Beyond uncal herniation: An updated diagnostic reappraisal of ipsilateral hemiparesis and the Kernohan-Woltman notch phenomenon.

PURPOSE: This works comprehensively analyses a modern cohort of patients with ipsilateral hemiparesis (IH) and discusses the pathophysiological theories elaborated to explain this paradoxical neurological sign according to the findings from contemporary neuroimaging and neurophysiological techniques. METHODS: A descriptive analysis of the epidemiological, clinical, neuroradiological, neurophysiological, and outcome data in a series of 102 case reports of IH published on since the introduction of CT/MRI diagnostic methods (years 1977-2021) was performed. RESULTS: IH mostly developed acutely (75.8%) after traumatic brain injury (50%), as a consequence of the encephalic distortions exerted by an intracranial haemorrhage eventually causing contralateral peduncle compression. Sixty-one patients developed a structural lesion involving the contralateral cerebral peduncle (SLCP) demonstrated by modern imaging tools. This SLCP showed certain variability in its morphology and topography, but it seems pathologically consistent with the lesion originally described in 1929 by Kernohan & Woltman. The study of motor evoked potentials was seldom employed for the diagnosis of IH. Most patients underwent surgical decompression, and a 69.1% experienced some improvement of the motor deficit. CONCLUSIONS: Modern diagnostic methods support that most cases in the present series developed IH following the KWNP model. The SLCP is presumably the consequence of either compression or contusion of the cerebral peduncle against the tentorial border, although focal arterial ischemia may also play a contributing role. Some improvement of the motor deficit should be expected even in the presence of a SLCP, provided the axons of the CST were not completely severed.

The Pacman Flap and Its Modifications for Reconstruction of Skin Cancer Surgical Wounds on the Scalp and Other Body Areas: A Review of 23 Cases. / [Artículo tradudico] El colgajo Pacman y sus modificaciones para la reconstrucción de heridas quirúrgicas oncológicas en el cuero cabelludo y otras áreas corporales: Revisión de 23 casos.

BACKGROUND: The Pacman flap is a modified V-Y advancement flap that showed to be versatile in repairing surgical and non-surgical wounds. Indeed, this flap has been used in any anatomical localization, except for the scalp, where its use has not been reported. Moreover, the versatility of the Pacman flap can be enhanced by applying simple modifications to its original design. MATERIALS AND METHODS: A case-series of 23 patients whose surgical breaches were repaired using standard or modified Pacman flap were included in this retrospective study. RESULTS: Most patients were male (65.2%) with a median age of 75.7 years. Squamous cell carcinoma was the tumor most commonly removed (60.9%), while scalp and face were the most frequent localizations (30.4%). Although 18 flaps were sculpted in the traditional Pacman shape, 5 were modified to fit the defect and localization. Complications occurred in 30% of flaps, but all of them were minor except for 1 extended necrosis. CONCLUSIONS: The Pacman flap can be used to repair surgical wounds localized in any body area, including the scalp. Three modifications can enhance the versatility of the flap and offer new repair options to dermatologic surgeons.

The Pacman Flap and Its Modifications for Reconstruction of Skin Cancer Surgical Wounds on the Scalp and Other Body Areas: A Review of 23 Cases.

BACKGROUND: The Pacman flap is a modified V-Y advancement flap that showed to be versatile in repairing surgical and non-surgical wounds. Indeed, this flap has been used in any anatomical localization, except for the scalp, where its use has not been reported. Moreover, the versatility of the Pacman flap can be enhanced by applying simple modifications to its original design. MATERIALS AND METHODS: A case-series of 23 patients whose surgical breaches were repaired using standard or modified Pacman flap were included in this retrospective study. RESULTS: Most patients were male (65.2%) with a median age of 75.7 years. Squamous cell carcinoma was the tumor most commonly removed (60.9%), while scalp and face were the most frequent localizations (30.4%). Although 18 flaps were sculpted in the traditional Pacman shape, 5 were modified to fit the defect and localization. Complications occurred in 30% of flaps, but all of them were minor except for 1 extended necrosis. CONCLUSIONS: The Pacman flap can be used to repair surgical wounds localized in any body area, including the scalp. Three modifications can enhance the versatility of the flap and offer new repair options to dermatologic surgeons.

Practical Considerations About Optimal Skin Incisions/Excisions in Dermatologic Surgery with Emphasis on Incisions Orientation and Primary Cutaneous Melanoma Surgery. / Consideraciones prácticas sobre incisiones/extirpaciones óptimas en cirugía dermatológica con énfasis en la orientación de las incisiones y la cirugía del melanoma cutáneo primario.

Dermatologic surgery has 2main objectives: 1) to guarantee surgical radicality; and 2) to achieve optimal aesthetic and functional results. These 2paradigms and their hierarchy must be considered when performing surgical procedures on the skin. Even the easiest intervention, the elliptical excision, presents some features that should be known to achieve such goals. One of these features is the incision orientation. The optimal incisions orientation is still matter of debate, especially because studies that compare the outcomes of performing incisions in different directions are lacking. However, some anatomical, clinical, and histological observations may point out why incising the skin in one orientation is better than another. Knowing the theory behind skin incisions/excisions become of outmost importance when dealing with primary cutaneous melanoma surgery. Especially if the melanocytic lesion is suspected to be an invasive melanoma and a sentinel lymph node biopsy will be required.

Prognostic Value of Vitamin D Serum Levels in Cutaneous Melanoma. / Efecto de los niveles séricos de vitamina D en el pronóstico del melanoma cutáneo.

INTRODUCTION: Vitamin D plays a fundamental role in many metabolic pathways, including those involved in cell proliferation and the immune response. Serum levels of this vitamin have been linked to melanoma risk and prognosis. This study aimed to assess the prognostic value of vitamin D serum level in melanoma. MATERIAL AND METHODS: Retrospective, observational, longitudinal, and analytical study of 286 patients with a histologic diagnosis of melanoma in whom serum levels of vitamin D were measured at the time of diagnosis. We analyzed associations between serum level and epidemiologic and clinical variables and pathology findings; we also analyzed the influence of vitamin D on overall survival. An iterative loop was used to identify a vitamin D serum level to test for its an association with survival. RESULTS: A vitamin D level less than 9.25ng/mL was associated with a histologic finding of ulceration. After a median follow-up period of 39.4 months, 24 patients (8.4%) had died. The cutoff of 9.25ng/mL was associated with lower overall survival according to both the Kaplan-Meier curves and multivariate Cox regression analysis. CONCLUSION: Vitamin D levels less than 9.25ng/mL are associated with ulceration in melanoma and serve as an independent prognostic factor for overall survival in this disease.

Patient-Reported Outcome Measures in Real-World Atopic Dermatitis Studies in Spain: A Systematic Review. / Medidas de los resultados percibidos por el paciente en estudios de vida real en dermatitis atópica en España: revisión sistemática de la literatura.

Atopic dermatitis (AD) is a chronic inflammatory skin disease with symptoms such as pruritus that can be a major burden for patients. Patient-reported outcomes (PRO) complement clinician-reported outcomes in AD. This systematic review aims to identify and describe patient-reported outcome measures (PROM) used in observational studies of AD over the last decade in Spain. Eighteen PROM were identified to measure 13 different PRO that assess multiple aspects of the disease, including symptoms and disease severity, impact on daily activities and on work productivity/functioning, psychosocial impact, patient empowerment, and health-related quality of life (HRQoL). HRQoL, symptoms (particularly pruritus), and anxiety/depression were the most frequently assessed PRO, and the Dermatology Quality of Life Index, the Visual Analogue Pruritus Scale, and the Hospital Anxiety and Depression Scale were the most frequently used PROM, respectively. The growing number of observational studies on AD including PROM in Spain suggests that PRO are becoming increasingly important in the management of AD.

Clinical features, diagnosis and therapy of pituicytoma: an update.

BACKGROUND: Pituicytomas (PTs) are extremely rare, low-grade glial tumors closely related to the neurohypophyseal axis. Definite conclusions concerning the optimal diagnostic and therapeutic approach to these neoplasms are lacking to date, as most of this information has been presented as case reports. METHODS: Retrospective review of case reports published in the scientific literature to date, including a new illustrative example treated in our department. RESULTS: 116 cases were collected. PTs had a higher prevalence in the fifth and sixth decades of life, with a slight male predominance. Main symptoms, which tended to be progressive, included visual field defects and pituitary-hypothalamic dysfunction. Radiologically, PTs were found anywhere along the hypothalamic-pituitary axis mimicking other, more frequent tumors growing in this anatomical region. Surgical treatment included both transcranial or transsphenoidal approaches, and resulted in gross total resection and morbidity rates of 46.8 and 59%, respectively; the latter essentially consisted in anterior and posterior pituitary dysfunction, with limited impact on daily quality of life. CONCLUSIONS: Due to both low frequency and the absence of pathognomonic clinical and/or radiological features, formulating a suspicion diagnosis of PT represents a considerable challenge even for experienced professionals. The indication for treatment should be made on an individual basis, but it is inescapable in the presence of a visual field defect. The surgical approach has to be tailored according to the topography of the tumor and preoperative symptoms; the greatest challenges in accomplishing a gross total removal are represented by the degree of adherence and vascularization of the PT.

Telediagnosis of oral lesions in primary care: The EstomatoNet Program.

OBJECTIVE: The diagnosis of oral lesions is often challenging for primary healthcare providers, which explains the high number of referrals to specialist care. This favors increases in waiting lines and delays in diagnosis, contributing to high mortality rates from oral cancer. This study aimed to summarize the experience of the EstomatoNet, a telediagnosis program catering to primary care dentists and physicians from southern Brazil. STUDY DESIGN: This exploratory study included all queries received by EstomatoNet from June 2015 to December 2016. Health providers (71 dentists and 18 physicians from primary care) submitted requests including clinical information and photographs of oral lesions by means of a cloud-based platform. Specialized oral medicine teleconsultants received the data, conveyed a diagnostic hypothesis, and conveyed management recommendations. RESULTS: Actinic cheilitis (n = 41, 15.8%), squamous cell carcinoma (n = 22, 8.5%), and inflammatory hyperplasia (21, 8.1%) were the most frequent diagnoses. Teleconsultants recommended referral to specialists in 42.9% of the cases, total biopsy in 23.6%, and follow-up in 16.2%. After the EstomatoNet use, the intention to refer the patients to face-to-face consultation reduced from 96.9% to 35.1%. CONCLUSION: Telediagnosis for oral lesions is feasible and has potential to improve the quality of primary health care by bridging the gap between primary and specialized health care.

Evidence for a spin-aligned neutron-proton paired phase from the level structure of (92)Pd.

Shell structure and magic numbers in atomic nuclei were generally explained by pioneering work that introduced a strong spin-orbit interaction to the nuclear shell model potential. However, knowledge of nuclear forces and the mechanisms governing the structure of nuclei, in particular far from stability, is still incomplete. In nuclei with equal neutron and proton numbers (N = Z), enhanced correlations arise between neutrons and protons (two distinct types of fermions) that occupy orbitals with the same quantum numbers. Such correlations have been predicted to favour an unusual type of nuclear superfluidity, termed isoscalar neutron-proton pairing, in addition to normal isovector pairing. Despite many experimental efforts, these predictions have not been confirmed. Here we report the experimental observation of excited states in the N = Z = 46 nucleus (92)Pd. Gamma rays emitted following the (58)Ni((36)Ar,2n)(92)Pd fusion-evaporation reaction were identified using a combination of state-of-the-art high-resolution γ-ray, charged-particle and neutron detector systems. Our results reveal evidence for a spin-aligned, isoscalar neutron-proton coupling scheme, different from the previous prediction. We suggest that this coupling scheme replaces normal superfluidity (characterized by seniority coupling) in the ground and low-lying excited states of the heaviest N = Z nuclei. Such strong, isoscalar neutron-proton correlations would have a considerable impact on the nuclear level structure and possibly influence the dynamics of rapid proton capture in stellar nucleosynthesis.

Myoclonic epilepsy in Down syndrome and Alzheimer disease. / Epilepsia mioclónica en el síndrome de Down y en la enfermedad de Alzheimer.

INTRODUCTION: Patients with Down syndrome (DS) who exhibit Alzheimer disease (AD) are associated with age. Both diseases with a common neuropathological basis have been associated with late-onset myoclonic epilepsy (LOMEDS). This entity presents electroencephalogram features as generalized polyspike-wave discharges. METHOD: We present a series of 11 patients with the diagnosis of DS or AD who developed myoclonic seizures or generalized tonic-clonic seizures. In all cases, clinical and neuroimaging studies and polygraph EEG monitoring was performed. RESULTS: In all cases, cognitive impairment progressed quickly after the onset of epilepsy causing an increase in the degree of dependence. The most common finding in the EEG was a slowing of brain activity with theta and delta rhythms, plus intercritical generalized polyspike-waves were objectified in eight patients. In neuroimaging studies was found cerebral cortical atrophy. The most effective drug in this series was the levetiracetam. CONCLUSIONS: The association of generalized epilepsy with elderly DS represents an epiphenomenon in evolution which is associated with a progressive deterioration of cognitive and motor functions. This epilepsy has some electroclinical characteristics and behaves as progressive myoclonic epilepsy, which is probably related to the structural changes that characterize the evolutionary similarity of DS with AD. Recognition of this syndrome is important, since it has prognostic implications and requires proper treatment.

Desmoplastic astrocytoma: new insights into its clinical profile, diagnosis, and treatment.

BACKGROUND: Desmoplastic astrocytoma (DA) is a rare intracranial tumor which usually affects pediatric patients. The aim of this study is to describe the clinical features and management of DA based on a joint analysis of the cases reported in the scientific literature. MATERIAL AND METHODS: A thorough review was carried out, gathering those pathologically proven DAs reported since the first description of this entity. Two new own cases were included in order to illustrate this review. Epidemiological, clinical, radiological, therapeutic, and follow-up data were analyzed with the software SPSS version 20. RESULTS: A total of 52 DAs were recorded. Most cases occurred in the first 2 years of life, although older patients were also reported. Patients mainly presented symptoms and signs of elevated intracranial pressure. According to their radiological features, we were able to classify DAs in four main groups, with distinct differential diagnosis and prognosis. After treatment, 14.2 % of patients presented persistent neurological impairment and the mortality rate was close to 10 %. CONCLUSION: DAs can be diagnosed at any age from birth to adolescence. These neoplasms can show up a wider range of radiological morphologies than previously thought. Surgery represents the treatment of choice for DAs, although chemotherapy can also be useful in the setting of recurrence or progression of the disease. Those DAs lacking classic radiological features, especially type 4 tumors, were linked with a poorer clinical outcome.

Exophthalmos and ocular pain as clinical debut of intracranial Hodgkin's lymphoma at diagnosis.

Intracranial involvement in Hodgkin's Lymphoma (HL) is extremely unusual, especially at the time of diagnosis. Because of its non-specific radiological behaviour, it can be confused with more common entities with a radically different prognosis. Pathologically, large and bi-nucleated cells, called Reed-Sternberg cells, embedded in an inflammatory network. In this report we describe the clinical case of a patient, with no medical history, with left ocular pain and exophthalmos as presetation of intracranial HL at diagnosis and review the most current literature. Intracranial involvement is often associated with extracranial disease. Therefore, a systemic study including body computed tomography, bone marrow biopsy and ophthalmological evaluation is necessary. Intracranial lesions respond favourably to treatment and the prognosis depends on the extracranial involvement. To date, there is no standardised management scheme for these patients. For us, the primary role of surgery in this context is to perform a biopsy to confirm the histological diagnosis.

Kernohan-Woltman notch phenomenon: an exceptional neurological picture?

INTRODUCTION: Ipsilateral hemiparesis (IH) can be defined as a paradoxical dysfunction of the first motor neuron involving the extremities on the opposite side to that expected, given the location of the triggering intracranial pathology. Compression of the corticospinal tract (CSt) along its course through the contralateral cerebral peduncle against the free edge of the tentorium, known as the Kernohan-Woltman notch phenomenon (KWNP), represents the main cause of IH. METHODS: This retrospective study analyses a series of 12 patients diagnosed with IH secondary to KWNP treated at our institution, including a descriptive study of epidemiological, clinical, radiological, neurophysiological, and prognostic variables. RESULTS: In 75% of the cases, symptoms had an acute or subacute onset. Initial imaging studies showed signs of significant mass effect in half of the patients, whereas magnetic resonance imaging (MRI) identified a structural lesion in the contralateral cerebral peduncle in two thirds of them. Impairment of the motor evoked potentials (MEP) was verified in 4 patients. During follow-up 7 patients experienced improvement in motor activity, and near half of the cases were classified in the first three categories of the modified Rankin scale. CONCLUSIONS: In contrast to prior historical series, most of our patients developed a KWNP secondary to a traumatic mechanism. MRI represents the optimal method to identify both the classic cerebral peduncle notch and the underlying structural lesion of the CSt. The use of MEP can help to establish the diagnosis, especially in those cases lacking definite radiological findings.

[Ischaemic or transient attack? Magnetic resonance imaging in transient ischaemic attack: a review of 106 cases]. / Accidente isquémico y ¿transitorio? Resonancia magnética en el AIT: experiencia de 106 casos.

INTRODUCTION: Transient ischaemic attack (TIA) has classically been defined as an episode of self-limited focal neurological deficit lasting up to 24 hours, with no neuroimaging evidence of established acute ischaemic injury. However, the definition of this entity is changing, and is adapting to new times and new diagnostic techniques, including magnetic resonance imaging (MRI) with diffusion sequences. An early and comprehensive approach to TIA, including MRI, is important to rule out clinically recovered established ischaemic strokes, in order to optimise the diagnostic and therapeutic management of patients. PATIENTS AND METHODS: Patients admitted to our stroke unit over a six-month period with suspected TIA were identified, and the definitive diagnosis and approach was studied based on the tests performed. RESULTS: A sample of 106 suspected cases of TIA were studied, in which early MRI was performed. Of these, 42 (39.62%) were clinically recovered ischaemic strokes (CRIS); 32 (30.18%), other pathologies (six epileptic seizures, five migraine auras, nine functional disorders, two amyloid spells and nine other causes, totalling 31); 26 (24.52%), TIAs; and six (5.66%), haemorrhagic stroke. Of 43 CRIS, eight (18.6%) were cardioembolic; eight (18.6%), atherothrombotic; eight (18.6%), embolic stroke of unknown origin; six (13.95%), lacunar stroke; five (11.62%) of infrequent cause; and four (9.3%), totalling 39, of undetermined cause. CRIS patients received significantly more individualised therapeutic management than TIA patients. CONCLUSIONS: The early use of MRI in the clinical suspicion of TIA makes it possible to gather evidence of CRIS and optimises the diagnostic and therapeutic approach for patients.

TITLE: Accidente isquémico y ¿transitorio? Resonancia magnética en el AIT: experiencia de 106 casos.Introducción. El accidente isquémico transitorio (AIT) clásicamente se ha definido como un episodio de déficit focal neurológico autolimitado con duración máxima de 24 horas, sin evidencia en la neuroimagen de lesión isquémica aguda establecida. Sin embargo, la definición de esta entidad está variando y se está adaptando a los nuevos tiempos y técnicas diagnósticas, incluida la resonancia magnética (RM) con secuencias en difusión. Es importante un abordaje íntegro y precoz del AIT, con RM cerebral, para descartar ictus isquémicos establecidos recuperados clínicamente, y así optimizar el manejo diagnóstico y terapéutico de los pacientes. Pacientes y métodos. Se identificó a los pacientes ingresados en un período de seis meses como sospecha de AIT en nuestra unidad de ictus, y se estudió el diagnóstico definitivo y su abordaje basándose en las pruebas realizadas. Resultados. Se estudiaron 106 sospechas de AIT en las que se realizó una RM precoz. De ellas, 43 (40,57%) fueron ictus isquémicos clínicamente recuperados (IICR); 31 (29,24%), otras patologías (nueve trastornos funcionales, seis crisis epilépticas, cinco auras migrañosas, dos amyloid spells y nueve otras causas); 26 (24,52%), AIT; y seis (5,66%), ictus hemorrágicos. De 43 IICR, ocho (18,6%) fueron cardioembólicos; ocho (18,6%), aterotrombóticos; ocho (18,6%), ictus embólico de origen desconocido; seis (13,95%), lacunares; cinco (11,62%) de causa infrecuente; cuatro (9,3%) microangiopáticos y cuatro (9,3%), de causa indeterminada. Los IICR recibieron un manejo terapéutico significativamente más individualizado respecto a los pacientes con AIT. Conclusiones. El uso de RM precoz en la sospecha clínica de AIT permite evidenciar la existencia de IICR y optimizar el abordaje diagnóstico y terapéutico de los pacientes.

[Cavernous haemangioma of the skull]. / Hemangioma cavernoso intraóseo craneal.

INTRODUCTION: Cavernous haemangiomas are benign tumours that rarely affect the skull. A correct suspicion diagnosis is seldom obtained when typical radiological signs are lacking. In this way a definite diagnosis is only obtained after a surgical procedure in most cases. CASE REPORT: A 52-year-old female presented a painless, slow-growing tumoration in her right forehead. Skull CT showed an osteolytic lesion located within the right frontal bone. On suspicion of a metastatic origin of the lesion, a systemic research for a primary tumour was performed without significative findings. Finally, en bloc resection of the lesion was performed followed by cranioplasty. Microscopically, the lesion proved to be a cavernous haemangioma of the frontal bone. CONCLUSION: Despite their low frequency, cavernous haemangiomas must be included in the differential diagnosis of slow-growing osteolytic lesions located within the skull. The elective treatment of this tumours includes a complete resection by craniectomy, with safe bony margins.