Corresponding author at: Acibadem Taksim Hospital, Inonu Neighbourhood Nizamiye Street N: 9/1, Sisli/Istanbul, Turkey.
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Idoneidad del tratamiento endovascular aislado con etilen vinil alcohol / dimetilsulfóxido (Onyx®). Presentación de un caso y revisión de la literatura" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "272" "paginaFinal" => "280" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Intracranial hypertension secondary to unruptured pial arteriovenous malformation. Suitability of isolated endovascular treatment with ethylene vinyl alcohol / dimethyl sulfoxide (Onyx®). Case report and literature review" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3351 "Ancho" => 3167 "Tamanyo" => 1200656 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Estudio posembolización inmediato. a) y b) La arteriografía cerebral diagnóstica posembolización muestra una oclusión satisfactoria de la MAVp. c) y d) Nótese en las imágenes arteriográficas sin sustracción como el material de embolización se distribuye por los diferentes aportes nidales. e) RM craneal secuencia T1 con contraste. No se evidencia realce del <span class="elsevierStyleItalic">nidus</span> tras la administración de gadolinio (flecha blanca). f) RM craneal secuencia T2. Corte focalizado a nivel orbitario. El edema de nervio óptico se ha resuelto bilateralmente (flechas blancas). g) En un nuevo registro de PIC se mostró normalización de las cifras persistentemente elevadas anteriormente documentadas, con una media de 12<span class="elsevierStyleHsp" style=""></span>mmHg. Estudio posembolización tras 5 años de seguimiento. h) e i) Arteriografía cerebral diagnóstica. Proyección anteroposterior. Circulación anterior y posterior, respectivamente. j) y k) Arteriografía cerebral diagnóstica. Proyección lateral. Circulación anterior y posterior, respectivamente. l) y m) Arteriografía cerebral diagnóstica. Proyección oblicua. Circulación anterior y posterior, respectivamente. n) y ñ) RM craneal secuencia T1 con contraste. Corte axial y sagital, respectivamente. Podemos apreciar exclusión completa de la MAVp en las distintas modalidades y proyecciones de neuro-imagen utilizadas.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Fernando García Pérez, José María Narro Donate, Félix Gallo Pineda, José Masegosa González" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Fernando" "apellidos" => "García Pérez" ] 1 => array:2 [ "nombre" => "José María" "apellidos" => "Narro Donate" ] 2 => array:2 [ "nombre" => "Félix" "apellidos" => "Gallo Pineda" ] 3 => array:2 [ "nombre" => "José" "apellidos" => "Masegosa González" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2529849624000364" "doi" => "10.1016/j.neucie.2024.07.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529849624000364?idApp=UINPBA00004B" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130147324000290?idApp=UINPBA00004B" "url" => "/11301473/0000003500000005/v1_202409030459/S1130147324000290/v1_202409030459/es/main.assets" ] "itemAnterior" => array:17 [ "pii" => "S1130147324000174" "issn" => "11301473" "doi" => "10.1016/j.neucir.2024.03.001" "estado" => "S300" "fechaPublicacion" => "2024-09-01" "aid" => "604" "documento" => "article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Neurocirugia. 2024;35:263-6" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Terson’s syndrome after endoscopic removal of a colloid cyst" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "263" "paginaFinal" => "266" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Sindrome de Terson tras resección endoscópica de quiste coloide" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 994 "Ancho" => 900 "Tamanyo" => 73818 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Postoperative CT scan that shows complete removal without any complication and with ventricular drain placed in left ventricle.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Angel Horcajadas Almansa, Ana M. Román Cutillas, Ana M. Jorques Infante, José M. Ortega Molina" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Angel" "apellidos" => "Horcajadas Almansa" ] 1 => array:2 [ "nombre" => "Ana M." "apellidos" => "Román Cutillas" ] 2 => array:2 [ "nombre" => "Ana M." "apellidos" => "Jorques Infante" ] 3 => array:2 [ "nombre" => "José M." "apellidos" => "Ortega Molina" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130147324000174?idApp=UINPBA00004B" "url" => "/11301473/0000003500000005/v1_202409030459/S1130147324000174/v1_202409030459/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Combined thalamic and pallidal deep brain stimulation in diabetic hemiballism/hemichorea" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "267" "paginaFinal" => "271" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Onur Ozturk, Nihan Hande Akcakaya, Mehmet Osman Akcakaya" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Onur" "apellidos" => "Ozturk" "email" => array:1 [ 0 => "onurozturk.ial@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Nihan Hande" "apellidos" => "Akcakaya" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Mehmet Osman" "apellidos" => "Akcakaya" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Neurosurgery, Acibadem Taksim Hospital, Istanbul, Turkey" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Neurology, Demiroglu Bilim University Medicine Faculty, Istanbul, Turkey" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Neurosurgery, Gayrettepe Florence Nightingale Hospital, Istanbul, Turkey" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author at</span>: Acibadem Taksim Hospital, Inonu Neighbourhood Nizamiye Street N: 9/1, Sisli/Istanbul, Turkey." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estimulación cerebral profunda talámica y pálida combinada en el hemibalismo/hemicorea diabético" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 965 "Ancho" => 975 "Tamanyo" => 76330 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hyperintense lesion in the right lentiform nucleus on T1-weighted axial magnetic resonance images.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Hemiballism/Hemichorea (HH) is a rare hyperkinetic movement disorder with an acute or a subacute onset. It is characterized by involuntary, unilateral, high amplitude flinging/flailing movements of the upper and lower extremities.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> HH is usually encountered in the clinical course of cerebrovascular diseases in older adults. However, it is also associated with severe nonketotic hyperglycemia in diabetes, iatrogenic surgical injuries, previous deep brain stimulation (DBS), and infections.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a> HH generally occurs secondary to lesions in the contralateral basal ganglia. Although the symptoms are more severe in patients with subthalamic nucleus (STN) lesions, lesions in the globus pallidus internus (GPi), thalamus, and other regions of the basal ganglia may also cause HH.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The clinical picture of HH usually improves gradually without any treatment.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Nevertheless, some patients demonstrate severe disabling symptoms despite aggressive medical treatment. Stereotactic surgery should be performed in such patients.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,4</span></a> Lesioning has been used for years to treat HH and various studies suggest thalamotomy or pallidotomy for the treatment of HH. However, the optimal target for better outcomes remained unclear. Although the reversible nature of DBS surgery has made it an attractive treatment method, the number of cases is limited.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Reports of surgery for diabetic HH are very rare. Till date, only four cases of drug-resistant HH have been treated with either lesioning of ventrolateral (VL) thalamus and pallidum (n = 2)<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> or DBS of the nucleus ventralis oralis (VO) and GPi (n = 2).<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Herein, we report a case of diabetic HH that was treated using a unique strategy. HH developed after a hyperglycemic attack in a patient with uncontrolled diabetes mellitus (DM). A combined thalamic and pallidal DBS surgery was applied. This is the first case that required surgical intervention for diabetic HH outside Japan and Korea and also the first report of a combined DBS surgery for diabetic HH.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5–7</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 75-year-old female with a 20-year history of type-II DM was referred to our department for the treatment of left-sided, progressive, involuntary movements. She had suffered from a metabolic crisis of hyperglycemia 12 months ago, and 6 months ago she developed continuous, involuntary, ballistic movements of the left arm and leg. Magnetic resonance imaging (MRI) of the brain revealed a hyperintense lesion in the lentiform nucleus on T1-weighted images. There were no significant radiological findings on T2-weighted and FLAIR images (shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The symptoms did not improve despite the medical treatment. Moreover, she developed left limb pain due to cramps caused induced by violent movements. She developed diabetic foot and underwent an endovascular intervention for revascularization 3 months ago. Because of the functional impairment, DBS surgery was planned to control her symptoms.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Bifocal DBS targeting the GPi and ventral intermediate (Vim) nucleus was performed under general anesthesia. On the operative day, after a cranial MRI was obtained, a stereotactic frame (Integra, CRW, New Jersey, USA) was placed onto the patient’s head. Thereafter, computed tomography (CT) of the head was obtained. Subsequently, the MRI and CT images were autofused using an image fusion program (Atlas Integra Software, New Jersey, USA) to target posteroventral GPi and thalamic Vim nucleus. Two DBS electrodes with eight contacts (DB-2001-45-DC; Boston Scientific, Valencia, California, USA) were implanted unilaterally with direct targeting (shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The skin incisions were closed, and the patient was shifted to the radiology unit. Another cranial CT was performed to confirm appropriate position of the permanent electrodes (shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Thereafter, the stereotactic frame was removed, and the impulse generator (Versice RC, Boston Scientific, Valencia, California, USA) was implanted and connected to the leads. The postoperative course was uneventful. The HH symptoms was almost completely suppressed due to the lesioning effect of the electrodes in the early postoperative period, as you may see in the video. Initially, Vim (1.7 mA, 60 μs, 130 Hz) and GPi (2.4 mA, 60 μs, 130 Hz) were simultaneously stimulated, resulting in complete resolution of the symptoms. The patient was regularly followed up for 14 months postoperatively, with no progression of the symptoms. The patient died due to cardiac complications related to severe type-II DM.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Although STN lesions have been proposed as the main cause of HH for years, recent studies have demonstrated that lesions outside STN may also cause HH. Animal studies in monkeys revealed that HH also appears after chemical ablation of putamen and globus pallidus extermus.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,7</span></a> Therefore, because of its connections with the striatum, thalamus has been suggested as a target in the treatment of HH. Nakano reported successful outcome after the VO complex was targeted for DBS in a patient with diabetic HH.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The putamen has been hypothesized as the center of dysfunction in HH. Due to the dysfunction of gammaaminobutyric acidergic neurons in putamen, irregular outputs are sent to the basal ganglia, which causes the disinhibition of motor thalamus. Son targeted GPi for DBS in diabetic HH and also reported excellent outcomes.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Diabetic HH is reportedly related to a striatal lesion, which can be detected on brain MRIs.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The lesion is usually located on the side opposite to that of the involuntary movement and is characterized by a hyperintense signal on T1-weighted and isointense to hypointense signal on T2-weighted images. The possible reasons for the MRI findings in diabetic HH are considered to be acute ischemia, hemorrhagic transformation, osmotic myelinosis, hyperviscosity-induced injury, vasogenic edema, and reversible calcium deposition. According to the MR-spectroscopy and histological biopsy findings, hyperviscosity, not ischemic and hemorrhagic processes, is the most possible cause of diabetic HH.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The lesioning era demonstrates that pallidotomy and thalamotomy produce effective results. The largest case series of thalamotomies with a considerably long follow-up was published by Krauss and Mundinger. In this series, 13 patients who were followed up for 11 years developed only a few mild side effects and demonstrates satisfactory symptom control.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Other case series also demonstrated good outcomes following thalamotomy.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> Takamatsu reported satisfactory outcomes in two patients with DM-associated HH who were treated with a VL thalamotomy.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Similar results have been also reported for pallidotomy in the studies with sufficient follow-up.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,11,12</span></a> Goto demonstrated a successful treatment of diabetic HH with pallidotomy.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Therefore, it is difficult to select the optimal targets.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Recently, multifocal targeting and combined stimulation have become attractive alternatives in the management of movement disorders.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,13</span></a> Nakano reported that combined pallidal and thalamic stimulation in neuroacanthocytosis provides better control of involuntary movements with fewer side effects. Although the exact mechanism remains known, combined pallidal and thalamic stimulation together provide better results than single target stimulation in neuroacanthocytosis.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Capelle reported a case with HH due to a surgical vascular injury that was treated with bifocal DBS.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Unlike Nakano, they did not prefer a combined stimulation approach. They investigated the threshold values for both targets separately and determined that GPi should be stimulated up to 5 mA (210 μs, 130 Hz) and the Vim up to 0.3 mA (210 μs, 130 Hz) to provide similar results of HH control in the same patient.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> HH cases treated with GPi-targeted DBS require more energy consumption. To our knowledge, there are only six published case reports of the patients treated with GPi DBS.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3,14,15</span></a> Oyama,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Son,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and Hasegawa<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> reported that 3.3 mA (90 μs, 135 Hz), 3.5 mA (130 μs, 100 Hz) and 4.5 mA (60 μs, 130 Hz) of GPi stimulation, respectively, was required for symptom control. Pabaney reported partial improvement of symtpoms with 2 mA (90 μs, 160 Hz) of GPi stimulation. However, the patient later deteriorated and was diagnosed with multisystem atrophy.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Ganapa did not provide any data regarding the stimulation parameters of their patient.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Nakano reported that VO complex stimulation with 2 mA (90 μs, 130 Hz) achieved symptom control.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Considering the data from previous studies, we preferred to implant one Vim and GPi electrode and assess the clinical response to single or combined stimulation. We found that thethreshold values for GPi stimulation required to achieve HH control were similar (4.8 mA, 60 μs, 130 Hz). These values are in accordance with those of cases reported by Capelle<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and Hasegawa,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and a little higher than those reported by Oyama and Son.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> The threshold value for Vim stimulationwas significantly higher value in our study than in the study by Capelle. The stimulation threshold for Vim DBS in our study (2.3 mA, 60 μs, 130 Hz) was similar to that for VO complex DBS in the study by Nakano.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The high pulse width preference of 210 μs in the study by Capelle (vs. 60 μs in our study) may have also played a role. Eventually, we found similar threshold differences for thalamic and pallidal DBS that were required to achieve HH control. When using combined stimulation, it was easy to reduce the voltage on both targets. We believe that this approach will prevent side effects due to chronic high voltage stimulation, particularly of GPi. Another advantage of the approach is the preservation of battery energy consumption. Although the implanted DBS pulse generator in our patient is rechargeable, they are not always utilized worldwide due to economic or social security issues. Hence, energy consumption should be considered when determining the treatment strategy.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Bifocal pallidal and thalamic DBS in addition to combined stimulation for the patients with HH provides excellent clinical outcome and lowers battery consumption of the DBS device. It is an easy and practical approach that should be considered for the management of HH and other rare movement disorders.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Funding</span><p id="par0060" class="elsevierStylePara elsevierViewall">No funding.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres2234337" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1870266" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xpalclavsec1870267" "titulo" => "Abbreviations" ] 3 => array:3 [ "identificador" => "xres2234336" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1870268" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 7 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-11-10" "fechaAceptado" => "2024-03-07" "PalabrasClave" => array:2 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1870266" "palabras" => array:4 [ 0 => "Deep brain stimulation" 1 => "Hemiballism-Hemichorea" 2 => "Diabetes mellitus" 3 => "Movement disorder" ] ] 1 => array:4 [ "clase" => "abr" "titulo" => "Abbreviations" "identificador" => "xpalclavsec1870267" "palabras" => array:13 [ 0 => "CT" 1 => "DBS" 2 => "DM" 3 => "GPi" 4 => "HH" 5 => "Hz" 6 => "mA" 7 => "MRI" 8 => "μs" 9 => "STN" 10 => "Vim" 11 => "VL" 12 => "VO" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1870268" "palabras" => array:4 [ 0 => "Estimulación cerebral profunda" 1 => "Hemibalismo-Hemicorea" 2 => "Diabetes mellitus" 3 => "Trastorno del movimiento" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Hemiballism/hemichorea (HH) is a hyperkinetic movement disorder observed mostly in older adults with cerebrovascular diseases. Although the symptoms improve without any treatment, lesioning or DBS (deep brain stimulation) may be rarely required to provide symptomatic relief for patients with severe involuntary movements. HH is a rare complication of uncontrolled diabetes. There are only a few reported cases of diabetic HH that have been surgically treated. Thus, herein, we have reported the case of a 75-year-old female with type-II diabetes mellitus that presented with disabling involuntary limb movements of the left side, despite being treated conservatively for six months. DBS targeting the globus pallidus internus (GPi) and ventral intermediate (Vim) thalamic nucleus was performed. Complete resolution of symptoms was achieved with a combined stimulation of the thalamic Vim nucleus (at 1.7 mA) and GPi (at 2.4 mA). The combined stimulation of the Vim nucleus and GPi effectively resolved the diabetes-induced HH symptoms in our patient. Thus, although certain conclusions cannot be drawn due to the rarity of the surgically treated patients with HH, the combined stimulation is a novel treatment option for resistant HH.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El hemibalismo/hemicorea (HH) es un trastorno del movimiento hipercinético que se observa principalmente en adultos mayores con enfermedades cerebrovasculares. Aunque los síntomas mejoran sin ningún tratamiento, rara vez se requiere la cirugía de lesional o estimulación cerebral profunda (DBS, por sus siglas en inglés) para proporcionar alivio sintomático a los pacientes con movimientos involuntarios graves. La HH es una complicación rara de la diabetes no controlada. Solo hay unos pocos casos reportados de HH diabético que han sido tratados quirúrgicamente. Por lo tanto, en este documento informamos del caso de una mujer de 75 años con diabetes mellitus tipo II que presentó movimientos involuntarios incapacitantes en las extremidades del lado izquierdo, a pesar de haber sido tratada de forma conservadora durante seis meses. Se realizó DBS dirigida al globo pálido interno (GPi) y al núcleo talámico intermedio ventral (Vim). La resolución completa de los síntomas se logró con una estimulación combinada del núcleo talámico Vim (a 1,7 mA) y GPi (a 2,4 mA). La estimulación combinada del núcleo Vim y GPi resolvió eficazmente los síntomas de HH inducidos por la diabetes en nuestro paciente. Por lo tanto, aunque no se pueden sacar ciertas conclusiones debido a la rareza de los pacientes con HH tratados quirúrgicamente, la estimulación combinada es una nueva opción de tratamiento para la HH resistente.</p></span>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0070" class="elsevierStylePara elsevierViewall">The following are Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0035" ] ] ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 965 "Ancho" => 975 "Tamanyo" => 76330 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hyperintense lesion in the right lentiform nucleus on T1-weighted axial magnetic resonance images.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 702 "Ancho" => 2000 "Tamanyo" => 329345 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Unilateral direct targeting to the right posteroventral GPi and thalamic Vim nucleus.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 962 "Ancho" => 1475 "Tamanyo" => 180508 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Electrode locations were confirmed by performing a cranial CT postoperatively.</p>" ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.rtf" "ficheroTamanyo" => 46405 ] ] 4 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 41413835 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rescue GPi-DBS for a stroke-associated hemiballism in a patient with STN-DBS" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Oyama" 1 => "N. Maling" 2 => "Avila-Thompson" 3 => "P.R. Zeilman" 4 => "K.D. Foote" 5 => "I.A. Malaty" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.7916/D8XP72WF" "Revista" => array:3 [ "tituloSerie" => "Tremor Other Hyperkinet Mov (NY)." "fecha" => "2014" "volumen" => "4" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of persistent hemiballism with deep brain stimulation of the globus pallidus internus: case report and literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S.V. Ganapa" 1 => "M.D. Ramani" 2 => "O.O. Ebunlomo" 3 => "R.K. Rahman" 4 => "Y. Herschman" 5 => "A. Mammis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.wneu.2019.08.247" "Revista" => array:6 [ "tituloSerie" => "World Neurosurg." "fecha" => "2019" "volumen" => "132" "paginaInicial" => "368" "paginaFinal" => "370" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31541757" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Globus pallidus internus deep brain stimulation for disabling diabetic hemiballism/hemichorea" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B.C. Son" 1 => "J.G. Choi" 2 => "H.C. Ko" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1155/2017/2165905" "Revista" => array:3 [ "tituloSerie" => "Case Rep Neurol Med." "fecha" => "2017" "volumen" => "2017" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Deep brain stimulation for treatment of hemichorea-hemiballism after craniopharyngioma resection: long term follow-up" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H.H. Capelle" 1 => "T.M. Kinfe" 2 => "J.K. Krauss" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3171/2011.6.JNS101388" "Revista" => array:6 [ "tituloSerie" => "J Neurosurg." "fecha" => "2011" "volumen" => "115" "paginaInicial" => "966" "paginaFinal" => "970" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21819190" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Two diabetics with hemichorea hemiballism and striatal lesions" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K. Takamatsu" 1 => "S. Ohta" 2 => "S. Sato" 3 => "A. Sano" 4 => "K. Takahashi" 5 => "Y. Murakami" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "No To Shinkei." "fecha" => "1995" "volumen" => "47" "paginaInicial" => "167" "paginaFinal" => "172" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pallidal neuronal activity in diabetic hemichorea-hemiballism" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T. Goto" 1 => "T. Hashimoto" 2 => "S. Hirayama" 3 => "K. Kitazawa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/mds.23058" "Revista" => array:6 [ "tituloSerie" => "Mov Disord." "fecha" => "2010" "volumen" => "25" "paginaInicial" => "1295" "paginaFinal" => "1297" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20629129" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful long-term deep brain stimulation for hemichorea-hemiballism in a patient with diabetes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "N. Nakano" 1 => "T. Uchiyama" 2 => "T. Okuda" 3 => "M. Kitano" 4 => "M. Taneda" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3171/jns.2005.102.6.1137" "Revista" => array:4 [ "tituloSerie" => "J Neurosurg." "fecha" => "2005" "paginaInicial" => "1137" "paginaFinal" => "1141" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Functional stereotactic surgery for hemiballism" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.K. Krauss" 1 => "F. Mundinger" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3171/jns.1996.85.2.0278" "Revista" => array:6 [ "tituloSerie" => "J Neurosurg." "fecha" => "1996" "volumen" => "85" "paginaInicial" => "278" "paginaFinal" => "286" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8755757" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outcome after streotactic thalamotomy for dystonia and hemiballismus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "F. Cardoso" 1 => "J. Jankovic" 2 => "R.G. Grossman" 3 => "W.J. Hamilton" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1227/00006123-199503000-00009" "Revista" => array:6 [ "tituloSerie" => "Neurosurgery." "fecha" => "1995" "volumen" => "36" "paginaInicial" => "501" "paginaFinal" => "508" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7753350" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Stereotactic Vim-Vo-thalamotomy for choreatic movement disorder" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Y. Kawashima" 1 => "A. Takahashi" 2 => "M. Hirato" 3 => "C. Ohye" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/978-3-7091-9160-6_29" "Revista" => array:6 [ "tituloSerie" => "Acta Neurochir Suppl (Wien)." "fecha" => "1991" "volumen" => "52" "paginaInicial" => "103" "paginaFinal" => "106" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1792948" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neuronal activity in the basal ganglia in patients with generalized dystonia and hemiballismus" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.L. Vitek" 1 => "V. Chockkan" 2 => "J.Y. Zhang" 3 => "Y. Kaneoke" 4 => "M. Evatt" 5 => "M.R. DeLong" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/1531-8249(199907)46:1<22::aid-ana6>3.0.co;2-z" "Revista" => array:6 [ "tituloSerie" => "Ann Neurol." "fecha" => "1999" "volumen" => "46" "paginaInicial" => "22" "paginaFinal" => "35" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10401777" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Response of postapoplectic hemichorea/ballism to GPi pallidotomy: progressive improvement resulting in complete relief" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Yamada" 1 => "M. Harada" 2 => "S. Goto" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/mds.20143" "Revista" => array:6 [ "tituloSerie" => "Mov Disord." "fecha" => "2004" "volumen" => "19" "paginaInicial" => "1111" "paginaFinal" => "1114" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15372609" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful combination of pallidal and thalamic stimulation for intractable involuntary movements in patients with neuroacanthosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "N. Nakano" 1 => "M. Miyauchi" 2 => "K. Nakanishi" 3 => "K. Saigoh" 4 => "Y. Mitsui" 5 => "A. Kato" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.wneu.2015.06.052" "Revista" => array:5 [ "tituloSerie" => "World Neurosurg." "fecha" => "2015" "volumen" => "84" "paginaInicial" => "1177.e1" "paginaFinal" => "1177.e7" ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The treatment of persistent vascular hemidystonia-hemiballismus with unilateral GPi deep brain stimulation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "H. Hasegawa" 1 => "N. Mundil" 2 => "M. Samuel" 3 => "J. Jarosz" 4 => "K. Ashkan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/mds.22598" "Revista" => array:6 [ "tituloSerie" => "Mov Disord." "fecha" => "2009" "volumen" => "24" "paginaInicial" => "1697" "paginaFinal" => "1698" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19452565" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful management of hemorrhage-associated hemiballism after subthalamic nucleus deep brain stimulation with pallidal stimulation: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Pabaney" 1 => "R. Ali" 2 => "P.A. Lewitt" 3 => "C. Sidiropoulos" 4 => "J.M. Schwalb" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.wneu.2015.06.070" "Revista" => array:5 [ "tituloSerie" => "World Neurosurg." "fecha" => "2015" "volumen" => "84" "paginaInicial" => "1176.e1" "paginaFinal" => "1176.e3" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/11301473/0000003500000005/v1_202409030459/S1130147324000186/v1_202409030459/en/main.assets" "Apartado" => array:4 [ "identificador" => "392" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Casos Clínicos" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/11301473/0000003500000005/v1_202409030459/S1130147324000186/v1_202409030459/en/main.pdf?idApp=UINPBA00004B&text.app=https://revistaneurocirugia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130147324000186?idApp=UINPBA00004B" ]