[Direct approach to carotid cavernosa fistula type of arterio venous dural malformation. Case report and review of the literature]. / Abordaje directo de la malformaci n arteriovenosa dural tipo fistula carotidacavernosa. Presentaci n de un caso y revisi n de la literatura.

OBJECTIVES: Barrow's D type carotid cavernosa fistula (FCC) with progressive symptoms and in whom endovascular procedures have failed meet criteria for a direct approach. We report a case of this type of vascular lesion in whom partial endovascular embolization was done together with a direct approach to the FCC, using a method of localization involving a transoperative imaging guide. Digital subtraction angiography and Estereoflex stereotactic system was used. PATIENTS AND METHODS: A female patient had had a previous minor head injury. She had a progressive neurological disorder with marked visual defect, and had been diagnosed on angiography as having FCC with afferents from branches of the internal carotid artery (ACI) and external carotid artery (ACE). After failure of endovascular treatment orbito zygomatic craniotomy was done with extra intradural dissection and exposure of the antero lateral triangle of the cavernous sinus (SC). The fistula was closed completely by anterior packing with the venous component. Transoperative stereotactic angiographic checks were done to localize and control the packing. CONCLUSIONS: The Barrow's type D FCC in which embolization treatment has failed may be treated using a direct approach to the anterolateral triangle of the SC. The AC1 remained permeable, fistula was occluded and there was minimal morbidity.

[Monitorization of the jugular oxygen saturation and cerebral ischaemia in the neurocritical patient]. / Monitorización de la saturación yugular de oxígeno y la isquemia cerebral en el paciente neurocrítico.

INTRODUCTION: Catheterization of the jugular bulb is of great value in the study of cerebral metabolism, since it permits diagnosis of episodes of hypoxia and cerebral ischaemia. OBJECTIVES: To determine the frequency of the appearance of episodes of desaturation and cerebral ischaemia, whether these were simultaneous and their relation to the mortality in an intensive care unit (ICU). PATIENTS AND METHODS: We studied 21 neurocritical patients, recording the following data: age, sex, diagnosis and state at the time of discharge from the ICU (alive or dead). In the group of patients in whom the jugular bulb had been catheterised we also recorded: the side cannulated, complications, SyO2, cerebral lactate oxygen index and modified cerebral lactate oxygen. RESULTS: In 57% of the patients we catheterised the jugular bulb and in 50% of them at least one episode of desaturation was recorded, and cerebral ischaemia in 42%. Only one patient had simultaneous desaturation and cerebral ischaemia. Of the six patients in whom desaturation was detected, 5 died in the ICU (83.3%). The mortality of patients with ischaemia was only 40%. 40% of the patients with head injuries were monitored and 50% of the non monitored patients had head injuries. CONCLUSIONS: Episodes of desaturation are frequent in neurocritical patients and are associated with increased mortality. Recordings of lactate are not useful at present in the diagnosis of cerebral ischaemia.