Chronic hyperglycemia and intracranial meningiomas.

Meningiomas are among the most common primary tumors of the central nervous system. Previous research into the meningioma histological appearance, genetic markers, transcriptome and epigenetic landscape has revealed that benign meningiomas significantly differ in their glucose metabolism compared to aggressive lesions. However, a correlation between the systemic glucose metabolism and the metabolism of the tumor hasn't yet been found. We hypothesized that chronic levels of glycaemia (approximated with glycated hemoglobin (HbA1c)) are different in patients with aggressive and benign meningiomas. The study encompassed 71 patients with de novo intracranial meningiomas, operated on in three European hospitals, two in Croatia and one in Spain. Our results show that patients with WHO grade 2 meningiomas had significantly higher HbA1c values compared to patients with grade 1 lesions (P = 0.0290). We also found a significant number of patients (19/71; 26.7%) being hyperglycemic, harboring all the risks that such a condition entails. Finally, we found a significant correlation between our patients' age and their preoperative HbA1c levels (P = 0.0008, ρ(rho) = 0.388), suggesting that older meningioma patients are at a higher risk of having their glycaemia severely dysregulated. These findings are especially important considering the current routine and wide-spread use of corticosteroids as anti-edematous treatment. Further research in this area could lead to better understanding of meningiomas and have immediate clinical impact.

Chronic traumatic encephalopathy: The unknown disease. / Encefalopatía crónica postraumática: aquella gran desconocida.

Chronic traumatic encephalopathy is a neurodegenerative disease produced by accumulated minor traumatic brain injuries; no definitive premortem diagnosis and no treatments are available for chronic traumatic encephalopathy. Risk factors associated with chronic traumatic encephalopathy include playing contact sports, presence of the apolipoprotein E4, and old age. Although it shares certain histopathological findings with Alzheimer disease, chronic traumatic encephalopathy has a more specific presentation (hyperphosphorylated tau protein deposited as neurofibrillary tangles, associated with neuropil threads and sometimes with beta-amyloid plaques). Its clinical presentation is insidious; patients show mild cognitive and emotional symptoms before progressing to parkinsonian motor signs and finally dementia. Results from new experimental diagnostic tools are promising, but these tools are not yet available. The mainstay of managing this disease is prevention and early detection of its first symptoms.

Glycemia and coagulation in patients with glioblastomas.

Glioblastomas are among the most malignant tumors which, despite aggressive treatment, currently have an abysmal prognosis. These lesions are known to cause local and systemic perturbations in the coagulation system, leading to neo-angiogenesis and a high risk of venous thromboembolism. Indeed, there have been multiple proposals of the coagulation system being a possible target for future treatment of these patients. However, non-selective anticoagulant therapy has proven suboptimal and leads to a significant increase of intracranial hemorrhage. Thus, recognizing factors which lead to hyper-coagulation is considered paramount. Hyperglycemia is a well-known pro-thrombotic factor, a fact which has received little attention in neuro-oncology so-far. We previously hypothesized that patients with brain tumors could be highly susceptible to iatrogenic glycemia dysregulation. Here, we analyzed the connection between glycated hemoglobin (HbA1c) and the routine coagulation markers (D-dimers, prothrombin time (PT) and activated partial thromboplastin time (aPTT)) in patients with de novo intracranial glioblastomas. Included in this study were 74 patients, operated on in three hospitals, Clinical Hospital Dubrava, Zagreb, Croatia; University Hospital Center Split, Split, Croatia and University Hospital de la Princesa, Madrid, Spain. We found a significant inverse correlation between HbA1c and aPTT (ρ=-0.379; P=0.0009). We also found a significant inverse correlation between Ki67 immunoreactivity and aPTT (ρ=-0.211; P=0.0082). No connection was found between HbA1c and D-dimers or PT. Our results suggest that hyperglycemic patients, with a more proliferative glioblastoma, could in fact have their coagulation profile significantly disrupted, primarily through the intrinsic coagulation pathway. Such findings could have great clinical importance. Further research in this area could help elucidate the vicious connection between glioblastomas and coagulation, and help combat the deadly disease.

Effects of cranioplasty in cerebral blood perfusion using quantification with 99m-Tc HMPAO SPECT-CT.

BACKGROUND AND PURPOSE: Syndrome of the trephined or sinking skin flap syndrome is an underdiagnosed condition of craniectomized patients that usually improves after cranioplasty. Among the pathophysiological theories proposed, the changes of cerebral blood perfusion (CBP) caused by cranial defects might have a role in the neurological deficiencies observed. We aim to assess the regional cortex changes in CBP after cranioplasty with Technetium 99m hexamethylpropylene-amine oxime (99mTc-HMPAO) SPECT-CT. METHODS: Twenty-eight craniectomized patients subject to cranioplasty were studied with 99mTc-HMPAO SPECT-CT in three different times, before cranioplasty, a week, and 3 months after. The images were processed with quantification software comparing CBP of 24 cortical areas with a reference area, and with a database of controls. A mixed effects model and T-Student were used. RESULTS: CBP increased significantly in both hemispheres after cranioplasty, either using ratio (ß = .019, p-value = .030 first postsurgical SPECT-CT and ß = .021, p-value = .015 in the second study, vs. presurgical) or Z-score (ß = .220, p-value = .026 and ß = .279, p-value = .005, respectively). Nine areas of the damaged side had a significant lower CBP ratio and Z-score than the undamaged. Posterior cingulate showed an increased CBP ratio (p-value = .034) and Z-score (p-value = .028) in the first postsurgical SPECT-CT. These posterior cingulate changes represent a 4.83% increase in ratio and 91.04% in Z-Score (p-value = .035 and .040, respectively). CONCLUSION: CBP changes significantly in specific cortical areas after cranioplasty. Posterior cingulate changes might explain some improvements in attention impairments. SPECT-CT could be a useful tool to assess CBP changes in these patients and might be helpful in their clinical management.

[Aneurysmal subarachnoid hemorrhage: group of study of cerebrovascular pathology of the Spanish society of neurosurgery management guideline]. / Hemorragia subaracnoidea aneurismática: guía de tratamiento del grupo de patología vascular de la sociedad Española de neurocirugía.

An actualized revision of the most important aspects of aneurismal subarachnoid hemorrhage is presented from the guidelines previously published by the group of study of cerebrovascular pathology of the Spanish Society of Neurosurgery. The proposed recommendations should be considered as a general guide for the management of this pathological condition. However, they can be modified, even in a significant manner according to the circumstances relating each clinical case and the variations in the therapeutic and diagnostic procedures available in the center attending each patient.

[Implementation of the Bologna system in medical education. Current status and future prospects]. / El desarrollo del proceso de "Bolonia" y el Grado de Medicina. Situación actual y expectativas para su implantación definitiva.

The implementation of the European Higher Education Area, (EEES in Spanish) inspired in the Bologna Declaration, pursues the introduction of new teaching and learning paradigms which require deep changes in the frame of superior education and university goals. However, in spite that the main purpose of the EEES is convergence and harmonization of curricula contents and titles throughout Europe in order to facilitate circulation of students and professionals, this goal is far from been reached when we are approaching the deadline for its implementation (year 2010). In addition, this process has led to reduce the total duration of the majority of degrees excepting for medicine and few more. In this article we analyze the underdevelopment of the so called Bologna Process in medical education as compared to other careers. Implementation of curricular innovations seems particularly restrained or threatened in Spain because of legal improvisation, lack of funding, and the chronic apathy of national bodies in medical education. As a consequence, and in contrast with other European countries where deep curricular changes have been already arranged, the majority of Spanish Faculties are at risk of introducing little more than cosmetic modifications in their medicine curricula.

[Embolization of indirect carotid-cavernous sinus fistula through the ophthalmic vein]. / Embolización de fístula cavernosa indirecta a través de la vena oftálmica superior.

Indirect or dural carotid cavernous fistulas are abnormal connections between the cavernous sinus and meningeal branches of the external and/or internal carotid arteries. Most of them are idiopathic and occurs spontaneously. Symptoms vary from a tiny episcleral injection to a severe visual loss. Conservative therapy is recomended in cases with few symptoms and no leptomeningeal drainage, as spontaneous resolution is not infrequent. Whenever symptoms worsen, treatment of the fistula should be prescribed. Nowadays, transvenous endovascular treatment consisting of packing the cavernous sinus is the first choice. In most cases, cavernous sinus can be approached through the inferior petrosal sinus. However, sometimes that is not possible, and an approach directly through the superior ophthalmic vein could be necessary. We report a case of a patient with a dural carotid cavernous fistula treated with embolization of the cavernous sinus through the ophthalmic vein.

[Surgical treatment for spontaneous intracerebral haemorrhage. Part II: infratentorial haematomas]. / Tratamiento quirúrgico de la hemorragia intracerebral espontánea. Parte II:Hemorragia infratentorial.

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.

[Magnetic resonance in moderate and severe head injury: comparative study of CT and MR findings. Characteristics related to the presence and location of diffuse axonal injury in MR]. / Resonancia magnética en trauma craneal moderado y grave: estudio comparativo de hallazgos en TC y RM. Características relacionadas con la presencia y localización de lesión axonal difusa en RM.

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.

Acute subdural and intratemporal hematoma as a complication of percutaneous compression of the gasserian ganglion for trigeminal neuralgia.

The case of a 68 year-old man who developed a fatal intracranial hemorrhagic complication following percutaneous compression of the gasserian ganglion for trigeminal neuralgia is reported. The complication was likely related to improper placement of the Fogarty catheter into the temporal fossa out of the Meckel's cave. The anatomical structures at risk of damage by misplaced needle or catheter and some relevant technical details aimed to prevent extratrigeminal complications related with this and other percutaneous trigeminal lesioning procedures are analyzed.

[Value of serial CT scanning and intracranial pressure monitoring for detecting new intracranial mass effect in severe head injury patients showing lesions type I-II in the initial CT scan]. / Utilidad de la TAC secuencial y la monitorización de la presión intracraneal para detectar nuevo efecto masa intracraneal en pacientes con traumatismo craneal grave y lesión inicial Tipo I-II.

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.

Cerebral aneurysm rupture after r-TPA thrombolysis for acute myocardial infarction.

BACKGROUND: Intracranial hemorrhage is the most dreaded risk of thrombolytic therapy for acute myocardial infarction because of the high mortality and disability rates associated with this complication. Brain structural lesions may predispose a patient to bleeding. To date, aneurysm rupture has not been described as a complication of such therapy. CASE DESCRIPTION: A 66-year-old hypertensive woman was admitted because of chest pain. Myocardial infarction was diagnosed and fibrinolytic therapy with recombinant tissue plasminogen activator (r-TPA) was initiated. Eight hours after admission she became unconscious. Brain computed tomography scan showed subarachnoid hemorrhage, and a cerebral arteriography showed an anterior communicating artery aneurysm. Because of her poor clinical condition treatment was postponed. Death occurred 7 days later because of multiorgan failure. CONCLUSIONS: Cerebral aneurysms should be considered as a possible contributing factor to intracranial bleeding after thrombolytic therapy.

[Postraumatic subdural collections: case report and review of the literature]. / Colecciones subdurales postraumáticas: presentación de un caso de revisión de la literatura.

Posttraumatic and postcraniectomy subdural fluid collections have been usually described with the general term of hygroma. Recently, different clinical entities have been described, such as simple or complex hygroma, subdural effusion or external hydrocephalus, based on the mechanisms of formation of the fluid collection, its biochemical composition or the characteristics exhibited in modern imaging studies. However, there is no agreement in the literature regarding the use of these terms. We report a new case of a mixed posttraumatic and postcraniectomy subdural fluid collection and review the literature concerning these entities.

Surgical treatment of trigonocephalies and associated hypoteleorbitism.

Premature closure of metopic suture is a relatively uncommon form of craniosyostosis with an estimated incidence of 0,3 per 1000 live births, comprising about 7% of surgical craniosynostosis referred to craniofacial centers. A broad phenotypical spectrum spreads from minor metopic ridges to severe trigonocephaly with pterional indentation supraorbital bar retrusion, temporal and parietal compensating bossings and hypotelorism. Most of the cases arise spontaneously although autosomal dominant inheritance has been described and association with cromosomal abnormalities and different syndromes has been widely reported. Surgical correction has been attempted with good cosmetic results using several variations of the standard frontoorbitary advance. However there is still a number of questions to be solved in relation to this entity, mainly on its pathogenesis, but also on its development, natural history and treatment. Direct surgical approach to associated hypotelorism is a matter of argument when considering the reestablishment of normal interorbitary distances. We have conducted a retrospective analysis of our serie consisting of twenty-eight cases of trigonocephalies. Surgical correction of hypotelorism was attempted in eleven cases while the resting seven children remained "not treated". The objective was to review the functional outcome and cosmetic results comparing the different techniques applied to the frontal bone and to observe evolution of the hypoteleorbitism after the treatment with or without osteotomies and grafting of the nasoethmoidal area.

[Subarachnoid hemorrhage secondary to dissecting aneurysms of the vertebral artery. Description of 2 cases and review of the literature]. / Hemorragia subaracnoidea secundaria a aneurismas disecantes de la arteria vertebral. Descripción de 2 casos y revisión de la literatura.

UNLABELLED: OBJECTIVES AND INTRODUCTION: The pathogenesis and natural history of intracranial vertebral artery dissection remain uncertain up to now due in part to its relative rarity. In this article we review the state of the art of this process and remark the good outcome obtained with embolization using Guglielmi detachable coiling (GDC). METHODS: Two cases with subarachnoid hemorrhage secondary to rupture of a vertebral dissection aneurysms are described. The first patient initially suffered brain stem infarction, followed by a subarachnoid hemorrhage a year later. The second patient who had a severe subarachnoid hemorrhage with two early rebleedings was successfully treated with embolization using GDC. CONCLUSIONS: Subarachnoid hemorrhage due to rupture of vertebral dissecting aneurysm is a relatively unknown disease with some important aspects that should be known. The high incidence of early rebleeding (up to 60%), makes early diagnosis and treatment important goals. Classically the preferred treatment has been proximal vertebral artery occlusion. However, the recent introduction of embolization with GDC has made possible the occlusion of the dissection with very good final outcome.

Oligodendroglioma and multiple sclerosis. A case report.

BACKGROUND: The concurrence of multiple sclerosis (MS) and glioma is uncommon. Approximately 30 cases have been reported, but in only six of them the tumour was pure or mixed oligodendroglioma. The appearance of new neurological symptoms and signs in a patient with multiple sclerosis is usually attributed to a relapse of this disease and neuroradiological studies are not always performed. When done, the finding of a new focal mass lesion is usually interpreted as a pseudotumoural plaque. CASE REPORT: A 37-year-old man was admitted because of partial simple seizures and an enlarging intracranial mass. He had been diagnosed of MS eleven years earlier. A MRI study performed eight years before admission showed a large mass in the right frontal lobe which was thought to be a pseudotumoural plaque. Two years later, he developed simple partial motor seizures that were initially controlled with valproic acid. He remained well until three months before admission, when seizures reappeared with a poor response to valproic acid. A new MRI study showed an heterogeneous right frontal enlarging mass lesion. A primary neoplasm was suspected and a subtotal removal was performed. The pathological diagnosis was oligodendroglioma with a periferic demyelinating area. CONCLUSION: Atypical MRI lesions in a patient with MS must be carefully interpreted. Pseudotumoural plaques have been described both clinically and radiologically to be hardly distinguishable from a tumoural lesion and histological confirmation is often required. The association between MS and glioma is uncommon but it must be kept in mind when a mass lesion develops in a patient with MS.

[Parasplenial arteriovenous malformations. Report of 15 surgically treated cases]. / Malformaciones arteriovenosas paraesplénicas. A propósito de 15 casos tratados quirúrgicamente.

INTRODUCTION: Yasargil called paraesplenial those AVMs located at the confluence of the hippocampus, the isthmus of the cingulate girus and the girus occipitotemporalis medialis. Large AVMs at this location are among the most difficult to delineate and to treat. OBJECTIVE: Analyze the clinical presentation, the findings in the imaging studies, the surgical management and the final outcome in 15 patients with paraesplenial AVMs treated with embolization (the last 4 cases), and microsurgical removal. RESULTS: Nine patients (60%) were female and 6 males of ages between 15 and 39 years (mean = 24 yrs). Eleven (75%) presented with hemorrhage, (intraventricular in most cases) and the remaining with epilepsy. The Spetzler-Martin grade was II in one Case, III in 5 cases, IV in 8 cases and V in one case. Preoperative embolization clearly improved surgical management. All the patients had complete resection of the lesion, 13 in a single stage and 2 in two stages. The final outcome was good but four patients developed defects of the visual field not seen preoperatively. CONCLUSIONS: The authors comment the peculiarities of paraesplenial AVMs which can be safely and completely removed with microsurgery and the aid of preoperative embolization.

Meningiomas of the basal posterior fossa. Surgical experience in 80 cases.

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.

[Arteriovenous malformation of the middle and posterior third section of the corpus callosum treated with embolization and surgery]. / Malformación arteriovenosa de los tercios medio y posterior del cuerpo calloso tratada con embolización y cirugía.

We are presenting the case of a 58 year-old woman with an arteriovenous malformation (AVM) of the middle and posterior thirds of the corpus callosum which had produced two episodes of bleeding before admission to our Department, when the patient was neurologically intact. The nidus was fed by the anterior and posterior pericallosal arteries draining through the left medial atrial vein to the vein of Galen, by parasagittal cortical veins to the superior sagittal sinus and by right temporal veins to the sphenoparietal sinus. The patient underwent embolization of the anterior and posterior feeders in two sessions separated by a week interval, and then the AVM was removed through a left paramedial parietooccipital craniotomy in a single stage. The patient showed transient mild short term memory deficit, but the final outcome was excellent.

Intratumoural bleomycin as a treatment for recurrent cystic craniopharyngioma. Case report and review of the literature.

INTRODUCTION: The majority of craniopharyngioma (CF) have a cystic component and only 10% are completely solid. In tumors with a large cystic component, stereotactic drainage or instillation of radioctive and/or chemotherapeutic agents have been used. Only several authors have reported the use of bleomycin for the treatment of cystic CF. CASE REPORT: The authors present the case of a nineteen years old patient with a recurrent cystic CF who was treated with intratumoral injections of bleomycin. The patient had been operated on three times before because of regrowth of the tumor. This last time he had a severe disturbance of his visual acuity and a huge regrowth of the cystic CF. An intracystic catheter stereotactically placed was connected to an Ommaya reservoir and, after assuring the impermeability of the cyst, bleomycin was administered through the reservoir up to a total dose of 45mg distributed in six doses. No complications were detected during and after the procedure. A MR performed 4 months after treatment showed a clear reduction in the size of the cyst but 10 months later a new regrowth of the cyst was detected by MR with no new signs or symptoms. A total dose of 30 mg divided in six doses was administered. No complications occurred. The MR 18 months after the first treatment showed the reduction in size of the tumor. The ophtalmological study showed almost normal visual acuity in both eyes. DISCUSSION: Although there is not an stablished protocol for the indication and the form of application of intracystic bleomycin, results with this treatment for cystic CF seem good in the literature. However, the risk of local complications after the administration of intratumoural bleomycin in these patients is around 10%, and some fatal toxic reactions have been recently reported. CONCLUSION: Intracystic administration of bleomycin is a valid option as adjuvant therapy for CF in patients with recurrences that are not surgical candidates because of the high risk of complications. The role of bleomycin as a primary treatment for CF and treatment protocols remain to be stablished with additional studies.