RESUMEN
PURPOSE: After standard treatment for glioblastoma, perfusion MRI remains challenging for differentiating tumor progression from post-treatment changes. Our objectives were (1) to correlate rCBV values at diagnosis and at first tumor progression and (2) to analyze the relationship of rCBV values at tumor recurrence with enhancing volume, localization of tumor progression, and time elapsed since the end of radiotherapy in tumor recurrence. METHODS: Inclusion criteria were (1) age > 18 years, (2) histologically confirmed glioblastoma treated with STUPP regimen, and (3) tumor progression according to RANO criteria > 12 weeks after radiotherapy. Co-registration of segmented enhancing tumor VOIs with dynamic susceptibility contrast perfusion MRI was performed using Olea Sphere software. For tumor recurrence, we correlated rCBV values with enhancing tumor volume, with recurrence localization, and with time elapsed from the end of radiotherapy to progression. Analyses were performed with SPSS software. RESULTS: Sixty-four patients with glioblastoma were included in the study. Changes in rCBV values between diagnosis and first tumor progression were significant (p < 0.001), with a mean and median decreases of 32% and 46%, respectively. Mean rCBV values were also different (p < 0.01) when tumors progressed distally (radiation field rCBV values of 1.679 versus 3.409 distally). However, changes and, therefore, low rCBV values after radiotherapy in tumor recurrence were independent of time. CONCLUSION: Chemoradiation alters tumor perfusion and rCBV values may be decreased in the setting of tumor progression. Changes in rCBV values with respect to diagnosis, with low rCBV in tumor progression, are independent of time but related to the site of recurrence.
Asunto(s)
Neoplasias Encefálicas , Glioblastoma , Humanos , Adulto , Persona de Mediana Edad , Glioblastoma/diagnóstico por imagen , Glioblastoma/radioterapia , Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/radioterapia , Recurrencia Local de Neoplasia/diagnóstico por imagen , Medios de Contraste , Quimioradioterapia , Imagen por Resonancia Magnética/métodosRESUMEN
The parasitic tapeworm Echinococcus granulosis causes hydatid disease, which is rarely encountered in nonendemic regions. It is a progressive disease with serious morbidity risks. Rarely, these cysts are found in the spine. They are mainly found epidurally, originating from direct extension from pulmonary, abdominal or pelvic infestation. Nevertheless, the main mechanism for intradural involvement is not yet clear. Antihelminthic treatment should be administered for a long period following early decompressive surgery. We report a case of recurrent hydatid disease that presented unusual intradural dissemination. Prognosis for spinal hydatid disease remains very poor and comparable to that of a malignant neoplasm.
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Equinococosis/patología , Médula Espinal/patología , Médula Espinal/parasitología , Columna Vertebral/patología , Columna Vertebral/parasitología , Animales , Antihelmínticos/uso terapéutico , Descompresión Quirúrgica , Equinococosis/tratamiento farmacológico , Equinococosis/parasitología , Equinococosis/cirugía , Echinococcus granulosus , Humanos , Masculino , Persona de Mediana Edad , Médula Espinal/cirugía , Columna Vertebral/cirugía , Resultado del TratamientoRESUMEN
OBJECTIVE: The aim of this study was to determine which factors were statistically related to radiological and clinical outcomes following radiosurgical treatment of arteriovenous malformations (AVMs). METHODS: The data of 59 patients receiving radiosurgical treatment at our department were retrospectivelly reviewed. Different clinical and biological data, including Spetzler-Martin grade, the presentation of symptoms, radiation dose, number of isocenters and both radiological and clinical outcome, were subjected to multivariate analysis. RESULTS: AVM obliteration was achieved in 77% of patients, the majority of them occurring between 3-5 years after treatment. Ten patients (17%) showed either acute or delayed complications. Only one patient died due tor hemorrhage during the follow-up after radiosurgery. A multivariate analysis showed that, hyperintensity on T2 MRI and a nidus smaller than 3 cm were the only factors statistically related to oclusion of the AVM (p=0.03 and p=0.05, respectively). CONCLUSION: The nidus size and the development of hyperintensity on T2 MRI after the treatment were the strongest predictive factors of obliteration in our series of AVMs radiosurgically treated. Moreover, given that many AVMs showed complete obliteration between 3-5 years after treatment, we recommend to wait untill 5 years after treatment before considering a new terapeuthic approach in patients showing small residual nidus at control imaging.
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Malformaciones Arteriovenosas , Imagen por Resonancia Magnética , Malformaciones Arteriovenosas/diagnóstico por imagen , Malformaciones Arteriovenosas/patología , Malformaciones Arteriovenosas/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Radiografía , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Some phase 2 trials had reported encouraging progression-free survival with Bevacizumab in monotherapy or combined with chemotherapy in glioblastoma. However, phase 3 trials showed a significant improvement in progression free survival without a benefit in overall survival. To date, there are no predictive biomarker of response for Bevacizumab in glioblastoma. METHODS: We used Immunochemical analysis on tumor samples and pretreatment and post-treatment perfusion-MRI to try to identify possible predictive angiogenesis-related biomarkers of response and survival in patients with glioblastoma treated with bevacizumab in the first recurrence. We analyzed histological parameters: vascular proliferation, mitotic number and Ki-67 index; molecular factors: MGMT promoter methylation, EGFR amplification and EGFR variant III; immunohistochemical: MET, Midkine, HIF1, VEGFA, VEGF-R2, CD44, Olig2, microvascular area and microvascular density; and radiological: rCBV. RESULTS: In the statistical analysis, no significant correlation of any histological, molecular, microvascular or radiological parameters could be demonstrated with the response rate, PFS or OS with bevacizumab treatment. CONCLUSION: Unfortunately, in this histopathological, molecular, immunohistochemical and neuroradiological study we did not find any predictive biomarker of response or survival benefit for Bevacizumab in glioblastoma.
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Inhibidores de la Angiogénesis/uso terapéutico , Antineoplásicos Inmunológicos/uso terapéutico , Bevacizumab/uso terapéutico , Neoplasias Encefálicas/tratamiento farmacológico , Glioblastoma/tratamiento farmacológico , Recurrencia Local de Neoplasia/tratamiento farmacológico , Adulto , Anciano , Biomarcadores de Tumor/análisis , Neoplasias Encefálicas/irrigación sanguínea , Neoplasias Encefálicas/química , Neoplasias Encefálicas/diagnóstico por imagen , Circulación Cerebrovascular , Metilasas de Modificación del ADN/metabolismo , Enzimas Reparadoras del ADN/metabolismo , Femenino , Amplificación de Genes , Genes erbB-1 , Glioblastoma/irrigación sanguínea , Glioblastoma/química , Glioblastoma/diagnóstico por imagen , Humanos , Inmunohistoquímica , Antígeno Ki-67/análisis , Masculino , Metilación , Microvasos/patología , Persona de Mediana Edad , Índice Mitótico , Recurrencia Local de Neoplasia/irrigación sanguínea , Recurrencia Local de Neoplasia/química , Recurrencia Local de Neoplasia/diagnóstico por imagen , Estudios Retrospectivos , Análisis de Matrices Tisulares , Proteínas Supresoras de Tumor/metabolismoRESUMEN
Spontaneous intracerebral haematoma (SICH) represents one the most severe subtypes of ictus. However, and despite a high incidence, medical treatment is almost limited to life support and to control intracranial hypertension and indications of surgical treatment are poorly defined. The aim of this paper was to review the evidence supporting surgical evacuation of SICH. Ten clinical trials and five meta-analyses studying the results of surgical treatment on this pathology were found on English literature. These studies considered all together, failed to show a significant benefit of surgical evacuation in patients with SICH considered as a whole. However, a subgroup of these patients has been considered to potentially present a better outcome after surgical treatment. Current recommendations on supratentorial intra-cerebral haemorrhage state that young patients with lobar haematomas causing deterioration on the level of consciousness should be operated on. Patients suffering from putaminal haematomas and fitting with the same criteria of age and neurological deterioration could also benefit from surgery, at least on terms of survival. Deep neurological deterioration with GCS<5, thalamic location, severe functional deterioration on basal condition or advanced age precluding an adequate functional outcome, have been traditionally considered criteria contraindicating surgery. Given the absence of strong scientific evidence to indicate surgery, this measure should be taken on a tailored manner, and taking into account the social-familiar environment of the patient, that will strongly condition his/her future quality of life.
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Hematoma Subdural Agudo/cirugía , Hematoma/cirugía , Hematoma/etiología , Hematoma/patología , Hematoma Subdural Agudo/etiología , Hematoma Subdural Agudo/patología , Humanos , Hipertensión Intracraneal/cirugía , Metaanálisis como Asunto , Literatura de Revisión como Asunto , Resultado del TratamientoRESUMEN
Surgery plays a mayor role in the management of some patients with cerebellar haematomas, although a universally accepted treatment guideline is lacking. The aim of this study was to review the existing evidence supporting surgical evacuation of the haematoma in this pathology. Without any clinical trial on this field, data derived from clinical series suggest that the level of consciousness, the size of the haematoma, the presence of hydrocephalus and the compression of the posterior fossa CSF containing spaces are the main criteria to decide management. Fourth ventricular compression seems to be the best indicator of the last parameter. Existing bibliography shows that haematomas greater than 4 cm or causing complete obliteration of the fourth ventricle or prepontine cistern need surgical evacuation irrespective of the level of consciousness, as they indicate a significant compression of the brainstem. On the other hand, it seems that haematomas of less than 3 cm and without fourth ventricular compression can be managed conservatively or by means of ventricular drainage if hydrocephalus exists and requires treatment. The management of intermediate sized haematomas is less clear although conservative approach could be adopted in presence of adequate neurological status, with EVD in the case of hydrocephalus with low consciousness level. If the level of consciousness is low despite the treatment of hydrocephalus, or in absence of this latter, haematoma evacuation is indicated. Finally, patients with flaccid tetraplejia and absent oculocephalic reflexes, and those whose age or basal condition precludes an adequate functional outcome are not suitable for aggressive treatment. Moreover, some studies have shown that comatose patients with CT scan evidence of severe brainstem compression present a reduced probability of good outcome. Anyway, management should be decided on an individual basis, as there is no enough evidence to support a strict treatment protocol.
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Hemorragia Cerebral/complicaciones , Hemorragia Cerebral/cirugía , Hematoma/complicaciones , Hematoma/cirugía , Procedimientos Neuroquirúrgicos/métodos , HumanosRESUMEN
Spontaneous regression of intracranial arteriovenous malformations (AVMs) is a rare phenomenon. Such an event is more likely to occur with small AVMs that present with intracranial hemorrhage, which are fed by a unique artery and drained through a single vein. The factors responsible for AVMs regression remain unclear. Thrombosis of the AVM secondary to intracranial hemorrhage ha been the most commonly associated factor. Other possible causes are the gliosis around the clot secondary to repeated frequent microbleedings or occlusion of the feeding arteries by small emboli. We report a new case of spontaneous regression of a AVM and review the literature related to this entity.
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Malformaciones Arteriovenosas Intracraneales , Remisión Espontánea , Anciano , Angiografía Cerebral , Humanos , Malformaciones Arteriovenosas Intracraneales/patología , Malformaciones Arteriovenosas Intracraneales/fisiopatología , Masculino , Persona de Mediana Edad , Literatura de Revisión como AsuntoRESUMEN
BACKGROUND AND PURPOSE: In glioblastoma, tumor progression appears to be triggered by expression of VEGF, a regulator of blood vessel permeability. Bevacizumab is a monoclonal antibody that inhibits angiogenesis by clearing circulating VEGF, resulting in a decline in the contrast-enhancing tumor, which does not always correlate with treatment response. Our objectives were: (1) to evaluate whether changes in DSC perfusion MRI-derived leakage could predict survival in recurrent glioblastoma, and (2) to estimate whether leakage at baseline was related to treatment outcome. MATERIALS AND METHODS: We retrospectively analyzed DSC perfusion MRI in 24 recurrent glioblastomas treated with bevacizumab as second line chemotherapy. Leakage at baseline and changes in maximum leakage between baseline and the first follow-up after treatment were selected for quantitative analysis. Survival univariate analysis was made constructing survival curves using Kaplan-Meier method and comparing subgroups by log rank probability test. RESULTS: Leakage reduction at 8 weeks after initiation of bevacizumab treatment had a significant influence on overall survival (OS) and progression-free survival (PFS). Median OS and PFS were 2.4 and 2.8 months longer for patients with leakage reduction at the first follow-up. Higher leakage at baseline was associated with leakage reduction after treatment. Odds ratio of treatment response was 9 for patients with maximum leakage at baseline >5. CONCLUSIONS: Leakage decrease may predict OS and PFS in recurrent glioblastomas treated with bevacizumab. Leakage reduction postulates as a potential biomarker for treatment response evaluation. Leakage at baseline seems to predict response to treatment, but was not independently associated with survival.
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Inhibidores de la Angiogénesis/uso terapéutico , Bevacizumab/uso terapéutico , Neoplasias Encefálicas/mortalidad , Medios de Contraste , Glioblastoma/mortalidad , Imagen por Resonancia Magnética/métodos , Recurrencia Local de Neoplasia/mortalidad , Adulto , Anciano , Neoplasias Encefálicas/tratamiento farmacológico , Neoplasias Encefálicas/metabolismo , Neoplasias Encefálicas/patología , Femenino , Estudios de Seguimiento , Glioblastoma/tratamiento farmacológico , Glioblastoma/metabolismo , Glioblastoma/patología , Humanos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/tratamiento farmacológico , Recurrencia Local de Neoplasia/metabolismo , Recurrencia Local de Neoplasia/patología , Estadificación de Neoplasias , Perfusión , Pronóstico , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
INTRODUCTION: Cranial CT has been the most extended evaluation means for patients suffering head trauma. However, it has low sensitivity in the identification of diffuse axonal injury and posterior fossa lesions. Cranial MR is a potentially more sensitive test but difficult to perform in these patients, a fact that has hampered its generalised use. OBJECTIVE: To compare the identification capability of traumatic intracranial lesions by both diagnostic tests in patients with moderate and severe head injury and to determine which radiological characteristics are associated with the presence of diffuse injury in MR and their clinical severity. MATERIAL AND METHODS: 100 patients suffering moderate or severe head injury to whom a MR had been performed in the first 30 days after trauma were included. All clinical variables related to prognosis were registered, as well as the data from the initial CT following Marshall et al., classification. The MR was blindly evaluated by two neuroradiologists that were not aware of the initial CT results or the clinical situation of the patient. All lesions were registered as well as the classification following the classification of lesions related to DAI described by Adams et al. CT and MR findings were compared evaluating the sensitivities of each test. Factors related to the presence of diffuse injury in MR were studied by univariate analysis using chi2 test and simple correlations. RESULTS: MR is more sensitive than CT for lesions in cerebral white matter, corpus callosum and brainstem. It also detects a greater number of cerebral contussions. The presence of diffuse axonal injury depends on the mechanism of the trauma, being more frequent in higher energy trauma, specially in traffic accidents. Among the radiological characteristics associated to DAI the most clearly related is intraventricular haemorrhage. The presence of a deeper injury and a higher score in the scales of Adams is associated with a lower score in the GCS and motor GCS, and so with a worse level of consciousness and bigger severity of injury, confirming Ommaya's model.
Asunto(s)
Traumatismos Craneocerebrales , Lesión Axonal Difusa , Imagen por Resonancia Magnética , Tomografía Computarizada por Rayos X , Adolescente , Adulto , Anciano , Encéfalo/anatomía & histología , Encéfalo/patología , Traumatismos Craneocerebrales/diagnóstico , Traumatismos Craneocerebrales/patología , Lesión Axonal Difusa/diagnóstico , Lesión Axonal Difusa/patología , Femenino , Escala de Coma de Glasgow , Humanos , Masculino , Persona de Mediana Edad , PronósticoRESUMEN
Gliomas are the most frequent primary tumors of the brain. The standard treatment includes surgery, radiotherapy and chemotherapy, but the outcomes of patients with these tumors have remained nearly unchanged for past years. Hopefully, recent advances in molecular biology are rising new clinical expectation for patients with brain tumors. Among the novel techniques in this new field of research a new field of research, the use of oncolytic viruses has been explored in different trials during last years. In the present review we analyze the advances in the understanding of the oncolytic viral therapy of gliomas.
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Neoplasias Encefálicas/genética , Neoplasias Encefálicas/terapia , Terapia Genética , Vectores Genéticos/uso terapéutico , Glioma/genética , Glioma/terapia , Virus/genética , HumanosRESUMEN
OBJECTIVE: To determine the incidence of pathological and intracranial pressure (ICP) changes during the acute posttraumatic period in severe head injury patients presenting with lesions Types I-II (TCDB classification) in the admission CT scan with the aim of defining the most appropriate strategy of sequential CT scanning and ICP monitoring for detecting new intra-cranial mass effect and improving the final outcome. MATERIAL AND METHODS: 56 patients (ages 15-80 years) consecutively admitted during a 2 years period were included. All had the initial CT scan < 24 hours after injury (mean interval = 150 min), several CT controls within the first days of the course and ICP monitoring after admission. Different epidemiological, clinical and radiological variables were recorded and deterioration defined as the development of sustained ICP over 20 mmHg requiring aggressive medical and/or surgical treatment was considered the dependent variable. Uni and multivariate analyses were made for determining the correlation between different parameters and the occurrence of deterioration and the final outcome as assessed with the GOS. RESULTS: The mean GCS score was 5 and 37% of the patients showed pupillary changes; 52.3% had peritraumatic hypotension-hypoxemia, 16.1% anemia and 12.3% coagulation changes. 50% of the patients showed petechial hemorrhages in the white matter or the brainstem, 66% SAH, 40% HIV, 39.3% brain contusion and 21.4% small extraaxial hematomas. 57.1% of the patients showed CT changes through the acute post-traumatic period consisting of new contusion (26.8% of the cases), growing of previous contusion (68.2%) or previous extraaxial hematoma (10.7%), and generalized brain swelling (10.7%). 64.9% of the patients made a favourable and 35.7% an unfavourable outcome. Overall, 27 (48.9%) patients developed deterioration, 21 (37.5%) with concurrent CT changes and 6 (10.7%) without new pathology as seen by the CT control. The remaining 29 (51.7%) patients in this series did not develop deterioration in spite that 11(19.6%) showed CT changes. The age, the initial score, the occurrence of peritraumatic hypotension-hypoxemia and coagulation disorders did not correlate with the risk of deterioration. By contrast, the presence of contusion at the initial CT scan (p= 0.01) and the occurrence of CT change (only generalized brain swelling, p= 0.003) significantly correlated with the risk of deterioration; in his turn deterioration increased by a factor of 10 (OR = 9.8) the risk of death and 7 out of the 8 patients who died developed intractable intracranial hypertension. The 8 (14.2%) patients requiring surgery showed simultaneous ICP deterioration and CT changes, but another 11 patients in a similar condition could be managed without surgery. With or without ICP deterioration, patients showing CT changes had a worse outcome than those without new pathologies, but the difference did not reach statistical significance, DISCUSSION AND CONCLUSIONS: Over 50% of the patients with initial Type I-II lesions developed new CT changes and nearly 50% showed intracranial hypertension during the acute posttraumatic period. Considering the high incidences of ICP and CT deterioration through the course, along with the absence of strong predictors and the discordances between CT and ICP changes (which were seen in 30.3% of the cases) we recommend ICP monitoring after admission in all patients and serial CT scanning at 2-4, 12, 24, 48 and 72 hours after injury with additional controls as indicated by clinical or ICP changes in all cases. Though it is clear that the presence of severe intra-cranial hypertension significantly increased the risk of death, the small size of the sample in this series prevented to assess to what extent the occurrence of new mass effect and/or raised ICP contributed to the development of moderate and severe disability in the survivors which were mainly due to the occurrence of diffuse axonal injury. Finally, demonstrating that sequential CT scanning and ICP monitoring improve the final outcome in this type of patients would require a prospective randomized trial which is impracticable for different reasons, among them the ethical ones.
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Traumatismos Craneocerebrales/diagnóstico por imagen , Hipertensión Intracraneal/etiología , Presión Intracraneal , Monitoreo Fisiológico , Tomografía Computarizada por Rayos X , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Daño Encefálico Crónico/etiología , Daño Encefálico Crónico/prevención & control , Edema Encefálico/diagnóstico , Edema Encefálico/etiología , Lesiones Encefálicas/diagnóstico , Lesiones Encefálicas/etiología , Traumatismos Craneocerebrales/clasificación , Traumatismos Craneocerebrales/complicaciones , Traumatismos Craneocerebrales/epidemiología , Traumatismos Craneocerebrales/cirugía , Craneotomía , Femenino , Escala de Coma de Glasgow , Humanos , Incidencia , Hipertensión Intracraneal/diagnóstico , Hipertensión Intracraneal/epidemiología , Masculino , Persona de Mediana Edad , Traumatismo Múltiple/epidemiología , Valor Predictivo de las Pruebas , Estudios Prospectivos , Factores de Riesgo , Centros Traumatológicos/estadística & datos numéricos , Resultado del TratamientoRESUMEN
Solitary fibrous tumor (SFT) is a mesenchymal neoplasm that has been recognized to occur almost all along the organism. Since its description in 1996 at the meninges, a total of 59 cases of meningeal SFT have been reported. Different authors have emphasized the difficulties in the differential diagnosis with other more frequent meningeal neoplasms such as meningioma or hemangiopericytoma, as the clinico-radiological characteristics of this lesion seem to be non specific and the morphological features on pathological study may resemble other spindle cell neoplasms. The diffuse and strong reactivity for CD34 and the negativity for EMA and S-100 are data allowing the diagnosis of SFT. We report the case of a 50-year-old woman suffering from headache, in whom MRI study showed a tentorial lesion initially thought to be a meningioma. In spite of morphological similarities with a fibrous meningioma, inmunohistochemical study finally led to the diagnosis of SFT. As occurred in previous cases, the findings in our patient reflect the similarities in clinico-radiological and pathological characteristics between meningeal SFT and other spindle cell meningeal neoplasms, mainly fibrous meningioma. When a clear diagnosis cannot be done based on typical findings on conventional hematoxylin-eosin study, inmunohistochemical study should be performed in meningeal spindle cell lesions to exclude SFT.
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Duramadre/patología , Neoplasias Meníngeas/patología , Neoplasias de Tejido Fibroso/patología , Fosa Craneal Posterior , Diagnóstico Diferencial , Femenino , Cefalea/patología , Humanos , Imagen por Resonancia Magnética , Persona de Mediana EdadRESUMEN
INTRODUCTION: Despite recent improvements in microsurgical and radiotherapy techniques, treatment of basal posterior fossa meningiomas still carries an elevated risk of morbidity. We present our results in a series of patients with this type of tumor and review the recent literature looking for the results obtained with different approaches and the new tendencies and algorithms proposed for managing these challenging lesions. MATERIAL AND METHODS: We analyzed retrospectively the clinical presentation and outcome of 80 patients consecutively operated between 1979 and 2003 for basal posterior fossa meningioma (foramen magnum tumors excluded). All patients had preoperative CT scans and the majority MRI studies. A total of 114 operations were performed including two-stage operations, reoperation for recurrence, CSF diversion, and XII-VII anastomosis. The most commonly used approaches were lateral suboccipital retrosigmoid, subtemporal-transtentorial, frontotemporal pterional and supra-infratentorial presigmoid. Thirteen patients received postoperative radiotherapy. RESULTS: There were 59 (73.7%) women and 21 men (mean age = 51.5 years; range = 18-78 yrs). Most common presenting symptoms were cranial nerve dysfunction, gait disturbances and intracranial hypertension. The mean duration of symptoms was 2.9 years. 70% of the tumors were over 3 cm in size. Fifty patients (62.5%) had a complete resection, 22 (27.5%) subtotal resection (> 90% tumor volume removed), and 8 (10%) only partial resection. Postoperative complications included hematoma, CSF leak, and infection. Fifty four (67.5%) patients developed new or increased cranial nerve deficits and 12.5% somatomotor, somatosensory or cerebellar deficits immediately after surgery with subsequent improvement in most cases. Following initial surgery 67 patients made a good recovery, 10 developed variable degrees of disability and 3 died. Eleven patients died later in the course for tumor recurrence with or without reoperation, malignant meningioma or unrelated causes. There were 9 recurrences in the subgroup of patients having complete resection initially (mean follow-up = 8.6 years). The majority of patients having initial subtotal or partial resections have been managed without reoperation during a mean follow-up period of 6.5 years (radiosurgery and/or observation). DISCUSSION AND CONCLUSION: Current microsurgical and radiotherapy techniques allow either a cure or an acceptable control of basal posterior fossa meningiomas. In patients with tumor invasion of the cavernous sinus, extracranial extension, violation of the arachnoidal membranes in front of the brainstem, or encasement and infiltration of major arteries, a subtotal excision seems preferable followed by observation and/ or radiosurgical treatment. Apart from the patients age and the clinical presentation (symptomatic or not), the size and secondary extensions of the tumor must be taken into account for planning treatment in the individual patient.
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Neoplasias Meníngeas/cirugía , Meningioma/cirugía , Adolescente , Adulto , Anciano , Fosa Craneal Posterior , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Neoplasias Meníngeas/diagnóstico , Meningioma/diagnóstico , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
INTRODUCTION: Recent technological advances along with new neuroimaging techniques and progress in neuro-monitoring have provided us with new therapeutical options from the neurosurgical point of view in the management of movement disorders. Deep brain stimulators become more and more frequently used in the last few years since they have reversible effects, are easily implantable and have shown good initial results. However, only now we start knowing the clinical effects in the middle run. AIM: To review the main neurosurgical options in Parkinson's disease and tremor. DEVELOPMENT: We reviewed the articles considering ablative or stimulating neurosurgical treatments in these diseases, and we grouped the results according to the technique performed and the time of follow-up. CONCLUSION: Clinical results are often similar despite the use of different techniques. However, the side-effects are critical in deciding which technique should be used once medical therapy has been considered insufficient.
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Temblor Esencial/cirugía , Procedimientos Neuroquirúrgicos , Enfermedad de Parkinson/cirugía , Terapia por Estimulación Eléctrica , Trasplante de Tejido Fetal , Globo Pálido/cirugía , Humanos , Técnicas Estereotáxicas , Subtálamo/metabolismo , Subtálamo/cirugía , Tálamo/metabolismo , Tálamo/cirugíaRESUMEN
BACKGROUND AND PURPOSE: Diffuse gliomas are classified as grades II-IV on the basis of histologic features, with prognosis determined mainly by clinical factors and histologic grade supported by molecular markers. Our aim was to evaluate, in patients with diffuse gliomas, the relationship of relative CBV and ADC values to overall survival. In addition, we also propose a prognostic model based on preoperative MR imaging findings that predicts survival independent of histopathology. MATERIALS AND METHODS: We conducted a retrospective analysis of the preoperative diffusion and perfusion MR imaging in 126 histologically confirmed diffuse gliomas. Median relative CBV and ADC values were selected for quantitative analysis. Survival univariate analysis was made by constructing survival curves by using the Kaplan-Meier method and comparing subgroups by log-rank probability tests. A Cox regression model was made for multivariate analysis. RESULTS: The study included 126 diffuse gliomas (median follow-up of 14.5 months). ADC and relative CBV values had a significant influence on overall survival. Median overall survival for patients with ADC < 0.799 × 10(-3) mm(2)/s was <1 year. Multivariate analysis revealed that patient age, relative CBV, and ADC values were associated with survival independent of pathology. The preoperative model provides greater ability to predict survival than that obtained by histologic grade alone. CONCLUSIONS: ADC values had a better correlation with overall survival than relative CBV values. A preoperative prognostic model based on patient age, relative CBV, and ADC values predicted overall survival of patients with diffuse gliomas independent of pathology. This preoperative model provides a more accurate predictor of survival than histologic grade alone.
Asunto(s)
Neoplasias Encefálicas/mortalidad , Neoplasias Encefálicas/patología , Glioma/mortalidad , Glioma/patología , Angiografía por Resonancia Magnética/estadística & datos numéricos , Modelos de Riesgos Proporcionales , Neoplasias Encefálicas/cirugía , Femenino , Glioma/cirugía , Humanos , Incidencia , Angiografía por Resonancia Magnética/métodos , Masculino , Persona de Mediana Edad , Modelación Específica para el Paciente/estadística & datos numéricos , Cuidados Preoperatorios/métodos , Cuidados Preoperatorios/estadística & datos numéricos , Pronóstico , Reproducibilidad de los Resultados , Estudios Retrospectivos , Medición de Riesgo/métodos , Factores de Riesgo , Sensibilidad y Especificidad , España/epidemiología , Análisis de Supervivencia , Tasa de SupervivenciaRESUMEN
BACKGROUND AND PURPOSE: In cerebral gliomas, rCBV correlates with tumor grade and histologic findings of vascular proliferation. Moreover, ADC assesses water diffusivity and is inversely correlated with tumor grade. In the present work, we have studied whether combined rCBV and ADC values improve the diagnostic accuracy of MR imaging in the preoperative grading of gliomas. MATERIALS AND METHODS: One hundred sixty-two patients with histopathologically confirmed diffuse gliomas underwent DWI and DSC. Mean rCBV and ADC values were compared among the tumor groups with the Student t test or ANOVA. ROC analysis was used to determine rCBV and ADC threshold values for glioma grading. RESULTS: rCBV had significantly different values between grade II and IV gliomas and between grade III and IV tumors, but there were no significant differences between grade II and III gliomas (P > .05). Grade II and III tumors also did not differ when astrocytomas, oligodendrogliomas, and oligoastrocytomas were considered separately. ADC values were significantly different for all 3 grades. The ADC threshold value of 1.185 × 10(-3) mm(2)/s and the rCBV cutoff value of 1.74 could be used with high sensitivity in the characterization of high-grade gliomas. The area under the ROC curve for the maximum rCBV and minimum ADC was 0.72 and 0.75, respectively. The combination of rCBV and ADC values increased the area under the ROC curve to 0.83. CONCLUSIONS: ADC measurements are better than rCBV values for distinguishing the grades of gliomas. The combination of minimum ADC and maximum rCBV improves the diagnostic accuracy of glioma grading.
Asunto(s)
Determinación del Volumen Sanguíneo/métodos , Neoplasias Encefálicas/patología , Imagen de Difusión por Resonancia Magnética/métodos , Glioma/patología , Aumento de la Imagen/métodos , Angiografía por Resonancia Magnética/métodos , Neovascularización Patológica/patología , Adulto , Anciano , Neoplasias Encefálicas/secundario , Femenino , Glioma/cirugía , Humanos , Masculino , Persona de Mediana Edad , Clasificación del Tumor , Neovascularización Patológica/cirugía , Cuidados Preoperatorios/métodos , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Adulto JovenRESUMEN
Dural arteriovenous fistulas presenting with ascending myelopathy are characterised by the presence of an abnormal retrograde drainage through spinal veins. The authors present a case of cranial dural arteriovenous fistula causing brainstem dysfunction secondary to venous hypertension, treated by surgical interruption of the pial venous drainage which resulted in complete clinical and radiological resolution of the brainstem lesion.
Asunto(s)
Isquemia Encefálica/etiología , Tronco Encefálico/irrigación sanguínea , Malformaciones Vasculares del Sistema Nervioso Central/complicaciones , Malformaciones Vasculares del Sistema Nervioso Central/cirugía , Procedimientos Neuroquirúrgicos , Anciano , Malformaciones Vasculares del Sistema Nervioso Central/diagnóstico , Angiografía Cerebral , Venas Cerebrales/cirugía , Humanos , Hipertensión/complicaciones , Imagen por Resonancia Magnética , Masculino , Piamadre/irrigación sanguíneaRESUMEN
Re-rupture of cerebral aneurysms during conventional angiography, demonstrated by contrast leakage into the extravascular space, is well known and well documented. However, the occurrence of this complication during computed tomography (CT) angiographic examinations has rarely been published despite its extensive use. We present the clinical and radiological features of a rebleeding event during a CT angiographic study. No hemodynamic or contrast-related factors can be evoked predisposing to he occurrence of this complication during this imaging technique. This, along with the short study time, may explain the rarity of this coincidence.
Asunto(s)
Aneurisma Roto/etiología , Angiografía Cerebral/efectos adversos , Aneurisma Intracraneal/diagnóstico por imagen , Tomografía Computarizada por Rayos X/efectos adversos , Aneurisma Roto/terapia , Arterias Cerebrales/diagnóstico por imagen , Medios de Contraste/administración & dosificación , Embolización Terapéutica/métodos , Extravasación de Materiales Terapéuticos y Diagnósticos/etiología , Humanos , Aneurisma Intracraneal/terapia , Masculino , Persona de Mediana Edad , Estado Vegetativo Persistente/etiología , Enfermedades Raras , RecurrenciaRESUMEN
Lymphocytic hypophysitis (LH) is an infrequent primary inflammatory disorder, which is usually diagnosed after surgery for lesions suspected to be pituitary adenomas. Some radiological features have been described that may allow a preoperative diagnosis, such as a symmetric enlargement of the gland with diffuse contrast enhancement extending to the basal hypothalamus in a tongue-like fashion. We describe the case of a patient with LH presenting with the MR imaging of a cystic lesion with ring contrast enhancement. It seems that this appearance in imaging studies is not unusual, and should be considered among the features suggesting this disease in an appropriate clinical context.