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INTRODUCTION: Trigeminal neuropathic pain (TNP) is a syndrome of severe, disabling, constant facial pain arising from the trigeminal nerve or ganglion. Arteriovenous malformations (AVM) are a rare cause of TNP. The limited choices of intervention of TNP include peripheral nerve stimulation, trigeminal nucleotomy and motor cortex stimulation. CASE REPORT: We present a 56-year-old man who suffered from trigeminal neuropathic pain secondary to nerve compression due to a giant posterior fossa AVM. The pain was refractory to drug treatment. From all the therapeutic options available we declined the microvascular decompression of the trigeminal nerve due to the presence of the giant AVM, or stereotactic radiosurgery because of the AVM´s diffuse nidus. After a multidisciplinary discussion we proposed a minimally invasive, safe and reversible treatment: Motor Cortical Stimulation (MCS). We placed a 16-pole epidural electrode on the right precentral gyrus. The patient had satisfactory pain control with some supplemental medication. No complications or side effects such as seizures, sensory disturbances or infections were presented. DISCUSSION: The limited choices of intervention of TNP include peripheral nerve stimulation, trigeminal nucleotomy and MCS. Henssen et al performed a systematic review where they investigated the effectiveness of MCS and discovered that this is significantly different among different chronic neuropathic orofacial pain disorders. A visual analogue scale (VAS) measured median pain relief of 66.5% was found. CONCLUSION: MCS should be one more tool to consider in highly selected cases, when other treatments are unfeasible.
Introducción: El dolor neuropático trigeminal (DNT) es un síndrome de dolor facial intenso, incapacitante y constante que surge del nervio o ganglio del trigémino. Las malformaciones arteriovenosas (MAV) son una causa rara de DNT. Las opciones terapéuticas de DNT incluyen la estimulación de los nervios periféricos, la nucleotomía del trigémino y la estimulación cortical motora. Caso clínico: Presentamos el caso de un varón de 56 años con dolor neuropático trigeminal secundario a compresión nerviosa por una MAV gigante de fosa posterior. El dolor era refractario al tratamiento farmacológico. De todas las opciones terapéuticas disponibles, desestimamos la descompresión microvascular del nervio trigémino por la presencia de la MAV gigante, o la radiocirugía estereotáctica, por ser difuso el nido de la MAV. Tras una discusión multidisciplinar propusimos un tratamiento mínimamente invasivo, seguro y reversible: Estimulación cortical motora (ECM). Colocamos un electrodo epidural en el giro precentral derecho. El paciente tuvo un control satisfactorio del dolor con medicación suplementaria. No presentó complicaciones ni efectos secundarios como convulsiones, alteraciones sensoriales o infecciones. Discusión: Las opciones limitadas de intervención de DNT incluyen estimulación nerviosa periférica, nucleotomía trigeminal y ECM. Henssen et al realizaron una revisión sistemática donde investigaron la efectividad de MCS y descubrieron que esto es significativamente diferente entre los diferentes trastornos de dolor orofacial neuropático crónico. Se encontró un promedio de alivio del dolor medida por una escala analógica visual del 66,5%. Conclusión: La ECM debería ser una herramienta más a considerar en casos estrictamente seleccionados donde otros tratamientos no son viables.
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Malformações Arteriovenosas , Córtex Motor , Neuralgia , Neuralgia do Trigêmeo , Masculino , Humanos , Pessoa de Meia-Idade , Neuralgia do Trigêmeo/terapia , Neuralgia do Trigêmeo/complicações , Neuralgia/etiologia , Neuralgia/terapia , Malformações Arteriovenosas/complicações , Resultado do TratamentoRESUMO
Presentamos el caso de una paciente con enfermedad de Parkinson y extrusión del fijador craneal del electrodo de estimulación cerebral profunda. Luego del explante de todo el sistema, se realizó un colgajo axial de fascia temporoparietal (TPFF) para cobertura del trépano residual y en el segundo tiempo se utilizó el colgajo para cubrir el nuevo implante. La paciente no presentó complicaciones durante el seguimiento de 2 años
We present the case of a patient with Parkinson's disease and extrusion of the cranial fixation of the deep brain stimulation electrode. After explantation of the entire system, an axial flap of temporoparietal fascia (TPFF) was performed to cover the residual Burr hole, and in the second procedure, the flap was used to cover the new implant. The patient did not experience any complications during the 2-year follow-up period.
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Humanos , Feminino , Pessoa de Meia-Idade , Couro Cabeludo/lesões , Cirurgia Plástica/métodos , Retalhos Cirúrgicos/transplante , Fixadores Internos , Assistência ao Convalescente , Estimulação Encefálica ProfundaRESUMO
INTRODUCTION: Neonatal cerebral aneurysms are very rare condition and distinct from those of the adults. CASE REPORT: We reported a 14-day-old male neonate who presented subarachnoid hemorrhage due to a ruptured anterior cerebral artery saccular aneurysm. In addition, we present a review of the relevant literature. CONCLUSION: Intracranial hemorrhage due to cerebral aneurysm rupture in a newborn is an uncommon diagnosis, but it must be unequivocally excluded.
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Aneurisma Roto , Aneurisma Intracraniano , Acidente Vascular Cerebral , Hemorragia Subaracnóidea , Adulto , Recém-Nascido , Humanos , Masculino , Aneurisma Intracraniano/cirurgia , Aneurisma Roto/diagnóstico , Angiografia CerebralRESUMO
La neuromodulación es una práctica médica implementada desde hace más de cuatro décadas. En lo que respecta a la Neurocirugía, cumple un papel en el tratamiento de diversas patologías (Parkinson, distonías, epilepsia, etc.) y con un gran potencial para aplicarlas en otras (trastorno obsesivo compulsivo [TOC], dolor pélvico). Es por ello que, en los últimos años, se cuadruplicaron las inversiones de empresas biotecnológicas en este campo por la demanda y aplicación de la terapia. La neuromodulación abarca también otras especialidades, como por ejemplo Otorrinolaringología (ORL) en implantes cocleares, Cardiología con diversos modelos de marcapasos cardíacos, Endocrinología con bombas de infusión de medicamentos, Uroginecología en incontinencia, etcétera. Nuestra institución aplica en su práctica clínica todas estas técnicas, y cumple una función jerárquica como centro de referencia en educación y políticas sanitarias. Por estos aspectos, sumados a su infraestructura, personal profesional y enfoque sanitario, puede ser considerada como un Centro de Neuromodulación referente en la región. (AU)
Neuromodulation is a medical practice established for more than forty years. In the neurosurgical field it plays a role in the treatment of different diseases (Parkinson, Dystonia, Epilepsy, etc) and has a great potential to apply in other pathologies (Obsessive Compulsive Disorder, Pelvic pain). In the last years the biotechnological industry has quadrupled the investment in this field because of the demand and therapy application. Neuromodulation encompasses other specialities, for example otorhinolaryngology in cochlear implants, in cardiology with different models of pacemakers, endocrinology with implanted infusion pumps, urological gynecology in incontinence treatments, etc. Our institution applies all these techniques in its clinical practice, having a hierarchical role as a reference center in education and health policies. Due to these aspects, added to its infrastructure, professional staff and health approach, it can be considered as a reference Neuromodulation Center in the region. (AU)
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Humanos , Doença de Parkinson/terapia , Neurotransmissores/uso terapêutico , Estimulação Encefálica Profunda , Dor Crônica/terapia , Epilepsia Resistente a Medicamentos/terapia , Manejo da Dor/métodos , Estado FuncionalRESUMO
El síndrome de Eagle está caracterizado por una elongación o una curvatura medial excesiva de la apófisis estiloides o por una calcificación del ligamento estilohioideo que puede provocar dolor cervicofacial o síntomas neurológicos por la compresión de los vasos o nervios del cuello. El tratamiento más eficaz es el quirúrgico y consiste en la resección de la apófisis estiloides; puede ser realizado por vía externa o mediante un abordaje transoral. Se describe el caso clínico de un paciente con síndrome de Eagle que fue tratado con éxito mediante un abordaje transoral, sin amigdalectomía y con asistencia de endoscopios. (AU)
Eagle syndrome is characterized by an elongation or excessive medial curvature of the styloid process or calcification of the stylohyoid ligament that can cause cervicofacial pain or neurological symptoms due to compression of the vessels or nerves of the neck. The most effective treatment is surgical and consists of resection of the styloid process, it can be performed by externally or through a transoral approach.The clinical case of a patient with Eagle syndrome who was successfully treated by a transoral approach, without tonsillectomy and with the assistance of endoscopes, is described. (AU)
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Humanos , Masculino , Pessoa de Meia-Idade , Osso Temporal/anormalidades , Osso Temporal/cirurgia , Ossificação Heterotópica/cirurgia , Ossificação Heterotópica/diagnóstico por imagem , Mandíbula/cirurgiaRESUMO
El manejo de pacientes debido a la aparición del nuevo coronavirus 2019 (COVID-19) representa un desafío para los equipos médicos y quirúrgicos, ya que modificó el funcionamiento de los sistemas de salud en casi todo el mundo. Para contribuir a la re organización del sistema de salud, el Servicio de Neurocirugía del Hospital Italiano de Buenos Aires trabajó en adoptar distintas medidas en concordancia con las tomadas a nivel institucional y nacional; por lo que se analizó la bibliografia publicada, asi como las normas dictadas por el comité de crisis de nuestra institucion. A su vez realizamos una breve encuesta dirigida a neurocirujanos de america latina para conocer como se manejaban actualmente en relación a niveles de protección y realización de cirugias. La actual pandemia de COVID-19 es el mayor desafío que enfrentan los sistemas nacionales de salud en los últimos tiempos. Los neurocirujanos podemos contribuir a la reducción del riesgo de infección nosocomial de los trabajadores de la salud al adaptar distintos protocolos en pacientes con COVID-19.
Patient's management due to the appearance of new coronavirus 2019 (COVID-19) represents a challenge for medical and surgical departments, since it modified the running of health systems in almost all the world. In order to help in this new situation, the Neurosurgical Department of our institution has adopted different measures in accordance with those taken at institutional and national level. In order to do this, we made a literature review and we added to this, the norms dictated by the crisis committee of our hospital. We also carried out a brief survey among neurosurgeons from Latin America to find out how they managed protection levels in relation to surgery. COVID-19 pandemic is certainly one of the greatest challenge national health systems face in a century. Adapting different protocols in neurosurgical patients with COVID-19 can contribute in reducing the risk of nosocomial infection of health workers.
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Humanos , Infecções por Coronavirus , Pessoal de Saúde , Coronavirus , Pandemias , Neurocirurgiões , NeurocirurgiaRESUMO
In construing meaning, the brain recruits multimodal (conceptual) systems and embodied (modality-specific) mechanisms. Yet, no consensus exists on how crucial the latter are for the inception of semantic distinctions. To address this issue, we combined electroencephalographic (EEG) and intracranial EEG (iEEG) to examine when nouns denoting facial body parts (FBPs) and nonFBPs are discriminated in face-processing and multimodal networks. First, FBP words increased N170 amplitude (a hallmark of early facial processing). Second, they triggered fast (~100 ms) activity boosts within the face-processing network, alongside later (~275 ms) effects in multimodal circuits. Third, iEEG recordings from face-processing hubs allowed decoding ~80% of items before 200 ms, while classification based on multimodal-network activity only surpassed ~70% after 250 ms. Finally, EEG and iEEG connectivity between both networks proved greater in early (0-200 ms) than later (200-400 ms) windows. Collectively, our findings indicate that, at least for some lexico-semantic categories, meaning is construed through fast reenactments of modality-specific experience.
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Encéfalo/fisiologia , Compreensão/fisiologia , Idioma , Modelos Neurológicos , Semântica , Adulto , Mapeamento Encefálico/métodos , Eletrocorticografia/métodos , Eletroencefalografia/métodos , Face , Feminino , Humanos , MasculinoRESUMO
Interoception, the monitoring of visceral signals, is often presumed to engage attentional mechanisms specifically devoted to inner bodily sensing. In fact, most standardized interoceptive tasks require directing attention to internal signals. However, most studies in the field have failed to compare attentional modulations between internally- and externally-driven processes, thus probing blind to the specificity of the former. Here we address this issue through a multidimensional approach combining behavioral measures, analyses of event-related potentials and functional connectivity via high-density electroencephalography, and intracranial recordings. In Study 1, 50 healthy volunteers performed a heartbeat detection task as we recorded modulations of the heartbeat-evoked potential (HEP) in three conditions: exteroception, basal interoception (also termed interoceptive accuracy), and post-feedback interoception (sometimes called interoceptive learning). In Study 2, to evaluate whether key interoceptive areas (posterior insula, inferior frontal gyrus, amygdala, and somatosensory cortex) were differentially modulated by externally- and internally-driven processes, we analyzed human intracranial recordings with depth electrodes in these regions. This unique technique provides a very fine grained spatio-temporal resolution compared to other techniques, such as EEG or fMRI. We found that both interoceptive conditions in Study 1 yielded greater HEP amplitudes than the exteroceptive one. In addition, connectivity analysis showed that post-feedback interoception, relative to basal interoception, involved enhanced long-distance connections linking frontal and posterior regions. Moreover, results from Study 2 showed a differentiation between oscillations during basal interoception (broadband: 35-110 Hz) and exteroception (1-35 Hz) in the insula, the amygdala, the somatosensory cortex, and the inferior frontal gyrus. In sum, this work provides convergent evidence for the specificity and dynamics of attentional mechanisms involved in interoception.
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Epilepsy surgery in children with refractory epilepsy is one of the most effective methods to control seizures. The proper selection and assessment of surgery candidates is critical for surgical treatment to be adequately effective and safe. The purpose of this article is to describe our experience with 43 consecutive pediatric patients that underwent epilepsy surgery for refractory epilepsy between September 2005 and May 2014. Effectiveness, safety, and prognostic factors were analyzed. The median age was 12 years old at the time of surgery and 4.5 years old at epilepsy onset, with a latency period of up to 6 years until surgery. Since the surgery, the 43 patients have been in follow-up for a median of 5.4 years (±2.3 years). Resective surgery was performed in 32 patients and hemispherectomy, in 11 patients. To date, 62.8% of patients remain seizure-free. Abetterprognosis was observed in patients who underwent surgery with a duration of epilepsy of less than two years and in patients in whom a complete resection of the epileptogenic zone was achieved.
La cirugía de la epilepsia en niños con epilepsia refractaria es uno de los métodos más efectivos para obtener el control de crisis epilépticas. La apropiada selección y evaluación de los candidatos esfundamentalpara alcanzar una adecuada efectividad y seguridad del tratamiento quirúrgico. El objetivo es presentar nuestra experiencia con 43 pacientes pediátricos consecutivos sometidos a tratamiento quirúrgico de su epilepsia refractaria entre septiembre de 2005 y mayo de 2014. Se analizó la efectividad, la seguridad y los factores pronósticos. La mediana de edad de la cirugía fue de 12 años y la mediana de edad del inicio de la epilepsia fue 4,5 años, con una latencia hasta la cirugía de 6 años. Los 43 pacientes se encuentran en seguimiento con una mediana de 5,4 años (±2,3) desde la cirugía. Los procedimientos realizados fueron, en 32 pacientes, cirugías resectivas y, en 11, desconexiones hemisféricas. Un 62,8% de los pacientes permanecen libres de crisis. Los pacientes que se operaron con una duración de la epilepsia menor de 2 años y en los que se pudo realizar una resección completa del área epileptógena presentaron un mejor pronóstico.
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Epilepsia Resistente a Medicamentos/cirurgia , Adolescente , Criança , Pré-Escolar , Estudos Transversais , Feminino , Humanos , Lactente , Masculino , Estudos Prospectivos , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE: Neurosurgery appears to be a reasonable alternative in carefully selected patients with refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE). We discuss the optimal timing of the surgery and the use of previous stereoelectroencephalography (SEEG) invasive evaluation. METHODS: We identified 3 patients (two pediatric and one adult) who underwent epilepsy surgery because of RSE or SRSE from our epilepsy surgery database, one of them with previous SEEG. RESULTS: Status epilepticus resolved acutely in all of them with no mortality and no substantial morbidity. At follow-up (median: 2 years), 1 patient was seizure-free, and 2 had significant improvement. CONCLUSION: Surgery should be considered in all cases of RSE and SRSE early in the course of the evolution of the disease.
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Interoception, the perception of our body internal signals, plays a key role in maintaining homeostasis and guiding our behavior. Sometimes, we become aware of our body signals and use them in planning and strategic thinking. Here, we show behavioral and neural dissociations between learning to follow one's own heartbeat and metacognitive awareness of one's performance, in a heartbeat-tapping task performed before and after auditory feedback. The electroencephalography amplitude of the heartbeat-evoked potential in interoceptive learners, that is, participants whose accuracy of tapping to their heartbeat improved after auditory feedback, was higher compared with non-learners. However, an increase in gamma phase synchrony (30-45 Hz) after the heartbeat auditory feedback was present only in those participants showing agreement between objective interoceptive performance and metacognitive awareness. Source localization in a group of participants and direct cortical recordings in a single patient identified a network hub for interoceptive learning in the insular cortex. In summary, interoceptive learning may be mediated by the right insular response to the heartbeat, whereas metacognitive awareness of learning may be mediated by widespread cortical synchronization patterns.
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Conscientização/fisiologia , Potenciais Evocados Auditivos/fisiologia , Retroalimentação Sensorial/fisiologia , Frequência Cardíaca/fisiologia , Interocepção/fisiologia , Percepção do Tempo/fisiologia , Estimulação Acústica , Adulto , Análise de Variância , Análise por Conglomerados , Eletrocardiografia , Eletroencefalografia , Epilepsia/patologia , Feminino , Humanos , Masculino , Desempenho Psicomotor/fisiologia , Adulto JovemRESUMO
BACKGROUND: Gangliogliomas (GGs) are rare brain tumors, and their malignant changes are still less frequent. In these cases, almost always the malignant component is the glial one. However, there are few cases in which the neuronal component exhibits malignant transformation. CASE DESCRIPTION: We described a case of a 14-year-old male patient who started with seizures and 5 years later, its frequency was almost daily despite being treated with several antiepileptic drugs. Magnetic resonance imaging showed a nonenhancing lesion located at the right inferior temporal gyri. He underwent surgery, and the tumor was completely removed. Histological diagnosis was GG. He had no seizures anymore, but 3 years later, the tumor recurred as a giant heterogeneously enhancing space-occupying mass within the right temporal lobe. A second surgical resection was performed. Histological diagnosis was a primitive neuroectodermal tumor (PNET). One month and a half later, the tumor has recurred again. He and his family decided not to undergo another operation, so he was referred to the radiotherapy department. CONCLUSION: As in this patient, GGs may recur as a primitive neuroectodermal tumor, likely because both types of neoplasm form part of the same heterogeneous group of brain tumors which contains neuronal components, but on the other side of the malignancy spectrum.
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OBJECTIVE: To define and grade neurosurgical and spinal postoperative complications based on their need for treatment. METHODS: Complications were defined as any deviation from the normal postoperative course occurring within 30 days of surgery. A four-grade scale was proposed based on the therapy used to treat the complications: grade I, any non-life-threatening complications treated without invasive procedures; grade II, complications requiring invasive management such as surgical, endoscopic, and endovascular procedures; grade III, life-threatening adverse events requiring treatment in an intensive care unit (ICU); and grade IV, deaths as a result of complications. Each grade was classified as a surgical or medical complication. An observational test of this system was conducted between January 2008 and December 2009 in a cohort of 1190 patients at the Hospital Italiano de Buenos Aires. RESULTS: Of 167 complications, 129 (10.84%) were classified as surgical, and 38 (3.19%) were classified as medical complications. Grade I (mild) complications accounted for 31.73%, grade II (moderate) complications accounted for 25.74%, and grade III (severe) complications accounted for 34.13%. The overall mortality rate was 1.17%; 0.84% of deaths were directly related to surgical procedures. CONCLUSIONS: The authors present a simple, practical, and easy to reproduce way to report negative outcomes based on the therapy administered to treat a complication. The main advantages of this classification are the ability to compare surgical results among different centers and times, the ability to compare medical and surgical complications, and the ability to perform future meta-analyses.
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Neurocirurgia/classificação , Procedimentos Neurocirúrgicos/efeitos adversos , Complicações Pós-Operatórias/classificação , Anestesia , Argentina/epidemiologia , Encéfalo/cirurgia , Estudos de Coortes , Cuidados Críticos , Humanos , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Reoperação , Medula Espinal/cirurgia , Coluna Vertebral/cirurgia , Resultado do TratamentoRESUMO
Objective. Stereotactic CT-guided biopsy is a safe procedure for the diagnosis of brain lesions unsuitable for surgical treatment because of their location, number, histology or poor medical status. The objective of this study is to analyze the indications,demography, topography, anatomopathologic diagnosis and complications in a series of stereotactic CT-guided brain biopsies. Method. 192 CT assisted stereotactic brain biopsies in 186 patients were retrospectively reviewed from june 1998 to june of 2008. Results. 186 patients, 101males (54.3%) and 85 females (45.7%), were analyzed. Mean age was 54.5 years. 144 (75%) of the biopsies were performed in hemispheric lesions, 43 (22.4%) in deep seated localization. The most frequent anatomopathologic diagnosis were glioblastoma (36,5%) and anaplasic astrocytoma (17%). 90,62% of the biopsies were positive, 7,3% were negative and 2,08% nondiagnostic. Morbility rate was 3,64% and mortality 2,08%. Conclusion.Stereotactic brain biopsy is a safe and effective procedure providing tissue for definitive anatomopathological diagnosis; it offers low morbidity and mortality rate. Our findings are similar to the literature.
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Biópsia , Neoplasias Encefálicas , Tomografia , Lesões Encefálicas TraumáticasRESUMO
Introduction. Surgical treatment of trigeminal neuralgia remains a matter of debate since there are no studies comparing long term effectiveness of the different surgical techniques. We present our 10 year experience. Description. Series: 40 patients. Period: 1998 - 2008. Surgical techniques: microvascular decompression, radiofrequency thermorhizotomy and balloon compression. Analyzed parameters: age, sex, nerve root involved, pain relief, recurrence, complications, need to restart medication and reintervention. Discussion. Microvascular decompression offers better long term results, radiofrequency is adequate for special cases (higher recurrence rate), and balloon compression is better for V1 neuralgia. Our sample is too small for statistics, yet our findings are coincident with the literature. Conclusion. Better patient selection criteria for each technique are needed. Microvascular decompression should be the treatment of choice when possible. How to treat recurrence remains unanswered.