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Introduction: Gliomas are the second most frequent primary brain tumors. Surgical resection remains a crucial part of treatment, as well as maximum preservation of neurological function. For this reason awake surgery has an important role.The objectives of this article are to present our experience with awake surgery for gliomas in a South American center and to analyze how intraoperative functional findings may influence the extent of resection and neurological outcomes. Materials and methods: Retrospective single center study of a cohort of adult patients undergoing awake surgery for brain glioma, by the same neurosurgeon, between 2012 and 2022 in the city of Buenos Aires, Argentina. Results: A total of 71 patients were included (mean age 34 years, 62% males). Seventy seven percent of tumors were low grade, with average extent of resection reaching 94% of preoperative volumetric assessment. At six months follow up, 81.7% of patients presented no motor or language deficit.Further analysis showed that having a positive mapping did not have a negative impact in the extent of resection, but was associated with short term postoperative motor and language deficits, among other variables, with later improvement. Conclusion: Awake surgery for gliomas is a safe procedure, with the proper training. In this study it was observed that guiding the resection by negative mapping did not worsen the results and that positive subcortical mapping correlated with short term postoperative neurological deficits with posterior improvement within six months in most cases.
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OBJECTIVE: Analyze the usefulness, efficacy, and safety of transoperative magnetic resonance imaging (tMRI) in glioma surgery in awake patients. METHODS: Retrospective, single-center, analytical study of a cohort of patients who underwent awake surgery for gliomas by the same surgeon in a third-level Argentine center, in the period between 2012 and 2022. Only patients with pathology-confirmed gliomas, with 6-month follow-up, who had preoperative and postoperative volumetric magnetic resonance imaging, were included in this sample. Subsequently, we analyzed which patients received surgery with the tMRI protocol and the results using multivariate regression analysis. RESULTS: A total of 71 patients were included. A tMRI study was performed on 22 (31%) of these patients. The use of tMRI increased the percentage of resection by 20% (P = 0.03), thereby increasing the possibility of gross total resection. However, using tMRI significantly extended surgical time by 84 minutes (P < 0.001). In 55% of the patients in whom tMRI was performed, the resection was continued after it. The use of tMRI did not increase the rate of infections or the development of surgically associated neurological deficits in the long term, despite the fact that 47% of the patients showed the development of a new deficit or worsening of a previous one during the intraoperative period. CONCLUSIONS: The use of tMRI in awake glioma surgery proved to be a safe tool that contributes to increasing the degree of tumor resection, compared to the use of neurophysiological mapping and neuronavigation, at the expense of increased surgical times and costs. We consider tMRI in awake glioma surgery should be used in properly selected cases.
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Neoplasias Encefálicas , Glioma , Imagen por Resonancia Magnética , Vigilia , Humanos , Glioma/cirugía , Glioma/diagnóstico por imagen , Neoplasias Encefálicas/cirugía , Neoplasias Encefálicas/diagnóstico por imagen , Masculino , Femenino , Persona de Mediana Edad , Imagen por Resonancia Magnética/métodos , Estudios Retrospectivos , Adulto , Centros de Atención Terciaria , Anciano , Procedimientos Neuroquirúrgicos/métodos , Adulto Joven , Resultado del Tratamiento , ArgentinaRESUMEN
Introducción: La hidrocefalia es una complicación frecuente dentro de la patología tumoral del SNC. La colocación de válvulas de derivación ventrículo-peritoneal (VDVP) en estos casos es, al día de la fecha, la práctica estándar para tratar esta patología y prevenir las complicaciones y comorbilidades que esta conlleva. Al momento, no existe un protocolo ni una presión valvular inicial establecida para estos pacientes, en los cuales hemos observado una tendencia al sobredrenado de líquido cefalorraquídeo (LCR). El objetivo de este trabajo es analizar nuestra experiencia en el tratamiento de hidrocefalias obstructivas secundarias a patología tumoral, determinar factores relacionados al advenimiento de sobredrenado, el manejo terapéutico del mismo y subsiguientemente protocolizar de manera sencilla y económica la colocación de este tipo de prótesis así como identificar una presión terapéutica que reduzca el riesgo de sobredrenado. Materiales y métodos: Estudio monocéntrico, analítico, retrospectivo de una cohorte de pacientes operados en nuestra institución por hidrocefalia obstructiva secundaria a patología tumoral entre los años 2013-2022.Se analizaron historias clínicas, imágenes y protocolos quirúrgicos. Se identificaron aquellos pacientes que desarrollaron sobredrenado. Subsiguientemente se analizaron mediante un modelo estadístico explicativo multivariado aquellas variables demográficas, clínicas y terapéuticas implicadas en el mismo.En una segunda etapa se propone un protocolo rápido, sencillo y económico a fin de determinar la presión óptima dentro de cada caso en particular. Resultados: Dentro de los 56 pacientes incluidos, 32 pacientes (57%) presentaron sobredrenado; 10 pacientes (18%) presentaron higromas en imágenes postoperatorias, y de estos, 3 pacientes (5.4%) requirieron intervenciones quirúrgicas. El 94% de los sobredrenados ocurrieron a presiones menores o igual a 160 mmH20. Así mismo, 8 de los 11 pacientes con VDVP de presión fija media (100-110 mmH20) no regulable presentaron sobredrenado.En un 27% de los pacientes debió aumentarse la presión valvular como consecuencia de hallazgos clínicos o radiológicos de sobredrenado. Conclusión: Las hidrocefalias secundarias a patología tumoral presentan un comportamiento distinto al de las normotensivas. La tasa de sobredrenado en estos pacientes es superior y por consiguiente debe ser tenida en cuenta como una posible complicación relevante. Dada la heterogeneidad de tumores, cada paciente presenta presiones de LCR distintas y por ende debe individualizarse el tratamiento. Proponemos el uso del protocolo de medición intraquirúrgica de presión a fin de colocar la VDVP a la presión óptima para cada paciente, y evitar de esta manera el sobredrenado de LCR
Background: Hydrocephalus is a common complication in CNS tumors pathology. The placement of ventriculoperitoneal shunt in these cases is, to date, the standard practice to treat this pathology and prevent the complications and comorbidities that it entails. At present, there is no protocol or initial valve pressure established for these patients, in whom we have observed a tendency toward overdrainage of cerebrospinal fluid (CSF).The objective of this work is to analyze our experience in the treatment of obstructive hydrocephalus secondary to tumor pathology, determine factors related to the occurrence of overdrainage, its therapeutic management and subsequently protocolize in a simple and economical way the placement of this type of prosthesis as well as identify a therapeutic pressure that reduces the risk of overdrainage. Methods: Monocentric, analytical, retrospective study of a cohort of patients operated on at our institution for obstructive hydrocephalus secondary to tumors, between the years 2013-2022.Medical records, images and surgical protocols were analyzed. Those patients who developed overdrainage were identified. Subsequently, the demographic, clinical and therapeutic variables involved in it were analyzed using a multivariate explanatory statistical model.In a second stage, a quick, simple, and economical protocol is proposed to determine the optimal pressure within each case. Results: Among the 56 patients included, 32 patients (57%) presented overdrainage; 10 patients (18%) presented hygromas on postoperative images, and of these, 3 patients (5.4%) required surgical interventions. 94% of overdrains occurred at pressures less than or equal to 160 mmH20. Likewise, 8 of the 11 patients with non-adjustable medium fixed pressure shunt (100-110 mmH20) presented overdrainage.In 27% of patients, valve pressure had to be increased because of clinical or radiological findings of overdrainage. Conclusion: Hydrocephalus secondary to tumors presents a different behavior than normotensive ones. The rate of overdrainage in these patients is higher and therefore must be considered as a possible relevant complication. Given the heterogeneity of tumors, each patient has different CSF pressures and therefore treatment must be individualized. We propose the use of the intrasurgical pressure measurement protocol to place the shunt at the optimal pressure for each patient, and thus avoid CSF overdrainage
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INTRODUCTION: Trigeminal neuralgia is a highly invalidating pathology, whose natural course has been modified thanks to decompressive microvascular surgery. The intervention can be carried out either with a microscope or via an endoscopic technique. Our goal was to compare these two techniques for the treatment of this complex pathology. METHODS: Retrospective, analytical study of a cohort of patients treated by a single surgeon at our institution, in the period between 2015 and 2021. RESULTS: We identified 31 patients and divided them into two groups: 15 (49%) treated using the microscopic technique (group M), and 16 (51%) exclusively via an endoscopic one (group E). Differences were observed between the means of the size of the craniectomy in group M (3.7 cm) compared to group E (2.5 cm); The mean length of hospital stay for patients in group E was shorter (4.46 days compared to that of patients in group M, whose hospital stay averaged 2.43 days). There were no differences between the two groups regarding the length of the procedure. In both groups, the predominant compression was due to the superior cerebellar artery (SCA). Pain outcomes were equivalent, with every patient in both groups having an improved postoperative Barrow Neurological Institute Pain Intensity Score (BNI). DISCUSSION: Endoscopic microvascular decompression is an attractive option for the resolution of neurovascular conflict as it provides functional results similar to the microscope technique, without requiring an extensive craniectomy and associated to shorter in-hospital stay, which is beneficial for both the patient and the institution.
Introducción: La descompresión microvascular (DMV) en la neuralgia trigeminal es una técnica quirúrgica cuyo objetivo es revertir la compresión a la que se ve sometido un nervio por una estructura vascular. El objetivo de este estudio fue realizar una comparación directa entre la descompresión microvascular endoscópica (DMV-E) y la misma a través del uso del microscopio (DMV-M) en el tratamiento de la neuralgia del trigémino. Métodos: Se realizó un estudio de cohorte retrospectivo de pacientes operados de neuralgia de trigémino, por un mismo cirujano, entre 2015 y 2021 en nuestra institución, tanto por técnica microquirúrgica como endoscópica. Resultados: Se obtuvieron un total de 31 pacientes divididos en dos grupos: Grupo M correspondiente a 15 (49%) pacientes abordados con técnica microscópica y Grupo E, con 16 (51%) pacientes intervenidos con técnica endoscópica. Se identificaron diferencias en el tamaño de la craniectomía, más pequeña en el grupo E (2.50 cm vs 3.70 cm grupo M); y en el tiempo de internación, de 2.43 días en el grupo E vs. 4.46 días en el grupo M. El tiempo de cirugía fue similar para ambas técnicas quirúrgicas La principal compresión fue dada por la arteria cerebelosa superior (ACS) en ambos grupos. Todos los pacientes presentaron mejoría del Barrow Neurological Institute Pain Intensity Score (BNI) en el postoperatorio en ambos grupos. Discusión: La DMV-E constituye una alternativa quirúrgica interesante a la ya conocida DMV-M para el tratamiento de la neuralgia trigeminal, por requerir menores dimensiones en la incisión cutánea y tamaño de la craniectomía, acortando el tiempo de internación, lo cual no solo implica un beneficio para el paciente, sino que también representa menor costo de internación.
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Cirugía para Descompresión Microvascular , Neuralgia del Trigémino , Humanos , Neuralgia del Trigémino/cirugía , Neuralgia del Trigémino/etiología , Estudios Retrospectivos , Endoscopía , Cirugía para Descompresión Microvascular/efectos adversos , Cirugía para Descompresión Microvascular/métodos , Resultado del TratamientoRESUMEN
Resumen Introducción: La descompresión microvascular (DMV) en la neuralgia trigeminal es una técnica quirúrgica cuyo objetivo es revertir la compresión a la que se ve someti do un nervio por una estructura vascular. El objetivo de este estudio fue realizar una comparación directa entre la descompresión microvascular endoscópica (DMV-E) y la misma a través del uso del microscopio (DMV-M) en el tratamiento de la neuralgia del trigémino. Métodos: Se realizó un estudio de cohorte retrospec tivo de pacientes operados de neuralgia de trigémino, por un mismo cirujano, entre 2015 y 2021 en nuestra institución, tanto por técnica microquirúrgica como endoscópica. Resultados: Se obtuvieron un total de 31 pacientes divididos en dos grupos: Grupo M correspondiente a 15 (49%) pacientes abordados con técnica microscópica y Grupo E, con 16 (51%) pacientes intervenidos con técnica endoscópica. Se identificaron diferencias en el tamaño de la cra niectomía, más pequeña en el grupo E (2.50 cm vs 3.70 cm grupo M); y en el tiempo de internación, de 2.43 días en el grupo E vs. 4.46 días en el grupo M. El tiempo de cirugía fue similar para ambas técnicas quirúrgicas La principal compresión fue dada por la arteria ce rebelosa superior (ACS) en ambos grupos. Todos los pacientes presentaron mejoría del Barrow Neurological Institute Pain Intensity Score (BNI) en el postoperatorio en ambos grupos. Discusión: La DMV-E constituye una alternativa qui rúrgica interesante a la ya conocida DMV-M para el tratamiento de la neuralgia trigeminal, por requerir menores dimensiones en la incisión cutánea y tamaño de la craniectomía, acortando el tiempo de internación, lo cual no solo implica un beneficio para el paciente, sino que también representa menor costo de internación.
Abstract Introduction: Trigeminal neuralgia is a highly invali dating pathology, whose natural course has been modi fied thanks to decompressive microvascular surgery. The intervention can be carried out either with a microscope or via an endoscopic technique. Our goal was to compare these two techniques for the treatment of this complex pathology. Methods: Retrospective, analytical study of a cohort of patients treated by a single surgeon at our institution, in the period between 2015 and 2021. Results: We identified 31 patients and divided them into two groups: 15 (49%) treated using the microscopic technique (group M), and 16 (51%) exclusively via an endoscopic one (group E). Differences were observed between the means of the size of the craniectomy in group M (3.7 cm) compared to group E (2.5 cm); The mean length of hospital stay for patients in group E was shorter (4.46 days compared to that of patients in group M, whose hospital stay averaged 2.43 days). There were no differences between the two groups regarding the length of the procedure. In both groups, the predomi nant compression was due to the superior cerebellar artery (SCA). Pain outcomes were equivalent, with every patient in both groups having an improved postoperative Barrow Neurological Institute Pain Intensity Score (BNI). Discussion: Endoscopic microvascular decompression is an attractive option for the resolution of neurovas cular conflict as it provides functional results similar to the microscope technique, without requiring an exten sive craniectomy and associated to shorter in-hospital stay, which is beneficial for both the patient and the institution.
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Third nerve palsy is a rare complication of transsphenoidal surgery and has been merely mentioned in different studies, but there is not any rigorous analysis focusing on this particular complication. The purpose of this study is to analyze this complication after transsphenoidal surgery for a pituitary adenoma to better understand its pathophysiology and outcome. The authors retrospectively analyzed 3 cases of third nerve palsy selected from the 377 patients operated via a transsphenoidal route between 2012 and 2021 at FLENI, a private tertiary neurology and neurosurgical medical center located in Buenos Aires, Argentina. The three patients who presented this complication were operated on via an endoscopic approach. It was observed that an extension into the cavernous sinus (Knosp grade 4) and to the oculomotor cistern was present in the three patients. The deficit was apparent immediately after surgery in two patients. For these two patients, the supposed mechanism of ophthalmoplegia was an intraoperative nerve lesion. The other patient became symptomatic in the 48 h following the surgery. The mechanism implied in this case was intracavernous hemorrhagic suffusion. The latter patient completely recovered the third nerve deficit in the 3 months that followed, while the other two recovered after 6 months postoperative. Oculomotor nerve palsy after transsphenoidal surgery is a very rare complication and appears to be transient in most cases. The invasion of both the cavernous sinus and the oculomotor cistern seems to be a major factor in its physiopathology and should be preoperatively analyzed on magnetic resonance imaging (MRI); recognizing such extension should play an important role in the surgeon's operative considerations.
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Adenoma , Cirugía Endoscópica por Orificios Naturales , Enfermedades del Nervio Oculomotor , Neoplasias Hipofisarias , Humanos , Neoplasias Hipofisarias/cirugía , Neoplasias Hipofisarias/patología , Estudios Retrospectivos , Enfermedades del Nervio Oculomotor/etiología , Procedimientos Neuroquirúrgicos/métodos , Cirugía Endoscópica por Orificios Naturales/efectos adversos , Cirugía Endoscópica por Orificios Naturales/métodos , Adenoma/cirugía , Adenoma/patología , Resultado del TratamientoRESUMEN
Resumen Introducción: La fístula dural arteriovenosa espinal (FDAVE) es una enfermedad vascular frecuentemente subdiagnosticada. El tratamiento puede ser microqui rúrgico o endovascular. Métodos: Estudio retrospectivo de una serie de pa cientes con FDAVE tratados por microcirugía entre los años 2010 y 2021. Fueron evaluados parámetros como edad, sexo, cuadro clínico pre y postoperatorio medido con las escalas de Aminoff-Logue y Rankin modificada (mRs). Los estudios diagnósticos se utilizaron para de terminar nivel lesional y resultados quirúrgicos. Resultados: Se incluyeron doce pacientes (10 hombres y 2 mujeres) con un promedio de edad de 60 años. El tiempo de evolución del cuadro clínico al diagnóstico fue menor a 12 meses salvo un caso de 32 meses. Las FDAVE fueron localizadas, 8 a nivel dorsal, 3 a nivel lumbar y una a nivel sacro. La arteria de Adamkiewicz se identificó en 5 casos en L1, 2 en D12, 2 en D10, 2 en D9 y un caso en D7. De los 12 pacientes operados, 3 fueron embolizados previamente; dos permanecieron estables en su evolución y 10 mejoraron uno o más puntos del mRs. No hubo complicaciones en el postoperatorio. Todos mostraron mejoría del edema medular en reso nancia magnética y la angiografía digital, luego de los 6 meses, fue negativa. El seguimiento promedio fue de 40 meses con un rango de 6 a 122 meses y ningún paciente presentó recidiva de la FDAVE. Conclusión: El tratamiento quirúrgico de las FDAVE es un método muy eficaz, de baja morbilidad y menor tasa de recurrencia comparado con el tratamiento en dovascular.
Abstract Introduction: Spinal dural arteriovenous fistula (SDA VF) is a rare vascular disease, of unknown etiology, fre quently underdiagnosed. Treatment can be microsurgical or endovascular. Methods: Retrospective and monocentric analysis of 12 SDAVF patients treated by microsurgery between 2010 and 2021. Parameters including age, sex, pre and postoperative clinical condition were analyzed according to modified Aminoff-Logue and Rankin scales. Diagnos tic studies such as magnetic resonance imaging (MRI), magnetic resonance angiogram (MRA) and spinal digital subtraction angiography (DSA), were evaluated for lesion level, as were surgical results. Results: Twelve patients (10 men and 2 women), average age: 60 years, were operated. The interval from symptom onset to diagnosis was <12 months in all cases except one (32 months). SDAVF locations were thoracic in 8 cases, between T6 and T12, 3 at lumbar spine (L1- L2) and at S1 in one case, with no difference regarding side. The Adamkiewicz artery was identified in 5 cases at L1, 2 at D12, 2 at D10, 2 at D9 and 1 at D7 (7 left-sided and 5 right-sided). Three of the 12 patients operated had undergone prior embolization. Postoperative neu rological outcomes showed: 2 patients remained stable and 10 improved one or more points on the mRs; no postoperative complications were observed. Follow-up MRI images improved in all cases and spinal DSA was negative at 6 months. Average follow-up was 40 months (range 6 to 122) and no patient presented recurrence. Conclusion: Microsurgical treatment of SDAVF proved to be efficient, with low morbidity and lower recurrence rates compared to endovascular results.
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INTRODUCTION: Spinal dural arteriovenous fistula (SDAVF) is a rare vascular disease, of unknown etiology, frequently underdiagnosed. Treatment can be microsurgical or endovascular. METHODS: Retrospective and monocentric analysis of 12 SDAVF patients treated by microsurgery between 2010 and 2021. Parameters including age, sex, pre and postoperative clinical condition were analyzed according to modified Aminoff-Logue and Rankin scales. Diagnostic studies such as magnetic resonance imaging (MRI), magnetic resonance angiogram (MRA) and spinal digital subtraction angiography (DSA), were evaluated for lesion level, as were surgical results. RESULTS: Twelve patients (10 men and 2 women), average age: 60 years, were operated. The interval from symptom onset to diagnosis was < 12 months in all cases except one (32 months). SDAVF locations were thoracic in 8 cases, between T6 and T12, 3 at lumbar spine (L1-L2) and at S1 in one case, with no difference regarding side. The Adamkiewicz artery was identified in 5 cases at L1, 2 at D12, 2 at D10, 2 at D9 and 1 at D7 (7 left-sided and 5 right-sided). Three of the 12 patients operated had undergone prior embolization. Postoperative neurological outcomes showed: 2 patients remained stable and 10 improved one or more points on the mRs; no postoperative complications were observed. Follow-up MRI images improved in all cases and spinal DSA was negative at 6 months. Average follow-up was 40 months (range 6 to 122) and no patient presented recurrence. CONCLUSION: Microsurgical treatment of SDAVF proved to be efficient, with low morbidity and lower recurrence rates compared to endovascular results.
Introducción: La fístula dural arteriovenosa espinal (FDAVE) es una enfermedad vascular frecuentemente subdiagnosticada. El tratamiento puede ser microquirúrgico o endovascular. Métodos: Estudio retrospectivo de una serie de pacientes con FDAVE tratados por microcirugía entre los años 2010 y 2021. Fueron evaluados parámetros como edad, sexo, cuadro clínico pre y postoperatorio medido con las escalas de Aminoff-Logue y Rankin modificada (mRs). Los estudios diagnósticos se utilizaron para determinar nivel lesional y resultados quirúrgicos. Resultados: Se incluyeron doce pacientes (10 hombres y 2 mujeres) con un promedio de edad de 60 años. El tiempo de evolución del cuadro clínico al diagnóstico fue menor a 12 meses salvo un caso de 32 meses. Las FDAVE fueron localizadas, 8 a nivel dorsal, 3 a nivel lumbar y una a nivel sacro. La arteria de Adamkiewicz se identificó en 5 casos en L1, 2 en D12, 2 en D10, 2 en D9 y un caso en D7. De los 12 pacientes operados, 3 fueron embolizados previamente; dos permanecieron estables en su evolución y 10 mejoraron uno o más puntos del mRs. No hubo complicaciones en el postoperatorio. Todos mostraron mejoría del edema medular en resonancia magnética y la angiografía digital, luego de los 6 meses, fue negativa. El seguimiento promedio fue de 40 meses con un rango de 6 a 122 meses y ningún paciente presentó recidiva de la FDAVE. Conclusión: El tratamiento quirúrgico de las FDAVE es un método muy eficaz, de baja morbilidad y menor tasa de recurrencia comparado con el tratamiento endovascular.
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Malformaciones Vasculares del Sistema Nervioso Central , Embolización Terapéutica , Masculino , Humanos , Femenino , Persona de Mediana Edad , Estudios Retrospectivos , Imagen por Resonancia Magnética , Malformaciones Vasculares del Sistema Nervioso Central/diagnóstico , Malformaciones Vasculares del Sistema Nervioso Central/terapia , Complicaciones Posoperatorias , Embolización Terapéutica/métodos , Médula Espinal/irrigación sanguínea , Médula Espinal/cirugía , Resultado del TratamientoRESUMEN
Objective: Analyze a series of pediatric patients with cPAs evaluating factors that may modify or determine the final outcome in terms of neurological status, CMS and hydrocephalus. Materials and methods: Single Center, retrospective cohort study of surgical patients with cPA and at least 12 months of follow-up. Clinical, imaging and surgical features, histopathology and adjuvancy were assessed. Clinical outcome was categorized using the FSS and modified Bloom-Scale in the short and long term. Recurrency, PFS and mortality were also analyzed. Results: A total of 100 patients with a mean follow-up of 53.9 months, with no gender predilection, and a mean age of 7.6 years were included. The most frequent location was central and 24% of the tumors presented brainstem invasion. 79 patients had hydrocephalus at diagnosis and 48% required preoperative treatment. RT was achieved in 67% of cases. CMS was observed in 15 patients, statistically associated with location, pontine invasion, preoperative Bloom-score, and postoperative meningitis/ventriculitis. The functional "outcome" was correlated with complications such as meningitis/ventriculitis and cerebellar hematoma, mutism and recurrence. Recurrence was observed in 26% of cases and surgical reintervention was the chosen therapy. Conclusion: The treatment of cPAs in pediatric patients is associated with relatively favorable results. Recurrence, CMS and surgical complications play a prognostic value in the outcome and therefore must be managed appropriately. Early treatment with the intention of GTR should be considered, opting, if this is not possible, to leave a tumor residue over neurological damage. The treatment of hydrocephalus in the preoperative instance requires individualized management.
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Resumen La infección por coronavirus (SARS-CoV-2/COVID-19) es responsable de un diverso rango de manifestaciones extrapulmonares entre las cuales se destaca el compromiso neurológico directo o indirecto. La apoplejía hipofisaria es una entidad médica y neuroquirúrgica de gravedad variable que suele asociarse a la presencia de un adenoma subyacente. Un escaso número de reportes han vinculado estas dos enfermedades entre sí. Este trabajo describe un caso de apoplejía hipofisaria manifestada clínicamente en for ma concomitante al diagnóstico de COVID 19, en un paciente con macroadenoma hipofisario desconocido y su manejo terapéutico, revisando los mecanismos potencialmente subyacentes al nexo entre ambas entidades.
Abstract Coronavirus disease (SARS-CoV-2/COVID-19) is responsible for a wide variety of extrapulmonary manifestations, among which direct or indirect neurological compromise stands out. Pituitary apoplexy is a clinical and neurosurgical entity of variable severity, usually associated with a pituitary adenoma. Literature is scarce regarding the association between these diseases. This paper reports a case of pituitary apoplexy, manifested concomitantly to the diagnosis of COVID 19 in a patient with unknown pituitary macroadenoma, and its therapeutic management, reviewing the mechanisms potentially underlying the link between both entities.
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Coronavirus disease (SARS-CoV-2/COVID-19) is responsible for a wide variety of extrapulmonary manifestations, among which direct or indirect neurological compromise stands out. Pituitary apoplexy is a clinical and neurosurgical entity of variable severity, usually associated with a pituitary adenoma. Literature is scarce regarding the association between these diseases. This paper reports a case of pituitary apoplexy, manifested concomitantly to the diagnosis of COVID 19 in a patient with unknown pituitary macroadenoma, and its therapeutic management, reviewing the mechanisms potentially underlying the link between both entities.
La infección por coronavirus (SARS-CoV-2/COVID-19) es responsable de un diverso rango de manifestaciones extrapulmonares entre las cuales se destaca el compromiso neurológico directo o indirecto. La apoplejía hipofisaria es una entidad médica y neuroquirúrgica de gravedad variable que suele asociarse a la presencia de un adenoma subyacente. Un escaso número de reportes han vinculado estas dos enfermedades entre sí. Este trabajo describe un caso de apoplejía hipofisaria manifestada clínicamente en forma concomitante al diagnóstico de COVID 19, en un paciente con macroadenoma hipofisario desconocido y su manejo terapéutico, revisando los mecanismos potencialmente subyacentes al nexo entre ambas entidades.
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Adenoma , COVID-19 , Apoplejia Hipofisaria , Neoplasias Hipofisarias , Humanos , SARS-CoV-2 , COVID-19/complicaciones , Apoplejia Hipofisaria/etiología , Apoplejia Hipofisaria/complicaciones , Neoplasias Hipofisarias/complicaciones , Neoplasias Hipofisarias/diagnóstico , Neoplasias Hipofisarias/cirugía , Adenoma/complicaciones , Adenoma/diagnóstico , Adenoma/cirugíaAsunto(s)
Lipomatosis , Neuralgia del Trigémino , Humanos , Lipomatosis/complicaciones , Lipomatosis/diagnóstico por imagen , Lipomatosis/cirugía , Imagen por Resonancia Magnética/métodos , Nervio Trigémino/cirugía , Neuralgia del Trigémino/diagnóstico por imagen , Neuralgia del Trigémino/etiología , Neuralgia del Trigémino/cirugíaRESUMEN
Calcifying pseudoneoplasm of the neuroaxis (CAPNON) is a rare, slow growing, and generally benign fibro osseous mass that can emerge throughout the entire central nervous system (CNS). When diagnosed, prompt surgical treatment can determine a good neurological outcome and possibly curative resolution. The objective of the present work is to present a step by step technical report with its video. We present a 37 year old female presented with occipital headache and cervical pain associated with dysphagia, nausea, and gait disturbances. Computed tomography (CT) scan showed a focal calcified lesion on the floor of the IV ventricle projecting toward the vermis with associated supratentorial hydrocephalus and transependymal edema. The telovelar approach was chosen for the procedure. The outcome was favorable, with no complications. Postoperative CT was performed, which revealed no residual lesion. A step by step report of a IV ventricle CAPNON that manifested with hydrocephalus is described.
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Calcinosis , Hidrocefalia , Adulto , Calcinosis/complicaciones , Calcinosis/diagnóstico por imagen , Calcinosis/cirugía , Sistema Nervioso Central/patología , Ventrículos Cerebrales/diagnóstico por imagen , Ventrículos Cerebrales/patología , Ventrículos Cerebrales/cirugía , Femenino , Humanos , Hidrocefalia/complicaciones , Hidrocefalia/cirugía , Tomografía Computarizada por Rayos XRESUMEN
Bow Hunter's syndrome is a rare cause of posterior circulation ischemia, produced by the mechanical and reversible occlusion of the vertebral artery during cephalic rotation. Diagnosis requires clinical suspicion and careful inspection of images with three-dimensional reconstruction. The study of choice is dynamic digital subtraction angiography (DSA). Treatment alternatives are: medical, surgical or endovascular. We report the case of an 8-year-old boy with recurrent infarctions of the posterior circulation secondary to the dissection of the vertebral artery, in association with an occipital bone spur. Dynamic DSA was negative. Conservative initial management was elected with cervical immobilization and anticoagulation, but due to persistence of symptoms, surgical decompression was decided. The patient did not repeat symptoms postoperatively and returned to his usual life. This is the first case reported to our knowledge of a surgical pediatric patient with asymptomatic atypical compression of VA secondary to BHS, whose dynamic angiography was negative, suggesting an alternative mechanism of the syndrome.
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Mucopolisacaridosis II , Insuficiencia Vertebrobasilar , Masculino , Humanos , Niño , Insuficiencia Vertebrobasilar/diagnóstico por imagen , Insuficiencia Vertebrobasilar/etiología , Insuficiencia Vertebrobasilar/cirugía , Mucopolisacaridosis II/complicaciones , Arteria Vertebral/diagnóstico por imagen , Arteria Vertebral/cirugía , Descompresión Quirúrgica/métodos , Angiografía de Substracción DigitalRESUMEN
Paciente masculino de 66 años que se presentó al servi-cio de guardia y urgencias por cuadro clínico caracteriza-do por mareos de 3 meses de evolución e inestabilidad de la marcha de 24 hs de evolución. Como único signo positi-vo al examen físico se constató dismetría de miembros su-periores. Se decidió estudiar con TC de cerebro en donde se identificó, en topografía pineal y tercer ventrículo, una voluminosa lesión ocupante de espacio, sólida, de aproxi-madamente 27 x 21 mm de densidad heterogénea, con pro-bable relación a restos hemáticos en distintos estadios evo-lutivos asociada a calcificaciones periféricas
Asunto(s)
Masculino , Ataxia Cerebelosa , Examen Físico , Urgencias Médicas , CerebroRESUMEN
Surgical management of vestibular schwannomas has improved over the last 30 years. Whereas in the past the primary goal was to preserve the patient's life, today neurological function safeguarding is the main objective, with numerous strategies involving single resection, staged resections, postoperative radiosurgery, or single radiosurgery. The retrosigmoid approach remains the primary pathway for surgical access to the cerebellopontine angle (CPA). The use of an endoscope has great advantages. It contributes to the visualization and resection of residual tumor and also reduces the need for cerebellar retraction. The authors present a fully endoscopic resection of a large-sized vestibular schwannoma with facial nerve preservation. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID21106.
RESUMEN
Introducción: la fístula dural arteriovenosa espinal (FDAVE) es una enfermedad vascular rara, de etiología desconocida y frecuentemente subdiagnosticada. El tratamiento puede ser microquirúrgico o endovascular. Material y Método: Análisis retrospectivo de una serie de 8 pacientes consecutivos con FDAVE tratados por microcirugía entre 2010 y 2020. Fueron evaluados parámetros como edad, sexo, cuadro clínico pre y postoperatorio medido con las escalas de Aminoff-Logue y Rankin modificada. Los estudios diagnósticos con RMN (Resonancia Magnética Nuclear), ARM (Angio Resonancia Magnética) y ADM (Angiografía Digital Medular) se utilizaron para determinar nivel lesional y resultados quirúrgicos. Resultados: Fueron operados 8 pacientes (7 masculinos y 1 femenino) con un promedio de edad de 58 años. El tiempo de evolución del cuadro clínico al diagnóstico fue menor a 12 meses salvo un caso de 32 meses. Las FDAVE fueron localizadas en: 6 a nivel dorsal entre D6 y D12, una en L2 y la última en S1 (5 derechas y 3 izquierdas). La arteria de Adamkiewicz se identificó en: 4 casos en L1, 2 en D12, 1 en D10 y un caso en D7 (6 izquierdas y 2 derechas). De los 8 pacientes operados, 3 fueron embolizados previamente. La evolución postoperatoria del cuadro neurológico fue: 2 de 8 permanecieron estables y 6 de 8 mejoraron uno o más puntos en la escala de Rankin modificada; no hubo complicaciones en el postoperatorio. Todos los pacientes mejoraron las imágenes en RMN diferida y la ADM luego de los 6 meses fue negativa. El seguimiento promedio fue de 48 meses con un rango de 11 a 116 meses, ningún paciente presentó recidiva de la FDAVE. Conclusiones: El tratamiento quirúrgico de las FDAVE es un método muy eficaz, de baja morbilidad y menor tasa de recurrencia comparado con el tratamiento endovascular.
Introduction: Spinal dural arteriovenous fistula (SDAVF) is a rare vascular disease, of unknown etiology and frequently underdiagnosed. Treatment can be microsurgical or endovascular. Material and Method: Retrospective analysis of a series of 8 SDAVF patients treated by microsurgery between 2010 and 2020. Parameters including age, sex, pre and postoperative clinical condition were analyzed according to modified Aminoff-Logue and modified Rankin scales. Diagnostic studies such as MRI (Magnetic Resonance Imaging), MRA (Magnetic Resonance Angiogram) and spinal DSA (Digital Subtraction Angiography), were evaluated for lesion level, as were surgical results. Results: Eight patients (7 male and 1 female), average age of 58 years were operated. The interval from symptom onset to diagnosis was less than 12 months in all cases except one (32 months). SDAVF locations were thoracic in 6 cases between T6 and T12, at L2 in one and at S1 in one case (5 on the right and 3 on the left). The Adamkiewicz artery was identified in: 4 cases at L1, 2 at D12, 1 at D10 and in one case at D7 (6 left-sided and 2 right-sided). Three of the 8 patients operated had undergone prior embolization. Postoperative neurological outcomes showed: 2 patients remained stable and 6 had improved one or more points on the modified Rankin scale; no postoperative complications were observed. Follow-up MRI images improved in all cases and spinal DSA was negative at six months. Average follow-up was 48 months (range 11 to 116 months), no patient presented recurrence. Conclusions: Microsurgical treatment of SDAVF proved to be efficient, with low morbidity and lower recurrence rates compared to endovascular results.