Inferior Vena Cava Syndrome: A Rare Complication.

Inferior vena cava syndrome is rare and often difficult to diagnose because of its rarity and consequent low suspicion. We describe the case of a 28-year-old female patient with a history of nephroblastoma of the right kidney, stage IV, with a favourable histology with epidural metastasis (D5-D9), diagnosed at 3 years of age. The patient underwent treatment with surgery, chemotherapy and radiotherapy. The patient suffered from sudden low back pain worsening over 2 weeks, with progressive inability to walk. The pain radiated to the front of the thighs. Concomitantly, oedema of the lower limbs with cephalocaudal progression was observed. At admission to our institution, the physical examination showed peripheral oedema, abdominal wall venous collaterals, an inability to walk due to low back pain in the supine position, with no neurological deficits. Lumbar MRI showed exuberant epidural venous congestion. The hypothesis of inferior vena cava thrombosis (IVCT) was considered and confirmed by angio-CT. IVCT is prevalent in patients with congenital anomalies of the inferior vena cava, occurring in approximately 60-80% of these cases, and most published series on inferior vena cava syndrome refer to thrombotic complications in this subgroup of patients. There are currently no guidelines defined or validated to guide the diagnosis and approach to IVCT. With this case, we would like to draw attention to a rare disease that should be suspected in all patients with inferior vena cava disease, whether resulting from congenital disease or after surgical procedures. LEARNING POINTS: Diagnosing IVCT can be challenging and a high index of suspicion is needed in presence of abnormalities of the inferior vena cava.In rare instances, IVCT can present with severe lumbar pain due to epidural venous congestion.

Short-Term Outcome Comparison Between Full-Endoscopic Interlaminar Approach and Open Minimally Invasive Microsurgical Technique for Treatment of Lumbar Disc Herniation.

OBJECTIVE: To compare postoperative pain control and functional outcome between full-endoscopic interlaminar approach (FEIA) and open minimally invasive microsurgical technique (MMST) for lumbar discectomy. METHODS: All consecutive patients treated with FEIA were prospectively followed. Clinical outcome parameters (low back and leg numeric rating scale and Quebec Back Pain Disability Scale) were measured. Analgesics use after surgery was quantified. Results were compared with a cohort of patients treated in the same period with MMST. The decision regarding which surgical technique to use was based on endoscope availability only. RESULTS: There were 26 patients treated with FEIA and 18 treated with MMST. Baseline patient characteristics were comparable. Sciatic pain was treated in both groups. Postoperative back pain was significantly lower in the FEIA group (numeric rating scale scores 1.5, 0.3, and 0.2 at 1, 2, and 4 weeks after FEIA vs. 3.6, 2.4, and 1.6 after MMST). In the FEIA group, 61.5% of patients did not take any pain medication. The average number of analgesics taken within 30 days was 4.0 in the FEIA group and 27.2 in the MMST group. The average Quebec Back Pain Disability Scale score decreased from 57.7 to 25.0, 18.0, and 14.2 at 1, 2, and 4 weeks after FEIA compared with a decrease from 58.8 to 41.1, 34.7, and 23.0 in the MMST group. No approach-related complications were reported. CONCLUSIONS: With less analgesic use, back and leg pain relief after 1 week in the FEIA group was comparable to that achieved in the MMST group after 1 month. This was also true for overall ability of patients to perform daily activities.

[AICA anatomic variation as a factor of worse prognosis for the surgical treatment of hemi-facial spasm]. / Variação anatómica da AICA condicionando falência do tratamento cirúrgico de doente com espasmo hemi-facial.

Hemifacial spasm is a neurovascular compression syndrome. These consist in a contacting vessel (most often an artery) to a cranial nerve in cerebelar-pontine angle. The most common is trigeminal neuralgia caused by contact between the superior cerebellar artery and the trigeminal nerve, and less commonly hemifacial spasm, vertiginous syndrome by contact of the antero inferior cerebelar artery with the eighth cranial nerve, glossopharyngeal neuralgia by contact of the postero inferior cerebelar artery and the IX cranial nerve, etc. These syndromes typically occur after the fifth decade of life, when the arterial tortuosity increases due to the arteriosclerosis process. They are however associated anatomical variations of the origin and course of the arteries, which facilitate contact with the nerves of the cerebellar-pontine angle. In hemifacial spasm, the vessel most often related is antero inferior cerebelar and the authors describe a case of a rare anatomical variant in the course of the artery that motivated the development of the disease, which was identified intraoperatively on a surgical approach to the cerebellar-pontine for vascular microdescompression.

O espasmo hemifacial é uma síndrome compressiva neurovascular. Estes consistem no contacto de um vaso (mais frequentemente uma artéria) e um nervo craniano no ângulo ponto-cerebeloso. O mais comum é a nevralgia do trigémio provocada pelo contacto entre a artéria cerebelosa superior e o nervo trigémio, sendo menos comuns o espasmo hemifacial, o síndrome vertiginoso por contacto da artéria cerebelosa ântero-inferior com o VIII par craniano, a nevralgia do glossofaríngeo por contacto da artéria cerebelosa posteroinferior com o IX par craniano, etc. Estas síndromes surgem normalmente a partir da quinta década de vida, altura em que a tortuosidade das artérias aumenta devido ao processo de arterioesclerose. Estão contudo associadas variações anatómicas da origem e percurso das artérias, que facilitam o contacto com os nervos do ângulo ponto-cerebeloso. No espasmo hemifacial, o vaso mais frequentemente relacionado é a artéria cerebelosa ântero-inferior e os autores descrevem um caso de uma variante anatómica rara no percurso da artéria cerebelosa ântero-inferior que motivou o desenvolvimento da patologia, e que foi identificada intra-operatóriamente numa abordagem cirúrgica ao ângulo ponto-cerebeloso para microdescompressão vascular.

A comparison of risk factors in the etiology of mirror and nonmirror multiple intracranial aneurysms.

BACKGROUND: Pure mirror intracranial aneurysms represent a subgroup of multiple aneurysm patients where a congenital predisposition may play a major etiologic role. The aim of this study was to compare the pattern of prevalence of known risk factors for aneurysm disease between pure mirror and pure nonmirror multiple aneurysm populations. METHODS: Clinical records of all patients with multiple intracranial aneurysms admitted to our institution between January 1985 and September 2001 were reviewed. Age, localization of aneurysms, gender, and history of cigarette smoking or hypertension were noted and compared using Fisher's exact test and logistic regression analysis. RESULTS: There were 33 patients presented with pure mirror aneurysms (MirAn) and 49 with nonmirror multiple aneurysms (nMirAn). Average age of rupture occurred in the 5th decade in both groups. Female:male ratio was 3.1:1 in MirAn; 2.1:1 in nMirAn. In MirAn patients younger than 40 years it was 1:1. Smoking was the most prevalent risk factor in nMirAn (59.2%). In MirAn this was true only for patients in the 5th or 6th decades (65%), and hypertension was the most prevalent risk factor over that age (62.5%). A total of 80% of mirror aneurysm patients under 40 years had no known extrinsic risk factor, compared with 20% in nMirAn (p < 0.05). CONCLUSIONS: Differences in the relative prevalence of risk factors between both groups supports the hypothesis of a different etiologic process occurring in mirror aneurysm disease. Early rupture in patients with no extrinsic risk factors lends support to the role of a congenital predisposition over degenerative causes in these patients.

Is aspect ratio a reliable predictor of intracranial aneurysm rupture?

OBJECTIVE: This study was undertaken to assess the reliability of the aspect ratio (AR) (i.e., aneurysm depth to aneurysm neck) in predicting aneurysm rupture. It has been shown that the AR is a key factor in predicting intraaneurysmal blood flow and aneurysm rupture. METHODS: Seventy-five patients with subarachnoid hemorrhage and multiple aneurysms were studied. The sizes of the aneurysms and their ARs were determined by examining the angiographic films. By comparing the difference between ruptured and unruptured aneurysms in the same individual, each patient in effect served as his or her own control. Each ruptured aneurysm was confirmed during surgery. RESULTS: There were 75 ruptured and 107 unruptured aneurysms. The mean AR was 2.70 for ruptured aneurysms, compared with 1.8 for unruptured aneurysms. This difference between the ARs was statistically significant (P < 0.001). The difference in aneurysm sizes in the two groups also was significant (P < 0.001). CONCLUSION: AR on its own is as reliable a variable as the size of the aneurysm for predicting aneurysm rupture.