RESUMEN
OBJECTIVE: Surgical treatment of trigeminal neuralgia (TN) associated with vertebrobasilar dolichoectasia is challenging. We analyze the treatments for this disease, discussing the advantages and drawbacks, and present our own technique and series. METHODS: This retrospective study covered the period January 2006 through January 2016. Vertebrobasilar dolichoectasia deviation from midline, basilar artery (BA) and vertebral artery diameter, and BA apex distance above the posterior clinoid process were measured on preoperative and postoperative magnetic resonance imaging. The BA was repositioned and kept in place with coagulation of the clival dura, Teflon pledgets, and fibrin glue. We also performed a thorough literature review using PubMed. RESULTS: Our cases included 5 men and 3 women with mean age 64.88 years ± 10.32 (range, 48-81 years); 7 cases were TN, and 1 case was painful tic convulsif. Pain was on the left side in 6 cases and on the right in 2 cases. All cases affected cranial nerve V2 and/or V3 divisions. Both V2 and V3 were affected in 4 cases, V3 was affected in 3 cases, and V2 was affected in 1 case. Hypertension was present in 5 cases. TN disappeared postoperatively in all cases. One patient took clonazepam 2 mg/24 hours for 3 months because of facial dysesthesia. Postoperative complications included hearing loss in 1 patient; facial paresis plus diplopia in 1 patient, which resolved in 3 months; and arterial hypertension. Postoperative arterial hypertension improved in all affected patients, although only 2 patients discontinued antihypertensive medications. Mean follow-up time was 56.50 months ± 40.08 (range, 14 months to 9 years 9 months). No patient showed pain recurrence. CONCLUSIONS: TN associated with vertebrobasilar dolichoectasia can be treated surgically with minimal morbidity. BA repositioning has the highest success rate. Our technique of inducing a dural scar to fix the BA in its new position away from the trigeminal nerve is simple, not technically demanding, and highly effective.
Asunto(s)
Cirugía para Descompresión Microvascular/métodos , Neuralgia del Trigémino/complicaciones , Neuralgia del Trigémino/cirugía , Insuficiencia Vertebrobasilar/complicaciones , Insuficiencia Vertebrobasilar/cirugía , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Neuralgia del Trigémino/diagnóstico por imagen , Insuficiencia Vertebrobasilar/diagnóstico por imagenRESUMEN
Extrahepatic portal vein obstruction, although rare in children, is a significant cause of portal hypertension (PHT) leading to life-threatening gastrointestinal bleeding in the pediatric age group. PHT may also lead to other complications such as hyperesplenism, cholangyopathy, ascites, and even hepatopulmonary syndrome and portopulmonary hypertension that may require organ transplantation. Herein we report the case of an asymptomatic 11-month-old infant wherein a hepatomegaly and cavernous transformation of the portal vein was detected by liver ultrasound. Neither signs of thrombosis in arteriovenous system, nor affectation of biliary tract were identified in the magnetic resonance imaging study. A significant enlargement of the caudate lobe of the liver was reported. No risk factors were detected. The differential diagnosis performed was extensive. Inherited thrombophilia and storage disorders were especially considered. Liver biopsy was normal. Upper gastrointestinal esophagogastroduodenoscopy detected two small varicose cords on the distal third of the esophagus. Finding a cavernous transformation of the portal vein with evidence of collateral circulation in such an early age is a challenging condition for professionals, since PHT may lead to severe complications during childhood and can compromise growth and development. Evidence-based guidelines for the management of PHT in adults have been published. However, follow-up and treatment of pediatric patients have not yet been standardized. Moreover, management of PHT in infants faces particular difficulties such as technical restrictions that could hinder their treatment.