Bilaminar Chitosan Scaffold for Sellar Floor Repair in Transsphenoidal Surgery.

BACKGROUND: Endoscopic endonasal transsphenoidal surgery (EETS) is a standard technique used to approach sellar tumors. It is relatively safe, minimally invasive and carries a low risk of complications. However, one of the common complications reported with this technique is CSF leakage which causes morbidity, an increase in recovery time and hospital costs. This complication usually occurs from violation of the diaphragma sellae and a defect in the structures of the sellar floor or incomplete repair. In this article we report the first case with the use of a novel bilaminar chitosan scaffold which can be potentially used in the repair of the sellar floor, primarily aiming to the bony part of this structure. CASE PRESENTATION: After a personalized design employing a tissue engineering strategy, we reconstructed the sellar floor in a 65-year-old woman who had undergone EETS for a pituitary adenoma with progressive bilateral visual loss. To repair the bony defect of the sellar floor, we used a novel bilaminar chitosan scaffold. The patient had an unremarkable postoperative course with no evidence of CSF leak. The polymer was well tolerated without toxicity, infection or complications. After 2 years of follow up the patient remains neurologically intact, and in good endocrinological status. CONCLUSION: This is the first report of the use of this biomaterial and its biocompatibility in a clinical setting for the repair of the sellar floor during EETS. Our experience with chitosan bilaminar scaffold and in several preclinical studies in the literature have demonstrated good biocompatibility and effective bioengineered bone regeneration due to its excellent osteoconductive properties, this study pretends to be one landmark for further clinical research and larger case series with the use of this personalized tissue engineering materials in order to see they real efficacy to increase the surgeon armamentarium.

Chitosan-Hydroxyapatite Scaffold for Tissue Engineering in Experimental Lumbar Laminectomy and Posterolateral Spinal Fusion in Wistar Rats.

STUDY DESIGN: Experimental study with an animal model. PURPOSE: To evaluate the role of a chitosan and hydroxyapatite composite for spinal fusion in a lumbar experimental model based on regenerative tissue engineering principles. OVERVIEW OF LITERATURE: Chitosan and hydroxyapatite represent an alternative biodegradable implant material for tissue engineering and regeneration. The combination of chitosan and hydroxyapatite in a 20:80 ratio could potentiate their individual properties as an implantable composite for experimental laminectomy. METHODS: Phase I: design and synthesis of a porous composite scaffold composed of chitosan-hydroxyapatite using a freeze drying technique. Phase II: experimental microsurgical lumbar laminectomy at L5. A total of 35 Wistar rats were categorized into three experimental groups: control (laminectomy alone), experimental (laminectomy with implant), and reference (intact spine) (n=5 per group). Postoperative structural and functional evaluations were performed using computed tomography scans. In addition, radiologic, clinical, histological, and immunohistochemical microstructures were evaluated. RESULTS: At the laminectomy site, the composite implant induced bone regeneration, which was observed in the axial reconstruction of the rat lumbar spine in all cases. Biomechanical changes in the lumbar spine were observed by radiology in both groups after the surgery. The posterolateral space was covered by a bone structure in the treated spine, a condition not seen in the control group. The range of motion was 7.662°±0.81° in the scaffold group versus 20.72°±3.47° in the control group. Histological findings revealed qualitatively more bone tissue formation in the implant group. CONCLUSIONS: A composite of chitosan-hydroxyapatite at a 20:80 ratio induced bone formation after experimental laminectomy in rats and led to spinal fusion, which was assessed by radiology and biomechanical tests. No functional complications in posture or walking were observed at 90 days post-surgery, despite biomechanical changes in the spine.

Paradoxical Herniation in the Postcraniectomy Syndrome: Report and Literature Update.

Introduction The decompressive craniectomy is a surgical strategy widely used with specific criteria to control the refractory intracranial pressure (ICP). However, it is important to warn about the presence of a postcraniectomy syndrome and analyze the risk-benefit on a long term. Case Report A 72-year-old male patient diagnosed with a subarachnoid hemorrhage secondary to the rupture of an anterior circulation aneurysm that develops vasospasm, secondary ischemia, and edema with signs of herniation that required a decompressive craniectomy on a first step. Afterwards, the aneurysm was approached and he consequently developed hydrocephaly. A ventriculoperitoneal shunt is installed, contralateral to the craniectomy, and progressive sinking of the skin flap, there is neurological deterioration and paradoxical herniation. Its association with the clinical deterioration by bronchoaspiration did not allow the cranioplasty to resolve the ICP decompensation. Conclusions The paradoxical herniation as part of the postcraniectomy syndrome is an increasingly common condition identified in adult patients with cortical atrophy, and who have also been treated with ventricular shunt systems. Timely cranioplasty represents the ideal therapeutic plan once the compromise from the mass effect has resolved to avoid complications derived from the decompressive craniectomy per se.

Neurofibromatosis type 1 and pregnancy: The transformation of a nodular to cystic neurofibroma in the cervical region.

BACKGROUND: The peripheral hallmarks of neurofibromatosis type 1 (NF1) are Café au lait and solid nodular neurofibromas. The morphological behavior of these lesions could be susceptible to modification during pregnancy. The present case report describes a case of cystic transformation of a nodular neurofibroma, with progressive growth and mass effect in the anterior cervical region, which was surgically resolved without any complications. CASE DESCRIPTION: A 33-year-old female patient with a known personal history of NF1, with annual control of the peripheral neurofibromas and cerebral and spinal magnetic resonance imaging follow-ups. Under genetic counseling, she decides to get pregnant following all the medical advises. Once the pregnancy is confirmed, she starts to notice the growth of one of them adjacent to the left cervical region. Such neurofibroma presented with the progressive gradual increase and in the last month, she presented dysphagia, dysphonia, and postural pain localized by the mass effect. Once the pregnancy concluded, the microsurgical approach was scheduled for resection of the lesion, where a cystic mass was found within the walls of the neurofibroma. The resection was uneventful. CONCLUSION: The transformation of a nodular to cystic neurofibroma during pregnancy is a very rare presentation, which may exacerbate the clinical symptomatology depending on the topography of the lesion due to the mass effect it may create. This condition may alert to the recommendations and vigilance in patients with NF1, who are pregnant or are planning on a future pregnancy. The neurosurgical resolution in this region is safe and beneficial.

[Temporal lobe epilepsy and active neurocysticercosis: two representative case reports]. / Epilepsia del lobulo temporal y neurocisticercosis activa: dos casos representativos.

INTRODUCTION: There are limited evidences reported of temporal lobe epilepsy associated with active cysticercosis in cystic stage. The objective is to present the correlation between active cysticercosis in topographical zones associated with temporal lobe epilepsy, with neuropsychiatric manifestations and pattern of secondarily generalized partial seizures. CASE REPORTS: Two cases of adult patients with neuropsychiatric manifestations of one year evolution, refractory to antipsychotic drug treatment, and who subsequently appear late onset partial-secondarily generalized seizures. Cysticercosis active presence in the temporal lobe in one patient, and the insula in the other, is identified. A better clinical control after albendazol treatment and subsequently anticonvulsant therapy only remained to evaluate pertinence of pharmacological withdrawal criteria. CONCLUSIONS: Active neurocysticercosis, may be the cause of acquired neuropsychiatric disorders and temporal lobe epilepsy of late onset when the topography is in the mesolimbic circuit. Early etiologic diagnosis and appropriate treatment allows adequate control of their symptoms and potentially final cure.

TITLE: Epilepsia del lobulo temporal y neurocisticercosis activa: dos casos representativos.Introduccion. Existen pocas evidencias notificadas de casos de epilepsia del lobulo temporal asociadas a cisticercosis activa en su fase quistica. El objetivo es presentar la correlacion entre cisticercosis activa en zonas topograficas asociadas a epilepsia del lobulo temporal, con las manifestaciones neuropsiquiatricas y el patron de crisis parciales secundariamente generalizadas. Casos clinicos. Dos casos de pacientes adultos con manifestaciones neuropsiquiatricas de un año de evolucion, refractarios a tratamiento farmacologico antipsicotico, y en quienes posteriormente aparecen crisis convulsivas parciales secundariamente generalizadas de inicio tardio. Se identifica la presencia de cisticercosis activa en el lobulo temporal en un paciente, y en la insula, en el otro. Buen control clinico posterior al tratamiento con albendazol, pero se mantiene el mismo tratamiento anticonvulsionante para considerar la pertinencia de su retirada farmacologica. Conclusiones. La neurocisticercosis activa puede ser causa de trastornos neuropsiquiatricos adquiridos y de epilepsia del lobulo temporal de inicio tardio cuando su topografia se encuentra en el circuito mesolimbico. El diagnostico etiologico oportuno y el tratamiento apropiado permiten el control adecuado de su sintomatologia y, potencialmente, su curacion definitiva.

Incidental consequences of antihelmintic treatment in the central nervous system.

BACKGROUND: Neurocysticercosis (NCC) is the most common parasitic infection in the central nervous system and the most common cause of acquired neurological symptoms in young adults living in developing countries. Many "asymptomatic" patients begin experiencing neurological symptoms after the use of antiparasitic drugs for gastrointestinal treatment. Patients who are previously diagnosed with NCC require special care during cysticidal treatment because of the inflammatory effects caused by the interaction between the drug, the parasite, and the host. CASE DESCRIPTION: Of a series of 46 cases, we selected five patients with a history of being "asymptomatic" and who began experiencing neurologic symptoms after the use of albendazole, which led to a diagnosis of cysticercosis. Another case of the patient, who already had been diagnosed of ventricular cysticercosis, was given a drug treatment without consulting the neurosurgeon and had a fatal outcome attributable to secondary meningoencephalitis. RESULTS: In the first five cases, with new neurological symptoms after antihelmintic treatment, the self-prescription is remarkable. The symptoms appear between the third and fifth day of treatment. All of them had a clinical course without complications. Only two cases minimally invasive techniques were required. The case who had been already diagnosed developed meningoencephalitis and died after eight days of antihelmintic treatment. CONCLUSIONS: Anthelminthic drug treatment requires tailor-based prescription considering risk-benefit ratio with the drug-parasite-host interaction in mind. Treatment is not harmless so patients have to be closely watched. In select cases, medical treatment cannot replace surgical procedures, which can be the primary approach with drug treatment as a complement.

Combined approach for experimental Oto-neurosurgical procedures.

BACKGROUND: Experimental procedures will continue to be a key element while going through the learning curve in the use of the endoscope and minimally invasive procedures. We describe the technical procedure of an experimental approach to middle ear in New Zealand rabbits through external auditory canal and its relevance as an ideal model to study graft materials and serve as a training tool for potential applications in otoneurology. METHODS: A group of 28 adult New Zealand rabbits were subjected to an experimental myringoplasty, combining the transmeatal and retroauricular approach with endoscopic assistance and microsurgical technique. The different anatomical steps and systematization of the complete experimental procedure are described. RESULTS: An experimental approach to middle ear live model and basic anatomic description was successfully used, standardizing the ideal technique. The eardrum could regenerate with no complications and with functional preservation in all the myringoplasty cases. This strategy involves a safe combined approach to the tympanic membrane and others neurosurgical as transcochlear and translaberyntic approaches and is useful as a test of other experimental procedures to evaluate biomaterials to repair the eardrum currently studied. This experimental myringoplasty model also facilitates functional tests such as impedanciometry and the endoscopic follow-up of the whole process. CONCLUSIONS: The method described to perform an experimental myringoplasty (type I tympanoplasty) in a New Zealand rabbit is an option to be used as a basic model to study the behavior of the graft in the tympanic membrane. Also, basic concepts for the use of combined instrumentation are established in the treatment of eardrum lesions, as a refinement of the technical training application in microsurgery and assisted endoscopy in the transcochlear and translaberintic approaches and otoneurology areas.

Long-term follow-up and pregnancy in a patient with neurenteric cyst: case report.

BACKGROUND: Neurenteric cysts (NC) are rare congenital anomalies. Cysts are secretory with an epithelial lining and features that resemble those of gastrointestinal and/or respiratory mucosa. They originate embryologically and result from an incomplete separation of the neurenteric canal from the foregut. CLINICAL CASE: We describe the 21-year follow-up of a female patient with a history of partial control of urinary and anal sphincters. The patient had a 6-month course of pain associated with saddle hypoesthesia, limited gait, chronic constipation, plus inferior paresthesia of the limbs. These features, along with the MRI findings, were compatible with the diagnosis of neurenteric cyst. The patient underwent two surgical procedures. We used a nonradical approach because of the connection of the cyst with the rectum and nerves in the deep plane. At age 22, she became pregnant and, after an uneventful gestation, gave birth to a healthy newborn. DISCUSSION: The selection of surgical strategy is oriented to mass effect resolution. In accordance with the literature, evaluation of the best choice for each patient is mandatory to obtain a balance of the risk and the potential functional preservation. This report demonstrates the importance of sensory and motor function preservation instead of using aggressive treatment. CONCLUSION: Our goal in each procedure was symptom alleviation, reduction of cyst size, clearance of the mass effect, and an attempt to resect the cyst capsule as much as possible without compromising quality of life and neurological functions.

Trans-supraorbital approach to supratentorial aneurysms.

OBJECTIVE: The trans-supraorbital approach has the advantage of combining the keyhole principle with cranial base surgery. The anatomic fields that can be visualized with the use of this procedure have been demonstrated in cadavers, and the advantages and potential surgical applications of this procedure are described in this report. This article is the first to describe a group of intracranial supratentorial aneurysms. METHODS: We used the trans-supraorbital approach in 22 cases of supratentorial aneurysms. In this technique, an incision is made through the eyebrow, then a 3.5-cm craniotomy is performed with en bloc extension to the orbital arch, complemented by different drilling extensions of the orbital roof according to the surgical objective. We describe the anatomic details of the experimental work as well as the clinical results. RESULTS: The trans-supraorbital technique offers an unlimited wide exposure of neurovascular structures in this microsurgical corridor. The craniotomy extension allows greater exposure than the conventional keyhole supraorbital approach, which makes the technique safe for the patient and comfortable for the surgeon. All patient outcomes were successful; no serious complications from the surgical technique occurred. Our success was achieved through better microscopic illumination in the deep field and by gaining access to the complete supratentorial vascular territory with minimal cerebral retraction and an acceptable cosmetic result. CONCLUSION: The trans-supraorbital approach is effective for gaining access to and treating supratentorial aneurysms. Also, the microsurgical field is more convenient in microscope-assisted surgery because total reliance on the endoscope is not required, and minimal brain retraction is needed. This modification of the keyhole procedure also provides multiple surgical options in this microsurgical corridor, using the principles of minimal invasiveness in cranial base surgery.

Trombosis intraluminal total en aneurisma gigante reporte de un caso / Total intraluminal thrombosis of a giant cerebral aneurysm. a case report

La trombosis intraluminal total de aneurismas gigantes, es un fenómeno raro. La presentación clínica y las imágenes diagnósticas sugieren un tumor, y debe ampliarse el diagnóstico diferencial. Nosotros reportamos el caso de una paciente con lesión en la región temporosilviana izquierda, asociada a neurismas sacuales bilaterales. Se discute la presentación clínica, los estudios radiológicos además de los mecanismos fisiopatológicos involucrados en la trombosis total en aneurismas gigantes. El neurocirujano debe considerar esta posibilidad, en los casos de lesiones intracraneales bien definidas, sin llenado angiográfico