Neuroinflammation in Parkinson's Disease: From Gene to Clinic: A Systematic Review.

Parkinson's disease is a neurodegenerative disease whose progression and clinical characteristics have a close bidirectional and multilevel relationship with the process of neuroinflammation. In this context, it is necessary to understand the mechanisms involved in this neuroinflammation-PD link. This systematic search was, hereby, conducted with a focus on the four levels where alterations associated with neuroinflammation in PD have been described (genetic, cellular, histopathological and clinical-behavioral) by consulting the PubMed, Google Scholar, Scielo and Redalyc search engines, including clinical studies, review articles, book chapters and case studies. Initially, 585,772 articles were included, and, after applying the inclusion and exclusion criteria, 84 articles were obtained that contained information about the multilevel association of neuroinflammation with alterations in gene, molecular, cellular, tissue and neuroanatomical expression as well as clinical-behavioral manifestations in PD.

Tumor microenvironment differences between primary tumor and brain metastases.

The present review aimed to discuss contemporary scientific literature involving differences between the tumor microenvironment (TME) in melanoma, lung cancer, and breast cancer in their primary site and TME in brain metastases (BM). TME plays a fundamental role in the behavior of cancer. In the process of carcinogenesis, cells such as fibroblasts, macrophages, endothelial cells, natural killer cells, and other cells can perpetuate and progress carcinogenesis via the secretion of molecules. Oxygen concentration, growth factors, and receptors in TME initiate angiogenesis and are examples of the importance of microenvironmental conditions in the performance of neoplastic cells. The most frequent malignant brain tumors are metastatic in origin and primarily originate from lung cancer, breast cancer, and melanoma. Metastatic cancer cells have to adhere to and penetrate the blood-brain barrier (BBB). After traversing BBB, these cells have to survive by producing various cytokines, chemokines, and mediators to modify their new TME. The microenvironment of these metastases is currently being studied owing to the discovery of new therapeutic targets. In these three types of tumors, treatment is more effective in the primary tumor than in BM due to several factors, including BBB. Understanding the differences in the characteristics of the microenvironment surrounding the primary tumor and their respective metastasis might help improve strategies to comprehend cancer.

Neurologic manifestations of elderly patients with cancer.

BACKGROUND: The incidence of cancer is an age-related phenomenon; therefore, the interest on clinical manifestations, diagnostic approach and treatment strategies for older patients diagnosed with cancer has increased lately. Neurologic symptoms are one of the main reasons for consultation and a common cause of decreased quality of life among cancer patients. AIMS: To identify the neurologic manifestations of patients ≥ 65 years of age diagnosed with cancer and compare them to those presented by a younger population. METHODS: Cross-sectional study of cancer patients referred to neuro-oncologic consultation at a Cancer Center. Sociodemographic, health and oncologic characteristics were obtained through clinical interviews. Clinical symptoms and final diagnoses were also recorded. Bivariate logistic regression analyses were carried out. RESULTS: More than 17,000 neuro-oncologic consultations in 3015 patients were given, 27% (n = 811) of them were ≥ 65 years of age. Most frequent primary neoplasms in elderly patients were: breast cancer, hematologic neoplasms, gynecological, urologic, skin and head and neck cancers. Elderly patients had an increased risk of having the following diagnoses: abnormal movements, stroke, peripheral vertigo, dementia, degenerative spine disorder, and delirium. DISCUSSION: Elderly patients are considered a vulnerable population. The present study found that the main neoplasms associated with neurological manifestations are similar to the reported previously. We described the main symptoms that led to a neuro-oncological assessment. Moreover, we enlisted the final diagnoses made on elderly patients and compared them with others reports. To the best of our knowledge, this study provides valuable information, since there is scarce evidence in the literature about this topic. CONCLUSION: Identifying the frequency and correlation of neurologic manifestations in older cancer patients will allow for the implementation of timely multidisciplinary care in an attempt to improve these patients' health-related quality of life.

Comorbidities, Clinical Features, and Prognostic Implications of Cancer Patients with Cerebrovascular Disease.

PURPOSE: The objective of this study was to identify and describe the comorbidities, clinical features, and prognostic implications of cancer patients with cerebrovascular disease. MATERIALS AND METHODS: All patients with cerebrovascular disease (CVD) seen in the neuro-oncology unit at a cancer referral center from April 2010 to November 2016 were included; demographic, oncologic diagnosis, risk factors, and prognostic considerations were presented as well. RESULTS: We report on 256 patients with CVD and cancer, of whom 66% were women. The mean age at the time CVD occurred was 56 years. The most frequently associated malignancies were gynecologic (including breast cancer), hematologic, head and neck, and urologic. The men had more smoking and alcohol consumption history, hemorrhagic CVD, and urologic and hematologic malignancies. The women, besides gynecologic cancer, had more ischemic CVD. Thrombotic CVD, followed by embolic and hemorrhagic CVDs, was more frequent. A comorbid condition besides cancer was found in 71% of the patients. The most frequent clinical presentation was focal motor weakness, altered mental status, and aphasia. The 10-year mortality was 59%; higher rates were found in men, in those with hemorrhagic CVD, in tobacco users, and in those with altered mental status. CONCLUSIONS: Cancer is a well-known risk factor for stroke, which has been associated with a higher frequency in cancer. We found that ischemic stroke due to thrombosis and cardioembolism was more common, and gender, comorbidities, clinical presentation, and type of CVD, but not cancer type, were elements associated with prognosis.

Central Nervous System Metastases in Patients With Cervical Carcinoma.

INTRODUCTION: Cervical cancer (CC) is the most common malignancy throughout developing countries, although considered rare, central nervous system metastasis (CNSm) does occur. OBJECTIVE: This study aimed to describe our experiences and compare them to other published cases. MATERIALS AND METHODS: From May 2009 to August 2015, the files of all patients with CC treated at our referral center were reviewed. RESULTS: We found 27 patients with CC and CNSm. Mean age at the time of CNS diagnosis was 50 ± 11 years, mean interval between initial CC and CNSm was 46 months; the most frequent initial International Federation of Gynecology and Obstetrics stage was IIB with 17 patients followed by IB in 4. Fifty-nine percent of patients had lung metastases at the time CNSm were diagnosed. Headache was the most common symptom, followed by weakness, altered mental status, and ataxia/cerebellar. Mean survival was 8.2 months after CNSm was discovered; 3 patients are still alive. CONCLUSIONS: The present study describes the largest series of patients with CNSm from CC; this rare complication should be suspected in patients with CC who present with headache, ataxia, cranial nerve palsy, visual disturbance, altered mental status, focal weakness, or other neurological symptom, without other plausible explanation.

[First Mexican consensus on recommendations of the multidisciplinary care of patients with glioblastoma multiforme (GBM): Mexican Interdisciplinary Group on Neuro-Oncology Research (GIMINO)]. / Primer consenso mexicano sobre recomendaciones de la atención multidisciplinaria del paciente con glioblastoma multiforme (GBM). Grupo Interdisciplinar Mexicano de Investigación en Neurooncología (GIMINO).

Glioblastoma multiforme is one of the most aggressive central nervous system tumors and with worse prognosis. Until now,treatments have managed to significantly increase the survival of these patients, depending on age, cognitive status, and autonomy of the individuals themselves. Based on these parameters, both initial or recurrence treatments are performed, as well as monitoring of disease by imaging studies. When the patient enters the terminal phase and curative treatments are suspended, respect for the previous wishes of the patient and development and implementation of palliative therapies must be guaranteed.

Clivus-Cervical Stabilization through Transoral Approach in Patients with Craniocervical Tumor: Three Cases and Surgical Technical Note.

Craniocervical tumors lead to cervical pain, instability, and neurological symptoms, reducing the quality of life. Effective surgical intervention at the craniocervical junction (CCJ) is critical and complex, involving comprehensive approaches and advanced reconstructive techniques. This study, conducted at Mexico City's National Institute of Cancerology, focused on three surgical cases that occurred in 2023 involving tumors at the CCJ: two chordomas and one prostate adenocarcinoma. We utilized a specialized technique: clivus-cervical stabilization reinforced with a polymethylmethacrylate (PMMA)-filled cervical mesh. Postoperatively, patients showed marked neurological recovery and reduced cervical pain, with enhanced Karnofsky and Eastern Cooperative Oncology Group (ECOG) scores indicating improved life quality. The surgical technique provided excellent exposure and effective tumor resection, utilizing PMMA-filled cervical mesh for stability. Tumoral lesions at the CCJ causing instability can be surgically treated through a transoral approach. This type of approach should be performed with precise indications to avoid complications associated with the procedure.

Surgical treatment of orbital tumors in a single center: Analysis and results.

Background: Orbital tumors, arising within the bony orbit and its contents, present diverse challenges due to their varied origins and complex anatomical context. These tumors, classified as primary, secondary, or metastatic, are further subdivided into intraconal and extraconal based on their relationship with the muscle cone. This classification significantly influences surgical approach and management. This study highlights surgical experiences with orbital tumors, underscoring the importance of tailored surgical approaches based on the lesion's site and its proximity to the optic nerve. Methods: This retrospective study at the National Institute of Cancer's Head and Neck Department (2005-2014) analyzed 29 patients with orbital tumors treated with surgery, radiotherapy, chemotherapy, or combinations of them. Patient demographics, tumor characteristics, and treatment responses were evaluated using computed tomography (CT), magnetic resonance imaging, and positron emission tomography-CT imaging. Malignant tumors often required orbital exenteration and reconstruction, highlighting the study's commitment to advancing orbital tumor treatment. Results: 29 patients (18 females and 11 males, age 18-88 years, mean 53.5 years) with orbital tumors exhibited symptoms such as decreased vision and exophthalmos. Tumors included primary lesions like choroidal melanoma and secondary types like epidermoid carcinoma. Treatments varied, involving a multidisciplinary team for surgical approaches like exenteration, with follow-up from 1 to 9 years. Radiotherapy and chemotherapy were used for specific cases. Conclusion: Our study underscores the need for a multidisciplinary approach in treating orbital tumors, involving various surgical specialists and advanced technologies like neuronavigation for tailored treatment. The integration of surgery with radiotherapy and chemotherapy highlights the effectiveness of multidimensional treatment strategies.

The Vertebrobasilar Trunk and Its Anatomical Variants: A Microsurgical Anatomical Study.

BACKGROUND: The trunk of the basilar artery has not been included in microanatomy studies. Anatomical variants of the perforant branches of the vertebrobasilar trunk and their relationship with neural structures are very important in surgical approaches. Surgical dissection for the treatment of vascular lesions requires a perfect knowledge of the microsurgical anatomy. METHODS: We conducted a descriptive analysis of 50 brains, which were fixed with formalin at 10% for 2 weeks, and the arterial system was injected with colored latex. After microsurgical dissection, it was divided into three segments: the lower portion went from the anterior spinal artery to the anteroinferior cerebellar artery, the middle segment was raised from the upper limit of the lower portion to the origin of the superior cerebellar artery, and the upper segment ranged from the previous portion until the origin of the posterior cerebral artery. RESULTS: The basilar artery had an average length of 30 mm. The average diameter at its junction with the vertebral arteries was 4.05 mm. The average middle segment was 3.4 mm in diameter and 15.2 mm in length. The diameter of the upper segment was 4.2 mm, and its average length was 3.6 mm. The average number of bulbar arteries was three, and their average diameter was 0. 66 mm. The number of caudal perforator arteries were five on average, with a diameter of 0.32 mm. We found three rare cases of anatomical variants in the vertebra-basilar junction. CONCLUSIONS: The basilar artery emits penetrating branches in its lower, middle, and upper portions. The origin of penetrating branches was single or divided after forming a trunk. However, we observed long branches from perforant arteries.

Low-Cost 3D Models for Cervical Spine Tumor Removal Training for Neurosurgery Residents.

BACKGROUND AND OBJECTIVES: Spinal surgery, particularly for cervical pathologies such as myelopathy and radiculopathy, requires a blend of theoretical knowledge and practical skill. The complexity of these conditions, often necessitating surgical intervention, underscores the need for intricate understanding and precision in execution. Advancements in neurosurgical training, especially with the use of low-cost 3D models for simulating cervical spine tumor removal, are revolutionizing this field. These models provide the realistic and hands-on experience crucial for mastering complex neurosurgical techniques, filling gaps left by traditional educational methods. MATERIALS AND METHODS: This study aimed to assess the effectiveness of 3D-printed cervical vertebrae models in enhancing surgical skills, focusing on tumor removal, and involving 20 young neurosurgery residents. These models, featuring silicone materials to simulate the spinal cord and tumor tissues, provided a realistic training experience. The training protocol included a laminectomy, dural incision, and tumor resection, using a range of microsurgical tools, focusing on steps usually performed by senior surgeons. RESULTS: The training program received high satisfaction rates, with 85% of participants extremely satisfied and 15% satisfied. The 3D models were deemed very realistic by 85% of participants, effectively replicating real-life scenarios. A total of 80% found that the simulated pathologies were varied and accurate, and 90% appreciated the models' accurate tactile feedback. The training was extremely useful for 85% of the participants in developing surgical skills, with significant post-training confidence boosts and a strong willingness to recommend the program to peers. CONCLUSIONS: Continuing laboratory training for residents is crucial. Our model offers essential, accessible training for all hospitals, regardless of their resources, promising improved surgical quality and patient outcomes across various pathologies.

Latex vascular injection as method for enhanced neurosurgical training and skills.

Background: Tridimensional medical knowledge of human anatomy is a key step in the undergraduate and postgraduate medical education, especially in surgical fields. Training simulation before real surgical procedures is necessary to develop clinical competences and to minimize surgical complications. Methods: Latex injection of vascular system in brain and in head-neck segment is made after washing out of the vascular system and fixation of the specimen before and after latex injection. Results: Using this latex injection technique, the vascular system of 90% of brains and 80% of head-neck segments are well-perfused. Latex-injected vessels maintain real appearance compared to silicone, and more flexible vessels compared to resins. Besides, latex makes possible a better perfusion of small vessels. Conclusions: Latex vascular injection technique of the brain and head-neck segment is a simulation model for neurosurgical training based on real experiencing to improve surgical skills and surgical results.

Intraoperative Ultrasound: An Old but Ever New Technology for a More Personalized Approach to Brain Tumor Surgery.

BACKGROUND: Although the use of transcranial ultrasound dates to the mid-20th century, the main purpose of this research work is to standardize its use in the resection of brain tumors. This is due to its wide availability, low cost, lack of contraindications, and absence of harmful effects for the patient and medical staff, along with the possibility of real-time verification of the complete resection of tumor lesions and minimization of vascular injuries or damage to adjacent structures. METHODS: A retrospective study was conducted from June to December 2022. The study included eight patients (three men and five women) aged between 32 and 76 years. Histological examination revealed two high-grade gliomas, one low-grade glioma, and five metastatic lesions. RESULTS: The low-grade glioma appeared as a homogeneously echogenic structure and easily distinguishable from brain parenchyma, whereas metastases and high-grade gliomas showed higher echogenicity, being identified as malignant lesions due to areas of low echogenicity necrosis and peritumoral edema identified as a hyperechogenic structure. CONCLUSIONS: The use of intraoperative transcranial ultrasound constitutes an important tool for neurosurgeons during tumor resection. Although it is easy to use, intraoperative ultrasound requires a relatively short learning curve and a good understanding of the fundamentals of ultrasound. Its main advantage over neuronavigation is that it is not affected by the "brain shift" phenomenon that commonly occurs during tumor resection, since the ultrasound images are updated during surgery.

Exploring Pathways for Pain Relief in Treatment and Management of Lumbar Foraminal Stenosis: A Review of the Literature.

BACKGROUND: Lumbar foraminal stenosis (LFS) involves the narrowing of neural foramina, leading to nerve compression, significant lower back pain and radiculopathy, particularly in the aging population. Management includes physical therapy, medications and potentially invasive surgeries such as foraminotomy. Advances in diagnostic and treatment strategies are essential due to LFS's complexity and prevalence, which underscores the importance of a multidisciplinary approach in optimizing patient outcomes. METHOD: This literature review on LFS employed a systematic methodology to gather and synthesize recent scientific data. A comprehensive search was conducted across PubMed, Scopus and Cochrane Library databases using specific keywords related to LFS. The search, restricted to English language articles from 1 January 2000 to 31 December 2023, focused on peer-reviewed articles, clinical trials and reviews. Due to the heterogeneity among the studies, data were qualitatively synthesized into themes related to diagnosis, treatment and pathophysiology. RESULTS: This literature review on LFS analyzed 972 articles initially identified, from which 540 remained after removing duplicates. Following a rigorous screening process, 20 peer-reviewed articles met the inclusion criteria and were reviewed. These studies primarily focused on evaluating the diagnostic accuracy, treatment efficacy and pathophysiological insights into LFS. CONCLUSION: The comprehensive review underscores the necessity for precise diagnostic and management strategies for LFS, highlighting the role of a multidisciplinary approach and the utility of a unified classification system in enhancing patient outcomes in the face of this condition's increasing prevalence.

Mexican Multicenter Experience of Metastatic Spinal Disease.

Background Spinal metastatic disease is a silent progressive cancer complication with an increasing prevalence worldwide. The spine is the third most common site where solid tumors metastasize. Complications involved in spinal metastasis include root or spinal cord compression, progressing to a declining quality of life as patient autonomy reduces and pain increases. The main objective of this study is to report the incidence of patients and typology of spinal metastases in three reference centers in Mexico. Methodology Retrospective cohorts of patients diagnosed with spinal metastases from January 2010 to February 2017 at the National Cancer Institute, National Rehabilitation Institute, and the Traumatology and Orthopedics Hospital "Lomas Verdes" in Mexico City were analyzed. Results A total of 326 patients (56% males) with spinal metastases were reported. The mean age was 58.06 ± 14.05 years. The main sources of spinal metastases were tumors of unknown origin in 53 (16.25%) cases, breast cancer in 67 (20.5%) cases, prostate cancer in 59 (18%) cases, myeloma in 24 (7.4%) cases, and lung cancer in 23 (7.1%) cases. Conclusions The data obtained in this analysis delivers an updated standpoint on Mexico, providing the opportunity to distinguish the current data from global references. Collecting more epidemiological information for better recording of cancer and its associated complications, as well as further studies on them, is necessary.

Clinical Outcome After Epidural Spinal Cord Stimulation in Patients With Severe Traumatic Brain Injury.

INTRODUCTION:  Epidural spinal cord stimulation is a minimally invasive procedure with a growing list of indications. It has a good safety profile and analgesic effect, reduces the severity of spasticity, and activates various brain regions. The purpose of this study is to evaluate the clinical outcome of epidural spinal cord stimulation in patients with spastic syndrome and chronic disorders of consciousness resulting from severe traumatic brain injury (sTBI). METHODS: Between 2021 and 2023, an epidural spinal cord stimulation test was performed in 34 patients with central paresis, severe hypertonia, and chronically altered consciousness following sTBI. The severity of spastic syndrome was assessed using a modified Ashworth scale. All patients underwent implantation of a cylindrical eight-contact test epidural electrode at C3-C5 cervical level, followed by neurostimulation and selection of individual modes. Tonic stimulation at a frequency of 60 Hz, "burst" mode, or a combination of the two was used. RESULTS:  Epidural spinal cord stimulation was administered for an average of 4 ± 1.5 days, with tonic stimulation mode applied in 15 (44.1%) patients, "burst" mode in 10 (29.4%), and a combination of two in nine (26.5%) patients. A reduction in spasticity with clinical improvement was observed in 21 patients (61.8%). The Ashworth scale scores for distal and proximal upper extremities decreased from 3 points to 2.5 points and from 3 points to 2 points, respectively. This was significant in the right upper limbs (p = 0.0152 distally and p = 0.0164 proximally). Significant improvements were also seen in the lower extremities. Active movements in paretic limbs increased or appeared in 12 patients (35.3%), while a heightened level of consciousness was observed in six patients (17.6%). Permanent neurostimulator implantation was performed in 12 patients (35.3%), with no reported surgical complications. CONCLUSION:  Epidural spinal cord stimulation shows promise as an invasive rehabilitation method for patients with sTBI sequelae. Its use reduced the severity of spastic syndrome in over half of patients and increased active movements in paretic limbs in over a third. Notably, neuromodulation at the cervical level yielded pronounced effects on the upper extremities, both proximally and distally. Findings regarding consciousness level improvement are particularly intriguing but warrant further validation through randomized trials.

Challenging assumptions: "unveiling meritocracy's reality in neurosurgery".

Introduction: Meritocracy, a concept revered as the cornerstone of fairness and equal opportunity, is critically examined in the context of neurosurgery. This article challenges the notion that success in this demanding field is solely determined by individual abilities and effort. It reveals that factors such as background, gender, and socioeconomic status significantly influence one's career trajectory. By investigating how these systemic barriers impact admissions to neurosurgical training programs and professional advancement, the paper underscores the complexity of meritocracy in neurosurgery, suggesting that the meritocratic ideal is more nuanced and influenced by external variables than commonly believed. Results: Certain universities deemed elite offer a curriculum divergent from that of their counterparts in low and middle-income countries. Students at these "elite" institutions gain exposure to new technologies and research incentives, which brings us to the realm of research. Remarkably, 75% of articles originating from developed nations account for just 25% of traumatic brain injury cases. This disparity highlights a significant research imbalance, and the common refrain underscores the need to bolster research capabilities in low-income countries. For neurosurgeons in the developing world, engaging in research often becomes a luxury due to multifaceted challenges. Financial barriers, including publication costs and paywalls for accessing articles, pose significant hurdles. Comparing salaries between countries underscores the glaring divide according to "Neurosurgeon Salary" in 2024. Neurosurgeons in the United States receive a median salary of $412,000 dollars per year, compared to $13,200 dollars in Latin America, as of June 2023. Given such incongruities, the prospect of even attending conferences or workshops abroad remains difficult for neurosurgeons from developing nations. Research isn't cast aside due to a lack of interest but due to resource limitations. The present landscape demands reconsideration. Conclusion: We underscore the journey towards a more inclusive and equitable future in neurosurgery as not just a goal, but a dynamic process fuelled by resilience, collaboration, and a commitment to diversity. The narrative promotes a collective endeavour to dismantle barriers and embrace innovation, emphasizing the importance of mentorship, cross-institutional collaboration, and the amplification of underrepresented voices.

Quantifying Lumbar Foraminal Volumetric Dimensions: Normative Data and Implications for Stenosis-Part 2 of a Comprehensive Series.

INTRODUCTION: Lumbar foraminal stenosis (LFS) occurs primarily due to degenerative changes in older adults, affecting the spinal foramina and leading to nerve compression. Characterized by pain, numbness, and muscle weakness, LFS arises from structural changes in discs, joints, and ligaments, further complicated by factors like inflammation and spondylolisthesis. Diagnosis combines patient history, physical examination, and imaging, while management ranges from conservative treatment to surgical intervention, underscoring the need for a tailored approach. MATERIALS AND METHODS: This multicenter study, conducted over six years at a tertiary hospital, analyzed the volumetric dimensions of lumbar foramina and their correlation with nerve structures in 500 patients without lumbar pathology. Utilizing high-resolution MRI with a standardized imaging protocol, eight experienced researchers independently reviewed the images for accurate measurements. The study emphasized quality control through the calibration of measurement tools, double data entry, validation checks, and comprehensive training for researchers. To ensure reliability, interobserver and intraobserver agreements were analyzed, with statistical significance determined by kappa statistics and the Student's t-test. Efforts to minimize bias included blinding observers to patient information and employing broad inclusion criteria to mitigate referral and selection biases. The methodology and findings aim to enhance the understanding of normal lumbar foramina anatomy and its implications for diagnosing and treating lumbar conditions. RESULTS: The study's volumetric analysis of lumbar foramina in 500 patients showed a progressive increase in foraminal volume from the L1/L2 to the L5/S1 levels, with significant enlargement at L5/S1 indicating anatomical and biomechanical complexity in the lumbar spine. Lateral asymmetry suggested further exploration. High interobserver and intraobserver agreement levels (ICC values of 0.91 and 0.95, respectively) demonstrated the reliability and reproducibility of measurements. The patient cohort comprised 58% males and 42% females, highlighting a balanced gender distribution. These findings underscore the importance of understanding foraminal volume variations for lumbar spinal health and pathology. CONCLUSION: Our study significantly advances spinal research by quantifying lumbar foraminal volumes, revealing a clear increase from the L1/L2 to the L5/S1 levels, indicative of the spine's adaptation to biomechanical stresses. This provides clinicians with a precise tool to differentiate between pathological narrowing and normal variations, enhancing the detection and treatment of lumbar foraminal stenosis. Despite limitations like its cross-sectional design, the strong agreement in measurements underscores the method's reliability, encouraging future research to further explore these findings' clinical implications.

[Neurosurgical importance of the superior petrosal venous complex]. / Importancia neuroquirúrgica del complejo venoso petroso superior.

OBJECTIVE: To study the microsurgical anatomy of the superior petrosal venous complex (SPVC). MATERIAL AND METHODS: We conducted a descriptive and prospective study. Six injected specimens were used (12 sides). The microsurgical anatomy of the SPVC was studied by means of an anterior, retrosigmoid and transpetrosal approach. Neurosurgical equipment, 0-degree rigid endoscopy and OPMI-1 surgical microscope with 6× to 20× magnification were all used in this study. The venous drainage pattern toward the superior petrosal sinus was analysed, as were the formation of tributary veins, the relationship with the trigeminal nerve and the anatomical variants of SPVC. RESULTS: The SPVC was present in all cases. A tributary, cerebellopontine fissure vein was identified in 100% of cases. The venous drainage pattern of the SPVC was divided into medial, intermediate and lateral with respect to the suprameatal crest. The SPVC was simple in 8 sides and duplicate in 4 sides. A triangle formed by the tentorium, the SPVC and part of the tentorial and petrosal surface of the cerebellum was also observed in the study. This triangle was called the petrosal-tentorial triangle. CONCLUSIONS: It is important to understand the microsurgical anatomy of the SPVC. Therefore, we propose the petrosal-tentorial triangle as a neurosurgical route for the management of pathologies from the cerebellopontine angle to the superior petroclival region.

Multiple Myeloma Treatment Challenges: A Case Report of Vertebral Artery Pseudoaneurysm Complicating Occipitocervical Arthrodesis and a Review of the Literature.

Multiple myeloma is a hematological neoplasm that frequently affects the spinal column. Less than a fifth of this vertebral involvement corresponds to the cervical spine and cranio-cervical junction. When there is instability or neurological involvement due to compression or deformity, approaches for anterior decompression and occipitocervical stabilization are required. The correct managment of vertebral artery aneurysm associated with occipitocervical arthrodesis requires extensive knowledge of anatomy and pathology. We present a case of a vertebral pseudoaneurysm that occurred late after the resection of a C1-C2 vertebral body multiple myeloma lesion managed with endonasal endoscopic approach and posterior occipitocervical arthrodesis as well as a systematic review of the related literature. The patient recovered well, without major neurological deficits.

Prognostic Factors Associated With Overall Survival in Breast Cancer Patients With Metastatic Spinal Disease.

Introduction The spine is the third most frequent site of metastasis, after the lungs and liver, in breast cancer patients. The current treatment modality is based on the prognosis calculated according to multiple clinical features; therefore, multiple scores have been developed to make the therapeutic decision; however, there are no specific scores to take an adequate therapeutic approach in the treatment of vertebral metastases due to breast cancer. The aim of the study is to identify the prognostic factors associated with survival in breast cancer patients with spinal metastatic disease. Methods A retrospective cohort study was carried out at the National Cancerology Institute (INCAN) in Mexico City from January 2011 to December 2017. To this extent, 56 consecutive cases of patients with breast cancer were included. Multiple demographic, laboratory, and clinical variables were taken into account for the survival calculation. Kaplan-Meier graphs and log-rank tests were performed to observe significant differences by subgroups in survival, and Cox regression was used for multivariate analysis. Results Concerning the survival analysis, the patients who presented extra-spinal metastases, an unstable spine, and Frankel grade C had a statistically significantly worse prognosis. In the multivariate analysis, the variables included extra-spinal metastases, age >50 years, spinal instability, serum alkaline phosphatase, and CA 15.3 serum levels, finding statistical significance with a p=0.015. Conclusion Prognostic factors associated with shorter overall survival in breast cancer patients with metastatic spinal disease were the presence of extra-spinal metastases and spinal instability. Additionally, the use of the Tomita and Tokuhashi scores for patients with breast cancer and spinal metastases is not justified at present. The study should be continued with a larger population to decrease biases and obtain a more homogeneous sample, as well as to obtain a personalized score to determine a more efficient treatment for these patients.