RESUMEN
Hemostasis in neurosurgery is of utmost importance. Bleeding management is one of the crucial steps of each neurosurgical procedure. Several strategies, namely thermal, mechanical, electric, and chemical, have been advocated to face blood loss within the surgical field. Over time, countless hemostatic agents and devices have been proposed. Furthermore, the ever-growing recent technological innovation has made available several novel and interesting tools. Pursuant to their impact on surgical practice, we perceived the imperative to update our previous disclosure paper. Therefore, we reviewed the literature and analyzed technical data sheets of each product in order to provide an updated and comprehensive overview in regard to chemical properties, mechanisms of action, use, complications, tricks, and pitfalls of topical hemostatic agents.
Asunto(s)
Hemostáticos , Neurocirugia , Pérdida de Sangre Quirúrgica/prevención & control , Hemorragia , Hemostáticos/uso terapéutico , Humanos , Procedimientos Neuroquirúrgicos/métodosRESUMEN
BACKGROUND: The choice of the ideal hemostatic agent for intraoperative cerebral bleeding is under continuous debate. Our aim was to assess the influence of such materials on bleeding time in hemorrhagic cerebral contusions. We compared oxidized regenerated cellulose in fibrillar form (ORC) to microfibrillar collagen fleece (CF) in an experimental study. METHODS: N=50 Sprague Dawley rats underwent a bilateral craniectomy. 3 separate standardized superficial cortical impacts were inflicted using a high-speed drill. Immediately after lesion placement, each of the 3 lesions was covered with (a) nothing (control), (b) ORC, or (c) CF. We observed the 3 lesions with a surgical microscope. The bleeding times were recorded for each cerebral lesion and compared using ANOVA test. RESULTS: All traumatic lesions produced significant bleeding. The statistical analysis showed a clear reduction in bleeding time for groups treated with either ORC or CF compared to the control group. Lesions covered with ORC and CF showed no significant difference with regard to bleeding time. CONCLUSIONS: ORC and CF significantly reduce blood loss from hemorrhagic contusions. Our data suggest that they effectively reduce bleeding time. We advocate the use of hemostatic material for limiting bleeding from superficial cortical lesions.
Asunto(s)
Hemorragia Encefálica Traumática/tratamiento farmacológico , Celulosa Oxidada/farmacología , Coagulantes/farmacología , Colágeno/farmacología , Técnicas Hemostáticas/tendencias , Animales , Tiempo de Sangría , Hemorragia Encefálica Traumática/patología , Hemorragia Encefálica Traumática/fisiopatología , Lesiones Encefálicas/complicaciones , Lesiones Encefálicas/fisiopatología , Celulosa Oxidada/química , Coagulantes/química , Colágeno/química , Modelos Animales de Enfermedad , Masculino , Ratas , Ratas Sprague-Dawley , Resultado del TratamientoRESUMEN
BACKGROUND: We report our surgical experience in the treatment of fifteen consecutive patients with benign craniovertebral junction tumors, observed from 1993 to 2000 at our department. METHOD: We treated 7 meningiomas, 3 epidermoids, 3 C1 neurinomas and 2 neurinomas of the lower cranial nerves. Clinical results were evaluated by Karnofsky Performance Scale and all patients underwent preoperative neuroradiological evaluation with CT, MRI and MRA; angiography was not routinely performed and was considered for each individual case. FINDINGS: 11 partial transcondilar and 4 retrocondilar approaches were performed. Total removal was achieved in 11 cases (73,3%) and subtotal removal in 4 patients (26,7%). None of the patients required occipitocervical fusion. Patients were followed for an average period of 24+/-31 months. Clinical and radiological follow-up showed no recurrence in cases with total removal. In all patients a statistically significant postoperative increase of KPS scores was recorded. The treatment of epidermoid tumors presented particular issues: debulking the lesion, we obtained a surgical window, avoiding a large removal of bone. In Nakasu grade 1 or 2 meningiomas, we carried out total removal by piecemeal resection and without complete condylectomy and bone fixation. INTERPRETATION: The choice of these approaches and the extent of bone resection should be defined according to the tumor's location and size. Moreover we emphasize that preoperative neuroradiological evaluations on presumptive tumor type could be helpful to the surgeon in order to tailor the technique to different lesions, providing the required exposure, without unnecessary surgical steps.
Asunto(s)
Vértebras Cervicales/diagnóstico por imagen , Vértebras Cervicales/cirugía , Neoplasias de los Nervios Craneales/diagnóstico por imagen , Neoplasias de los Nervios Craneales/cirugía , Quiste Epidérmico/diagnóstico por imagen , Quiste Epidérmico/cirugía , Neoplasias Meníngeas/diagnóstico por imagen , Neoplasias Meníngeas/cirugía , Meningioma/diagnóstico por imagen , Meningioma/cirugía , Neurilemoma/diagnóstico por imagen , Neurilemoma/cirugía , Neoplasias Craneales/diagnóstico por imagen , Neoplasias Craneales/cirugía , Neoplasias de la Columna Vertebral/diagnóstico por imagen , Neoplasias de la Columna Vertebral/cirugía , Adolescente , Adulto , Anciano , Vértebras Cervicales/patología , Neoplasias de los Nervios Craneales/patología , Quiste Epidérmico/patología , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Neoplasias Meníngeas/patología , Meningioma/patología , Persona de Mediana Edad , Neurilemoma/patología , Evaluación de Resultado en la Atención de Salud , Cuidados Preoperatorios , Estudios Retrospectivos , Neoplasias Craneales/patología , Neoplasias de la Columna Vertebral/patología , Tomografía Computarizada por Rayos XRESUMEN
OBJECT: The management of intracranial aneurysms has truly evolved after the introduction of endovascular treatment by Guglielmi Detachable Coils (GDC). In our department, for every case (ruptured or unruptured aneurysm) we discuss in the first place endovascular treatment. When coiling is feasible, it is done as a first choice. If not (intracranial compressive haematoma, coiling unfeasible or dangerous), the patient is operated upon. Failure of the endovascular technique, like incomplete treatment and regrowth of the residual sac, becomes a subject of discussion. Some cases need complementary treatment for large or unstable residual aneurysm. METHODS: Thus, between 1997 and 2000, 59 ruptured aneurysms were treated using an endovascular method by means of GDC. In 15 of this cases complementary treatment was needed, due to the size or instability of the residual aneurysm. In 8 cases a new embolization was possible and in 7 cases a complementary surgical procedure was needed, due to the impossibility of further endovascular treatment. RESULTS: Out of these 7 cases who were operated upon after coiling, clipping of the residual neck was possible in 4 cases; in 3 cases clipping was impossible due to the partial filling of the aneurysm neck by the coils. In these 3 cases, a ligation of the residual neck, associated with coagulation of the sac was performed. DISCUSSION: The difficulty of the treatment of an residual aneurysm after coiling is discussed as well as those surgical techniques alternative to clipping (wrapping or coagulation of the residual sac).
Asunto(s)
Aneurisma Roto/terapia , Embolización Terapéutica/métodos , Aneurisma Intracraneal/terapia , Adulto , Anciano , Aneurisma Roto/patología , Femenino , Humanos , Aneurisma Intracraneal/patología , Ligadura , Masculino , Persona de Mediana Edad , Recurrencia , Reoperación , Instrumentos QuirúrgicosRESUMEN
INTRODUCTION: Resection of cerebral tumors or vascular lesions requires a precise localization to minimize the skin, bone and cerebral approach. The image-guided surgery is currently considered to be of undisputed value in microneurosurgical technique. METHODS: Between 1998 and 2000, 13 patients were operated in our service for resection of a cavernous malformation deeply located using the MRI assisted image guidance (Sofamor-Danek Neuronavigation Cranial 3 System). RESULTS: The computer-calculated registration accuracy ranged between 0.8 and 2.0 mm (median 1.1 mm). The exact location of the cavernous malformation was possible in all the cases. Total resection of the lesion was always achieved. Operative mortality and transient morbidity were 0 % and 16 %, respectively. DISCUSSION: The image-guided technique offers a better help than the previously used methods (preoperative localization with CT scan or stereotactic implantation of guiding catheters) to resect intracranial lesions, especially if the lesion is deeply situated in the brain or in an eloquent area. Preoperative MRI-based 3D models, performed using special skin markers, and surgical computer-assisted neuronavigation allow us to find and to resect small and deep lesions with minimal mortality and low morbidity rate.
Asunto(s)
Hemangioma Cavernoso/cirugía , Microcirugia/métodos , Procedimientos Neuroquirúrgicos/métodos , Neoplasias Supratentoriales/cirugía , Cirugía Asistida por Computador/métodos , Adolescente , Adulto , Anciano , Mapeo Encefálico/métodos , Niño , Craneotomía/métodos , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
We report a case of a 31 year-old woman who in 1991 presented a clinical history of headaches, nausea and vomiting. CT scan showed a right frontotemporal meningioma. The first operation achieved a macroscopically complete resection. The tumour was histologically classified as a transitional meningioma. There were recurrences of the intracranial meningioma in 1994, 1996, 1997 and 1998. These recurrences were accompanied by differentiation to atypical and anaplastic meningioma. In all of these operations, a macroscopically complete resection of the tumour was performed. In 1996 adjuvant radiation therapy was given. In 1998 therapy with bromocriptine was adopted. In April 1999, the patient presented with lumbosacral pain associated with L5 bilateral sciatica. MRI showed a gadolinium enhancing mass lesion at L5-S1 level. Complete tumour resection was performed. The histological findings were the same as in 1998. In December 1999 the patient presented with perineal pain and MRI showed a L4 and S3 recurrence and the tumour was resected. The histological findings were those of a malignant meningioma. In February 2000 an intracranial recurrence was detected and operated on. The histological diagnosis was malignant meningioma. A review of the literature was undertake and is discussed.
Asunto(s)
Neoplasias Encefálicas/patología , Región Lumbosacra/patología , Meningioma/secundario , Recurrencia Local de Neoplasia/patología , Neoplasias de la Columna Vertebral/secundario , Adulto , Neoplasias Encefálicas/cirugía , Femenino , Humanos , Región Lumbosacra/cirugía , Meningioma/cirugía , Recurrencia Local de Neoplasia/cirugía , Neoplasias de la Columna Vertebral/cirugía , Columna Vertebral/patología , Columna Vertebral/cirugía , Telencéfalo/patología , Telencéfalo/cirugíaRESUMEN
Dural ectasia denotes circumferential expansion or dilatation of the dural sac, and has been frequently reported in association with type 1 neurofibromatosis (NF1). The pathogenesis has not been defined, but its correlation with NF1 infers a congenital malformative hypothesis. The neural elements in the dilated sleeve typically are not enlarged or abnormal, nevertheless the enlarged area contain an increased amount of cerebrospinal fluid. The dura in the area of ectasia is extremely thin and fragile, and erodes the surrounding bony structures destabilising the spine and permitting spectacular spinal deformities. We present two cases with lumbosacral dural ectasia, enlargement of the intervertebral foramina and posterior scalloping of vertebral bodies. Neurological examination showed sciatic nerve irritation. As the etiology of this malformation remains uncertain and dysplastic changes of the spine may be intrinsic or secondary controversies remain about optimum treatment. We conclude that patients affected by NF-1 require an accurate neuroradiological study of the whole spine in order to detect possible dural and spinal anomalies. Surgical treatment is indicated only in patients with progressive neurological deterioration. The thin dural sac predisposes to a high morbidity if surgery is undertaken.
Asunto(s)
Duramadre/fisiopatología , Neurofibromatosis 1/fisiopatología , Adulto , Dilatación Patológica , Duramadre/patología , Humanos , Región Lumbosacra , Imagen por Resonancia Magnética , Masculino , Neurofibromatosis 1/diagnóstico , Tomografía , Tomografía Computarizada por Rayos XRESUMEN
Endoscopic third ventriculostomy has become a routine intervention for the treatment of non-communicating hydrocephalus. This technique is largely considered safe and a very low incidence of complications is reported. However, hemorrhage in the course of neuroendoscopy is still a problem difficult to manage. The authors present a case in which endoscopic third ventriculostomy and tumor biopsy were performed in a young patient with a huge tumor growing in the posterior part of the third ventricle. The surgical approach to realize the stoma was difficult because the tumor size reduced the third ventricle diameter. Surgical manipulation produced a traumatic subependymal hematoma. This hematoma drained spontaneously after few minutes into the ventricle and the blood was washed away. The postoperative neurological course was uneventful and the ventriculostomy showed to work well by reducing the size of the lateral ventricles and the intracranial pressure in three days. This complication during endoscopic third ventriculostomy has never been reported before. We emphasize the difficulty of endoscopic procedures in patients with huge tumors in the third ventricle. Where reduction in size of the third ventricle and of the foramen of Monro ist present we suggest a careful approach to the third ventricle.
Asunto(s)
Hemorragia Cerebral/etiología , Neoplasias del Ventrículo Cerebral/cirugía , Endoscopía/efectos adversos , Glioma Subependimario/cirugía , Hematoma/etiología , Tercer Ventrículo/cirugía , Ventriculostomía/efectos adversos , Adolescente , Humanos , MasculinoAsunto(s)
Encefalopatías/complicaciones , Enfermedades de las Arterias Carótidas/complicaciones , Quiste Epidérmico/complicaciones , Aneurisma Intracraneal/complicaciones , Lóbulo Temporal , Adulto , Encefalopatías/cirugía , Enfermedades de las Arterias Carótidas/cirugía , Quiste Epidérmico/cirugía , Femenino , Humanos , Aneurisma Intracraneal/cirugíaRESUMEN
BACKGROUND: To analyze factors influencing surgical results after microsurgical reconstruction of injured nerves. METHODS: We report a series of 32 cases of microsurgical nerve reconstruction after traumatizing lesions using nervous autografts. The series comprises 8 reconstructions of radial nerve, 8 of median nerve, 6 of ulnar, and 10 of sciatic nerve. Motor and sensitive deficits have been evaluated preoperatively using a standard grading. RESULTS: A useful sensory recovery has been obtained in radial nerve, as well as in median and ulnar nerve reconstruction. Good results regarding the motor recovery have been obtained in superior limb nerve reconstruction. Sciatic nerve reconstruction showed the worse results. CONCLUSIONS: There is a big discrepance between superior limb vs inferior limb results. A more than 10 cm gap has a negative influence on the progression of regenerating axons, especially in median and ulnar nerves.
Asunto(s)
Regeneración Nerviosa , Neuroma/cirugía , Neoplasias del Sistema Nervioso Periférico/cirugía , Nervio Sural/trasplante , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Nervio Mediano/citología , Nervio Mediano/cirugía , Microcirugia , Persona de Mediana Edad , Neuronas Motoras/fisiología , Neuronas Aferentes/fisiología , Nervio Radial/citología , Nervio Radial/cirugía , Nervio Ciático/citología , Nervio Ciático/cirugía , Trasplante Autólogo , Nervio Cubital/citología , Nervio Cubital/cirugíaRESUMEN
The territories of the central branches of the middle cerebral artery (MCA) were examined in 21 injected human brains. It was noted that these central arteries supplied: the caudate nucleus (dorsolateral half of the rostral part of its head; the entire caudal part of the head; the body and rostral portion of the tail in some cases), the putamen (dorsolateral part of its rostral portion, the remainder of the putamen, except the most caudal part occasionally), the globus pallidus (the entire lateral segment, except the ventrorostral and, sometimes, the most caudal part), the basal forebrain (lateral parts of the basal nucleus of Meynert and the nucleus of the diagonal band, as well as fiber bundles in this region), the internal capsule (dorsal and ventrocaudal part of the anterior limb, dorsal part of the genu, dorsal and ventrorostral part of the posterior limb), the corona radiata (a narrow strip close to the internal capsule) and the cerebral cortex (the caudal orbitofrontal cortex occasionally). The presented data may have certain neuroradiologic, neurologic and neurosurgical significance.