Indirect costs associated with glioblastoma: Experience at one hospital. / Costes indirectos asociados al glioblastoma. Experiencia en un centro.

INTRODUCTION: Glioblastoma is the most common primary brain tumour. Despite advances in treatment, its prognosis remains dismal, with a mean survival time of about 14 months. Many articles have addressed direct costs, those associated with the diagnosis and treatment of the disease. Indirect costs, those associated with loss of productivity due to the disease, have seldom been described. MATERIAL AND METHOD: We conducted a retrospective study in patients diagnosed with glioblastoma at Hospital Universitario Donostia between January 1, 2010 and December 31, 2013. We collected demographics, data regarding the treatment received, and survival times. We calculated the indirect costs with the human capital approach, adjusting the mean salaries of comparable individuals by sex and age and obtaining mortality data for the general population from the Spanish National Statistics Institute. Past salaries were updated to 2015 euros according to the annual inflation rate and we applied a discount of 3.5% compounded yearly to future salaries. RESULTS: We reviewed the records of 99 patients: 46 women (mean age 63.53) and 53 men (mean age 59.94); 29 patients underwent a biopsy and the remaining 70 underwent excisional surgery. Mean survival was 18.092 months for the whole series. The total indirect cost for the series was €11 080 762 (2015). Mean indirect cost per patient was €111 926 (2015). DISCUSSION: Although glioblastoma is a relatively uncommon type of tumour, accounting for only 4% of all cancers, its poor prognosis and potential sequelae generate disproportionately large morbidity and mortality rates which translate to high indirect costs. Clinicians should be aware of the societal impact of glioblastoma and indirect costs should be taken into account when cost effectiveness studies are performed to better illustrate the overall consequences of this disease.

[Multiple extraneural metastasis of glioblastoma multiforme].

INTRODUCTION: Glioblastoma multiforme is the most frequent primary tumor in the brain. Despite improvements in its surgical, chemotherapy and radiotherapy treatment, prognosis remains poor. Extracranial metastases of glioblastoma are a rare complication in this disease. Its appearance has been described in lung, liver, bone or lymph nodes. CASE REPORT: We describe the case of a 20 year-old patient who complained of a subacute-onset headache. In the MRI an enhancing right temporal lesion was detected suggesting a high grade glioma as first diagnosis. Surgery was performed, obtaining a gross total resection of the lesion. Our patient underwent adjuvant radiotherapy and chemotherapy treatment, according to our hospital's protocol. Five months after initial surgery our patient complained of chest pain and a hacking cough. A thoracic-abdominal-pelvic CT scan was obtained, which showed bilateral lung infiltrates with pleural effusion, a pancreatic nodule and several vertebral lytic lesions. The lung lesions were biopsied. The pathologic diagnosis was metastatic glioblastoma multiforme. The patient died eight months after initial diagnosis. CONCLUSION: Extracranial metastases of glioblastoma remain a rare event although its incidence is increasing, probably due to the improvement in survival among these patients and better imaging techniques. The mechanisms for extracranial dissemination of glioblastoma are not entirely known, as several theories exist in this regard. Physicians must be aware of this complication and keep it in mind as a differential diagnosis to improve the quality of life of our patients.

[Surgical management in metastatic squamous cell carcinoma of the larynx to the cavernous sinus. Case report]. / Metástasis de carcinoma escamoso de laringe en seno cavernoso. Presentación de un caso.

The spread to the cavernous sinus in laryngeal cancer means the presence of a disseminated disease and short survival. The aim of this paper is to report a case of laryngeal squamous carcinoma of the larynx. A search was conducted in the databases of Medline and SciELO DOYMA using the words "cavernous sinus metastasis". We found 10 published cases of laryngeal squamous carcinoma with metastasis to the cavernous sinus. The average survival of the 10 cases reported in the literature was 4.1 months; in our case it was 9 months. Patients who received radiotherapy improved symptomatically. In some cases the diagnosis was confirmed only after necropsy. In this type of lesions, surgery is used for diagnosis rather than as a therapeutic tool.

Early mortality in spontaneous supratentorial intracerebral haemorrhage.

BACKGROUND: Spontaneous supratentorial intracerebral haemorrhage is a severe, frequent, and poorly understood condition. Despite the publication of 12 randomised controlled trials on this subject, the role of surgery remains controversial and no treatment has proved to be effective. We report on a ten year prospective cohort study based on a defined population treated with or without surgery and their outcome in terms of early survival. METHODS: Population based, ten year prospective observational study directed to patients consecutively admitted to the Intensive Care Unit (ICU) in a tertiary centre with spontaneous supratentorial intracerebral haemorrhage. Patients were distributed in five groups according to the Glasgow Coma Score (GCS) at admission. Haemorrhages were classified as deep-seated or superficial. All patient received standard medical care, and additionally surgery if it was found indicated by the duty neurosurgeon. Primary endpoint was early mortality defined as dead occurred by any cause during the admission in the ICU. FINDINGS: During the ten year period, 1.485 patients were admitted to our centre with primary intracerebral haemorrhage. Of these, 376 were admitted to the intensive care unit and 285 sustained supratentorial haemorrhages. Low GCS was strong predictor of early mortality. Despite the larger size of haematomas in patients undergoing surgical evacuation, surgery was associated with lower early mortality in all GCS subgroups. Maximal benefit was observed in patient with admission GCS of 4-8. Superficial haematomas were operated on more often, and were associated with lower mortality rate than deep-seated cases. CONCLUSIONS: Our findings suggest that craniotomy for haematoma evacuation may reduce early mortality in patients with primary supratentorial intracerebral haemorrhage. Surgery seems specially useful in patients with admission GCS between 4 and 8, and in those with superficial haemorrhages.

[Skull-base plasmacytoma with craniocervical instability]. / Plasmocitoma de base craneal con inestabilidad cráneo-cervical.

INTRODUCTION: Cranio-cervical instability is, in some cases, the main surgical concern in posterior skull base tumors. We report on a case in which a solitary plasmacytoma of the skull base presented with cranio-cervical instability. Vertebral artery was injured during surgery. The surgical anatomy is reviewed, with emphasis in vascular complications avoidance. CASE REPORT: A 66 year-old woman was diagnosed of a cranial base solitary plasmacytoma and treated with radio and chemotherapy with complete remission. After receiving that treatment, she presented with tetraparesis and a cranio-cervical instability was diagnosed. She was operated on, under cranial traction, of posterior occipito-cervical instrumentation with C1 to C2 transarticular Magerl screws. The right vertebral artery was injured during surgery without additional neurological deficit. Two years after the operation she remains independent for daily activities. CONCLUSIONS: Transarticular screws at the C1 to C2 level of the cervical spine may provide rigid fixation in posterior cranio-cervical instrumentation for osteolytic lesions, but there is a risk of injury to the vertebral artery, specially when some variations in the surgical anatomy exist.

[Spinal cord compression due to a epidural lipoma]. / Compresión medular por lipoma epidural dorsal.

INTRODUCTION: The spinal extradural space is normally occupied by adipose tissue and a venous plexus, so it should be not surprising that lipomas arise and reach sufficient size to compress symptomatically the spinal cord. Nevertheless, the spinal epidural lipomas are rare and benign tumours may present as a progressive spinal cord compression syndrome. Magnetic resonance imaging is useful in demonstrating the full extent and characteristics of these lesions, the severity of cord compression and the location in the canal. Usually, the lesion is amenable to total surgical extirpation and the functional prognosis is good. Histopathologically the tumour consists of a mature adipose cells matrix intermixed with vascular endothelial channels, that is the reason why it is also named angiolipomas. CASE REPORT: A 47 year-old woman complained of dorsal and bilateral submamarian pain lasting two years and progressive loss of sensibility and weakness in her legs. Following magnetic resonance studies a posterior spinal cord compression by an extradural tumour at T3-T7 levels was observed. She was operated on and we found an extradural yellow tumour easily to dissect and it was completely removed. One year later she is asymptomatic. CONCLUSIONS: Spinal epidural lipoma is a benign tumour which initially presents itself with local or radicular pain accompanied by progressive spinal cord compression syndrome. The choice treatment is laminectomy and total excision. Probably, this is one of the easiest tumours to remove of the spinal canal and a source of satisfaction because a complete recovery can usually be achieved.

Aspergillus granuloma of the cavernous sinus: magnetic resonance imaging with pathologic correlation.

This case illustrates the correlation between Magnetic Resonance Imaging (MRI) and the pathological findings in a case of cavernous sinus (CS) aspergilloma.

[Anatomical landmarks and surgical limits in the suboccipital transmeatal approach to the acoustic neuroma]. / Referencias anatómicas y límites quirúrgicos en el abordaje suboccipital transmeatal del neurinoma acústico.

INTRODUCTION: To completely remove the intracanalicular portion of the acoustic neuroma through the retrosigmoid approach, we must open the posterior wall of the internal auditory canal (IAC). Therefore, drilling the IAC is one of the key steps we need to take in the transmeatal surgical approach. Nevertheless, there are no clear anatomical landmarks to identify structures such as the semicircular canals, the jugular bulb or air cells. The individual anatomical variations and those caused by the tumour itself make preoperative evaluation essential if we wish to avoid complications such as deafness, cerebrospinal fluid leakage, bleeding and air embolism. OBJECTIVE: We describe here the personal experience of the senior author (EU) in drilling the posterior wall of the IAC, with special reference to the anatomical landmarks and surgical limits in the suboccipital approach to the intracanalicular portion of the acoustic neuromas. MATERIAL AND METHODS: This work is based on anatomical data obtained from drilling human temporal bones obtained from cadavers, along with our experience with 20 patients who were operated on for acoustic neuroma using Samii's technique. RESULTS: We did not operate on any purely intracanalicular neurinomas using this approach. Two tumors were grade II (up to 20mm in diameter), 12 were grade III and 6 were grade IV. We did not drill far enough in any of these cases to be able to see the fundus of the IAC, which was confirmed by postoperative CT. Despite this, the tumor was considered to be completely removed in 17 cases. There was no mortality and we has no major complications as a result of drilling the IAC such as cerebrospinal fluid leakage or air embolism. we cannot guarantee that hearing loss of postoperative deafness, which were the norm except in one case of grade II, were caused by nervous, ischemic or labyrinthine lesions. CONCLUSION: In our material it was not possible to completely expose the IAC fundus using a retrosigmoid approach without injury to labyrinth. The areas in which the risk of secondary complications is greatest when drilling are the inferior wall and the IAC fundus. The medial extension of the suboccipital craniotomy makes drilling the intrameatal tumor exposure easier. There are no intraoperative landmarks to locate the petrous structures while drilling the IAC except for those provided by the surgeon's own experience.

[Evaluation of the Mullan's technique in the treatment of trigeminal neuralgia]. / Valoración de la técnica de Mullan en el tratamiento de la neuralgia del trigémino.

OBJECTIVE: The aim of the present study is to examine the operative technique and results of the treatment of trigeminal neuralgia (TN) by percutaneous microcompression of the trigeminal ganglion (Mullan's technique) in 20 consecutive patients over 3 years. PATIENTS AND METHODS: The average age of the patients was 63 years. There were 8 men and 12 women. The operative technique is similar to Mullan and Lichtor's original description with some modifications. RESULTS: On average it takes 30 minutes to complete the procedure. On 2 occasions the catheter had to be replaced as the balloon burst without clinical repercussions. Detectable changes were noted in systemic blood pressure and cardiac rhythm in 10 cases. On 17 occasions the radiographic appearance of the balloon was pear-shaped and in the remaining cases it was oval or irregular. Follow-up ranged from 6 months to 3 years. All but 1 patient were initially relieved of pain and it was progressively possible to suspend treatment with carbamazepine. The recurrence rate was 25%. Mean time until recurrence was 18 months. There was no relation between pain location and recurrence. Morbidity: some degree of transient cheek discomfort, herpes simplex perioralis, hypesthesia and masseter weakness were the rule. Meningitis in one case. CONCLUSIONS: Early results indicate that Mullan's technique provides a reliable, safe, cheap and effective, with low morbidity and no mortality.

Delayed glossopharyngeal and vagus nerve paralysis following occipital condyle fracture. Case report.

This report describes a case of delayed glossopharyngeal and vagus nerve paralysis following a closed head injury. A depressed fracture of the occipital condyle was diagnosed using high-resolution computerized tomography (CT) scanning and three-dimensional CT images. Magnetic resonance imaging complemented the study. The anatomical features, mechanisms, diagnosis, and treatment of this unusual lesion are discussed.

Macroscopic effects of percutaneous trigeminal ganglion compression (Mullan's technique): an anatomic study.

After the use of Mullan's technique, macroscopic changes take place on the gasserian ganglion and the surrounding structures. These changes were studied on 20 trigeminal nerves of 10 fresh adult cadavers. Changes took place on the dura as well as in the neural elements. There was compression on the ganglion and on the trigeminal nerve, and there were changes in the position of the trigeminal root, with shortening of its cisternal segment. When the balloon was inflated to capacity (0.75-1.0 ml), dural stretching in an area of 15 x 10 mm took place. This stretching of the dura extended from the lateral wall of the cavernous sinus to the level of the porus trigemini. Despite these important mechanical effects, we never found a rupture or tear on the dura or the trigeminal nerve fibers. We discuss the relationship between mechanical effects and clinical results.

[Epidermoid cyst of the corpus callosum]. / Kyste épidermoïde du corps calleux.

Epidermoid cysts are most commonly located in the cerebellopontine angle and the parasellar regions. The authors report a case of an epidermoid cyst of unusual location: it arises in the midline and involves the body of the corpus callosum with interhemispheric exophytic growth. Reviewing the literature they did not find any similar report. C.T. scan and M.R.I. are the methods of choice for establishing the diagnosis and differentiating between epidermoid cyst, dermoid cyst, lipoma and arachnoid cyst. M.R.I. is highly sensitive and is especially useful in determining tumour extension, particularly in the sagittal and coronal planes, essential for surgical treatment planning. Treatment should be complete surgical resection in order to avoid recurrence and chemical meningitis.