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El número de pacientes con patología cardíaca congénita que se intervienen de cirugía no cardíaca está en aumento. El manejo de este tipo de pacientes en neurocirugía requiere de una planificación anestésico-quirúrgica minuciosa. La necesidad de intervención urgente junto con la presencia de una cardiopatía congénita evolucionada a síndrome de Eisenmenger, asociadas a una vía aérea difícil, van a suponer un reto para el anestesiólogo. La utilización de dexmedetomidina puede ser una alternativa. Presentamos el caso de una paciente con síndrome de Down y síndrome de Eisenmenger que fue sometida a un drenaje de absceso cerebral de urgencias siendo posteriormente reintervenida de forma programada. Se comparan las diferentes técnicas anestésicas empleadas en ambos procedimientos, analizando las implicaciones que tuvieron sobre las principales alteraciones fisiopatológicas que presentaba la paciente.(AU)

Adults patients with congenital heart disease increasingly present for non cardiac surgery. The anesthetic management this type of patients in neurosurgery requires a meticulous surgical anesthetic planning. The need for urgent intervention, with the presence of a congenital heart disease evolved to Eisenmenger Syndrome, associated to a difficult airway, is a challenge for the anesthesiologist. The use of dexmedetomidine may be a valid alternative. We present the case of a patient with Down syndrome, and Eisenmenger syndrome who underwent drainage of brain abscess from the emergency department and was subsequently scheduled for reintervention. We compare the different anesthetic techniques used in both procedures, analyzing the implications they had on the main physiopathological alterations presented by the patient.(AU)

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Adults patients with congenital heart disease increasingly present for non cardiac surgery. The anesthetic management this type of patients in neurosurgery requires a meticulous surgical anesthetic planning. The need for urgent intervention, with the presence of a congenital heart disease evolved to Eisenmenger syndrome, associated to a difficult airway, is a challenge for the anesthesiologist. The use of dexmedetomidine may be a valid alternative. We present the case of a patient with Down syndrome, and Eisenmenger syndrome who underwent drainage of brain abscess from the emergency department and was subsequently scheduled for reintervention. We compare the different anesthetic techniques used in both procedures, analyzing the implications they had on the main physiopathological alterations presented by the patient.

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Adults patients with congenital heart disease increasingly present for non cardiac surgery. The anesthetic management this type of patients in neurosurgery requires a meticulous surgical anesthetic planning. The need for urgent intervention, with the presence of a congenital heart disease evolved to Eisenmenger Syndrome, associated to a difficult airway, is a challenge for the anesthesiologist. The use of dexmedetomidine may be a valid alternative. We present the case of a patient with Down syndrome, and Eisenmenger syndrome who underwent drainage of brain abscess from the emergency department and was subsequently scheduled for reintervention. We compare the different anesthetic techniques used in both procedures, analyzing the implications they had on the main physiopathological alterations presented by the patient.

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OBJECTIVE: The endoscopic endonasal approach (EEA) has been proposed as an alternative in the surgical removal of ventral brainstem lesions. However, the feasibility and limitations of this approach to treat such pathologies are still poorly understood. This study aimed to report our experience in five consecutive cases of intrinsic brainstem lesions that were managed via an EEA, as well as the specific anatomy of each case. METHODS: All patients were treated in a single center by a multidisciplinary surgical team between 2015 and 2019. Before surgery, a dedicated anatomical analysis of the brainstem safe entry zone was performed, and proper surgical planning was carried out. Neurophysiological monitoring was used in all cases. Anatomical dissections were performed in three human cadaveric heads using 0° and 30° endoscopes, and specific 3D reconstructions were executed using Amira 3D software. RESULTS: All lesions were located at the level of the ventral brainstem. Specifically, one mesencephalic cavernoma, two pontine ca- vernomas, one pontine gliomas, and one medullary diffuse midline glioma were reported. Cerebrospinal fluid leak was the major complication that occurred in one case (medullary diffuse midline glioma). From an anatomical standpoint, three main safe entry zones were used, namely the anterior mesencephalic zone (AMZ), the peritrigeminal zone (PTZ, used in two cases), and the olivar zone (OZ). Reviewing the literature, 17 cases of various brainstem lesions treated using an EEA were found. CONCLUSIONS: To our knowledge, this was the first preliminary clinical series of intrinsic brainstem lesions treated via an EEA presented in the literature. The EEA can be considered a valid surgical alternative to traditional transcranial approaches to treat selected intra-axial brainstem lesions located at the level of the ventral brainstem. To achieve good results, surgery must involve comprehensive anatomical knowledge, meticulous preoperative surgical planning, and intraoperative neurophysiological moni- toring.

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Objetivo e Importancia: La detección de los eventos isquémicos intraoperatorios puede contribuir a la resolución de su causa y a la prevención del establecimiento definitivo de un infarto postquirúrgico. Queremos ilustrar las posibilidades que ofrece la monitorización intraoperatoria de la presión tisular de oxígeno (Pti02) en áreas críticas durante un procedimiento neuroquirúrgico vascular, resaltando su fiabilidad e inmediatez en la obtención de información sobre el estado de oxigenación tisular como marcador de isquemia del territorio vascular expuesto a riesgo. Presentación clínica: Presentamos el caso de un varón de 32 años con una malformación arteriovenosa (MAV) profunda situada en la región insular. El paciente había sido tratado inicialmente mediante radiocirugía sin resultado satisfactorio.Intervención: La exéresis de la MAV se realizó a través de un abordaje transilviano transinsular. La Ptio2 se monitorizó en el polo temporal (área de referencia) y en la región temporal posterior (área de riesgo). Ambas mantuvieron niveles de oxigenación tisular parejos hasta la fase final de la resección de la MAV en la que, durante la hemostasia de un supuesto vaso aferente, se produjo una brusca caída de la tensión de oxígeno en la región temporal posterior. En el postoperatorio se observó un infarto isquémico en este área. Conclusión: La monitorización de la Pti02 tiene una alta fiabilidad en la detección de hipoxia tisular intraoperatoria. Los datos que nos proporciona pueden servir para identificar precozmente estos acontecimientos y, en la medida de lo posible, solventar la situación creada para prevenir la instauración definitiva de un infarto isquémico (AU)

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OBJECTIVE AND IMPORTANCE: Detection of intraoperative ischemic events could lead to the resolution of their cause and to the prevention of the definitive establishment of a postoperative infarct. We want to illustrate the possibilities that intraoperative monitoring of oxygen tissue pressure (PtiO2) in critical areas during a neurosurgical vascular procedure offers, enhancing its reliability and immediacy in obtaining information about tissue oxygenation status as a marker of ischemia in the vascular territory at risk. CLINICAL PRESENTATION: We report the case of a 32 year-old male with a deep arteriovenous malformation (AVM) localised in the insular region. The patient had been previously treated with radiosurgery without achieving a satisfactory result. INTERVENTION: AVM removal was performed through a transylvian transinsular approach. PtiO2 was monitorised at the temporal pole (reference area) and at the posterior temporal region (risk area). Both probes maintained close tissue oxygenation levels until the last stage of the AVM resection when, during the coagulation of a supposed afferent vessel, a brisk fall of the oxygen tissue pressure in the posterior temporal region was detected. An ischemic infarct in this area was observed postoperatively. CONCLUSIONS: PtiO2 monitoring has a high reliability in the detection of intraoperative tissue hypoxia. Data obtained could lead to early identification of these events and, whatever possible, to resolve this situation preventing the definitive establishment of an ischemic infarct.

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Objetivo. Presentar nuestra experiencia sobre 20 casos de malformaciones arteriovenosas (MAV) de fosa posterior. Pacientes y métodos. Durante el período 1991-1999 se han recogido de forma prospectiva datos clínicos radiológicos, terapéuticos y resultados de todos los pacientes adultos que fueron tratados por malformaciones arteriovenosas, de los que hemos seleccionado 20 casos con una MAV en fosa posterior. Resultados. La media de edad fue de 39,6 años (1564). Trece (65 por ciento) eran varones. La mayoría de los pacientes, 16 casos (80 por ciento), se manifestaron clínicamente por hemorragia cerebelosa, hemorragia subaracnoidea o intraventricular, ingresando 6 (30 por ciento) pacientes en coma. Según la escala de Spetzler y Martin: grado I, 1 paciente (5 por ciento); grado II, 8 pacientes (40 por ciento); grado III, 8 pacientes (40 por ciento), y grado V 3 pacientes (15 por ciento). Un paciente tenía un aneurisma pedicular asociado, otro una MAV supratentorial y otro paciente varios cavernomas. Nueve pacientes necesitaron un drenaje ventricular externo que en 4 se convirtió en un sistema derivativo de LCR permanente. Se empleó tratamiento endovascular en 8 pacientes, en dos pacientes se hizo radiocirugía y cirugía en 9, sólo en los casos en los que se empleó la cirugía se consiguió la extirpación completa de la MAV (dos pacientes intervenidos habían sido tratados previamente con embolizaciones y radiocirugía). La mortalidad de esta serie fue del 20 por ciento, en los cuatro casos por resangrado. Se obtuvo un buen resultado en 11 (55 por ciento) pacientes, y en el resto, 5 (25 por ciento) pacientes, quedaron secuelas. Conclusión. El elevado porcentaje de hemorragias como forma de presentación, con una mortalidad muy superior con respecto a las MAV de localización supratentorial, nos debe obligar a tomar una actitud terapéutica más enérgica (AU)

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