Continuous cerebral PtO2 measurements in awake patients as a diagnostic tool in suspected chronic adult hydrocephalus--a retrospective study of 10 cases.

BACKGROUND: During the last decade of the 20th century, continuous invasive PtO(2) recording has become a widely accepted and well-established means of monitoring patients with acute traumatic or spontaneous cerebral lesions. It is considered a safe and reliable tool for the detection of hypoxia in the ICU setting. However, while invasive measurements of intracranial pressure are being used both in the ICU and in standard diagnostic protocols for suspected chronic adult hydrocephalus the same has not yet happened in relation to PtO(2) recordings. METHODS: We report our experience with the first 10 patients who have been evaluated for suspected CAH applying a protocol that includes continuous cerebral PtO(2) measurements. The relationship between PtO(2) and ICP including a characteristic wave pattern (inverse waves) on the PtO(2) curve is analyzed and clinical and outcome data are recorded. RESULTS AND CONCLUSIONS: 1. PtO(2) recording in awake patients is safe and reliable. 2. The combination of classical Lundberg waves in the ICP recording with phases of inverse waves in the PtO(2) recording may predict good outcome after shunting. 3. The effect of concomitant conditions on the brain oxygenation can be estimated for individual patients and used as a negative predictor for surgical outcome. 4. Invasive intracranial monitoring is not free of potentially serious bleeding complications and can only be performed with risk enhancing factors (AVM/haemorrhagic diathesis) excluded.

Anton's syndrome due to a giant anterior fossa meningioma. The problem of routine use of advanced diagnostic imaging in psychiatric care.

We present a case of blindness and Anton's syndrome in a psychiatric patient with late diagnosis of a giant frontal meningioma. The criteria for advanced diagnostic imaging in the psychiatric population are discussed. We conclude that MR or CT scan is indicated in psychiatric in-patients who fail to improve with standard psychiatric treatment. This strategy should be submitted to a cost-benefit analysis.

[Psychosis in a case of temporal lobe epilepsy associated with a dysembryoplastic neuroepithelial tumour]. / Psicosis en un caso de epilepsia temporal asociado a un tumor neuroepitelial disembrioplasico.

INTRODUCTION: Psychosis is an acknowledged, although infrequent, complication that occurs in 0.5 9% of all cases of epilepsy. In this work, we present a case of complex partial epilepsy due to a dysembryoplastic neuroectodermal tumour in the right hippocampus, which began as acute psychosis and was cured following its surgical removal. Both its aetiology and its pathogenesis are discussed. CASE REPORT: We describe the case of a 17 year old male with a family history of schizophrenia. While studying his last years of secondary education, and apparently well adapted, he was taken into custody and hospitalised urgently because of personality disorders. The patient suffered from somatic and auditory hallucinations, simple visual pseudohallucinations, formal alterations to his thinking, cosmovisions, delusions of influence, persecution, grandeur and of a mystic nature, with no other neurological focus. At the same time, the patient also had complex partial seizures. Magnetic resonance imaging revealed a cystic tumour in the right temporal lobe. Pathology laboratory findings showed a dysembryoplastic neuroepithelial tumour. For a period of two years following surgical removal, the schizophrenic symptoms and the complex partial seizures disappeared and the patient no longer required antipsychotic medication. CONCLUSIONS: Epileptic psychosis may be related to pathological conditions of the hippocampus. In this study we present what we believe to be the first case of a dysembryoplastic neuroepithelial tumour giving rise to such psychosis. Surgical removal of the tumour cured both entities.

[Atlanto-axial dislocation associated with os odontoideum. Reduction and fixation with sublaminar wires in Cl and pedicle screws in C2. Case report]. / Subluxación atloaxoidea. "Os odontoideum." Reducción y fijación posterior con alambres sublaminares en C1 anclados en tornillos pediculares de C2. Caso clínico.

This report describes a case of atlanto-axial dislocation associated with os odontoideum. This 18-year-old male had a traumatic episode when he was 2 years old. As a result he suffered progressive chronic myelopathy on the verge of death. For the reduction and fixation of the atlanto-axial dislocation, sublaminar wires have been used anchored to C1 and to screws placed in the pedicles of C2. The authors present a surgical technique that has not been previously described.

[Island of Reil and pharmacoresistance in epilepsy]. / Insula de Reil y epilepsia farmacorresistente.

INTRODUCTION: Over the last few years surgery has been developing, with promising results, methods to treat an important number of cases of partial epilepsy that are related, to different extents, with the lobe of the insula and display pharmacoresistance. Better knowledge of the anatomofunctional particularities of this region of the cortex, new neuroimaging and neurophysiological techniques, together with the use of the surgical microscope, stereotactic support and neuronavigation, have had a strong influence on the development of this type of surgery. CASE REPORT: In this paper we report three cases of patients with epilepsy and who were diagnosed as suffering from structural lesions of the insular region: two cavernomas and an oligodendroglioma. The preoperative study was carried out using magnetic resonance imaging, angiography and video EEG. The surgical procedure consisted in a transsylvian approach with electrocorticography, which provided us with the clinical results we have studied. CONCLUSIONS: The correct approach to the diagnosis of the epileptogenic insular lesions must include a complete neurophysiological study and preoperative planning with angiography. This allows their surgical resection through the transsylvian approach and enables us to obtain, with a very low degree of morbidity, clearly satisfactory results as regards the decrease in the number of seizures in these patients

[Hourglass retroperitoneal ganglioneuroma]. / Ganglioneuroma retroperitoneal en reloj de arena.

INTRODUCTION: Ganglioneuromas are neuroblastic tumours with a higher degree of histological differentiation and clinical benignity. They are well defined, encapsulated tumours that are made up of mature ganglionar cells. They are located mainly in the sympathetic ganglia of the mediastinum and the retroperitoneum. In this latter place they can be very large and even penetrate through the intervertebral foramen in the spinal canal in the shape of an hourglass and produce medullar compression. They are tumours that are produced in childhood or infancy. CASE REPORT: In the course of the diagnosis of an acute digestive haemorrhage in a 29 year old female patient, an abdominal computerised axial tomography (CAT) scan revealed, by chance, an abdominal retroperitoneal tumour that had introduced itself into the spinal canal in the shape of an hourglass. The patient had had lumbar pain that irradiated to the anterior side of the abdomen although up to that moment it was not considered very important. From the CAT scan and magnetic resonance imaging of the lumbar region a large, solid tumour was detected which protruded out in the shape of an hourglass from the vertebral canal at the point between L2 and L3. The patient was submitted to a surgical intervention in two stages and the tumour was removed. Because it was highly vascularised, hours before the intervention an arterial embolization of the tumour was performed in order to limit surgical bleeding. CONCLUSIONS: Due to the unspecific and late symptomatology of ganglioneuromas, we maintained the therapeutical criterion of carrying out a biopsy puncture, as well as a follow up and control if the histological study did not show up any kind of malignity. Because of the possibility of this kind of tumour becoming malign and the fact that there is little chance of guaranteeing a correct diagnosis by means of biopsy puncture, extirpation should be carried out as completely and early as possible

[Physiopathology of adult onset external hydrocephalus]. / Fisiopatología de la hidrocefalia externa del adulto.

AIMS: In this paper we report on a new disorder known as adult onset external hydrocephalus. DEVELOPMENT: There is sufficient evidence to be able to establish the pathogenic hypotheses proposed here. Adult onset external hydrocephalus is related with traumatic injuries, surgery, subarachnoid haemorrhages and neurosurgical treatment of aneurysms. This disorder is produced by an expansion of the subarachnoid and subdural space due to the rupture of some part of the arachnoid membrane, which then allows fluid to flow into this compartment. In all cases there are three essential factors: the presence of some kind of intracranial bleeding, tearing of the arachnoid membrane and an excessive quantity of cerebrospinal fluid (CSF), probably because of reduced reabsorption by the arachnoid granulations. The degree to which reabsorption of CSF is affected is what conditions the prognosis in these patients rather than the accumulation within the subarachnoid or subdural cavity. Once this type of hydrocephalus is confirmed the patient requires a ventricular CSF shunt. We offer a classification of the different types of presentation. It is not very clear exactly when this shunt should be inserted or how to treat the isolated extra axial collection in absence of ventricular dilatation. CONCLUSIONS: The physiopathology of adult onset external hydrocephalus is a scientific challenge that will lay down the foundations for treatment with ventriculoperitoneal shunts

[Fusiform aneurysm of the middle cerebral artery]. / Aneurisma fusiforme de la arteria cerebral media.

Introduction. The main objective of the treatment of intracranial aneurysms is to isolate them from the cerebral blood circulation. A fusiform aneurysm, because of its shape, cannot be treated using the usual techniques and usually requires techniques of arterial reconstruction and revascularization using by pass. Currently it is possible to find the vascular territories with the greatest risk of causing neurological defects and where revascularization is necessary. CASE REPORT. A 20 year old man with no previous history of illness who had several transient ischaemic episodes. Emergency laboratory tests, ECG and plain chest Xray were all normal. Imaging investigations showed the presence of a fusiform aneurysm of the anterosuperior division of the right middle cerebral artery. No associated systemic disease was detected. Wada s test showed the vascular territory with the greatest risk of neurological deficit. Extra intra cranial by pass was done from the right superficial temporal artery to the distal portion of the anteriorsuperior branch of this artery. The operation was done using a right pterion approach with dissection of the superficial temporal artery, and the aneurysm, trapping and termino lateral anastomosis. Cerebral protectors and mild hypothermia were used during the operation. The post operative course was uneventful. Anatomo pathological diagnosis was of an atherosclerotic fusiform aneurysm with osseous and chondroid metaplasia. After six months follow up the patient remains asymptomatic. Discussion and conclusions. Treatment of fusiform cerebral aneurysms is complex and usually requires procedures for cerebral revascularization. Correct pre operative evaluation is essential to identify the vascular territory with the greatest risk of causing neurological deficit. Wada s test is useful for this, since it permits selective evaluation of the different vascular territories safely and quickly. High or low flow by pass of these territories prevents cerebral ischaemia and permits the treatment of choice for these aneurysms.

[Surgical indications in non traumatic intracerebral haemorrhage]. / Indicaciones quirúrgicas de la hemorragia intracerebral no traumática.

INTRODUCTION AND OBJECTIVE: The treatment of non traumatic intra cerebral haemorrhage is one of the therapeutic challenges at the present time. In spite of present day technology and advances in understanding its physiopathology, the prognosis is the same as it was fifteen years ago. We review the surgical treatments used to date and their results, and describe new approaches to investigation so as to try to establish the most suitable surgical indications. DEVELOPMENT: To date six randomised studies have been done to evaluate surgical treatment as compared with conservative treatment of intracerebral haemorrhage. There is no clear evidence that surgical treatment is better than conservative management. Recent investigations in this field consider cerebral blood flow, oedema and the degradation products of blood. CONCLUSIONS: Indications for surgery in intracerebral haemorrhage are: a) cerebral haemorrhage > 3cm, with neurological deterioration or with signs of compression of the brainstem and hydrocephalus due to obstruction of the ventricle; b) haemorrhage associated with an anatomical lesion such as an aneurysm, arteriovenous malformation or angioma cavernosa, when the prognosis of the patient is good and the lesion is surgically accessible; c) a young patient with a moderate or large lobular haemorrhage; d) it is recommended that surgery, when applicable, be undertaken during the first 12 hours after onset of the condition; e) when surgery is used, stereotaxic surgery may lead to better results.

[Microvascular decompression of trigeminal neuralgia caused by vertebrobasilar dolichoectasia]. / Descompresión microvascular de la neuralgia del trigémino causado por dolicoectasia vertebrobasilar.

INTRODUCTION: Trigeminal neuralgia due to vertebrobasilar dolichoectasia is an acquired disease whose true incidence is not known. Microvascular decompression is the most effective technique both for symptomatic relief and for the conservation of nerve structure and function, in spite of the potential complications of all major surgery. In cases which are drug-resistant and have a life expectancy of over five years, microvascular decompression may be done using several techniques. CLINICAL CASES: We present three cases with drug-resistant trigeminal neuralgia. One patient had a history of previous cerebrovascular ischaemia, another had arterial and pulmonary hypertension. In all cases vertebrobasilar dolichoectasia was seen on magnetic resonance. Microvascular decompression of the trigeminal nerve was done, placing pieces of Teflon between the tentorium and the artery to displace it. Postoperatively the pain disappeared in two cases and was much relieved in the other, making good progress with no complications. CONCLUSIONS: Trigeminal neuralgia due to vertebrobasilar dolichoectasia is a progressive acquired disease. The imaging technique of choice is magnetic resonance. Cerebral angiography may be useful for confirmation. This new technique of microvascular decompression avoids excessive manipulation of the ectatic, arteriosclerotic basilar artery and also pulsatile compression, so that the risk of secondary effects is reduced and the efficacy of the decompression maintained. Further cases are needed to confirm the usefulness of this technique.

[Surgical treatment of spondylodiscitis in ankylosing spondylitis. Two cases report]. / Tratamiento quirúrgico de la espondilodiscitis en la espondilitis anquilosante. Presentación de dos casos.

INTRODUCTION: Spondylodiscitis in ankylosing spondylitis has a prevalence of 5%. Mechanical and inflammatory factors are involved in its pathogenesis. Neurosurgical operation is required when neurological complications or vertebral instability occur. Surgery is complicated by the increased fragility of the vertebral column, advanced stage of the disease in many patients, and serious pulmonary complications. CLINICAL CASES: We report two patients who had had ankylosing spondylitis for over 20 years. Both presented complaining of symptoms for several months with lumbar pain and signs of spinal cord lesions. There were signs of discitis and destruction of the adjacent vertebral bodies at T11 T12 and T12 L1 on imaging investigations of the first and second patient respectively. In both cases an anterior approach was used for discectomay and resection of the adjacent vertebral plates. Then an autologous rib graft was done, and anterolateral fixation with plate and screws to the adjacent vertebral bodies. The patients condition improved. Their pain and previous clinical neurological disorder had disappeared by 5 and 1 year later. DISCUSSION AND CONCLUSIONS: The prevalence of patients operated on for spondylodiscitis in the context of ankylosing spondylitis is not known. Dorsolumbar pain with inflammatory characteristics of recent onset in patients with chronic ankylosing spondylitis should lead to suspicion of spondylodiscitis. Although it may be related to previous trauma, discitis is the fundamental mechanism. MR is the most sensitive imaging technique. There may be marked osteoporosis and stenosis of the vertebral canal together with marked ossification of all the paraspinal ligaments. This hinders the approach to the vertebral bodies and their subsequent fixation. Decompression of the vertebral canal using an anterior approach (thoracotomy or thoraco phreno laparotomy) and anterior spinal fixation is the treatment of choice in cases with neurological involvement or involvement of the anterior and medial columns of Denis.

[Glioblastoma multiforme in a patient with a second complete remission of Hodgkin's disease]. / Glioblastoma multiforme en un paciente en segunda remisión completa de enfermedad de Hodgkin.

INTRODUCTION: Treatment of Hodgkin's disease contributes to the appearance of second malignant neoplasias such as glioblastoma multiforme. Amongst the known etiological hypotheses is alteration of the immune system secondary to chemotherapy. We seek new hypotheses relating this rare association. With better understanding of the causes provoking the appearance of these tumors new strategies could be designed for treatment. CLINICAL CASE: A 26 year old man who was in a second complete remission of a nodular sclerosis type of Hodgkin's disease complained of headache and evening fever. Magnetic resonance showed a right frontal 6 x 5 x 4 cm cystic lesion with a vascular solid zone, with irregular margins and surrounded by vasogenic oedema. On investigation there were reduced levels of immunoglobulins G (522 mg/dl)) and M (38 mg/dl). The lesion was removed surgically and histological studies confirmed the diagnosis of glioblastoma multiforme. CONCLUSIONS: Although immunosuppression may contribute to the appearance of secondary neoplasia, it is not the only hypothesis in the case of glioblastoma multiforme occurring in a patient with Hodgkin's disease. In the literature similar cases, both isolated and familial, have been reported and may have been affected by genetic or environmental factors which are as yet unknown.