HGDG VDOYR HQ ORV QLxRV PHQRUHV GH DxRV
TXLHQHVSDUHFHQWHQHUPD\RUPRUWDOLGDGTXHORVVXMHWRVGH
HGDGHVHQWUH\DxRV/RVSDFLHQWHVPD\RUHVGHDxRV
WLHQHQFDVLGREOHPRUWDOLGDGTXHORVPHQRUHVGHHVDHGDG
\SXHVWRTXHHOSURPHGLRGHHQIHUPRVHQHVWDGRYHJHWDWLYR
(9VHGLVWULEX\HSRULJXDOHQWRGRVORVJUXSRVGHHGDGHV
SRVLEOHTXHODPD\RUPRUWDOLGDGGHODSREODFLyQDQFLDQDVH
H[SOLTXHSRUTXHVXIUHQPD\RUGDxRFHUHEUDODLJXDOJUDYH
GDGGHOWUDXPDWLVPR3RURWURODGRGLYHUVRVHVWXGLRVKDQ
GHPRVWUDGRTXHODPRUWDOLGDGHQODVSULPHUDVKRUDVWUDV
HOLPSDFWRHVVLPLODUHQWRGRVORVJUXSRVGHHGDG
6HJ~Q DXPHQWD OD HGDG GH ORV SDFLHQWHV VH KDFHQ
PiVIUHFXHQWHVODVOHVLRQHVGHWLSRIRFDOVXEGXUDODJXGR
\ KHPDWRPD LQWUDFHUHEUDO OD LQFLGHQFLD GH KHPRUUDJLD
VXEDUDFQRLGHDODFRPSUHVLyQGHYHQWUtFXORV\FLVWHUQDV\
HOGHVSOD]DPLHQWRGHODOtQHDPHGLDDVRFLDGRVWRGRVHOORVD
SHRUSURQyVWLFR(QUHODFLyQFRQHOPHFDQLVPRGHOWUDXPD
ODV FDtGDV SUHGRPLQDQ HQ ORV QLxRV HQWUH \ DxRV \
HQ ORV PD\RUHV GH DxRV HQ TXLHQHV WDPELpQ VRQ PiV
IUHFXHQWHV ORV DWURSHOORV HQ WDQWR TXH ORV DFFLGHQWHV GH
WUi¿FR\SRUWDQWRODOHVLyQD[RQDOGLIXVD/$'RFXUUHQ
SULQFLSDOPHQWHHQWUHORV\ORVDxRV
5HVSXHVWDSXSLODU\PRYLPLHQWRVRFXODUHV
/D IDOWD GH UHDFWLYLGDG SXSLODU R OD SUHVHQFLD GH
DQLVRFRULD VH DVRFLDQ D PDO SURQyVWLFR \ DPERV IDFWRUHV
KDQ GHPRVWUDGR TXH VRQ LQGLFDGRUHV SURQyVWLFRV VLJQL¿
FDWLYRVHQPRGHORVPXOWLYDULDEOHV(OYDORUSURQyVWLFRGH
ODUHVSXHVWDSXSLODUHVPD\RUHQSDFLHQWHVFRQOHVLRQHVQR
TXLU~UJLFDV /RV SDFLHQWHV FRQ DPEDV SXSLODV DUUHDFWLYDV
WLHQHQFDVLHOGREOHGHPRUWDOLGDGTXHORVTXHVyOR
PXHVWUDQXQDGHHOODVDUUHDFWLYDWHQGHQFLDLQFOXVR
PiVSURQXQFLDGDHQVXMHWRVPD\RUHVGHDxRV(QSULQ
FLSLRODPLGULDVLVELODWHUDODUUHDFWLYDHVLQGLFDGRUDGHSUR
QyVWLFRIDWDODXQTXHH[LVWHQH[FHSFLRQHVO
/D SUHVHQFLD GH PRYLPLHQWRV RFXODUHV DXVHQWHV R
DOWHUDGRV LQFOX\HQGR OD DOWHUDFLyQ HQ ORV UHÀHMRV RFXOR
FHIiOLFRVRFXORYHVWLEXODUHV\FRUQHDOHVVHDVRFLDQDPDO
SURQyVWLFR KDELGD FXHQWD GH TXH WUDGXFHQ DIHFWDFLyQ GHO
Documento descargado de http://www.revistaneurocirugia.com el 17/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
1HXURFLUXJtD
)DFWRUHVSURQyVWLFRVHQHOWUDXPDWLVPRFUDQHRHQFHIiOLFRJUDYH
WURQFRGHOHQFpIDOR/DGHWHUPLQDFLyQGHGLYHUVRVUHÀHMRV
WURQFRHQFHIiOLFRVIURQWRRUELFXODURFXORFHIiOLFRYHUWLFDO
SXSLODUDODOX]RFXORFHIiOLFRKRUL]RQWDO\RFXORFDUGtDFR
MXQWRFRQOD*&6FRQVWLWX\HQODOODPDGD*ODVJRZ/LHJH
6FDOH$XQTXHFRQHVWDHVFDODVHDOFDQ]DQSUHGLFFLRQHV
FRUUHFWDVGHUHFXSHUDFLyQIXQFLRQDOHQHOGHORVFDVRV
LQFOXVRWUDVDMXVWDUSRUODHGDGFLIUDVTXHPHMRUDQODFDSD
FLGDGSDUDUHDOL]DUSURQyVWLFRVGHOD*&6DLVODGDPHQWHQR
GHEH ROYLGDUVH TXH HVWRV UHÀHMRV VH YHQ LQWHUIHULGRV SRU
IiUPDFRVVHGRUHODMDQWHV\TXHVXH[SORUDFLyQHVWiVXMHWD
DPD\RUYDULDELOLGDGLQWHUREVHUYDGRUTXHODUHFRJLGDGHOD
UHDFWLYLGDGSXSLODURGHODUHVSXHVWDPRWRUD
6HJ~Q /HYDWL \ FROV FXDQGR OD UHVSXHVWD SXSLODU
HVWiDXVHQWHDOLQJUHVR\DGHPiVODRFXORFHIiOLFDWDPELpQ
VH HQFXHQWUD DXVHQWH R DOWHUDGD HO GH ORV SDFLHQWHV
IDOOHFHQ6LDPEDVUHVSXHVWDVSHUPDQHFHQDOWHUDGDVGXUDQWH
PiVGHKRUDVODPRUWDOLGDGHVGHO
0HFDQLVPRWUDXPiWLFR
$XQTXHHOPHFDQLVPRGHOWUDXPDVHKDUHODFLRQDGRFRQ
HOSURQyVWLFRQRHVWiFODURTXHDFW~HFRPRXQIDFWRUSUR
QyVWLFRLQGHSHQGLHQWH'HKHFKR-HQQHWW\FROVHQFRQWUD
URQSRFDUHODFLyQHQWUHHVWDYDULDEOH\HOSURQyVWLFRHQVX
VHULHGHSDFLHQWHVFRQ7&(*
/RV VXMHWRV TXH VXIUHQ FDtGDV WLHQHQ PD\RU PRUWDOL
GDG TXH HO UHVWR GH SDFLHQWHV \D TXH VXHOHQ VHU GH HGDG
DYDQ]DGD \ IUHFXHQWHPHQWH SUHVHQWDQ OHVLRQHV DVRFLDGDV
GHPDVDLQWUDFUDQHDO$VLPLVPRORVSDFLHQWHVTXHVXIUHQ
DJUHVLRQHV WDPELpQ SUHVHQWDQ FRQ IUHFXHQFLD OHVLRQHV GH
PDVD LQWUDFUDQHDO \ PD\RU PRUWDOLGDG TXH HO UHVWR /RV
VXMHWRVDWURSHOODGRVWLHQHQSDUWLFXODUPHQWHPDOSURQyVWLFR
SRVLEOHPHQWHGHELGRDODKLSRWHQVLyQHKLSR[LDIUHFXHQWH
PHQWH DVRFLDGDV /RV WUDXPDWLVPRV GH DOWD YHORFLGDG VH
UHODFLRQDQFRQOD/$'\ORVSDFLHQWHVTXHORVVXIUHQWLHQHQ
XQ SURQyVWLFR UHODWLYDPHQWH PHMRU TXH HO UHVWR TXL]iV
SRUTXHHQJHQHUDOVRQPiVMyYHQHV\SUHVHQWDQSXQWXDFLR
QHVPiVDOWDVHQOD*&6JOREDO\PRWRUDFRPRVXFHGHFRQ
ORVPRWRFLFOLVWDV
/HVLRQHVVHFXQGDULDV
$SUR[LPDGDPHQWHHOGHORVSDFLHQWHVFRQ7&(*
VHGHWHULRUDQWUDVHOWUDXPDWLVPRLQLFLDOGHELGRDORVOODPD
GRVLQVXOWRVVHFXQGDULRVTXHSXHGHQVHUGHRULJHQH[WUDR
LQWUDFUDQHDO \ HQWUH ORV TXH VH HQFXHQWUDQ OD KLSRWHQVLyQ
ODKLSR[LDOD3,&HOHYDGDHOYDVRHVSDVPR\ODOHVLyQGH
ORVYDVRVLQWUDFUDQHDOHVPD\RUHV(OFRP~QGHQRPLQDGRU
GH WRGRV HOORV HV OD LVTXHPLD FHUHEUDO 6L HVWRV LQVXOWRV
VHFXQGDULRVSXGLHUDQHYLWDUVHVLQGXGDHOSURQyVWLFRGHORV
SDFLHQWHVPHMRUDUtDO
/D SUHVHQFLD GH KLSRWHQVLyQ DUWHULDO WHQVLyQ DUWHULDO
7$VLVWyOLFDPHQRURLJXDODPP+JSDUHFHHPSHRUDU
HOSURQyVWLFRGHORVSDFLHQWHVFRQ7&(*GHPDQHUDVLJQL¿
FDWLYD&XDOTXLHUHSLVRGLRGHKLSRWHQVLyQHQHOSHUtRGR
TXHWUDQVFXUUHGHVGHHOWUDXPDWLVPRDODOOHJDGDDOKRVSL
WDOGXSOLFDODPRUWDOLGDGHLQFUHPHQWDFRQVLGHUDEOHPHQWH
OD PRUELOLGDG LQGHSHQGLHQWHPHQWH GH RWURV IDFWRUHV /D
SUHVHQFLD GH KLSRWHQVLyQ LQWUDRSHUDWRULD HQ SDFLHQWHV FRQ
7&(*FRQOOHYDWDPELpQPD\RUPRUWDOLGDG(QHO7UDX
PDWLF&RPD'DWD%DQN0DUPDURX\FROVOGHPRVWUDURQ
TXHHOSURQyVWLFRVHUHODFLRQDHVWUHFKDPHQWHFRQODSURSRU
FLyQGHPHGLFLRQHVKRUDULDVGH7$SRUGHEDMRGHPP
+JGHWDOPDQHUDTXHH[LVWHXQDUHODFLyQHVWDGtVWLFDPHQWH
VLJQL¿FDWLYDHQWUHODSUHVHQFLDGHKLSRWHQVLyQ\ODSUREDEL
OLGDGGHPRULURTXHGDUYHJHWDWLYRDORVPHVHVGHOWUDX
PDWLVPRGHVSXpVGHXQDMXVWHVHJ~QODHGDGODUHVSXHVWD
PRWRUD\ODUHDFWLYLGDGSXSLODU3RUWDQWRODSUHVHQFLDGH
KLSRWHQVLyQ HQ FXDOTXLHU PRPHQWR WUDV HO WUDXPDWLVPR
VH DVRFLD D SHRU SURQyVWLFR GHELGR SUREDEOHPHQWH D OD
LVTXHPLD FHUHEUDO TXH FRQOOHYD SRU GLVPLQXFLyQ GH SHU
IXVLyQ FHUHEUDO \ PX\ HVSHFLDOPHQWH FXDQGR VH DVRFLDQ
PDVDVLQWUDFUDQHDOHVR3,&HOHYDGD7DPELpQVHKDUHODFLR
QDGRODKLSRWHQVLyQDUWHULDOSUHFR]FRQHOVZHOOLQJ\FRQ
HOHYDFLRQHVGLIHULGDVGH3,&
'H LJXDO PDQHUD OD KLSR[LD SUHVLyQ DUWHULDO GH 2
SD2PHQRURLJXDODPP+JWDPELpQVHKDUHODFLR
QDGR FRQ DOWD PRUELPRUWDOLGDG HQ GLYHUVRV HVWXGLRV VLQ
HPEDUJRQRSDUHFHVHUXQIDFWRUSURQyVWLFRLQGHSHQGLHQWH
HQORVPRGHORVGHUHJUHVLyQORJtVWLFD
(LVHQEHUJ \ FROV UHODFLRQDURQ OD KLSR[LD \ OD
KLSRWHQVLyQSUHFR]FRQODSUHVHQFLDGHVZHOOLQJGLIXVR
HQ OD 7& FUDQHDO LQLFLDO :D[PDQ \ FROV DQDOL]DURQ OD
UHODFLyQ GH OD 7$ VLVWyOLFD \ OD YHQWLODFLyQ HVSRQWiQHD
FRQ HO SURQyVWLFR 'H IRUPD VHSDUDGD DPEDV YDULDEOHV
VH HQFRQWUDEDQ UHODFLRQDGDV FRQ HVWH ~OWLPR SHUR HQ XQ
PRGHOR PXOWLYDULDEOH VyOR OD 7$ VLVWyOLFD GHPRVWUy VHU
IDFWRU SURQyVWLFR LQGHSHQGLHQWH 6LQ HPEDUJR FXDQGR VH
DxDGLy OD LQIRUPDFLyQ GH OD7& FUDQHDO DO PRGHOR OD7$
VLVWyOLFD WDPELpQ SHUGLy HVWD FRQGLFLyQ OR FXDO LOXVWUD OR
TXHSXHGHVXFHGHUFXDQGRYDULDVYDULDEOHVHVWiQUHODFLRQD
GDVHQWUHVt\DODYH]FRQRWUD
3RU RWUR ODGR OD SUHVHQFLD GH KLSHUWHQVLyQ DUWHULDO
FRPR SDUWH GH OD UHVSXHVWD VLVWpPLFD DO WUDXPDWLVPR
QHXUROyJLFR VH KD UHODFLRQDGR FRQ 3,& HOHYDGD HGHPD
KHPRUUDJLDVLQWUDFHUHEUDOHVGLIHULGDV\SRUWDQWRWDPELpQ
FRQPDOSURQyVWLFR
'XUDFLyQGHOFRPD
$OJXQRV DXWRUHV OR KDQ HPSOHDGR FRPR PHGLGD GH OD
JUDYHGDG GHO WUDXPDWLVPR DVXPLHQGR TXH HQ JHQHUDO
FXDQWR PiV WLHPSR GXUH HO HVWDGR GH FRPD SHRU VHUi HO
SURQyVWLFRGHOSDFLHQWH*HQQDUHOOL\FROVREVHUYDURQ
TXH H[LVWtD PD\RU PRUWDOLGDG HQ SDFLHQWHV TXH SHUPDQH
FtDQHQFRPDGXUDQWHPiVGHKRUDVTXHHQDTXpOORVTXH
Documento descargado de http://www.revistaneurocirugia.com el 17/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
%RWR\FRO
SUHVHQWDEDQFRPDVGHPHQRUGXUDFLyQ
7DPELpQVHKDUHODFLRQDGRODGXUDFLyQGHODDOWHUDFLyQ
GH OD FRQFLHQFLD HVWLPDGD FRPR DPQHVLD SRVWUDXPiWLFD
FRQ HO SURQyVWLFR (VWH WLSR GH DPQHVLD GH¿QLGD FRPR
HO SHUtRGR GXUDQWH HO FXDO QR VH KD DOPDFHQDGR LQIRUPD
FLyQ WHQGUtD YDORU SURQyVWLFR VyOR FXDQGR IXHUD GH FRUWD
GXUDFLyQ LPSOLFDQGR HQWRQFHV EXHQ SURQyVWLFR \D TXH
QLODDPQHVLDSRVWUDXPiWLFDGHODUJDGXUDFLyQQLHOFRPD
SURORQJDGRFRQGXFHQQHFHVDULDPHQWHDPDOSURQyVWLFR
2WURVLQGLFDGRUHVSURQyVWLFRVGHWLSRFOtQLFR
$SUR[LPDGDPHQWHODPLWDGGHORVSDFLHQWHVFRQ7&(*
SUHVHQWDQ OHVLRQHV DVRFLDGDV H[WUDFUDQHDOHV TXH VHJ~Q
DOJXQRV DXWRUHV HPSHRUDQ VX SURQyVWLFR
2WURVLQYHVWLJDGRUHVVLQHPEDUJRHVWLPDQTXHHVWHIDFWRU
WLHQH VyOR XQ HIHFWR FXHVWLRQDEOH H LQFOXVR LQVLJQL¿FDQWH
VREUHHOSURQyVWLFRFXDQGRQRHVWiDVRFLDGRDKLSRWHQVLyQ
R KLSR[LD \D TXH VX SUHVHQFLD YD UHFRJLGD DO PHQRV HQ
SDUWHHQOD*&6'HOPLVPRPRGRVHFXHVWLRQDVLHO
WUDXPDWLVPRWRUiFLFRRDEGRPLQDOTXHUHTXLHUHFLUXJtDHV
XQLQGLFDGRUSURQyVWLFRUHOHYDQWH
6HKDVXJHULGRTXHODSURJHVWHURQDSRGUtDDFWXDUFRPR
XQDJHQWHQHXURSURWHFWRUHQODVPXMHUHVKDFLHQGRTXHpVWDV
VHUHFXSHUHQPHMRUWUDVXQ7&(*\SRUWDQWRWHQJDQPHMRU
SURQyVWLFRTXHORVKRPEUHV6LQHPEDUJRHVWRVKDOOD]JRV
QRKDQSRGLGRVHUFRUURERUDGRVSRURWURVDXWRUHVHLQFOXVR
DOJXQRVKDQHQFRQWUDGRSHRUSURQyVWLFRHQPXMHUHVSUHPH
QRSiXVLFDVTXHHQKRPEUHV
/RV DQWHFHGHQWHV PpGLFRV SDUHFHQ LQÀXLU HQ HO SUR
QyVWLFRSHURVyORHQORVSDFLHQWHVPD\RUHVGHDxRV(O
QLYHOGHLQWHOLJHQFLDSUHYLRDOWUDXPDWLVPRHVGHWHUPLQDQWH
VREUH HO SURQyVWLFR LQWHOHFWXDO SRVWHULRU VHJ~Q DOJXQRV
DXWRUHVSRUFRQWUDRWURVKDQSXEOLFDGRTXHORVSDFLHQWHV
FRQ PD\RU LQWHOLJHQFLD SUHYLD DO LPSDFWR GHVDUUROODUiQ
PD\RUSpUGLGDLQWHOHFWXDODSRVWHULRUL/RVVXMHWRVTXH\D
KDQVXIULGRFRQDQWHULRULGDGRWUR7&(*VRQWDPELpQPiV
VXVFHSWLEOHVDOGDxRFHUHEUDO\WLHQHQSHRUSURQyVWLFRTXH
TXLHQHVQXQFDKDQWHQLGRSUHYLDPHQWHXQ7&(*4XL]iVHO
PDOSURQyVWLFRUHODFLRQDGRFRQWRGRVHVWRVIDFWRUHVSXHGD
H[SOLFDUVH SRU XQ VRSRUWH IDPLOLDU \ VRFLDO LQDGHFXDGR R
SRUXQDGHWHUPLQDGDSUHGLVSRVLFLyQJHQpWLFD
3RURWURODGRQRGHEHPRVROYLGDUQRVGHODOFRKROTXH
HVWi LPSOLFDGR HQ XQ JUDQ Q~PHUR GH 7&(V GH FXDOTXLHU
JUDGRGHJUDYHGDG3HVHDTXHORVVXMHWRVEDMRVXVHIHFWRV
WLHQHQSXQWXDFLRQHVLQLFLDOHVHQOD*&6PiVEDMDVTXHORV
QRLQWR[LFDGRVQRVHKDFRQVHJXLGRGHPRVWUDUFRUUHODFLyQ
HQWUHHOQLYHOGHDOFRKROHPLD\HOSURQyVWLFR¿QDO
'HWLSRUDGLROyJLFR
7&FUDQHDO
1HXURFLUXJtD
(OWLSRGHOHVLyQLQWUDFUDQHDOLQÀX\HVLJQL¿FDWLYDPHQWH
HQHOSURQyVWLFRGHWDOPDQHUDTXHSDUDPXFKRVDXWRUHVHV
XQGDWRWDQLPSRUWDQWHDODKRUDGHKDFHUSUHGLFFLRQHVHQHO
7&(*FRPRODSURSLD*&6$XQTXHODVXPDGHDPERVIDF
WRUHVSXHGHPHMRUDUODFDSDFLGDGGHSUHGLFFLyQGHORVGLIH
UHQWHV PRGHORV SURQyVWLFRV HQ HO 7&(* QR VRQ PXFKRV
ORV HVWXGLRV PXOWLYDULDEOHVTXH KDVWD OD IHFKD LQFOX\DQ OD
LQIRUPDFLyQGHOD7&FUDQHDO
8Q HVFiQHU FUDQHDO FRPSOHWDPHQWH QRUPDO DO LQJUHVR
FRQOOHYDEDMDPRUWDOLGDG\PHMRUSURQyVWLFRIXQFLRQDOTXH
XQRSDWROyJLFRLQFOXVRHQWUHVXMHWRVFRQSXQWXDFLRQHVHQ
OD*&6GHy3RURWURODGRODDSDULFLyQGHQXHYDV
OHVLRQHV HQ ODV 7&V FUDQHDOHV VHFXHQFLDOHV VH DVRFLD D
PDO SURQyVWLFR 3RU FRQWUD HO PDQHMR DJUH
VLYR GH ODV OHVLRQHV LQWUDFUDQHDOHV LQFOX\HQGR OD PHQRU
GHPRUD SRVLEOH HQ HO WUDWDPLHQWR TXLU~UJLFR PHMRUD HO
SURQyVWLFRGHODVPLVPDV6HJ~Q:D[PDQ\FROV
HO Q~PHUR GH DQRPDOtDV HQ OD 7& FUDQHDO VH UHODFLRQD
VLJQL¿FDWLYDPHQWHFRQHOSURQyVWLFR$VtODVOHVLRQHVSUR
IXQGDVWURQFRFHUHEUDORJDQJOLRVGHODEDVHGHFXDOTXLHU
WDPDxRORVKHPDWRPDVLQWUDFUDQHDOHVGHJUDQYROXPHQ!
FF SULQFLSDOPHQWH SDUHQTXLPDWRVRV \ VXEGXUDOHV OD
FRPSUHVLyQRDXVHQFLDGHFLVWHUQDVEDVDOHVVZHOOLQJ\
HOGHVSOD]DPLHQWRGHODOtQHDPHGLD!PPVHKDQDVR
FLDGRD3,&HOHYDGDDOWDPRUWDOLGDG\PHQRUSUREDELOLGDG
GHUHFXSHUDFLyQIXQFLRQDO
/DUHODFLyQHQWUHODVGLIHUHQWHVOHVLRQHVLQWUDFUDQHDOHV\
HOSURQyVWLFRVHSXHGHUHVXPLUGHODVLJXLHQWHPDQHUD
&RQWXVLRQHV\KHPDWRPDVFHUHEUDOHV
3UREDEOHPHQWH ODV FRQWXVLRQHV FHUHEUDOHV VHDQ ODV
OHVLRQHV PiV IUHFXHQWHV GHO 7&( (O IDFWRU SULQFLSDO TXH
GHWHUPLQDHOSURQyVWLFRGHOSDFLHQWHFRQHVWHWLSRGHOHVLyQ
HV HO HVWDGR FOtQLFR SUHYLR D OD FLUXJtD SHRU SURQyVWLFR
FXDQWRPiVEDMDVHDODSXQWXDFLyQHQOD*&6
/$'
$SDUHFH HQ WUDXPDWLVPRV GH DOWD YHORFLGDG \ FXDQGR
HVJUDYHVHDVRFLDDFRPDSURORQJDGRVLQLQWHUYDORO~FLGR
'HVSXpV GHO KHPDWRPD VXEGXUDO DJXGR DVRFLDGR D VZH
OOLQJFHUHEUDOHVODOHVLyQFRQSHRUSURQyVWLFRFRQFLIUDV
GHPRUWDOLGDGVXSHULRUHVDODVGHOVZHOOLQJGLIXVRRDODV
GHODVOHVLRQHVIRFDOHV\TXHDOFDQ]DQSRUHMHPSORHO
GHORVSDFLHQWHVFRQ*&6HQWUH\
+HPDWRPDVXEGXUDODJXGR
(O SURQyVWLFR GH HVWD OHVLyQ GHSHQGH GH OD HGDG GHO
SDFLHQWH GH VX HVWDGR QHXUROyJLFR \ GH OD UDSLGH] GH OD
LQWHUYHQFLyQ TXLU~UJLFD SHRU D PD\RU HGDG SXQWXDFLyQ
PiVEDMDHQOD*&6\PD\RUGHPRUDTXLU~UJLFD&XDQGR
VH DFRPSDxD GH VZHOOLQJ FHUHEUDO VH FRQYLHUWH HQ OD
OHVLyQGHPD\RUPRUWDOLGDG
Documento descargado de http://www.revistaneurocirugia.com el 17/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
1HXURFLUXJtD
)DFWRUHVSURQyVWLFRVHQHOWUDXPDWLVPRFUDQHRHQFHIiOLFRJUDYH
+HPDWRPDHSLGXUDO
&RQOOHYD PD\RU PRUWDOLGDG FXDQGR VH DVRFLD D HGDG
DYDQ]DGDDQRPDOtDVSXSLODUHVSHRUSXQWXDFLyQHQOD*&6
UiSLGD SURJUHVLyQ GH VLJQRV ORFDOL]DFLyQ WHPSRUDO JUDQ
YROXPHQGHQVLGDGPL[WDGHOKHPDWRPDHQOD7&FUDQHDO
VDQJUDGRDFWLYROHVLRQHVLQWUDGXUDOHVFRH[LVWHQWHV\3,&
HOHYDGD
+HPRUUDJLDVXEDUDFQRLGHDWUDXPiWLFD+6$W
/D +6$W WDPELpQ SDUHFH WHQHU YDORU SURQyVWLFR
GXSOLFDQGR HO ULHVJR GH PRUWDOLGDG FXDQGR VH FRPSDUD
FRQSDFLHQWHVTXHQRODSUHVHQWDQ(VWHULHVJRSDUHFHPiV
UHODFLRQDGR FRQ OD JUDYHGDG GHO SURSLR WUDXPDWLVPR TXH
FRQORVHIHFWRVGHPRUDGRVGHODLVTXHPLDRULJLQDGDSRUHO
YDVRHVSDVPR
5HVRQDQFLDPDJQpWLFD50FUDQHDO
6H KD PRVWUDGR WDPELpQ ~WLO D OD KRUD GH GHWHUPLQDU
SURQyVWLFR \D TXH HV FDSD] GH LGHQWL¿FDU OHVLRQHV HQ OD
VXVWDQFLD EODQFD \ HO WURQFR FHUHEUDO TXH D PHQXGR QR
VRQ YLVLEOHV HQ OD 7& FUDQHDO \ TXH FRQOOHYDQ PDO SUR
QyVWLFR :LOEHUJHU \ FROV GHPRVWUDURQ TXH
SDFLHQWHV FRQ OHVLRQHV H[WHQVDV GH ORV KHPLVIHULRV R GHO
WURQFR FHUHEUDO YLVXDOL]DGDV HQ 50 WLHQHQ PiV GL¿FXOWDG
SDUDUHFXSHUDUFRQFLHQFLDDXQFXDQGROD7&FUDQHDO\OD
3,&VHDQQRUPDOHV
(QWUH VXV GHVYHQWDMDV ¿JXUDQ OD SURORQJDGD GXUDFLyQ
GH VXV HVWXGLRV OD DXVHQFLD GH GLVSRQLELOLGDG HQ DOJXQRV
FHQWURV\ODLPSRVLELOLGDGGHSUDFWLFDUODHQRFDVLRQHVSRU
GL¿FXOWDGHVWpFQLFDVLQKHUHQWHVDOPDQHMRGHHVWRVSDFLHQ
WHV
'HWLSR¿VLROyJLFR
3,&\SUHVLyQGHSHUIXVLyQFHUHEUDO33&
/RV GDWRV GH 3,& WLHQHQ JUDQ YDORU SURQyVWLFR GH WDO
PDQHUD TXH OD KLSHUWHQVLyQ LQWUDFUDQHDO VH DVRFLD D PDO
SURQyVWLFRLQGHSHQGLHQWHPHQWHGHODJUDYHGDGLQLFLDOGHO
WUDXPDWLVPRGHELGRDODLVTXHPLDFHUHEUDOTXHFDXVD
0LOOHU \ FROV GHPRVWUDURQ TXH OD KLSHUWHQVLyQ
LQWUDFUDQHDOIXHHOPRWLYRSULQFLSDOGHPRUWDOLGDGHQFHUFD
GH OD PLWDG GH ORV SDFLHQWHV TXH IDOOHFLHURQ HQ VX HVWX
GLR 0DUPDURX \ FROV D¿UPDURQ TXH HO SURQyVWLFR VH
UHODFLRQDHVWUHFKDPHQWHFRQODSURSRUFLyQGHPHGLFLRQHV
KRUDULDV GH 3,& SRU HQFLPD GH PP +J LQGHSHQGLHQ
WHPHQWH GH RWURV IDFWRUHV FRPR OD HGDG HO *&6 PRWRU \
OD UHDFWLYLGDG SXSLODU$XQTXH VH KDQ GHVFULWR H[FHOHQWHV
UHFXSHUDFLRQHV HQ SDFLHQWHV FRQ KLSHUWHQVLyQ LQWUDFUDQHDO
SURORQJDGD JHQHUDOPHQWH MyYHQHV \ FRQ *&6 PD\RU
D ORV SDFLHQWHV FRQ 3,& SRU HQFLPD GH PP
+J GH PDQHUD VRVWHQLGD \ UHIUDFWDULD D WUDWDPLHQWR QR
VXHOHQ VREUHYLYLU 6LQ HPEDUJR ODV PHGLGDV GH 3,&
VH UHODFLRQDQ SRFR FRQ IXQFLRQHV SURQyVWLFDV GH tQGROH
QHXURSVLFROyJLFRFRPRODPHPRULD
/DLQFDSDFLGDGSDUDPDQWHQHUXQD33&DGHFXDGDDOUH
GHGRURSRUHQFLPDGHPP+JWDPELpQVHKDUHODFLR
QDGR FRQ PDO SURQyVWLFR DXQTXH FRQ PHQRU LPSRUWDQFLD
TXHODHOHYDFLyQGHOD3,&$GHPiVVHKDHQFRQWUDGR
FRUUHODFLyQ HQWUH DOWHUDFLRQHV GHO VLVWHPD QHUYLRVR DXWy
QRPR3,&HOHYDGD33&GLVPLQXLGD\PDOSURQyVWLFR
3(V\HOHFWURHQFHIDORJUDPD((*
/RV 3(V VH KDQ HPSOHDGR SDUD GHWHUPLQDU OD JUDYH
GDGGHORVSDFLHQWHVFRQ7&(*\SUHGHFLUDVtVXSURQyV
WLFR$ GLIHUHQFLD GH OD *&6 TXH
YDORUD SULQFLSDOPHQWH OD HVIHUD PRWRUD ORV 3(V UHÀHMDQ
IXQGDPHQWDOPHQWH OD LQWHJULGDG IXQFLRQDO GH YtDV VHQVR
ULDOHV 'DGR TXH QR UHTXLHUHQ FRODERUDFLyQ SRU SDUWH GHO
SDFLHQWH\TXHQRVHLQWHU¿HUHQSRUIiUPDFRVVRQHVSHFLDO
PHQWH~WLOHVHQVXMHWRVFRPDWRVRVTXHVHHQFXHQWUDQVHGR
UHODMDGRV $XQTXH VX XVR SXHGH HVWDU OLPLWDGR SRUTXH
OD LQIRUPDFLyQ TXH SURSRUFLRQDQ QR HV FRPSOHWDPHQWH
LQGHSHQGLHQWH GH OD GH ORV GDWRV FOtQLFRV GLVPLQX\HQ ODV
SUHGLFFLRQHV IDOVDPHQWH SHVLPLVWDV VLHQGR pVWD RWUD GH
VXV SULQFLSDOHV YHQWDMDV /RV 3(V YLVXDOHV VRQ ORV
PiVIiFLOHVGHREWHQHUHLQWHUSUHWDU\IXHURQORVSULPHURV
HVWXGLDGRVHQSDFLHQWHVFRQ7&(VLQHPEDUJRORVTXHVH
H[SORUDQ FRQ PiV IUHFXHQFLD VRQ ORV VRPDWRVHQVRULDOHV
/RV DXGLWLYRV QR KDQ VLGR DPSOLDPHQWH DFHSWDGRV SDUD
UHDOL]DUSUHGLFFLRQHV\DTXHDXQTXHVRQORVTXHPHQRVVH
LQWHU¿HUHQSRUEDUELW~ULFRVUHTXLHUHQXQDDXGLFLyQLQWDFWD
HQWUHXQ\XQGHORVSDFLHQWHVFRQ7&(WLHQHQ
SpUGLGDDXGLWLYDQHXURVHQVRULDOVXSRGHUGHSUHGLFFLyQHV
PHQRUTXHHOGHORVVRPDWRVHQVRULDOHV\DGHPiVSURSRU
FLRQDQFRQIUHFXHQFLDUHVXOWDGRVQRUPDOHVHQSDFLHQWHVFRQ
PDOSURQyVWLFR(PSOHDQGR3(VPXOWLPRGDOHV*UHHQ
EHUJ \ FROV IXHURQ FDSDFHV GH SUHGHFLU PRUWDOLGDG GH
RULJHQ FHUHEUDO SUHFR]PHQWH PHGLD GH GtDV HQ SDFLHQWHV FRPDWRVRV WUDV 7&(* FDVL FRQ WRWDO H[DFWLWXG
1DUD\DQ\FROVOFRPSDUDQGRHOH[DPHQFOtQLFRORV3(V
PXOWLPRGDOHV ORV KDOOD]JRV HQ OD7& FUDQHDO \ ODV FLIUDV
GH3,&HQFRQWUDURQTXHHOH[DPHQFOtQLFRHVHOLQGLFDGRU
PiV ¿DEOH GH SURQyVWLFR \ TXH ORV RWURV GDWRV HVSHFLDO
PHQWHORV3(VPXOWLPRGDOHVPHMRUDQODVHJXULGDGGHODV
SUHGLFFLRQHV /LQGVD\ \ FROV GHPRVWUDURQ TXH ORV
WLHPSRVGHFRQGXFFLyQGHGLYHUVRV3(VVHFRUUHODFLRQDEDQ
ELHQFRQODJUDYHGDGGHO7&(*\FRQHOSURQyVWLFRDORV
PHVHV VLQ HPEDUJR OD FDSDFLGDG JOREDO SDUD SUHGHFLU
QR PHMRUy VLJQL¿FDWLYDPHQWH FXDQGR HVWD LQIRUPDFLyQ VH
DxDGLyDGLYHUVRVLQGLFDGRUHVFOtQLFRV\SRUWDQWRVXXVRQR
SDUHFHMXVWL¿FDGRHQSDFLHQWHVTXHSXHGHQVHUH[DPLQDGRV
QHXUROyJLFDPHQWHGHPDQHUDDGHFXDGD
(O ((* FRQYHQFLRQDO QR KD PRVWUDGR XWLOLGDG D OD
Documento descargado de http://www.revistaneurocirugia.com el 17/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
1HXURFLUXJtD
%RWR\FRO
KRUD GH UHDOL]DU SUHGLFFLRQHV HQ HO 7&( IXQGDPHQWDO
PHQWHSRUTXHVHLQWHU¿HUHSRUGLYHUVRVIiUPDFRVO(Q
FDPELR HO ((* FRPSXWDUL]DGR GH UHJLVWURV FRQWLQXRV VH
KD HPSOHDGR SDUD GHWHUPLQDU OD SURIXQGLGDG GHO FRPD \
DGHPiV KD PRVWUDGR EXHQD FRUUHODFLyQ FRQ HO SURQyVWLFR
PDOSURQyVWLFRVLDSDUHFHQUHJLVWURVOHQWRV\PRQyWRQRV
GH WDO PDQHUD TXH SDUD DOJXQRV DXWRUHV HV XQ LQGLFDGRU
SURQyVWLFR VXSHULRU D ORV 3(V OD 7& FUDQHDO R OD SURSLD
*&6VLHQGRFDSD]GHLGHQWL¿FDUPHMRUTXHHVWD~OWLPDORV
SDFLHQWHV TXH WHQGUiQ EXHQD UHFXSHUDFLyQ %5 DXQTXH
HVWLPDQGRSHRUORVTXHPRULUiQ
7DQWRORV3(VFRPRHO((*KDQGHUHFRJHUVHFRQWLQXD
PHQWHGXUDQWHYDULRVGtDVUHTXLHUHQSHUVRQDODGLHVWUDGRHQ
VXLQWHUSUHWDFLyQ\QRVXSRQHQXQDDSRUWDFLyQVLJQL¿FDWLYD
UHVSHFWRDRWUDVYDULDEOHVDODKRUDGHKDFHUSUHGLFFLRQHV
HQ HO7&(* 3RU WDQWR VX XVR QR SDUHFH MXVWL¿FDGR \ GH
KHFKR QR VH XWLOL]DQ UXWLQDULDPHQWH HQ OD PD\RUtD GH ORV
KRVSLWDOHV
)6&\VDWXUDFLyQ\XJXODUGHR[tJHQR6MY2
'LYHUVRV HVWXGLRV KDQ GHPRVWUDGR TXH DXQTXH H[LVWH
FRQVLGHUDEOH YDULDELOLGDG HO )6& HV FDUDFWHUtVWLFDPHQWH
EDMRGXUDQWHHOSULPHUGtDWUDVHOWUDXPDWLVPRSDUDDXPHQ
WDU GHVSXpV KDVWD XQ Pi[LPR HQ WRUQR DO WHUFHU R FXDUWR
GtD/RVSDFLHQWHVTXHPDQWLHQHQXQ)6&SRVWUDXPiWLFR
EDMR WLHQHQ XQD PRUWDOLGDG PD\RU TXH ORV TXH OR WLHQHQ
QRUPDO R HOHYDGR GDWR TXH KD GHPRVWUDGR VLJQL¿FD
FLyQ SURQyVWLFD HQ DOJXQRV PRGHORV GH UHJUHVLyQ ORJtV
WLFD 2WURV DXWRUHV VLQ HPEDUJR KDQ HQFRQWUDGR
SURQyVWLFRV GHVIDYRUDEOHV HQ SDFLHQWHV FRQ KLSHUHPLD
SUHFR] WUDV HO WUDXPDWLVPR HVSHFLDOPHQWH FXDQGR pVWD VH
DVRFLDDKLSHUWHQVLyQLQWUDFUDQHDO$OJXQRVDXWRUHVKDQ
UHODFLRQDGRYHORFLGDGHVEDMDVHQHOÀXMRGHODDUWHULDFHUH
EUDOPHGLDPHGLGRFRQGRSSOHUWUDQVFUDQHDOFRQPDOSUR
QyVWLFRVLQHPEDUJRQRHVSRVLEOHH[WUDHUFRQFOXVLRQHV
GH¿QLWLYDVEDViQGRVH~QLFDPHQWHHQHVWHSDUiPHWUR\DTXH
SRU HMHPSOR WDQWR HO YDVRHVSDVPR FRPR HO )6& HOHYDGR
SXHGHQRULJLQDUYHORFLGDGHVHOHYDGDV(QFXDOTXLHUFDVR
HOSURQyVWLFRQRGHEHUtDFRQ¿DUVH~QLFDPHQWHDQLQJXQDGH
HVWDVPHGLGDVUHODFLRQDGDVFRQHO)6&GDGDVXFRQVLGHUD
EOHYDULDELOLGDGDG
3RU RWUR ODGR HVWXGLRV GH XWLOL]DFLyQ FHUHEUDO GH JOX
FRVDKDQGHPRVWUDGRXQSHUtRGRGHKLSHUPHWDEROLVPRWUDV
HO7&(*KRUDVHQDQLPDOHV\GtDVHQKXPDQRVOOHJDQGR
DUHODFLRQDUXQFRQVXPRSURPHGLRFHUHEUDOGH2EDMRFRQ
PRUWDOLGDG R VLWXDFLyQ YHJHWDWLYD KDOOD]JR TXH KD DOFDQ
]DGRVLJQL¿FDFLyQHQPRGHORVGHUHJUHVLyQORJtVWLFD\TXH
SDUDDOJXQRVDXWRUHVHVGHPD\RUYDORUSURQyVWLFRTXHHO
SURSLR)6&
&DUDFWHUtVWLFDPHQWH HO QLYHO GH H[WUDFFLyQ GH 2
DXPHQWDGXUDQWHHOSULPHUGtDWUDVXQ7&(*SDUDYROYHU
GHVSXpVDYDORUHVQRUPDOHVGHWDOPDQHUDTXHH[LVWHXQD
IXHUWH DVRFLDFLyQ HQWUH GHVDWXUDFLyQ \XJXODU WUDQVLWRULD
6MY2 PHQRU DO GXUDQWH PiV GH PLQXWRV TXH
UHÀHMDLVTXHPLDFHUHEUDO\PDOSURQyVWLFRPD\RUPRUWDOL
GDGDPD\RUQ~PHURGHHSLVRGLRVGHGHVDWXUDFLyQ6LQ
HPEDUJRHVWDVPHGLFLRQHVQRVRQ~WLOHVSDUDUHDOL]DUSUH
GLFFLRQHV\DTXHODWpFQLFDQRHVFDSD]GHGHWHFWDUFDPELRV
UHJLRQDOHVHQODSHUIXVLyQWLVXODU\ORVYDORUHVREWHQLGRVHQ
XQDYHQD\XJXODUQRVRQUHSUHVHQWDWLYRVGHODWRWDOLGDGGHO
ÀXMR YHQRVR FHUHEUDO OR TXH VH WUDGXFH HQ TXH SDFLHQWHV
FRQYDORUHVGH6MY2EDMRVSXHGDQWHQHUEXHQSURQyVWLFR\
YLFHYHUVD5HFLHQWHPHQWHVHKDWUDWDGRGHUHODFLRQDUORV
QLYHOHVGHR[LJHQDFLyQGHOWHMLGRFHUHEUDOHQUHVSXHVWDDORV
FDPELRVGHSD2FRQHOSURQyVWLFR
'HWLSRELRTXtPLFR
7UDV XQ 7&( GLYHUVDV VXVWDQFLDV GHO LQWHULRU GH ODV
FpOXODV QHUYLRVDV HQ]LPDV SURWHtQDV VRQ OLEHUDGDV
DO HVSDFLR H[WUDFHOXODU OtTXLGR FHIDORUUDTXtGHR /&5 \
VDQJUHGHWDOIRUPDTXHDPD\RUJUDYHGDGGHOWUDXPDWLVPR
PD\RUOLEHUDFLyQGHHVWDVVXVWDQFLDVSHRUSXQWXDFLyQHQOD
*&6\SHRUSURQyVWLFR$XQTXHORVQLYHOHVGHGLFKDVVXV
WDQFLDVSXHGHQGHWHUPLQDUVHHQVDQJUHODVGHWHUPLQDFLRQHV
HQ/&5VRQPiVVHQVLEOHV3HVHDTXHQRVLUYHQD~QSDUD
GLIHUHQFLDUHQWUHGLIHUHQWHVFDWHJRUtDVSURQyVWLFDVFRPEL
QDGDVFRQORVGDWRVFOtQLFRVSXHGHQPHMRUDUODFDSDFLGDG
GHSUHGLFFLyQGHpVWRV
(Q/&5
/RV QLYHOHV GH FUHDWLQ IRVIRTXLQDVD LVRHQ]LPD %%
&3.%%ODFWDWRODFWDWRGHVKLGURJHQDVDFDWHFRODPL
QDV\FLWRTXLQDVVHKDQFRUUHODFLRQDGRFRQHOSURQyVWLFR
1LYHOHV HOHYDGRV GH &3.%% VH UHODFLRQDQ HVWUHFKD
PHQWH FRQ EDMD SXQWXDFLyQ HQ OD *&6 \ PDO SURQyV
WLFR+DQV\FROVGHPRVWUDURQTXHFXDQGRVH
FRPSDUDEDODHGDGODSXQWXDFLyQHQOD*ODVJRZ/LHJH
6FDOHODLQFLGHQFLDGHWUDXPDWLVPRWRUiFLFROD3,&\
ORV QLYHOHV GH &3.%% HQ /&5 pVWRV WHQtDQ DLVODGD
PHQWHODFDSDFLGDGGHSUHGLFFLyQPiVDOWDDOFDQ
]DQGRXQGHH[DFWLWXGFXDQGRVHFRPELQDEDQWRGDV
ODVYDULDEOHV'HOPLVPRPRGRORVQLYHOHVHOHYDGRVGH
ODFWDWR HQ /&5 VH DVRFLDQ D PDO SURQyVWLFR
6LQ HPEDUJR D GLIHUHQFLD GH ORV QLYHOHV GH &3.%%
TXH PXHVWUDQ XQ SLFR SUHFR]PHQWH WUDV HO WUDXPDWLVPR
\ GHVSXpV GHVDSDUHFHQ UiSLGDPHQWH YLGD PHGLD GH KRUDVORVGHODFWDWRFRQWLQ~DQHOHYiQGRVHHQSDFLHQWHV
FRQPDOSURQyVWLFRUHÀHMRGHVXSURGXFFLyQPDQWHQLGD
$Vt XQ GHVFHQVR HQ ORV QLYHOHV GH ODFWDWR HQ ORV SUL
PHURVGtDVWUDVHOWUDXPDWLVPRHVVLJQRGHPHMRUtD
FOtQLFD PLHQWUDV XQRV QLYHOHV FRQVWDQWHPHQWH HOHYDGRV
R HQ DXPHQWR HYLGHQFLDQ GHWHULRUR FOtQLFR 1LYHOHV
HOHYDGRV GH iFLGR KLGUR[LLQGRODFpWLFR PHWDEROLWR GH
Documento descargado de http://www.revistaneurocirugia.com el 17/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
)DFWRUHVSURQyVWLFRVHQHOWUDXPDWLVPRFUDQHRHQFHIiOLFRJUDYH
ODVHURWRQLQD\GHODSURWHtQD&WDXXQDIUDJPHQWR
SURWHtQLFRQHXURQDOWDPELpQVHKDQUHODFLRQDGRFRQ
PDO SURQyVWLFR 3RU FRQWUD OD HOHYDFLyQ HQ /&5 GH OD
LQWHUOHXFLQD PHGLDGRU GH SURFHVRV LQÀDPDWRULRV VH
KD UHODFLRQDGR FRQ EXHQ SURQyVWLFR 2WUDV VXV
WDQFLDV FRPR OD DSROLSRSURWHtQD ( SHUPDQHFHQ HQ HO
SDUpQTXLPD GHO VLVWHPD QHUYLRVR FHQWUDO HQ UHVSXHVWD
D XQ 7&(* SUREDEOHPHQWH FRQ XQ ¿Q SURWHFWRU \ SRU
WDQWRVXVQLYHOHVHQ/&5VHHQFXHQWUDQGLVPLQXLGRVWUDV
HOWUDXPDWLVPR
(QVDQJUH
/RV QLYHOHV GH QRUDGUHQDOLQD 1$ DGUHQDOLQD $ \
GRSDPLQD HQ ODV SULPHUDV KRUDV WUDV XQ 7&( VH UHOD
FLRQDQ FRQ OD SXQWXDFLyQ GH ORV SDFLHQWHV HQ OD *&6 \
SRU WDQWR FRQ OD JUDYHGDG GHO WUDXPDWLVPR QLYHOHV PiV
DOWRVHQSDFLHQWHVFRQ7&(VPiVJUDYHV(VWDVVXVWDQFLDV
WDPELpQD\XGDQDSUHGHFLUSURQyVWLFRLQGHSHQGLHQWHPHQWH
GHOD*&6GHWDOPDQHUDTXHHOHYDFLRQHVVLJQL¿FDWLYDVGH
1$\$VHUHODFLRQDQFRQPDOSURQyVWLFR1RREVWDQWHORV
QLYHOHVGHFDWHFRODPLQDVVpULFDVDXPHQWDQDQWHFXDOTXLHU
SROLWUDXPDWLVPR HVSHFLDOPHQWH FXDQGR YD DVRFLDGR D
KLSRWHQVLyQKHPRUUiJLFD\SRUWDQWRFDUHFHQGHHVSHFL¿FL
GDGORFXDOOLPLWDVXXWLOLGDG3RURWURODGRORVVXMHWRV
FRQ 7&( IUHFXHQWHPHQWH GHVDUUROODQ KLSHUJOXFHPLD GH
WDO IRUPD TXH HQ SDFLHQWHV DGXOWRV D PD\RUHV QLYHOHV GH
JOXFHPLDPD\RUJUDYHGDGGHOWUDXPDWLVPR\SHRUSURQyV
WLFR$VLPLVPR ORV QLYHOHV VpULFRV HOHYDGRV GH
&3.%%WDPELpQVHKDQUHODFLRQDGRFRQPDOSURQyVWLFR\
DXQTXHODPXHVWUDHVPiVIiFLOGHREWHQHUTXHODGHO/&5
VXSRGHUGHSUHGLFFLyQHVPHQRU $PD\RUJUDYHGDG
GHO 7&( \ SRU WDQWR SHRU SURQyVWLFR VH KDQ HQFRQWUDGR
QLYHOHV VpULFRV PiV HOHYDGRV GH SURVWDJODQGLQDV GH
ODFWDWRGHVKLGURJHQDVDGHGLYHUVRVPDUFDGRUHVGHGDxR
R[LGDWLYRGHODSURWHtQDEiVLFDGHODPLHOLQD\GHOD
SURWHtQD6%/DVDOWHUDFLRQHVGHOD
FRDJXODFLyQIUHFXHQWHVWUDVXQ7&(*VHKDQUHODFLRQDGR
WDPELpQ FRQ HO SURQyVWLFR /D DSDULFLyQ GH FRDJXOD
FLyQ LQWUDYDVFXODU GLVHPLQDGD UHÀHMR GHO JUDGR GH GDxR
WLVXODU VH DVRFLD D PDO SURQyVWLFR 2WURV DXWRUHV KDQ
HQFRQWUDGRTXHORVSURGXFWRVGHGHJUDGDFLyQGHOD¿EULQD
DOLQJUHVRWLHQHQXQYDORUSURQyVWLFRVLPLODUDODSXQWXD
FLyQ HQ OD *&6 D PiV HOHYDGRV SHRU SURQyVWLFR 'HO
PLVPRPRGRQLYHOHVSODVPiWLFRVGHIDFWRUHV¿EULQROtWLFRV
HOHYDGRV DO LQJUHVR WDPELpQ VH KDQ UHODFLRQDGR FRQ PDO
SURQyVWLFRO
(VFDODVSURQyVWLFDVHQHO7&(*
8QDGHODVHVFDODVPiVXWLOL]DGDDODKRUDGHHYDOXDUHO
SURQyVWLFR¿QDOGHORVSDFLHQWHVFRQ7&(*HVOD*ODVJRZ
2XWFRPH 6FDOH *26 TXH GLVWLQJXH FLQFR FDWHJRUtDV
1HXURFLUXJtD
SURQyVWLFDV %5 LQFDSDFLGDG PRGHUDGD ,0 LQFDSDFL
GDG JUDYH ,* (9 \ H[LWXV /D GLIHUHQFLDIXQGDPHQWDO
HQWUH ,0 H ,* HVWULED HQ TXH ORV SDFLHQWHV FRQ ,0 VRQ
LQGHSHQGLHQWHVSDUDVXVTXHKDFHUHVGLDULRV*HQHUDOPHQWH
ODHVWLPDFLyQ¿QDOGHOSURQyVWLFRVHUHDOL]DDORVPHVHV
GHOWUDXPDWLVPRSRUTXHHVHQWRQFHVFXDQGRODPD\RUtDGH
ORVSDFLHQWHVSUHVHQWDQXQDVLWXDFLyQFOtQLFDUHODWLYDPHQWH
HVWDEOH$XQTXHKD\SDFLHQWHVTXHSXHGHQH[SHULPHQ
WDUPHMRUtDVVLJQL¿FDWLYDVDORVDxRVGHO7&(*HLQFOXVR
GHVSXpVSULQFLSDOPHQWHHQODIDFHWDFRJQLWLYD\VRFLDOQR
SDUHFHMXVWL¿FDGRVXUHFDWHJRUL]DFLyQGHQWURGHOD*26
$GHPiVVLODHYDOXDFLyQVHGHPRUDPiVDOOiGHORVPHVHV
FRQ REMHWR GH REWHQHU UHVXOWDGRV PiV ¿DEOHV VH FRUUH HO
ULHVJRGHSHUGHUXQQ~PHURLQGHWHUPLQDGRGHSDFLHQWHV
6HHVWLPDTXHJOREDOPHQWHODGHWHUPLQDFLyQGHOSURQyV
WLFRHQHO7&(*SRUPHGLRGHOD*26DORVPHVHVVHUi
FRUUHFWDHQDSUR[LPDGDPHQWHHOGHORVVXMHWRV
6HKDQGLVHxDGRRWUDVHVFDODVSURQyVWLFDVHQHO7&(*
GLVWLQWDV D OD *26 DXQTXH QLQJXQD KD FRQVHJXLGR OD
DFHSWDFLyQ GH pVWD (QWUH HOODV HVWi OD GHQRPLQDGD *26
DPSOLDGDTXHLQFOX\HXQWRWDOGHFDWHJRUtDVSURGXFWR
GHODIRUPDFLyQGHGRVVXEJUXSRVGHSURQyVWLFRGLIHUHQWH
GHQWURGHODVFDWHJRUtDVGH%5,0H,*6LQHPEDUJROD
*26KDGHPRVWUDGRPD\RU¿DELOLGDGLQWHUREVHUYDGRUTXH
OD*26DPSOLDGD
2WUD GH HVWDV HVFDODV HV OD 'LVDELOLW\ 5DWLQJ 6FDOH
GH5DSSDSRUW\FROVTXHYDORUDODLQFDSDFLGDGWUDVXQ
7&(*GHVGHFXDWURHVIHUDVVLWXDFLyQQHXUROyJLFDJHQHUDO
VHJ~QOD*&6FDSDFLGDGFRJQLWLYDSDUDFXLGDUGHVtPLVPR
GHSHQGHQFLD ItVLFD GH RWURV \ DGDSWDELOLGDG SVLFRVRFLDO
SDUDHOWUDEDMRRHOHVWXGLR(VWDHVFDODTXHYDGHUHFX
SHUDFLyQVLQLQFDSDFLGDGDSXQWRVPXHUWHKDGHPRV
WUDGREXHQD¿DELOLGDGLQWHUREVHUYDGRU\PD\RUXWLOLGDGTXH
RWUDVDODKRUDGHGHWHUPLQDUHOSURJUHVRLQGLYLGXDOGHORV
SDFLHQWHVSHURVXXVRSXHGHUHVXOWDUGHPDVLDGRFRPSOHMR
HQHVWXGLRVFRQJUDQQ~PHURGHVXMHWRV
&RQREMHWRGHFRQRFHUODLQFDSDFLGDGQHXURSVLFROyJLFD
TXH DTXHMDUiQ ORV SDFLHQWHV FRQ 7&(* WDQ IUHFXHQWH \
SUREDEOHPHQWHPiVLQYDOLGDQWHTXHODSURSLDLQFDSDFLGDG
QHXUROyJLFDRItVLFDVHKDQGHVDUUROODGRGLYHUVDVHVFDODV
QHXURSVLFROyJLFDV TXH HYDO~DQ HVWD HVIHUD 1R REVWDQWH
ORV WHVWV XWLOL]DGRV HQ HVWDV HVFDODV VRQ ODUJRV FRVWRVRV
GLItFLOHVGHLQWHUSUHWDUHQRFDVLRQHV\UHTXLHUHQXQPtQLPR
JUDGRGHFRRSHUDFLyQSRUSDUWHGHORVVXMHWRVGHWDOPDQHUD
TXHVyORVRQDSOLFDEOHVDSDFLHQWHVHQEXHQDVLWXDFLyQFOt
QLFD
2WUD GH ODV IRUPDV PiV IUHFXHQWHPHQWH XWLOL]DGDV D
ODKRUDGHGHWHUPLQDUHOSURQyVWLFRHQHO7&(*FRQVLVWH
HQ FDOFXODU ORV VLPSOHV SRUFHQWDMHV GH PRUWDOLGDG 6LQ
HPEDUJR VXSHGLWDU HO SURQyVWLFR JOREDO GHO 7&(* DO
IHQyPHQR GH OD PRUWDOLGDG VXEHVWLPD OD PDJQLWXG GHO
SUREOHPD \D TXH OD PD\RUtD GH ORV SDFLHQWHV TXH VREUH
YLYHQDXQFRQLQFDSDFLGDGHVORKDFHQFRQXQDHVSHUDQ]D
Documento descargado de http://www.revistaneurocirugia.com el 17/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
%RWR\FRO
GHYLGDPHGLDFDVLQRUPDO\SRUWDQWRODGHVFULSFLyQGHO
SURQyVWLFRHQHVWRVVXMHWRVUHVXOWDFRQVLGHUDEOHPHQWHPiV
FRPSOHMD
$JUDGHFLPLHQWRV
(VWHWUDEDMRKDVLGR¿QDQFLDGRHQVXPD\RUSDUWHSRU
OD EHFD ),6 FRQFHGLGD DO 3URI 'U 5DPLUR 'tH]
/REDWR
%LEOLRJUDItD
O$OEHULFR$0:DUG-'&KRL6&0DUPDURX$
<RXQJ+)2XWFRPHDIWHUVHYHUHKHDGLQMXU\5HODWLRQVKLS
WRPDVVOHVLRQVGLIIXVHLQMXU\DQG,&3FRXUVHLQSHGLDWULFDQG
DGXOWSDWLHQWV-1HXURVXUJ
$QGHUVRQ '& %XQGOLH 6 5RFNVZROG */ 0XO
WLPRGDOLW\ HYRNHG SRWHQWLDOV LQ FORVHG KHDG WUDXPD $UFK
1HXURO
$QGUHZV %7 3URJQRVLV LQ VHYHUH KHDG LQMXU\ (Q
&RRSHU35*RO¿QRV-*HGV+HDG,QMXU\HG1HZ<RUN
0F*UDZ+LOOSS
$QyQLPR7KH%UDLQ7UDXPD)RXQGDWLRQ7KH$PHULFDQ
$VVRFLDWLRQ RI 1HXURORJLFDO 6XUJHRQV7KH -RLQW 6HFWLRQ RQ
1HXURWUDXPDDQG&ULWLFDO&DUH5HVXVFLWDWLRQRIEORRGSUHV
VXUHDQGR[\JHQDWLRQ-1HXURWUDXPD
$QyQLPR7KH%UDLQ7UDXPD)RXQGDWLRQ7KH$PHULFDQ
$VVRFLDWLRQ RI 1HXURORJLFDO 6XUJHRQV7KH -RLQW 6HFWLRQ RQ
1HXURWUDXPDDQG&ULWLFDO&DUH*ODVJRZFRPDVFDOHVFRUH-
1HXURWUDXPD
$QyQLPR7KH%UDLQ7UDXPD)RXQGDWLRQ7KH$PHULFDQ
$VVRFLDWLRQ RI 1HXURORJLFDO 6XUJHRQV7KH -RLQW 6HFWLRQ RQ
1HXURWUDXPDDQG&ULWLFDO&DUH$JH-1HXURWUDXPD
$QyQLPR7KH%UDLQ7UDXPD)RXQGDWLRQ7KH$PHULFDQ
$VVRFLDWLRQ RI 1HXURORJLFDO 6XUJHRQV7KH -RLQW 6HFWLRQ RQ
1HXURWUDXPD DQG &ULWLFDO &DUH 3XSLOODU\ GLDPHWHU DQG OLJKW
UHÀH[-1HXURWUDXPD
$QyQLPR7KH%UDLQ7UDXPD)RXQGDWLRQ7KH$PHULFDQ
$VVRFLDWLRQ RI 1HXURORJLFDO 6XUJHRQV7KH -RLQW 6HFWLRQ RQ
1HXURWUDXPDDQG&ULWLFDO&DUH+\SRWHQVLRQ-1HXURWUDXPD
$QyQLPR7KH%UDLQ7UDXPD)RXQGDWLRQ7KH$PHULFDQ
$VVRFLDWLRQ RI 1HXURORJLFDO 6XUJHRQV7KH -RLQW 6HFWLRQ RQ
1HXURWUDXPD DQG &ULWLFDO &DUH &RPSXWHG WRPRJUDSK\ VFDQ
IHDWXUHV-1HXURWUDXPD
$WKLDSSDQ 6 0XWKXNXPDU 1 6ULQLYDVDQ 86
,QÀXHQFH RI EDVDO FLVWHPV PLGOLQH VKLIW DQG SDWKRORJ\ RQ
RXWFRPHLQKHDGLQMXU\$QQ$FDG0HG6LQJDSRUH
$YH]DDW &- YDQ GHQ %HUJH +- %UDDNPDQ 5
(\HPRYHPHQWVDVDSURJQRVWLFIDFWRU$FWD1HXURFKLU6XSSO
1HXURFLUXJtD
:LHQ
%DND\5$6ZHHQH\.0:RRG-+3DWKRSK\
VLRORJ\RIFHUHEURVSLQDOÀXLGLQKHDGLQMXU\3DUW%LRFKHPL
FDOPDUNHUVIRUFHQWUDOQHUYRXVV\VWHPWUDXPD1HXURVXUJHU\
%DUGW7)8QWHUEHUJ$:+DUWO5.LHQLQJ./
6FKQHLGHU *+ /DQNVFK :5 0RQLWRULQJ RI EUDLQ WLVVXH
32 LQ WUDXPDWLF EUDLQ LQMXU\ HIIHFW RI FHUHEUDO K\SR[LD RQ
RXWFRPH$FWD1HXURFKLU6XSSO:LHQ
%DUHOOL $ 9DOHQWH 05 &OHPHQWH $ %R]]D 3
3URLHWWL 5 'HOOD &RUWH ) 6HULDO PXOWLPRGDOLW\HYRNHG
SRWHQWLDOV LQ VHYHUHO\ KHDGLQMXUHG SDWLHQWV GLDJQRVWLF DQG
SURJQRVWLFLPSOLFDWLRQV&ULW&DUH0HG
%HFNHU '3 0LOOHU -' :DUG -' *UHHQEHUJ
53<RXQJ+)6DNDODV57KHRXWFRPHIURPVHYHUHKHDG
LQMXU\ZLWKHDUO\GLDJQRVLVDQGLQWHQVLYHPDQDJHPHQW-1HX
URVXUJ
%HKU5(KUOLQVSLHO'&KULVWRSKLV37HPSHUDWXUH
UHJXODWLRQ DV SRVVLEOH SURJQRVWLF LQGLFDWRU LQ SDWLHQWV ZLWK
DFXWHLQWUDFUDQLDOOHVLRQV$FWD1HXURFKLU:LHQ
%HXWK : .RWVFK\ 0 .DVSU]DN +$ 5RVF '
2VLQVNL 3 6QLHJRFNL 0 >7LVVXH SODVPLQRJHQ DFWLYDWRU
73$ DQG WLVVXH SODVPLQRJHQ DFWLYDWRU LQKLELWRU 3$, LQ
SDWLHQWVDIWHUKHDGLQMXU\@1HXURO1HXURFKLU3RO3RO
%RUQ -'$OEHUW$ +DQV 3 %RQQDO - 5HODWLYH
SURJQRVWLF YDOXH RI EHVW PRWRU UHVSRQVH DQG EUDLQ VWHP
UHÀH[HV LQ SDWLHQWV ZLWK VHYHUH KHDG LQMXU\ 1HXURVXUJHU\
%RZHUV6$0DUVKDOO/)2XWFRPHLQFRQVHFX
WLYHFDVHVRIVHYHUHKHDGLQMXU\WUHDWHGLQ6DQ'LHJR&RXQW\
DSURVSHFWLYHDQDO\VLV1HXURVXUJHU\
%UDDNPDQ 5 *HOSNH *- +DEEHPD -' 0DDV
$,0LQGHUKRXG-06\VWHPDWLFVHOHFWLRQDISURJQRVLVIHD
WXUHVLQSDWLHQWVZLWKVHYHUHKHDGLQMXU\1HXURVXUJHU\
%ULFROR$7XUD]]L6)HULRWWL*3URORQJHGSRVW
WUDXPDWLFXQFRQVFLRXVQHVVWKHUDSHXWLHDVVHWVDQGOLDELOLWLHV-
1HXURVXUJ
%XWWHUZRUWK-)WK6HOKRUVW-%*UHHQEHUJ53
0LOOHU -' *XGHPDQ 6. )ODFFLGLW\ DIWHU KHDG LQMXU\
GLDJQRVLVPDQDJHPHQWDQGRXWFRPH1HXURVXUJHU\
&DUWHU%*%XWW:5HYLHZRIWKHXVHRIVRPDWR
VHQVRU\HYRNHGSRWHQWLDOVLQWKHSUHGLFWLRQRIRXWFRPHDIWHU
VHYHUHEUDLQLQMXU\&ULW&DUH0HG
&HOOL3)UXLQ$&HUYRQL/6HYHUHKHDGWUDXPD
5HYLHZDIWKHIDFWRUVLQÀXHQFLQJWKHSURJQRVLV0LQHUYD&KLU
&KDPEHUV,57UHDGZHOO/0HQGHORZ$''HWHU
PLQDWLRQRIWKUHVKROGOHYHOVRIFHUHEUDOSHUIXVLRQSUHVVXUHDQG
LQWUDFUDQLDOSUHVVXUHLQVHYHUHKHDGLQMXU\E\XVLQJUHFHLYHU
Documento descargado de http://www.revistaneurocirugia.com el 17/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
)DFWRUHVSURQyVWLFRVHQHOWUDXPDWLVPRFUDQHRHQFHIiOLFRJUDYH
RSHUDWLQJFKDUDFWHULVWLFFXUYHVDQREVHUYDWLRQDOVWXG\LQ
SDWLHQWV-1HXURVXUJ
&KDQ.+0LOOHU-''HDUGHQ10,QWUDFUDQLDO
EORRGÀRZYHORFLW\DIWHUKHDGLQMXU\UHODWLRQVKLSWRVHYHULW\
RI LQMXU\ WLPH QHXURORJLFDO VWDWXV DQG RXWFRPH - 1HXURO
1HXURVXUJ3V\FKLDWU\
&KDQJDULV '* 0F*UDZ &3 5LFKDUGVRQ -'
*DUUHWVRQ +' $USLQ (- 6KLHOGV &% &RUUHODWLRQ RI
FHUHEUDOSHUIXVLRQSUHVVXUHDQG*ODVJRZ&RPD6FDOHWRRXW
FRPH-7UDXPD
&KDW¿HOG'$=HPODQ)3'D\'-0HQRQ'.
'LVFRUGDQWWHPSRUDOSDWWHUQVRI6EHWDDQGFOHDYHGWDXSUR
WHLQHOHYDWLRQDIWHUKHDGLQMXU\DSLORWVWXG\%U-1HXURVXUJ
&KHVQXW 50 0DUVKDOO /) .ODXEHU 05 HW DO
7KH UROH RI VHFRQGDU\ EUDLQ LQMXU\ LQ GHWHUPLQLQJ RXWFRPH
IURPVHYHUHKHDGLQMXU\-7UDXPD
&KHVQXW 50 0DUVKDOO 6% 3LHN - %OXQW %$
.ODXEHU050DUVKDOO/)(DUO\DQGODWHV\VWHPLFK\SR
WHQVLRQ DV D IUHTXHQW DQG IXQGDPHQWDO VRXUFH RI FHUHEUDO
LVFKHPLDIROORZLQJVHYHUHEUDLQLQMXU\LQWKH7UDXPDWLF&RPD
'DWD%DQN$FWD1HXURFKLU6XSSO:LHQ
&KR'<:DQJ<&&RPSDULVRQRIWKH$3$&+(
,,,$3$&+(,,DQG*ODVJRZ&RPD6FDOHLQDFXWHKHDGLQMXU\
IRUSUHGLFWLRQRIPRUWDOLW\DQGIXQFWLRQDORXWFRPH,QWHQVLYH
&DUH0HG
&KRL 6& %DUQHV 7< 3UHGLFWLQJ RXWFRPH LQ WKH
KHDGLQMXUHG SDWLHQW (Q 1DUD\DQ 5.:LOEHUJHU -( 3RYOLV
KRFN-7HGV1HXURWUDXPD1HZ<RUN0F*UDZ+LOO
SS
&KRL6&%DUUHV7<%XOORFN5*HUPDQVRQ7$
0DUPDURX$<RXQJ+)7HPSRUDOSUR¿OHRIRXWFRPHVLQ
VHYHUHKHDGLQMXU\-1HXURVXUJ
&KRL6&1DUD\DQ5.$QGHUVRQ5/:DUG-'
(QKDQFHGVSHFL¿FLW\RISURJQRVLVLQVHYHUHKHDGLQMXU\-1HX
URVXUJ
&ODUN56.RFKDQHN302EULVW:'HWDO&HUH
EURVSLQDO ÀXLG DQG SODVPD QLWULWH DQG QLWUDWH FRQFHQWUDWLRQV
DIWHUKHDGLQMXU\LQKXPDQV&ULW&DUH0HG
&OLIWRQ*/*URVVPDQ5*0DNHOD0(0LQHU
0( +DQGHO 6 6DGKX9 1HXURORJLFDOFRXUVH DQG FRUUH
ODWHG FRPSXWHUL]HG WRPRJUDSK\ ¿QGLQJV DIWHU VHYHUH FORVHG
KHDGLQMXU\-1HXURVXUJ
&OLIWRQ*/+D\HV5//HYLQ+60LFKHO0(
&KRL 6& 2XWFRPH PHDVXUHV IRU FOLQLFDO WULDOV LQYROYLQJ
WUDXPDWLFDOO\ EUDLQLQMXUHG SDWLHQWV UHSRUW RI D FRQIHUHQFH
1HXURVXUJHU\
&RLPEUD5+R\W'%3RWHQ]D%0)RUWODJH'
+ROOLQJVZRUWK)ULGOXQG3'RHVVH[XDOGLPRUSKLVPLQÀXHQFH
RXWFRPHRIWUDXPDWLFEUDLQLQMXU\SDWLHQWV"7KHDQVZHULVQR
-7UDXPD
&ROG * (QHYROGVHQ ( 0DOPURV 5 9HQWULFXODU
1HXURFLUXJtD
ÀXLG ODFWDWH S\UXYDWH ELFDUERQDWH DQG S+ LQ XQFRQVFLRXV
EUDLQLQMXUHGSDWLHQWVVXEMHFWHGWRFRQWUROOHGYHQWLODWLRQ$FWD
1HXURO6FDQG
&ROTXKRXQ,5%XUURZV(+7KHSURJQRVWLFVLJQL
¿FDQFHRIWKHWKLUGYHQWULFOHDQGEDVDOFLVWHUQVLQVHYHUHFORVHG
KHDGLQMXU\&OLQ5DGLRO
&RQWDQW&)-U1DUD\DQ5.3URJQRVLVDIWHUKHDG
LQMXU\(Q<RXPDQV-5HG1HXURORJLFDO6XUJHU\HG3KL
ODGHOSKLD:%6DXQGHUV9ROSS
&RRSHU35&KDOLI'-5DPVH\-)0RRUH5-
5DGLRLPPXQRDVVD\ RI WKH EUDLQ W\SH LVRHQ]\PH RI FUHDWLQH
SKRVSKRNLQDVH &.%% D QHZ GLDJQRVWLF WRRO LQ WKH HYD
OXDWLRQRISDWLHQWVZLWKKHDGLQMXU\1HXURVXUJHU\
&RRSHU350DUDYLOOD.0RRG\6&ODUN:.
6HULDOFRPSXWHUL]HGWRPRJUDSKLFVFDQQLQJDQGWKHSURJQRVLV
RIVHYHUHKHDGLQMXU\1HXURVXUJHU\
&RUPLR09DODGND$%5REHUWVRQ&6(OHYDWHG
MXJXODU YHQRXV R[\JHQ VDWXUDWLRQ DIWHU VHYHUH KHDG LQMXU\ -
1HXURVXUJ
&URFNDUG+$7D\ORU$56HULDO&6)ODFWDWHS\UX
YDWHYDOXHVDVDJXLGHWRSURJQRVLVLQKHDGLQMXU\FRPD(XU
1HXURO
&URQH.5/HH.6.HOO\'/-U&RUUHODWLRQRI
DGPLVVLRQ¿EULQGHJUDGDWLRQSURGXFWVZLWKRXWFRPHDQGUHVSL
UDWRU\IDLOXUHLQSDWLHQWVZLWKVHYHUHKHDGLQMXU\1HXURVXUJHU\
&UX]-5HODWLRQVKLSEHWZHHQHDUO\SDWWHUQVRIFHUH
EUDOH[WUDFWLRQRIR[\JHQDQGRXWFRPHIURPVHYHUHDFXWHWUDX
PDWLFEUDLQVZHOOLQJFHUHEUDOLVFKHPLDRUFHUHEUDOYLDELOLW\"
&ULW&DUH0HG
'HOOD &RUWH ) *LRUGDQR $ 3HQQLVL 0$ HW DO
4XDQWLWDWLYHFHUHEUDOEORRG ÀRZ DQG PHWDEROLVPGHWHUPLQD
WLRQLQWKH¿UVWKRXUVDIWHUVHYHUHKHDGLQMXU\ZLWKDQHZ
G\QDPLF 63(&7 GHYLFH$FWD 1HXURFKLU :LHQ 'H6DOOHV $$ .RQWRV +$ %HFNHU '3 HW DO
3URJQRVWLF VLJQL¿FDQFH RI YHQWULFXODU &6) ODFWLF DFLGRVLV LQ
VHYHUHKHDGLQMXU\-1HXURVXUJ
'LPRSRXORXO.RU¿DV6'DIQL8HWDO3URWHLQ6
EVHUXPOHYHOVLQWUDXPDLQGXFHGEUDLQGHDWK1HXURORJ\
'RPtQJXH]5ROGiQ -0 0XULOOR&DEH]DV )
0XxR]6iQFKH] $ *RQ]iOH]0HQpQGH] ( +LJKULVN
FHUHEUDOLQMXULHVOHDGLQJWRFHUHEUDOGHDWKHDUO\GHWHFWLRQRI
SRWHQWLDORUJDQGRQRUV7UDQVSODQW3URF
'RZOLQJ-/9ROOPHU'*3URJQRVLVLQKHDGLQMXU\
(Q7LQGDOO*7&RRSHU35%DUURZ'/HGV7KH3UDFWLFHRI
1HXURVXUJHU\ %DOWLPRUH :LOOLDPV :LONLQV 9RO SS
(GQD7+5LVNIDFWRUVLQWUDXPDWLFKHDGLQMXU\$FWD
1HXURFKLU:LHQ
(LVHQEHUJ +0 *DU\ +( -U$OGULFK () HW DO
Documento descargado de http://www.revistaneurocirugia.com el 17/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
%RWR\FRO
,QLWLDO&7¿QGLQJVLQSDWLHQWVZLWKVHYHUHKHDGLQMXU\$
UHSRUWIURPWKH1,+7UDXPDWLF&RPD'DWD%DQN-1HXURVXUJ
(OOHQEHUJ-+/HYLQ+66D\GMDUL&3RVWWUDXPD
WLFDPQHVLDDVDSUHGLFWRURIRXWFRPHDIWHUVHYHUHFORVHGKHDG
LQMXU\ 3URVSHFWLYH DVVHVVPHQW$UFK 1HXURO (VSHUVHQ-23HWHUVHQ2)&RPSXWHUL]HGWRPRJUD
SK\ &7 LQ SDWLHQWV ZLWK KHDG LQMXULHV$VVHVVPHQW RI RXW
FRPHEDVHGXSRQLQLWLDOFOLQLFDO¿QGLQJVDQGLQLWLDO&7VFDQV
$FWD1HXURFKLU:LHQ
)DFFR(0XQDUL0'RQD%HWDO6SDWLDOPDS
SLQJRI6(3LQFRPDWRVHSDWLHQWVLPSURYHGRXWFRPHSUHGLF
WLRQE\FRPELQHGSDULHWDO1DQGIURQWDO1DQDO\VLV%UDLQ
7RSRJU
)DULQ$'HXWVFK5%LHJRQ$0DUVKDOO/)6H[
UHODWHGGLIIHUHQFHVLQSDWLHQWVZLWKVHYHUHKHDGLQMXU\JUHDWHU
VXVFHSWLELOLW\WREUDLQVZHOOLQJLQIHPDOHSDWLHQWV\HDUVRI
DJHDQG\RXQJHU-1HXURVXUJ
)HOGPDQ = 7KH OLPLWV RI VDOYDJHDELOLW\ LQ KHDG
LQMXU\ (Q 1DUD\DQ 5. :LOEHUJHU -( 3RYOLVKRFN -7 HGV
1HXURWUDXPD1HZ<RUN0F*UDZ+LOOSS
)HOGPDQQ+.ODJHV**DUWQHU)6FKDUIHQEHUJ-
7KHSURJQRVWLFYDOXHRILQWUDFUDQLDOSUHVVXUHPRQLWRULQJDIWHU
VHYHUHKHDGLQMXULHV$FWD1HXURFKLU6XSSO:LHQ
)LUVFKLQJ 5 :RLVFKQHFN ' 'LHGULFK 0 HW DO
(DUO\PDJQHWLFUHVRQDQFHLPDJLQJRIEUDLQVWHPOHVLRQVDIWHU
VHYHUHKHDGLQMXU\-1HXURVXUJ
)LUVFKLQJ5:RLVFKQHFN'.OHLQ6/XGZLJ.
'RKULQJ:%UDLQVWHPOHVLRQVDIWHUKHDGLQMXU\1HXURO5HV
)UDQ]*%HHU5.DPSÀ$HWDO$P\ORLGEHWD
DQGWDXLQFHUHEURVSLQDOÀXLGDIWHUVHYHUHWUDXPDWLFEUDLQ
LQMXU\1HXURORJ\
)URZHLQ5$3URJQRVWLFDVVHVVPHQWRIFRPDLQUHOD
WLRQWRDJH$FWD1HXURFKLU6XSSO:LHQ
*HQQDUHOOL7$6SLHOPDQ*0/DQJ¿WW7:HWDO
,QÀXHQFHRIWKHW\SHRILQWUDFUDQLDOOHVLRQRQRXWFRPHIURP
VHYHUHKHDGLQMXU\-1HXURVXUJ
*LDQQRWWD6/:HLQHU-0.DUQD]H'3URJQRVLV
DQGRXWFRPHLQVHYHUHKHDGLQMXU\(Q&RRSHU35HG+HDG
,QMXU\HG%DOWLPRUH:LOOLDPV:LONLQVSS
*yPH]3$/REDWR5'%RWR*5GHOD/DPD$
*RQ]iOH]3- GHOD&UX]-$JHDQGRXWFRPHDIWHUVHYHUH
KHDGLQMXU\$FWD1HXURFKLU:LHQ
*RSLQDWK635REHUWVRQ&6&RQWDQW&)HWDO
-XJXODUYHQRXVGHVDWXUDWLRQDQGRXWFRPHDIWHUKHDGLQMXU\-
1HXURO1HXURVXUJ3V\FKLDWU\
*UHHQEHUJ53%HFNHU'30LOOHU-'0D\HU'-
(YDOXDWLRQ RI EUDLQ IXQFWLRQ LQ VHYHUH KXPDQ KHDG WUDXPD
ZLWKPXOWLPRGDOLW\HYRNHGSRWHQWLDOV3DUW/RFDOL]DWLRQRI
1HXURFLUXJtD
EUDLQG\VIXQFWLRQDQGFRUUHODWLRQZLWKSRVWWUDXPDWLFQHXUROR
JLFDOFRQGLWLRQV-1HXURVXUJ
*UHHQEHUJ530LOOHU-'%HFNHU'3(DUO\SURJ
QRVLVDIWHUVHYHUHKXPDQKHDGLQMXU\XWLOL]LQJPXOWLPRGDOLW\
HYRNHGSRWHQWLDOV$FWD1HXURFKLU6XSSO:LHQ
*UHHQEHUJ531HZORQ3*+\DWW061DUD\DQ
5.%HFNHU'33URJQRVWLFLPSOLFDWLRQVRIHDUO\PXOWLPR
GDOLW\ HYRNHG SRWHQWLDOV LQ VHYHUHO\ KHDGLQMXUHG SDWLHQWV$
SURVSHFWLYHVWXG\-1HXURVXUJ
*URVZDVVHU = &RKHQ 0 .HUHQ 2 )HPDOH 7%,
SDWLHQWV UHFRYHU EHWWHU WKDQ PDOHV %UDLQ ,QM *XWWHUPDQ 3 6KHQNLQ +$ 3URJQRVWLF IHDWXUHV LQ
UHFRYHU\IURPWUDXPDWLFGHFHUHEUDWLRQ-1HXURVXUJ
+DOO . &RSH '1 5DSSDSRUW 0 *ODVJRZ 2XW
FRPH6FDOHDQG'LVDELOLW\5DWLQJ6FDOHFRPSDUDWLYHXVHIXO
QHVVLQIROORZLQJUHFRYHU\LQWUDXPDWLFKHDGLQMXU\$UFK3K\V
0HG5HKDELO
+DPLOO5::RROI3'0F'RQDOG-9/HH/$
.HOO\0&DWHFKRODPLQHVSUHGLFWRXWFRPHLQWUDXPDWLFEUDLQ
LQMXU\$QQ1HXURO
+DQV 3$OEHUW$ %RUQ -' &KDSHOOH -3 'HUL
YDWLRQRIDELRFOLQLFDOSURJQRVWLFLQGH[LQVHYHUHKHDGLQMXU\
,QWHQVLYH&DUH0HG
+DQV3$OEHUW$)UDQVVHQ&%RUQ-,PSURYHG
RXWFRPHSUHGLFWLRQEDVHGRQ&6)H[WUDSRODWHGFUHDWLQHNLQDVH
%% LVRHQ]\PH DFWLYLW\ DQG RWKHU ULVN IDFWRUV LQ VHYHUH KHDG
LQMXU\-1HXURVXUJ
+HLGHQ-66PDOO5&DWRQ::HLVV0.XU]H
76HYHUHKHDGLQMXU\&OLQLFDODVVHVVPHQWDQGRXWFRPH3K\V
7KHU
+ROOLGD\32UG.HOO\'/-U%DOO01RUPDO
FRPSXWHG WRPRJUDPV LQ DFXWH KHDG LQMXU\ FRUUHODWLRQ RI
LQWUDFUDQLDOSUHVVXUHYHQWULFXODUVL]HDQGRXWFRPH1HXURVXU
JHU\
+RXOGHQ '$ /L & 6FKZDUW] 0/ .DWLF 0
0HGLDQ QHUYH VRPDWRVHQVRU\ HYRNHG SRWHQWLDOV DQG WKH
*ODVJRZ &RPD 6FDOH DV SUHGLFWRUV RI RXWFRPH LQ FRPDWRVH
SDWLHQWVZLWKKHDGLQMXULHV1HXURVXUJHU\
+XNNHOKRYHQ&:6WH\HUEHUJ(:5DPSHQ$-
HW DO 3DWLHQW DJH DQG RXWFRPH IROORZLQJ VHYHUH WUDXPDWLF
EUDLQLQMXU\DQDQDO\VLVRISDWLHQWV-1HXURVXUJ
-DJJL -/ 2EULVW :' *HQQDUHOOL 7$ /DQJ¿WW
7:5HODWLRQVKLSRIHDUO\FHUHEUDOEORRGÀRZDQGPHWDER
OLVPWRRXWFRPHLQDFXWHKHDGLQMXU\-1HXURVXUJ
-DQH -$ )UDQFHO 3& $JH DQG RXWFRPH RI KHDG
LQMXU\ (Q 1DUD\DQ 5. :LOEHUJHU -( 3RYOLVKRFN -7 HGV
1HXURWUDXPD1HZ<RUN0F*UDZ+LOOSS
-DQH-$5LPHO5:3URJQRVLVLQKHDGLQMXU\&OLQ
Documento descargado de http://www.revistaneurocirugia.com el 17/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
)DFWRUHVSURQyVWLFRVHQHOWUDXPDWLVPRFUDQHRHQFHIiOLFRJUDYH
1HXURVXUJ
-HQQHWW % %RQG 0$VVHVVPHQW RI RXWFRPH DIWHU
VHYHUHEUDLQGDPDJH/DQFHW
-HQQHWW%6QRHN-%RQG05%URRNV1'LVD
ELOLW\DIWHUVHYHUHKHDGLQMXU\REVHUYDWLRQVRQWKHXVHRIWKH
*ODVJRZ 2XWFRPH 6FDOH - 1HXURO 1HXURVXUJ 3V\FKLDWU\
-HQQHWW%7HDVGDOH*%UDDNPDQ5HWDO3UHGLF
WLQJ RXWFRPH LQ LQGLYLGXDO SDWLHQWV DIWHU VHYHUH KHDG LQMXU\
/DQFHW
-HQQHWW%7HDVGDOH*%UDDNPDQ50LQGHUKRXG
- +HLGHQ - .XU]H 7 3URJQRVLV RI SDWLHQWV ZLWK VHYHUH
KHDGLQMXU\1HXURVXUJHU\
-HUHPLWVN\ ( 2PHUW / 'XQKDP &0 3URWHWFK
- 5RGUtJXH]$ +DUELQJHUV RI SRRU RXWFRPH WKH GD\ DIWHU
VHYHUHEUDLQLQMXU\K\SRWKHUPLDK\SR[LDDQGK\SRSHUIXVLRQ
-7UDXPD
-XGVRQ-$&DQW%56KDZ1$(DUO\SUHGLFWLRQ
RI RXWFRPH IURP FHUHEUDO WUDXPD E\ VRPDWRVHQVRU\ HYRNHG
SRWHQWLDOV&ULW&DUH0HG
-XXO10RUULV*)0DUVKDOO6%0DUVKDOO/)
,QWUDFUDQLDO K\SHUWHQVLRQ DQG FHUHEUDO SHUIXVLRQ SUHVVXUH
LQÀXHQFHRQQHXURORJLFDOGHWHULRUDWLRQDQGRXWFRPHLQVHYHUH
KHDG LQMXU\ 7KH ([HFXWLYH &RPPLWWHH RI WKH ,QWHUQDWLRQDO
6HOIRWHO7ULDO-1HXURVXUJ
.DQH 10 &XUU\ 6+ 5RZODQGV &$ HW DO
(YHQWUHODWHG SRWHQWLDOVQHXURSK\VLRORJLFDO WRROV IRU SUH
GLFWLQJ HPHUJHQFH DQG HDUO\ RXWFRPH IURP WUDXPDWLF FRPD
,QWHQVLYH&DUH0HG
.DUQD]H'6:HLQHU-00DUVKDOO/)$XGLWRU\
HYRNHGSRWHQWLDOVLQFRPDDIWHUFORVHGKHDGLQMXU\DFOLQLFDO
QHXURSK\VLRORJLFFRPDVFDOHIRUSUHGLFWLQJRXWFRPH1HXUR
ORJ\
.DVWH 0 +HUQHVQLHPL - 6RPHU + +LOOERP 0
.RQWWLQHQ $ &UHDWLQH NLQDVH LVRHQ]\PHV LQ DFXWH EUDLQ
LQMXU\-1HXURVXUJ
.D\$'3HW]ROG$.HUU0.HLU*7KRPSVRQ
(-1LFROO-$&HUHEURVSLQDOÀXLGDSROLSRSURWHLQ(FRQFHQ
WUDWLRQGHFUHDVHVDIWHUWUDXPDWLFEUDLQLQMXU\-1HXURWUDXPD
.HOO\ ') .RUGHVWDQL 5. 0DUWLQ 1$ HW DO
+\SHUHPLD IROORZLQJ WUDXPDWLF EUDLQ LQMXU\ UHODWLRQVKLS WR
LQWUDFUDQLDOK\SHUWHQVLRQDQGRXWFRPH-1HXURVXUJ
.HOO\')0DUWLQ1$.RUGHVWDQL5HWDO&HUH
EUDOEORRGÀRZDVDSUHGLFWRURIRXWFRPHIROORZLQJWUDXPDWLF
EUDLQLQMXU\-1HXURVXUJ
.LODUX 6 *DUE - (PKRII 7 HW DO /RQJWHUP
IXQFWLRQDOVWDWXVDQGPRUWDOLW\RIHOGHUO\SDWLHQWVZLWKVHYHUH
FORVHGKHDGLQMXULHV-7UDXPD
.ODXEHU 05 0DUVKDOO /) %DUUHWW&RQQRU (
%RZHUV6$3URVSHFWLYHVWXG\RISDWLHQWVKRVSLWDOL]HGZLWK
KHDGLQMXU\LQ6DQ'LHJR&RXQW\1HXURVXUJHU\
1HXURFLUXJtD
.QREOLFK 2( *DDE 0 3URJQRVWLF LQIRUPDWLRQ
IRU((*DQG,&3PRQLWRULQJDIWHUVHYHUHFORVHGKHDGLQMXULHV
LQWKHHDUO\SRVWWUDXPDWLFSKDVH$FOLQLFDODQGH[SHULPHQWDO
VWXG\$FWD1HXURFKLU6XSSO:LHQ
.RKL<00HQGHORZ$'7HDVGDOH*0$OODU
GLFH*0([WUDFUDQLDOLQVXOWVDQGRXWFRPHLQSDWLHQWVZLWK
DFXWH KHDG LQMXU\ UHODWLRQVKLS WR WKH *ODVJRZ &RPD 6FDOH
,QMXU\
.RWZLFD = -DNXERZVNL -. +HDGLQMXUHG DGXOW
SDWLHQWVZLWK*&6RIRQDGPLVVLRQZKRKDYHDFKDQFHWR
VXUYLYH"$FWD1HXURFKLU:LHQ
.UDXV-&RQUR\&&R[35DPVWHLQ.)LIH'
6XUYLYDOWLPHVDQGFDVHIDWDOLW\UDWHVRIEUDLQLQMXUHGSHUVRQV
-1HXURVXUJ
.XVKL+0RUL\D76DLWR7.LQRVKLWD.6KL
EX\D 7 +D\DVKL 1 ,PSRUWDQFH RI PHWDEROLF PRQLWRULQJ
V\VWHPVDVDQHDUO\SURJQRVWLFLQGLFDWRULQVHYHUHKHDGLQMXUHG
SDWLHQWV$FWD1HXURFKLU6XSSO:LHQ
.XVKLPRWR6<DPDPRWR<6KLEDWD<6DWR+
.RLGR<,PSOLFDWLRQVRIH[FHVVLYH¿EULQRO\VLVDQGDOSKD
SODVPLQ LQKLELWRU GH¿FLHQF\ LQ SDWLHQWV ZLWK VHYHUH KHDG
LQMXU\1HXURVXUJHU\
/DP$0:LQQ+5&XOOHQ%)6XQGOLQJ1
+\SHUJO\FHPLD DQG QHXURORJLFDO RXWFRPH LQ SDWLHQWV ZLWK
KHDGLQMXU\-1HXURVXUJ
/DQJ¿WW 7: 2EULVW :' *HQQDUHOOL 7$
2
&RQQRU0-:HHPH&$&RUUHODWLRQRIFHUHEUDOEORRG
ÀRZZLWKRXWFRPHLQKHDGLQMXUHGSDWLHQWV$QQ6XUJ
/DQQRR ( YDQ 5LHWYHOGH ) &RODUG\Q ) HW DO
(DUO\SUHGLFWRUVRIPRUWDOLW\DQGPRUELGLW\DIWHUVHYHUHFORVHG
KHDGLQMXU\-1HXURWUDXPD
/H 5RX[ 3' 1HZHOO ': /DP $0 *UDG\
06:LQQ+5&HUHEUDODUWHULRYHQRXVR[\JHQGLIIHUHQFH
DSUHGLFWRURIFHUHEUDOLQIDUFWLRQDQGRXWFRPHLQSDWLHQWVZLWK
VHYHUHKHDGLQMXU\-1HXURVXUJ
/HH-+0DUWLQ1$$OVLQD*HWDO+HPRG\QD
PLFDOO\VLJQL¿FDQWFHUHEUDOYDVRVSDVPDQGRXWFRPHDIWHUKHDG
LQMXU\DSURVSHFWLYHVWXG\-1HXURVXUJ
/HKPDQQ85HJHO*(OOHQGRUI%HWDO>,QLWLDO
FUDQLDO &7 IRU HYDOXDWLQJ WKH SURJQRVLV RI FUDQLRFHUHEUDO
WUDXPD@8QIDOOFKLUXUJ*HU
/HYDWL$ )DULQD 0/9HFFKL * 5RVVDQGD 0
0DUUXELQL0%3URJQRVLVRIVHYHUHKHDGLQMXULHV-1HXUR
VXUJ
/HYLQ +6 +DPLOWRQ :- *URVVPDQ 5* 2XW
FRPH DIWHU KHDG LQMXU\ (Q %UDDNPDQ 5 HG +HDG ,QMXU\
+DQGERRN RI &OLQLFDO 1HXURORJ\ 9RO $PVWHUGDP (OVH
YLHU6FLHQFH3XEOLVKHUV%9SS
/HYLQ +6 6D\GMDUL & (LVHQEHUJ +0 HW DO
9HJHWDWLYH VWDWH DIWHU FORVHGKHDG LQMXU\$7UDXPDWLF &RPD
'DWD%DQN5HSRUW$UFK1HXURO
Documento descargado de http://www.revistaneurocirugia.com el 17/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
%RWR\FRO
/HZ +/ 'LNPHQ 6 6OLPS - HW DO 8VH RI
VRPDWRVHQVRU\HYRNHGSRWHQWLDOVDQGFRJQLWLYHHYHQWUHODWHG
SRWHQWLDOVLQSUHGLFWLQJRXWFRPHVRISDWLHQWVZLWKVHYHUHWUDX
PDWLFEUDLQLQMXU\$P-3K\V0HG5HKDELO
/LQGVD\ . 3DVDRJOX $ +LUVW ' $OODUG\FH *
.HQQHG\,7HDVGDOH*6RPDWRVHQVRU\DQGDXGLWRU\EUDLQ
VWHPFRQGXFWLRQDIWHUKHDGLQMXU\DFRPSDULVRQZLWKFOLQLFDO
IHDWXUHV LQ SUHGLFWLRQ RI RXWFRPH 1HXURVXUJHU\ /LQGVD\.:&DUOLQ-.HQQHG\,)U\-0F,Q
QHV $ 7HDVGDOH *0 (YRNHG SRWHQWLDOV LQ VHYHUH KHDG
LQMXU\DQDO\VLVDQGUHODWLRQWRRXWFRPH-1HXURO1HXURVXUJ
3V\FKLDWU\
/LSSHU0+.LVKRUH35(QDV**'RPLQJXHV
GD6LOYD$$&KRL6&%HFNHU'3&RPSXWHGWRPRJUD
SK\ LQ WKH SUHGLFWLRQ RI RXWFRPH LQ KHDG LQMXU\$-5$P -
5RHQWJHQRO
/REDWR 5' &RUGREpV ) 5LYDV -- HW DO 2XW
FRPHIURPVHYHUHKHDGLQMXU\UHODWHGWRWKHW\SHRILQWUDFUD
QLDO OHVLRQ$ FRPSXWHUL]HG WRPRJUDSK\ VWXG\ - 1HXURVXUJ
/REDWR5'*yPH]3$$OGD\5HWDO6HTXHQ
WLDOFRPSXWHUL]HGWRPRJUDSK\FKDQJHVDQGUHODWHG¿QDORXW
FRPH LQ VHYHUH KHDG LQMXU\ SDWLHQWV$FWD 1HXURFKLU :LHQ
/REDWR5'5LYDV--3RUWLOOR-0HWDO3URJ
QRVWLFYDOXHRIWKHLQWUDFUDQLDOSUHVVXUHOHYHOVGXULQJWKHDFXWH
SKDVH RI VHYHUH KHDG LQMXULHV$FWD 1HXURFKLU 6XSSO :LHQ
/RNNHEHUJ $5 *ULPHV 50 $VVHVVLQJ WKH
LQÀXHQFH RI QRQWUHDWPHQW YDULDEOHV LQ D VWXG\ RI RXWFRPH
IURPVHYHUHKHDGLQMXULHV-1HXURVXUJ
/XELOOR 6 %RODxRV - &DUUHLUD / &DUGHxRVD -
$UUR\R-0DQ]DQR-3URJQRVWLFYDOXHRIHDUO\FRPSXWHUL
]HGWRPRJUDSK\VFDQQLQJIROORZLQJFUDQLRWRP\IRUWUDXPDWLF
KHPDWRPD-1HXURVXUJ
/XHUVVHQ7*.ODXEHU050DUVKDOO/)2XW
FRPHIURPKHDGLQMXU\UHODWHGWRSDWHQWVDJH$ORQJLWXGLQDO
SURVSHFWLYHVWXG\RIDGXOWDQGSHGLDWULFKHDGLQMXU\-1HXUR
VXUJ
0DDV$, %UDDNPDQ 5 6FKRXWHQ +- 0LQGHU
KRXG -0 YDQ =RPHUHQ$+$JUHHPHQW EHWZHHQ SK\VL
FLDQVRQDVVHVVPHQWRIRXWFRPHIROORZLQJVHYHUHKHDGLQMXU\
-1HXURVXUJ
0DULRQ':2XWFRPHIURPVHYHUHKHDGLQMXU\(Q
1DUD\DQ5.:LOEHUJHU-(3RYOLVKRFN-7HGV1HXURWUDXPD
1HZ<RUN0F*UDZ+LOOSS
0DULRQ ': &DUOLHU 30 3UREOHPV ZLWK LQLWLDO
*ODVJRZ &RPD 6FDOH DVVHVVPHQW FDXVHG E\ SUHKRVSLWDO
WUHDWPHQWRISDWLHQWVZLWKKHDGLQMXULHVUHVXOWVRIDQDWLRQDO
VXUYH\-7UDXPD
0DUNLDQRV06HUHWLV$.RWVRX$&KULVWRSRXORV
0&6)QHXURWUDQVPLWWHUPHWDEROLWHVLQFRPDWRVHKHDGLQMXU\
1HXURFLUXJtD
SDWLHQWVGXULQJFKDQJHVLQWKHLUFOLQLFDOVWDWH$FWD1HXURFKLU
:LHQ
0DUNLDQRV 0 6HUHWLV $ .RWVRX 6 %DOWDV ,
6DFKDURJLDQQLV + &6) QHXURWUDQVPLWWHU PHWDEROLWHV DQG
VKRUWWHUPRXWFRPHRISDWLHQWVLQFRPDDIWHUKHDGLQMXU\$FWD
1HXURO6FDQG
0DUPDURX $ $QGHUVRQ 5/ :DUG -' HW DO
,PSDFW RI ,&3 LQVWDELOLW\ DQG K\SRWHQVLRQ RQ RXWFRPH LQ
SDWLHQWV ZLWK VHYHUH KHDG WUDXPD - 1HXURVXUJ 6XSSO66
0DUVKDOO/)*DXWLOOH7.ODXEHU05HWDO7KH
RXWFRPHRIVHYHUHFORVHGKHDGLQMXU\-1HXURVXUJ
6XSSO66
0DUVKDOO/)0DUVKDOO6%.ODXEHU05HWDO
$ QHZ FODVVL¿FDWLRQ RI KHDG LQMXU\ EDVHG RQ FRPSXWHUL]HG
WRPRJUDSK\-1HXURVXUJ6XSSO66
0LOOHU-'%HFNHU'3:DUG-'6XOOLYDQ+*
$GDPV:(5RVQHU0-6LJQL¿FDQFHRILQWUDFUDQLDOK\SHU
WHQVLRQLQVHYHUHKHDGLQMXU\-1HXURVXUJ
0LOOHU -' *XGHPDQ 6. .LVKRUH 35 %HFNHU
'3 &7 VFDQ ,&3 DQG HDUO\ QHXURORJLFDO HYDOXDWLRQ LQ WKH
SURJQRVLVRIVHYHUHKHDGLQMXU\$FWD1HXURFKLU6XSSO:LHQ
0RXOWRQ 5- %URZQ -, .RQDVLHZLF] 6-
0RQLWRULQJ VHYHUH KHDG LQMXU\ D FRPSDULVRQ RI ((* DQG
VRPDWRVHQVRU\HYRNHGSRWHQWLDOV&DQ-1HXURO6FL
66
0XUU56WXPPHU:6FKXUHU/3RODVHN-&HUH
EUDOODFWDWHSURGXFWLRQLQUHODWLRQWRLQWUDFUDQLDOSUHVVXUHFUD
QLDOFRPSXWHGWRPRJUDSK\¿QGLQJVDQGRXWFRPHLQSDWLHQWV
ZLWK VHYHUH KHDG LQMXU\$FWD 1HXURFKLU :LHQ 1DUD\DQ 5. *UHHQEHUJ 53 0LOOHU -' HW DO
,PSURYHG FRQ¿GHQFH RI RXWFRPH SUHGLFWLRQ LQ VHYHUH KHDG
LQMXU\ $ FRPSDUDWLYH DQDO\VLV RI WKH FOLQLFDO H[DPLQDWLRQ
PXOWLPRGDOLW\ HYRNHG SRWHQWLDOV &7 VFDQQLQJ DQG LQWUDFUD
QLDOSUHVVXUH-1HXURVXUJ
1LHGHJJHQ$$GHOW'%HPGW5+RSI7&UHD
WLQHNLQDVH%%DIWHUVHYHUHKHDGLQMXU\DVDQLQGH[RISURJ
QRVLV LQ UHODWLRQ WR QDWXUH RI WUDXPD DQG SDWLHQW
V DJH$FWD
1HXURFKLU:LHQ
1RUGE\+.8UGDO3&UHDWLQHNLQDVH%%LQEORRG
DVLQGH[RISURJQRVLVDQGHIIHFWRIWUHDWPHQWDIWHUVHYHUHKHDG
LQMXU\$FWD1HXURFKLU:LHQ
2EULVW:'*HQQDUHOOL7$6HJDZD+'ROLQV
NDV&$/DQJ¿WW7:5HODWLRQRIFHUHEUDOEORRGÀRZWR
QHXURORJLFDO VWDWXV DQG RXWFRPH LQ KHDGLQMXUHG SDWLHQWV -
1HXURVXUJ
2YHUJDDUG - +YLG+DQVHQ 2 /DQG$0 HW DO
3URJQRVLVDIWHUKHDGLQMXU\EDVHGRQHDUO\FOLQLFDOH[DPLQD
WLRQ/DQFHW
3DO - %URZQ 5 )OHLV]HU ' 7KH YDOXH RI WKH
*ODVJRZ &RPD 6FDOH DQG ,QMXU\ 6HYHULW\ 6FRUH SUHGLFWLQJ
Documento descargado de http://www.revistaneurocirugia.com el 17/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
)DFWRUHVSURQyVWLFRVHQHOWUDXPDWLVPRFUDQHRHQFHIiOLFRJUDYH
RXWFRPH LQ PXOWLSOH WUDXPD SDWLHQWV ZLWK KHDG LQMXU\ -
7UDXPD
3DROLQ$ 1DUGLQ / *DHWDQL 3 HW DO 2[LGDWLYH
GDPDJHDIWHUVHYHUHKHDGLQMXU\DQGLWVUHODWLRQVKLSWRQHXUR
ORJLFDORXWFRPH1HXURVXUJHU\
3DSDQLFRODX $& /RULQJ ': (LVHQEHUJ +0
5D]1&RQWUHUDV)/$XGLWRU\EUDLQVWHPHYRNHGUHVSRQ
VHVLQFRPDWRVHKHDGLQMXUHGSDWLHQWV1HXURVXUJHU\
3DWHO +& 0HQRQ '. 7HEEV 6 +DZNHU 5
+XWFKLQVRQ3-.LUNSDWULFN3-6SHFLDOLVWQHXURFULWLFDOFDUH
DQGRXWFRPHIURPKHDGLQMXU\,QWHQVLYH&DUH0HG
3DWHUDNLV..DUDQWDQDV$+.RPQRV$9ROLNDV
= 2XWFRPH RI SDWLHQWV ZLWK GLIIXVH D[RQDO LQMXU\ WKH VLJ
QL¿FDQFH DQG SURJQRVWLF YDOXH RI 05, LQ WKH DFXWH SKDVH -
7UDXPD
3LHWURSDROL-$5RJHUV)%6KDFNIRUG65:DOG
6/ 6FKPRNHU -' =KXDQJ - 7KH GHOHWHULRXV HIIHFWV RI
LQWUDRSHUDWLYHK\SRWHQVLRQRQRXWFRPHLQSDWLHQWVZLWKVHYHUH
KHDGLQMXULHV-7UDXPD
3RKOPDQQ(GHQ % 'LQJHWKDO . %HQGHU +-
.RHOIHQ : +RZ UHOLDEOH LV WKH SUHGLFWLYH YDOXH RI 6(3
VRPDWRVHQVRU\ HYRNHG SRWHQWLDOV SDWWHUQV LQ VHYHUH EUDLQ
GDPDJH ZLWK VSHFLDO UHJDUG WR WKH ELODWHUDO ORVV RI FRUWLFDO
UHVSRQVHV",QWHQVLYH&DUH0HG
3RQGDDJ : 'LVVHPLQDWHG LQWUDYDVFXODU FRDJXOD
WLRQUHODWHGWRRXWFRPHLQKHDGLQMXU\$FWD1HXURFKLU6XSSO
:LHQ
3ULFH '- .QLOO-RQHV 5 7KH SUHGLFWLRQ RI RXW
FRPHRISDWLHQWVDGPLWWHGIROORZLQJKHDGLQMXU\LQFRPDZLWK
ELODWHUDO¿[HGSXSLOV$FWD1HXURFKLU6XSSO:LHQ
4XDWWURFFKL.%3UDVDG3:LOOLWV1+:DJQHU
)&-U4XDQWL¿FDWLRQRIPLGOLQHVKLIWDVDSUHGLFWRURISRRU
RXWFRPH IROORZLQJ KHDG LQMXU\ 6XUJ 1HXURO 4XLJOH\059LGRYLFK'&DQWHOOD':LOEHUJHU
-( 0DURRQ -& 'LDPRQG ' 'H¿QLQJ WKH OLPLWV RI VXU
YLYRUVKLS DIWHU YHU\ VHYHUH KHDG LQMXU\ - 7UDXPD 5DDEH$*UROPV&.HOOHU0'RKQHUW-6RUJH
26HLIHUW9&RUUHODWLRQRIFRPSXWHGWRPRJUDSK\¿QGLQJV
DQGVHUXPEUDLQGDPDJHPDUNHUVIROORZLQJVHYHUHKHDGLQMXU\
$FWD1HXURFKLU:LHQ
5DDEH$*UROPV&6HLIHUW96HUXPPDUNHUVRI
EUDLQGDPDJHDQGRXWFRPHSUHGLFWLRQLQSDWLHQWVDIWHUVHYHUH
KHDGLQMXU\%U-1HXURVXUJ
5DDEH$*UROPV&6RUJH2=LPPHUPDQQ0
6HLIHUW96HUXP6%SURWHLQLQVHYHUHKHDGLQMXU\1HX
URVXUJHU\
5DDEH$.RSHWVFK2:RV]F]\N$HWDO6HUXP
6% SURWHLQ DV D PROHFXODU PDUNHU LQ VHYHUH WUDXPDWLF
1HXURFLUXJtD
EUDLQLQMXU\5HVWRU1HXURO1HXURVFL
5DDEH$ 0HQRQ '. *XSWD 6 &]RVQ\ND 0
3LFNDUG -' -XJXODU YHQRXV DQG DUWHULDO FRQFHQWUDWLRQV RI
VHUXP 6% SURWHLQ LQ SDWLHQWV ZLWK VHYHUH KHDG LQMXU\
D SLORWVWXG\ - 1HXURO 1HXURVXUJ 3V\FKLDWU\ 5DDEH $ 6HLIHUW 9 )DWDO VHFRQGDU\ LQFUHDVH LQ
VHUXP6%SURWHLQDIWHUVHYHUHKHDGLQMXU\5HSRUWRIWKUHH
FDVHV-1HXURVXUJ
5DDEH $ 6HLIHUW 9 3URWHLQ 6% DV D VHUXP
PDUNHU RI EUDLQ GDPDJH LQ VHYHUH KHDG LQMXU\ SUHOLPLQDU\
UHVXOWV1HXURVXUJ5HY
5DERZ / &RRN ' /LSSHU 0+ HW DO 5HODWLR
QVKLS EHWZHHQ &7 DWWHQXDWLRQ FKDQJHV DQG SRVWWUDXPDWLF
&6)&.%%DFWLYLW\ DIWHU VHYHUH KHDG LQMXU\ LQ PDQ $FWD
1HXURFKLU:LHQ
5DERZ/'H6DOOHV$)%HFNHU'3HWDO&6)
EUDLQFUHDWLQHNLQDVHOHYHOVDQGODFWLFDFLGRVLVLQVHYHUHKHDG
LQMXU\-1HXURVXUJ
5DH*UDQW$'(FNHUW1%DUERXU3-HWDO2XW
FRPHRIVHYHUHEUDLQLQMXU\DPXOWLPRGDOLW\QHXURSK\VLRORJLF
VWXG\-7UDXPD
5DR&-6KXNOD3.0RKDQW\65HGG\<-3UH
GLFWLYHYDOXHRIVHUXPODFWDWHGHK\GURJHQDVHLQKHDGLQMXU\-
1HXURO1HXURVXUJ3V\FKLDWU\
5DSSDSRUW0+DOO.0+RSNLQV.%HOOH]D7
&RSH '1 'LVDELOLW\ UDWLQJ VFDOH IRU VHYHUH KHDG WUDXPD
FRPDWRFRPPXQLW\$UFK3K\V0HG5HKDELO
5HJQHU$.DXIPDQ0)ULHGPDQ*&KHPDOH/
,QFUHDVHG VHUXP 6EHWD SURWHLQ FRQFHQWUDWLRQV IROORZLQJ
VHYHUHKHDGLQMXU\LQKXPDQVDELRFKHPLFDOPDUNHURIEUDLQ
GHDWK"1HXURUHSRUW
5HVQLFN '. 0DULRQ ': &DUOLHU 3 2XWFRPH
DQDO\VLV RI SDWLHQWV ZLWK VHYHUH KHDG LQMXULHV DQG SURORQJHG
LQWUDFUDQLDOK\SHUWHQVLRQ-7UDXPD
5LFKDUG .( )URZHLQ 5$ 6LJQL¿FDQFH RI LQWUD
FUDQLDOSUHVVXUHDQGQHXURORJLFDOGH¿FLWDVSURJQRVWLFIDFWRUV
LQ DFXWH VHYHUH EUDLQ OHVLRQV$FWD 1HXURFKLU 6XSSO :LHQ
5LFKDUGV 3 6HYHUH KHDG LQMXU\ WKH ¿UVW KRXU %U
0HG-
5LWWHU$00XL]HODDU-3%DUQHV7HWDO%UDLQ
VWHPEORRGÀRZSXSLOODU\UHVSRQVHDQGRXWFRPHLQSDWLHQWV
ZLWKVHYHUHKHDGLQMXULHV1HXURVXUJHU\
5REHUWVRQ&6&RQWDQW&)*RNDVODQ=/1DUD
\DQ 5. *URVVPDQ 5* &HUHEUDO EORRG ÀRZ DUWHULRYH
QRXVR[\JHQGLIIHUHQFHDQGRXWFRPHLQKHDGLQMXUHGSDWLHQWV
-1HXURO1HXURVXUJ3V\FKLDWU\
5RVHQEOXP :, *UHHQEHUJ 53 6HHOLJ -0
%HFNHU'30LGEUDLQOHVLRQVIUHTXHQWDQGVLJQL¿FDQWSURJ
QRVWLF IHDWXUH LQ FORVHG KHDG LQMXU\ 1HXURVXUJHU\ Documento descargado de http://www.revistaneurocirugia.com el 17/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
%RWR\FRO
5RVV$03LWWV/+.RED\DVKL63URJQRVWLFD
WRUVRIRXWFRPHDIWHUPDMRUKHDGLQMXU\LQWKHHOGHUO\-1HX
URVFL1XUV
5RWKRHUO5':RHUWJHQ&+RO]VFKXK00HW]
&%UDZDQVNL$6VHUXPOHYHOVDIWHUPLQRUDQGPDMRU
KHDGLQMXU\-7UDXPD
5RYOLDV$ .RWVRX 67KH LQÀXHQFH RI K\SHUJO\
FHPLD RQ QHXURORJLFDO RXWFRPH LQ SDWLHQWV ZLWK VHYHUH KHDG
LQMXU\1HXURVXUJHU\
5XGQLFN$:RMWDFKD0:HQFHO7%D]RZVNL3
7KHSURJQRVWLFYDOXHRIVRPHFOLQLFDODQGGLDJQRVWLFIDFWRUV
LQ WUDXPDWLF LQWUDFUDQLDO KDHPDWRPD $FWD 1HXURFKLU 6XSSO
:LHQ
6DOFPDQ06FKHSS56'XFNHU7%&DOFXODWHG
UHFRYHU\UDWHVLQVHYHUHKHDGWUDXPD1HXURVXUJHU\
6DXO7*'XFNHU7%(IIHFWRILQWUDFUDQLDOSUHV
VXUH PRQLWRULQJ DQG DJJUHVVLYH WUHDWPHQW RQ PRUWDOLW\ LQ
VHYHUHKHDGLQMXU\-1HXURVXUJ
6HLW]+'2FNHU.7KHSURJQRVWLFDQGWKHUDSHX
WLFLPSRUWDQFHRIFKDQJHVLQWKH&6)GXULQJWKHDFXWHVWDJHRI
EUDLQLQMXU\$FWD1HXURFKLU:LHQ
6HOODGXUDL %0 -D\DNXPDU 5 7DQ << /RZ
+&2XWFRPHSUHGLFWLRQLQHDUO\PDQDJHPHQWRIVHYHUHKHDG
LQMXU\ DQ H[SHULHQFH LQ 0DOD\VLD %U - 1HXURVXUJ 6HOODGXUDL %0 9LFNQHVZDUDQ 0 'XUDLVDP\ 6
$WDQ0&RDJXORSDWK\LQDFXWHKHDGLQMXU\DVWXG\RILWVUROH
DVDSURJQRVWLFLQGLFDWRU%U-1HXURVXUJ
6HUYDGHL ) 0XUUD\ *' 3HQQ\ . HW DO 7KH
YDOXH RI WKH ZRUVW FRPSXWHG WRPRJUDSKLF VFDQ LQ FOLQLFDO
VWXGLHV RI PRGHUDWH DQG VHYHUH KHDG LQMXU\ (XURSHDQ %UDLQ
,QMXU\&RQVRUWLXP1HXURVXUJHU\
6HUYDGHL ) 0XUUD\ *' 7HDVGDOH *0 HW DO
7UDXPDWLF VXEDUDFKQRLG KHPRUUKDJH GHPRJUDSKLF DQG FOL
QLFDO VWXG\ RI SDWLHQWV IURP WKH (XURSHDQ EUDLQ LQMXU\
FRQVRUWLXP VXUYH\ RI KHDG LQMXULHV 1HXURVXUJHU\ 6LQJKDO$%DNHU$-+DUH*05HLQGHUV);
6FKOLFKWHU /& 0RXOWRQ 5- $VVRFLDWLRQ EHWZHHQ FHUH
EURVSLQDOÀXLGLQWHUOHXNLQFRQFHQWUDWLRQVDQGRXWFRPHDIWHU
VHYHUHKXPDQWUDXPDWLFEUDLQLQMXU\-1HXURWUDXPD
6OHLJK-:+DYLOO-+)ULWK5.HUVHO'0DUVK
1 8O\DWW ' 6RPDWRVHQVRU\ HYRNHG SRWHQWLDOV LQ VHYHUH
WUDXPDWLFEUDLQLQMXU\DEOLQGHGVWXG\-1HXURVXUJ
6WHXGHO:,.UXJHU-8VLQJWKHVSHFWUDODQDO\VLV
RIWKH((*IRUSURJQRVLVRIVHYHUHEUDLQLQMXULHVLQWKH¿UVW
SRVWWUDXPDWLFZHHN$FWD1HXURFKLU6XSSO:LHQ
6ZHHW5&0LOOHU-'/LSSHU0.LVKRUH35
%HFNHU'36LJQL¿FDQFHRIELODWHUDODEQRUPDOLWLHVRQWKH&7
1HXURFLUXJtD
VFDQLQSDWLHQWVZLWKVHYHUHKHDGLQMXU\1HXURVXUJHU\
7DNDKDVKL + 8UDQR 7 7DNDGD < 1DJDL 1
7DNDGD$)LEULQRO\WLFSDUDPHWHUVDVDQDGPLVVLRQSURJQRV
WLFPDUNHURIKHDGLQMXU\LQSDWLHQWVZKRWDONDQGGHWHULRUDWH
-1HXURVXUJ
7DNDQDVKL< 6KLQRQDJD 0 1DNDMLPD ) >5HOD
WLRQVKLS EHWZHHQ K\SHUJO\FHPLD IROORZLQJ KHDG LQMXU\ DQG
QHXURORJLFDORXWFRPH@1R7R6KLQNHL-SQ
7HDVGDOH*-HQQHWW%$VVHVVPHQWRIFRPDDQG
LPSDLUHGFRQVFLRXVQHVV$SUDFWLFDOVFDOH/DQFHW
7HDVGDOH*-HQQHWW%$VVHVVPHQWDQGSURJQRVLV
RI FRPD DIWHU KHDG LQMXU\$FWD 1HXURFKLU :LHQ 7HDVGDOH * -HQQHWW % 0XUUD\ / 0XUUD\ *
*ODVJRZFRPDVFDOHWRVXPRUQRWWRVXP/DQFHW
OHWWHU
7HDVGDOH * .QLOO-RQHV 5 YDQ GHU 6DQGH -
2EVHUYHUYDULDELOLW\LQDVVHVVLQJLPSDLUHGFRQVFLRXVQHVVDQG
FRPD-1HXURO1HXURVXUJ3V\FKLDWU\
7HDVGDOH * 0XUUD\ * 3DUNHU / -HQQHWW %
$GGLQJ XS WKH *ODVJRZ &RPD 6FRUH$FWD 1HXURFKLU 6XSSO
:LHQ
7HDVGDOH*6NHQH$3DUNHU/-HQQHWW%$JH
DQG RXWFRPH RI VHYHUH KHDG LQMXU\ $FWD 1HXURFKLU 6XSSO
:LHQ
7HDVGDOH*01LFROO-$0XUUD\*)LGGHV0
$VVRFLDWLRQRIDSROLSRSURWHLQ(SRO\PRUSKLVPZLWKRXWFRPH
DIWHUKHDGLQMXU\/DQFHW
7HDVGDOH*03HWWLJUHZ/(:LOVRQ-70XUUD\
* -HQQHWW % $QDO\]LQJ RXWFRPH RI WUHDWPHQW RI VHYHUH
KHDGLQMXU\DUHYLHZDQGXSGDWHRQDGYDQFLQJWKHXVHRIWKH
*ODVJRZ2XWFRPH6FDOH-1HXURWUDXPD
7KDWFKHU 5: &DQWRU '6 0F$ODVWHU 5 *HLV
OHU).UDXVH3&RPSUHKHQVLYHSUHGLFWLRQVRIRXWFRPHLQ
FORVHGKHDGLQMXUHGSDWLHQWV7KHGHYHORSPHQWRISURJQRVWLF
HTXDWLRQV$QQ1<$FDG6FL
7KHLOHQ +- 5DJDOOHU 0 7VFKR 8 0D\ 6$
6FKDFNHUW*$OEUHFKW0'(OHFWURHQFHSKDORJUDPVLOHQFH
UDWLRIRUHDUO\RXWFRPHSURJQRVLVLQVHYHUHKHDGWUDXPD&ULW
&DUH0HG
7KRPDV '* 5DERZ / 7HDVGDOH * 6HUXP
P\HOLQ EDVLF SURWHLQ FOLQLFDO UHVSRQVLYHQHVV DQG RXWFRPH
RIVHYHUHKHDGLQMXU\$FWD1HXURFKLU6XSSO:LHQ
7RXWDQW60.ODXEHU050DUVKDOO/)HWDO
$EVHQWRUFRPSUHVVHGEDVDOFLVWHUQVRQ¿UVW&7VFDQRPLQRXV
SUHGLFWRUVRIRXWFRPHLQVHYHUHKHDGLQMXU\-1HXURVXUJ
7VHPHQW]LV6$*RUGRQ$*LOOLQJKDP)-3URJ
QRVLF VLJQV GXULQJ FRQWLQXRXV PRQLWRULQJ RI WKH YHQWULFXODU
ÀXLGSUHVVXUHLQSDWLHQWVZLWKVHYHUHEUDLQLQMXU\$FWD1HXUR
Documento descargado de http://www.revistaneurocirugia.com el 17/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
)DFWRUHVSURQyVWLFRVHQHOWUDXPDWLVPRFUDQHRHQFHIiOLFRJUDYH
FKLU6XSSO:LHQ
8]]HOO %3 'ROLQVNDV &$ :LVHU 5) /DQJ¿WW
7:,QÀXHQFHRIOHVLRQVGHWHFWHGE\FRPSXWHGWRPRJUDSK\
RQ RXWFRPH DQG QHXURSV\FKRORJLFDO UHFRYHU\ DIWHU VHYHUH
KHDGLQMXU\1HXURVXUJHU\
9DODGND$%*RSLQDWK63&RQWDQW&)8]XUD
05REHUWVRQ&65HODWLRQVKLSRIEUDLQWLVVXH32WRRXW
FRPHDIWHUVHYHUHKHDGLQMXU\&ULW&DUH0HG
9DQ'RQJHQ.-%UDDNPDQ5*HOSNH*-7KH
SURJQRVWLF YDOXH RI FRPSXWHUL]HG WRPRJUDSK\ LQ FRPDWRVH
KHDGLQMXUHGSDWLHQWV-1HXURVXUJ
9DQ6DQWEULQN+YG%ULQN:$6WH\HUEHUJ(:
&DUPRQD6XD]R-$$YH]DDW&-0DDV$,%UDLQWLVVXH
R[\JHQUHVSRQVHLQVHYHUHWUDXPDWLFEUDLQLQMXU\$FWD1HXUR
FKLU:LHQ
9DSDODKWL07URXSS+3URJQRVLVIRUSDWLHQWVZLWK
VHYHUHEUDLQLQMXULHV%U0HG-
9HVSD 30 %RVFDUGLQ :- +RYGD '$ HW DO
(DUO\DQGSHUVLVWHQWLPSDLUHGSHUFHQWDOSKDYDULDELOLW\RQFRQ
WLQXRXV HOHFWURHQFHSKDORJUDSK\ PRQLWRULQJ DV SUHGLFWLYH RI
SRRURXWFRPHDIWHUWUDXPDWLFEUDLQLQMXU\-1HXURVXUJ
9ROOPHU '* 3URJQRVLV DQG RXWFRPH RI VHYHUH
KHDGLQMXU\(Q&RRSHU35HG+HDG,QMXU\HG%DOWLPRUH
:LOOLDPV:LONLQVSS
9ROOPHU'*7RUQHU-&-DQH-$HWDO$JHDQG
RXWFRPHIROORZLQJWUDXPDWLFFRPDZK\GRROGHUSDWLHQWVIDUH
ZRUVH"-1HXURVXUJ6XSSO66
:DOGHU$'<HRPDQ307XUQEXOO$7KHDEEUH
YLDWHGLQMXU\VFDOHDVDSUHGLFWRURIRXWFRPHRIVHYHUHKHDG
LQMXU\,QWHQVLYH&DUH0HG
:D[PDQ.6XQGLQH0-<RXQJ5),VHDUO\SUH
GLFWLRQRIRXWFRPHLQVHYHUHKHDGLQMXU\SRVVLEOH"$UFK6XUJ
:HGHNLQG&)LVFKEDFK53DNRV37HUKDDJ'
.OXJ 1 &RPSDUDWLYH XVH RI PDJQHWLF UHVRQDQFH LPDJLQJ
DQGHOHFWURSK\VLRORJLFLQYHVWLJDWLRQIRUWKHSURJQRVLVRIKHDG
LQMXU\-7UDXPD
:HGHNLQG & +HVVHOPDQQ9 /LSSHUW*UXQHU 0
(EHO 0 7UDXPD WR WKH SRQWRPHVHQFHSKDOLF EUDLQVWHPD
PDMRUFOXHWRWKHSURJQRVLVRIVHYHUHWUDXPDWLFEUDLQLQMXU\
%U-1HXURVXUJ
:LOEHUJHU-(-U'HHE=5RWKIXV:0DJQHWLF
UHVRQDQFHLPDJLQJLQFDVHVRIVHYHUHKHDGLQMXU\1HXURVXU
JHU\
:LOOLDPV -0 *RPHV ) 'UXGJH 2: .HVVOHU
0 3UHGLFWLQJ RXWFRPH IURP FORVHG KHDG LQMXU\ E\ HDUO\
DVVHVVPHQW RI WUDXPD VHYHULW\ - 1HXURVXUJ :LOVRQ-73HWWLJUHZ/(7HDVGDOH*06WUXF
1HXURFLUXJtD
WXUHG LQWHUYLHZV IRU WKH *ODVJRZ 2XWFRPH 6FDOH DQG WKH
H[WHQGHG*ODVJRZ2XWFRPH6FDOHJXLGHOLQHVIRUWKHLUXVH-
1HXURWUDXPD
:LQFKHOO 5- +R\W '% $QDO\VLV RI KHDUWUDWH
YDULDELOLW\DQRQLQYDVLYHSUHGLFWRURIGHDWKDQGSRRURXWFRPH
LQSDWLHQWVZLWKVHYHUHKHDGLQMXU\-7UDXPD
:LQFKHOO 5- 6LPRQV 5. +R\W '% 7UDQVLHQW
V\VWROLFK\SRWHQVLRQ$VHULRXVSUREOHPLQWKHPDQDJHPHQWRI
KHDGLQMXU\$UFK6XUJ
:LQWHU &' 3ULQJOH $. &ORXJK *) &KXUFK
0.5DLVHGSDUHQFK\PDOLQWHUOHXNLQOHYHOVFRUUHODWHZLWK
LPSURYHG RXWFRPH DIWHU WUDXPDWLF EUDLQ LQMXU\ %UDLQ :RHUWJHQ&5RWKRHUO5'+RO]VFKXK00HW]
&%UDZDQVNL$&RPSDULVRQRIVHULDO6DQG16(VHUXP
PHDVXUHPHQWVDIWHUVHYHUHKHDGLQMXU\$FWD1HXURFKLU:LHQ
:RHUWJHQ&5RWKRHUO5'0HW]&%UDZDQVNL
$&RPSDULVRQRIFOLQLFDOUDGLRORJLFDQGVHUXPPDUNHUDV
SURJQRVWLFIDFWRUVDIWHUVHYHUHKHDGLQMXU\-7UDXPD
:RROI3'+DPLOO5:/HH/$&R[&0F'R
QDOG-97KHSUHGLFWLYHYDOXHRIFDWHFKRODPLQHVLQDVVHVVLQJ
RXWFRPHLQWUDXPDWLFEUDLQLQMXU\-1HXURVXUJ
<DPDNL 7 0XUDNDPL 1 ,ZDPRWR < HW DO
3DWKRORJLFDOVWXG\RIGLIIXVHD[RQDOLQMXU\SDWLHQWVZKRGLHG
VKRUWO\DIWHULPSDFW$FWD1HXURFKLU:LHQ
<DQJ6<*DR=;'HWHUPLQDWLRQDQGFOLQLFDOVLJ
QL¿FDQFH RI SODVPD OHYHOV RI SURVWDJODQGLQV LQ SDWLHQWV ZLWK
DFXWHEUDLQLQMXU\6XUJ1HXURO
<RXQJ % 2WW / 'HPSVH\ 5 +DDFN '7LEEV
3 5HODWLRQVKLS EHWZHHQ DGPLVVLRQ K\SHUJO\FHPLD DQG QHX
URORJLFRXWFRPHRIVHYHUHO\EUDLQLQMXUHGSDWLHQWV$QQ6XUJ
=DJDUD*6FDUDYLOOL30DVWRUJLR36HYHVR0
9DOLGDWLRQ RI D SURJQRVWLF V\VWHP LQ VHYHUH EUDLQLQMXUHG
SDWLHQWV-1HXURVXUJ6FL
=HPODQ )3 -DXFK (& 0XOFKDKH\ -- HW DO
&WDXELRPDUNHURIQHXURQDOGDPDJHLQVHYHUHEUDLQLQMXUHG
SDWLHQWV DVVRFLDWLRQ ZLWK HOHYDWHG LQWUDFUDQLDO SUHVVXUH DQG
FOLQLFDORXWFRPH%UDLQ5HV
%RWR *5 *yPH] 3$ 'H OD &UX] - /REDWR 5'
)DFWRUHV SURQyVWLFRV HQ HO WUDXPDWLVPR FUDQHRHQFHIiOLFR
JUDYH1HXURFLUXJtD
&RUUHVSRQGHQFLD SRVWDO *UHJRULR 5RGUtJXH] %RWR $YHQLGD
'RFWRU*DUFtD7DSLD(VF'ž%0DGULG
Descargar