[Experience with the radiosurgical treatment of brain metastases]. / Experiencia en el manejo de metástasis cerebrales tratadas con radiocirugía estereotáctica.

OBJECTIVE: To analyse the survival rate of a cohort of patients with intracranial metastases treated with radiosurgery, and to determine the factors that influence the results. PATIENTS AND METHOD: Retrospective analysis performed on a cohort of 126 patients undergoing radiosurgery for brain metastases. Patients treated with surgery before or after radiosurgery were excluded. Survival is analysed based on clinical (age, sex, primary tumour), radiological (number, location and volume of lesions), and radiotherapy factors (treatment dose, holocraneal radiation). Univariate and multivariate analyses were performed to determine significant prognostic factors. RESULTS: A total of 225 brain metastases in 126 patients, with a mean age of 59.8±11.6years, were treated between February 2008 and April 2015. The mean survival was 8.2 months. The overall survival rates at 6months, 1year, and 2years were 60.3%, 31.5%, and 12.8%, respectively. Lung (59.5%) and breast (14.3) were the most common primary tumours, and the most common site for metastases was the cerebral hemisphere (77%) and the average volume was 10.35 cc (0.2-43.5). Significant survival factors were: age under 60 (P=.046), female (P<.001), breast cancer (P<.001), KPS >80 (P=.001), SIR6 >5 (P=.031), and GPA ≥2.5 (P=.003). CONCLUSIONS: Radiosurgery is an appropriate technique for the treatment of brain metastases, and the main prognostic factors include being age under 65, female, breast cancer, and good scores on Karnofsky, SIR, and GPA scales.

[High-grade glioma after stereotactic radiosurgery for vestibular schwannoma]. / Glioma radioinducido secundario a tratamiento radioquirúrgico de un schwannoma del nervio vestibular.

Stereotactic radiosurgery undoubtedly represents an important therapeutic procedure for various intracranial pathologies, especially tumours, although they are not entirely complication-free. Radiosurgery have been considered a good management strategy for the majority of small-to-medium size vestibular schwannomas. The authors describe a case of high-grade glioma associated with a previous radiosurgery treatment for a vestibular schwannoma in a 69 year-old woman. A detailed description of these cases is provided, as well as a summary of the related literature.

[Bilateral chronic subdural haematoma: Analysis of a series of 190 patients]. / Hematoma subdural crónico bilateral: análisis de una serie de 190 pacientes.

OBJECTIVE: The aim of this study is to analyse the clinical findings and surgical results in a series of patients with bilateral chronic subdural haematoma (BCSDH), and compare the results with a series of patients treated for unilateral chronic subdural haematoma (UCSDH). PATIENTS AND METHODS: A retrospective study was performed on 1523 patients diagnosed and surgically treated for chronic subdural haematoma over a period of 30 years. Patients were divided into 2 groups: The study group consisting of 190 patients operated on for a BCSDH and the control group consisting of patients operated on for an UCSDH (1333 cases). RESULTS: The patient series included 126 males (66.3%) and 64 females (33.7%), with a mean age at diagnosis of 74.8±10.2. The control group consisted of 870 males (65.2%) and 463 women (34.8%), with a mean age of 73.2±12.1. The most common presenting symptoms was cognitive impairment in 63 patients (33.2%) with BCSDH and 416 (29.5%) with UCSDH. Recurrence rates were 9.4% (18 patients) and 5.7% (77 patients) in unilateral and bilateral haematomas, respectively. The mortality was 10 patients (5.2%) with BCSDH and 55(4%) with UCSDH. Factors significantly related to recurrence in the univariate analysis were being male (P=.040), anticoagulant/antiplatelet therapy (P=.032), and poor neurological status at admission (P=.039). CONCLUSIONS: This study indicates that BCSDH is more frequent in males, and the most common presentation is headache. The most important factors influencing recurrences are being male, intake of anticoagulant-antiaggregant drugs, and worse clinical status at admission.

[Imaging diagnosis of arachnoid cysts]. / Diagnóstico por imagen de los quistes aracnoideos.

Arachnoid cysts are malformed lesions that contain a fluid similar to the cerebrospinal fluid, and are usually located within the arachnoidal membrane. They represent 1% of all intracranial lesions, and in recent years, with the development of radiological techniques, the clinical detectability of arachnoid cysts seems to have increased. Although the majority of diagnosed arachnoid cysts are located in the cranial cavity and especially in the Sylvian fissure, a small number are located at spinal level and they can occur extra- or intra-spinally. An analysis is carried out, detailing the various tests used for the diagnosis of both intracranial and spinal arachnoids cysts, analysing the indications of each one depending on the location of the cysts and patient age.

[Congenital medulloblastoma associated with intracranial arachnoid cyst]. / Meduloblastoma congénito asociado a quiste aracnoideo intracraneal.

Arachnoid cysts are very common lesions in paediatric patients, with treatment depending on their location and symptomatology. They are usually solitary cysts but may be associated with other central nervous system diseases such as tumours and congenital deformities. We describe the case of a neonate diagnosed with an arachnoid cyst of the quadrigeminal cistern treated by endoscopy. After the operation, the child's condition worsened; a CT scan revealed a midline posterior fossa tumour not visible in the preoperative neuroradiological tests. The tumour, a medulloblastoma, was partially removed. Given the child's age and the poor prognosis, oncological treatment was not undertaken. The association between medulloblastoma and arachnoid cyst is very rare, and we could find only one such case in the literature.

[Chronic subdural hematoma in young patients]. / Hematoma subdural crónico en pacientes jóvenes.

OBJECTIVE: The objective of this study was to analyse demographic, clinical and radiological findings and surgical results in a series of chronic subdural haematomas (CSDH) in young adult patients. PATIENTS AND METHODS: This retrospective study included 42 patients under 40 years of age who were diagnosed and surgically treated for a CSDH during a 30-year period (1982-2011). RESULTS: Of the 42 cases analysed, 32 were males and 10 were females, and the mean age at diagnosis was 29.3±8.9 years (range: 4 to 39 years). The mean interval from trauma to appearance of clinical symptoms was 33.4±9.7 days (range: 19 to 95 days). The main symptoms were headache (59.5%) and seizures (21.4%), and the most frequent predisposing factors were ventriculoperitoneal shunting in 5 (11.9%) patients and haematological disorders in another 5 (11.9%) cases. CSDH was right-sided in 21 cases (50%), left-sided in 19 cases (45.3%) and bilateral in the remaining 2 patients (4.7%). Postoperative complications occurred in 2 patients (1 recurrence and 1 acute subdural haematoma). CONCLUSIONS: CSDH is a rare pathology during the first decades of life. It mainly affects males and headache is usually the first symptom. Prognosis is good in young patients, since postoperative complications and recurrences are less frequent at this age than in older populations.

Parkinsonism secondary to subdural haematoma.

Parkinsonism consists of several extrapyramidal signs, characterized by tremor, muscle rigidity, and loss of postural reflexes. The most common cause of parkinsonism is idiopathic Parkinson's disease, whereas the secondary forms include drug exposure, trauma, infection, and chronic subdural haematomas. Four patients with parkinsonism out of 1,289 chronic subdural haematomas were admitted to our hospital between 1985 and 2010. Nineteen patients identified in the literature were also included in this revision. Of the 23 cases reviewed (19 men and 4 women; age at diagnosis ranged between 38 and 83 years; mean, 68.8), the interval between initial symptoms and haematoma diagnosis ranged between 1 week and 1 year (mean interval, 8 weeks). The haematoma was unilateral in 13 cases and bilateral in 10 cases. All chronic subdural haematomas were resolved using different surgical techniques with marked improvement following surgery. Parkinsonism is a rare presentation of chronic subdural haematoma. However, the sudden onset of parkinsonisms requires prompt neuroimaging to rule out this potentially reversible aetiology. The prognosis of chronic subdural haematoma-related parkinsonism is favourable after surgical evacuation.

Continuous Subcutaneous Apomorphine Infusion before Subthalamic Deep Brain Stimulation: A Prospective, Comparative Study in 20 Patients.

BACKGROUND: Studies comparing the clinical efficacy of apomorphine infusion (APO) with subsequent subthalamic deep brain stimulation (STN-DBS) in advanced Parkinson's disease (aPD) are currently lacking. Retrospective data have shown that patients treated with APO are usually older, have a more prolonged disease, and a more severe phenotype. OBJECTIVE: To compare the benefit of APO with that of STN-DBS on motor, non-motor, cognitive, and quality of life in the same patient when given sequentially. METHODS: We prospectively analyzed 20 aPD patients over 3 different treatment phases: baseline (optimized medical treatment), during APO treatment, and during subsequent STN-DBS treatment. The APO and STN-DBS phases were stable for 6 months, and evaluation of the different treatments was separated by 6 months. RESULTS: Compared to baseline, APO, and STN-DBS reduced mean daily off time by 70.5% and 89.3% (P = 0.012), respectively, and scores for Unified Parkinson's Disease Rating Scale (UPDRS) IV by 27.5% and 80.5% (P ≤ 0.001), Non-motor symptoms scale (NMSS) by 24.6% and 49.3% (P ≤ 0.001), Montgomery Asberg depression scale (MADRS) by 7.4% and 39.0% (P = 0.27), Starkstein apathy scale (SAS) by 51.1% and 39.9% (P = 0.734), Parkinson's disease sleep scale 2 (PDSS-2) by 25.7% and 56.7% (P ≤ 0.001), and Parkinson's disease questionnaire 39 item (PDQ-39) by 39.6% and 64.9% (P ≤ 0.001). Global cognition did not change with either therapy, but phonetic fluency worsened after STN-DBS compared to APO (P = 0.022). CONCLUSIONS: Both APO and STN-DBS improved motor and non-motor symptoms and quality of life compared to optimized medical treatment in aPD. Overall, STN-DBS was the most effective treatment, but APO showed a pronounced benefit on motor symptoms. Effective treatment for aPD should not be delayed, even when waiting for surgery.

[Chronic subdural haematomas in very elderly patients]. / Hematoma subdural crónico en pacientes muy ancianos.

INTRODUCTION: Chronic subdural haematoma (CSDH) is one of the most common neurosurgical conditions and is especially prevalent among elderly individuals. The objective of this study was to analyse the demographic, clinical and radiological findings, and surgical outcomes in a series of chronic subdural haematoma in patients older than 85 years. PATIENTS AND METHODS: A review was carried out on all patients over 85 years with CSDH treated in our neurosurgical service from April 1986 to November 2015. A record was made of the baseline patient characteristics (age, sex, comorbidities, known risk factors, imaging characteristics, and number of burr-holes) and surgical outcomes (complications, especially recurrences and mortality). An analysis was carried out on the special characteristics of these patients, as well as the relationships between gender, clinical grade, anti-platelet or anticoagulant therapy, internal architecture of the haematoma, and midline shift, with mortality and recurrence of the haematoma. RESULTS: A total of 200 patients were included, with a mean age of 88.5 (range 85-104) years, and the male: female sex ratio was 1:1.1. History of injury was reported in 114 (57%) cases. Anti-platelet or anticoagulant therapy was being used by 71 (35.5%) patients. On admission, 114 patients (57%) were in satisfactory condition (Markwalder grades 0-2). The main symptom was behavioural disturbance in 82 (41%) cases. CSDH was left-sided in 89 (44.5%) patients, right-sided in 78 (39%) cases (39%), and bilateral in the remaining 33 (16.5%) cases). Postoperative complications were observed in 59 cases (29 recurrences). Preoperative Markwalder grade correlated significantly with recurrence rate and mortality (P<.0001). CONCLUSIONS: CSDH was a very common disease in very elderly patients. Behavioural disturbance and neurological deficits are the most common first symptom. Preoperative neurological status at admission is the most important factor in recurrences and mortality.