Normal ventricular-CSF may comfound the diagnosis of tuberculous meningitis hydrocephalus.

BACKGROUND: The standard procedure for the diagnosis of central nervous system (CNS) infections consists of cerebrospinal fluid (CSF) sampling, which is usually accomplished by a lumbar puncture. However, in some patients presenting with acute hydrocephalus submitted to immediate CSF drainage, the fluid is customarily obtained from the placed draining system. In addition, the CSF obtained from the ventricular and lumbar spaces in some cases may show unusual differences, both in physiological and pathological conditions. ILLUSTRATIVE CASES: We report two children who presented with confounding results in the initial studies of their ventricular and lumbar CSF who were subsequently diagnosed with tuberculous meningitis, causing delay in diagnosis and treatment. AIM. By reporting these cases, we wanted to alert the treating physician about the possibility of this discrepancy to avoid the delayed diagnosis and management of the affected patients. DISCUSSION: We comment on the possible pathophysiological mechanisms that may result in this dissociation in ventricular and lumbar CSF composition. CONCLUSIONS; Normal results in CSF studies, especially those of the ventricular fluid, do not always rule out the presence of tuberculous meningitis. We suggest obtaining a CSF sample from the lumbar subarachnoid space in doubtful, or suspicious, cases of CNS infection even in the presence of a normal ventricular CSF.

[Radiosurgery as adjuvant treatment of a recurrent adult medulloblastoma. Ultra-early response]. / Radiocirugía como tratamiento complementario del meduloblastoma recidivadodel adulto: respuesta ultratemprana.

The role of radiosurgery after multimodality treatment of recurrent desmoplastic adult medulloblastoma is analyzed. The ultra-early clinical and pathological response of this tumor to adjunctive radiosurgery is stressed.

[Bone marrow stem cell transplantation in amyotrophic lateral sclerosis: technical aspects and preliminary results from a clinical trial]. / Terapia celular para la esclerosis lateral amiotrófica: aspectos técnicos y resultados preliminares del estudio CMN/ELA.

Patients with amyotrophic lateral sclerosis (ALS) experience progressive and irreversible paralysis as a result of the continued loss of motor neurons, which leads to death in less than five years. To date, there is no treatment that can change the progression of this disease. Bone marrow stem cells have shown neural regenerative and neural repairing properties. Specifically, our group showed in a murine model of the disease that these cells, when injected in the spinal cord, can rescue motor neurons through the secretion of GDNF. Based on these results, we designed a phase I/II clinical trial for the purpose of demonstrating the viability of the intraspinal injection of autologous bone marrow mononuclear cells in patients with bulbar onset ALS, with an evolution between 6 and 36 months, with a forced vital capacity (FVC) 50% and T90 29%. This article describes the technique for extracting 60 mL of bone marrow used for the intervention, processing it by density gradient, and the neurosurgical technique used for implanting it. After 6 months of follow-up, the few adverse events reported in the first seven patients included seem to show that the procedure is safe and viable. Most of these patients, including two with a rapid deterioration, have stabilized the progression of their FVC and the neurologic scales measured. The data obtained so for seem to justify the design of new trials more oriented toward the efficacy of the procedure.

[Reversible primary empty sella. Case report]. / Silla turca vacía primaria reversible. A propósito de un caso.

We report the case of a 13-year-old girl with an increased hypophysis that mimicked an adenoma, who developed a partial empty sella on MRI after an acute episode of hydrocephalus. After replacement of a CSF shunt, the intracranial pressure returned to normal and the hypophysis filled up again all the sellar fossa. We discuss the possibility of the involvement by an ischemic atrophy of the adenohypophysis in the development of a primary empty sella with idiopathic chronic raised intracranial pressure that prevents the recovery of the gland volume after restoring the intracranial pressure to normal values. Restitution of empty sella may be an indicator of normal intracranial pressure in these cases.

[Usefulness of hyperbaric oxygen in the treatment of radionecrosis and symptomatic brain edema after LINAC radiosurgery]. / Eficacia del oxígeno hiperbárico en el tratamiento de la radionecrosis y el edemacerebral sintomáticos tras radiocirugía con acelerador lineal.

Radionecrosis with brain edema is a complication of radiosurgery. Three female patients harbouring a frontal pole, petrous and parasagital parietoocipital meningiomas respectively who had been treated with LINAC radiosurgery are presented. Those patients developed, between two and eight months later, a severe symptomatic radionecrosis with a huge brain edema resistant to the usual steroid therapy. Only after 40 sessions of hyperbaric oxygen, a good remission of the lesions was obtained. There are few cases reported in the literature with such a good outcome. Consequentely, this therapy must be taken into account to treat this type of radiosurgical complication before considering surgery.

[Bidimensional-ultrasound guided-craniotomy in the excision of supratentorial brain tumours]. / Craneotomía guiada por ultrasonografía bidimensional para exéresis de tumor cerebral supratentorial.

OBJECTIVES: With this 1-year retrospective study we aimed to analyze our experience on the utilization of real-time bidimensional (2-D) ultrasonography as an aid for the localization of deep-seated supratentorial brain tumours. MATERIAL AND METHODS: During the year 2006 we performed 2-D ultrasonographic localization studies in patients undergoing excision of subcortical supratentorial brain tumours whose nature was pathologically proven. The ultrasound machines utilized were 2410 A ultrasounds HP and Phillips HDI 3500 ATL. To check gross anatomical structures we used a 3 MHz probe and then a 5 MHz sound to define the brain tumour characteristics. Coronal and sagittal cuts were obtained during parietal or temporal craniotomies, and axial and sagittal slices in the case of frontal masses. After brain tumour removal and after a thorough irrigation with saline, new image acquisitions were performed to confirm the completeness of tumour excision. The amount of removed tumour was also verified by a post-contrast computerized tomography (CT) scan performed after the surgery. RESULTS: The study group was composed by 30 patients with ages comprised between 28 and 82 years. The time required for tumour localization was 17.5 (+/- 1.9) min. The lesions were approached though 8 temporal, 7 parieto-occipital, 8 parietal, 2 fronto-parietal and 5 temporo-parietal craniotomies. Mean depth of the lesions was 5.3 (+/- 1.6) cm. The histopathologic diagnosis was 17 high-grade gliomas, 3 low-grade astrocytomas, 8 metastatic lesions and 2 oligo-astrocytomas. High-grade gliomas were more echogenic than low-grade tumours and than oedema. No residual tumour was detected at the end of the surgery except in two cases in which a tumoral rest was left due to the proximity of the lesion to eloquent cerebral areas. Postoperative CT scans confirmed the completeness of tumour removal in the patients of the study as assessed by intraoperative ultrasounds. CONCLUSIONS: Real-time 2-D ultrasonography affords an adequate image quality for performing guided-craniotomy in supratentorial brain tumours, as it allows for a safe and accurate localization of the lesions. Its use is mainly indicated in the removal of tumours located in, or close to, important anatomical and functional brain areas and to depict the presence of tumour rests after surgical removal of cerebral neoplasms.

Cavernomas in children with brain tumors: a late complication of radiotherapy.

BACKGROUND: Delayed complications of radiation therapy comprise cerebral atrophy, radionecrosis and induction of tumors. Recent reports indicate the possibility of the "de-novo" formation of intracranial cavernomas in patients submitted to radiation therapy to the brain. OBJECTIVES: To report three children, two with medulloblastomas and one with a pineal germinoma, treated with radiotherapy that developed intracerebral cavernous hemangiomas some years after treatment. With this work, we aim to draw attention to this occurrence in the neurosurgical community. RESULTS: The patients were two girls and one boy with ages comprised between 2.5 and 7 years (mean 5.2 years). The average interval from irradiation to the appearance of cavernoma was of 5.3 years (range 5-6 years). The lesions were found during the routine neuroimaging studies performed for the follow-up of their primary neoplasms. No patient showed signs or symptoms related to the cavernomas. However, the three children will need both clinical and neuroimaging surveillance to monitor the evolution of these incidentally discovered lesions. CONCLUSIONS: Intracranial cavernomas can occur years after cerebral radiation therapy. In spite of previous reports that show a high incidence of bleeding lesions, cavernomas may be found incidentally during the neuroimaging surveillance studies that are performed to children with brain tumors previously treated with radiotherapy. In these cases, a conservative attitude seems to be advisable, reserving surgery only for those lesions that grow or bleed.

[Brain abscess. Evaluation of prognostic factors: does the use of antibiotic prescribing protocols improve outcome?]. / Abscesos cerebrales: análisis de factores pronóstico e influencia del tratamiento antibiótico protocolizado en su evolución.

BACKGROUND: the aim of this study was to evaluate prognostic factors in brain abscess (AB) and influence of management with antibiotic prescribing protocols (APP). PATIENTS AND METHODS: observational study of a cohort of non-paediatric patients with BA admitted at a 944-bed hospital (1976-2005). Data collection from clinical records has been done according to a standard protocol. We analysed epidemiological, clinical, radiological, microbiological and laboratory data associated with mortality. From 1976 to 1983 (Period I), antibiotic treatment was not done according to any internal APP; from 1983 (Period II), antibiotic management was done according to a APP designed by infectious diseases specialists and neurosurgeons. Predictors of mortality were identified by univariate analysis. The influence of the use of APP in outcome was assessed. RESULTS: 104 patients with BA were included (mean age 45 years; range 12-86); presumed primary pathogenic mechanism of BA was identified in 89%; microbiologic diagnosis was made in 76%. Overall mortality was 16.3%. Factors statistically associated with higher mortality were: age > 40 years, ultimately fatal underlying disease, acute severe clinical condition at the onset of BA, altered mental status and inadequate empirical treatment; 33 patients were treated in Period I and 71 in Period II; no statistically significant differences were found between epidemiological, clinical, radiological or microbiological characteristics of the groups except for mean age (> 40 years in 36% and 62% respectively in Period I and II). Rates of resolution of BA were 60 vs. 77.4% (p < 0.05); relapses 21 vs. 7% (p < 0.05) and mortality 18 vs. 15.4% (p > 0.05), in Period I and II respectively. CONCLUSIONS: main prognostic factors associated with mortality in patients with BA are age, rapidly fatal underlying disease, acute severe clinical condition at the onset of BA, altered mental status and inadequate empirical treatment. Empiric treatment according to APP was associated with greater resolution and lower relapse rates.

Late prevertebral abscess following anterior cervical plating: the missing screw.

A 51-year-old man underwent a C5-C7 anterior decompression and fusion. Six years later the patient complained of dysphagia caused by displacement of the cervical plate. One week after the scheduled removal of the implanted material, the patient developed a painful cervical swelling and fever. His cervical radiographs showed that a screw was missing compared to previous studies. Computerized tomography showed a large prevertebral abscess anterior to C4-C7. He underwent emergency surgical drainage of the abscess that was followed by total recovery. This report is aimed at describing this unusual complication of cervical instrumentation and to briefly review its pathogenesis and management options.

Regression of syringomyelia and tonsillar herniation after posterior fossa arachnoid cyst excision. Case report and literature review.

BACKGROUND: Some reports have documented posterior fossa cysts resulting in syringomyelic obstruction of cerebrospinal fluid (CSF) flow caused by cyst displacement within the foramen magnum. Rarely the syringomyelia is caused by acquired Chiari malformation due to a retrocerebellar arachnoid cyst. OBJECTIVE: To report the case of a 38-year-old man with hydrocephalus and syringomyelia, who was found to have a Chiari malformation secondary to a posterior fossa arachnoid cyst. After endoscopic third ventriculostomy, the patient was submitted to foramen magnum decompression and arachnoid cyst removal that were followed by resolution of both the Chiari malformation and the syringomyelia. DISCUSSION: In most published cases the syringomyelia has been attributed to obstruction of CSF flow at the foramen magnum by the arachnoid cyst itself. There is only one previous report of a posterior fossa arachnoid cyst producing tonsillar descent and syringomyelia. CONCLUSIONS: Posterior fossa arachnoid cysts can result in acquired Chiari malformation and syringomyelia. In our view, the management of these patients should be directed at decompressing the foramen magnum and include the removal of the walls of the coexistent arachnoid cyst as it seems to be the crucial factor that accounts for the development of the syringomyelia that these patients present.

Non-surgical management of intracranial subdural hematoma complicating spinal anesthesia.

We report the case of a 29 year-old woman who presented a symptomatic intracranial subdural hematoma developing shortly after spinal anesthesia. The patient was fully conscious at clinical onset, and thus we treated her conservatively with an epidural autologous blood patch and close neurological observation. Given the clinical improvement the possibility of surgery was discauded in agreement with the neurosurgical team. Most cases of subdural hematoma appearing after spinal anesthesia are treated with surgery. In the present case the subdural hemorrhage was detected at our hospital 20 days after the anesthetic procedure, and given the excellent state of consciousness, we choosed a conservative management.

[Spinal cord tethering in myelomeningocele and lipomeningocele patients: the second operation]. / Reanclaje medular en pacientes con mielomeningocele y lipomeningocele: la segunda operación.

BACKGROUND: Spinal cord rethetering can occur after the primary surgical repair of myelomeningoceles (MMC) and lipomeningoceles (LMC) and produce devastating physical and psychological consequences. The inadvertent introduction of skin elements at the time of the initial surgery can lead to the growth of intraspinal epidermoid or dermoid cysts. OBJECTIVES: To review the incidence of spinal cord tethering following surgery for open and occult spinal dysraphism and to analyze factors that might influence the appearance of this complication. We also aimed to search technical measures at the time of the primary operation that might prevent the occurrence of symptomatic cord retethering. MATERIAL AND METHODS: We reviewed the medical records of patients submitted to surgical repair of MMC (n=162) or occult spinal dysraphism (n= 54) during the period 1975-2005 who developed symptomatic tethered cord syndrome. RESULTS: Eleven of 162 (6.79%) patients with MMC and 2 of 54 (3.7%) with LMC developed clinical symptoms and signs of spinal cord tethering after intervals ranging from 2 to 37 years after the initial surgical repair of their back lesions. Indications for surgical re-exploration were based mainly on clinical grounds. Postoperative fibrosis was a constant finding in all instances. Other surgical findings included inclusion tumors of cutaneous origin (n=3), lumbar canal stenosis (n= 2), foreign body reactions (n= 2), residual lipoma (n= 1), and a tight hyalinized filum (n=1). Interestingly, 3 of 162 (or 1.85%) myelomeningoceles were found to harbor an intradural epidermoid tumor at the time of spinal cord dethetering, accounting for an incidence of cutaneous inclusion tumors of 27% in cases of post- MMC repair tethering. After a mean follow-up time of 5.5 years, eight patients were improved, two were unchanged and one was worsened. CONCLUSIONS: Neurological deterioration is not a necessary consequence of the natural history of patients with MMC or LMC. Early or late clinical deterioration can be due to spinal cord re-tethering and deserves timely investigation and surgical exploration. Results of surgical intervention were rewarding as 92% of the patients showed improvement or stabilization in their otherwise deteriorating condition. We also report two infrequent causes of spinal cord deterioration: lumbar canal stenosis and intense foreign-body reactions to implanted materials.

Retrograde migration of ventriculoperitoneal shunt to the neck. Case report.

We report a patient, given a ventriculoperitoneal shunt at the neonatal period, who presented with a painless subcutaneous mass on his neck. Plain radiographs of the cervical region showed that the swelling was made up by a migrated and coiled peritoneal catheter. We briefly discuss the proposed mechanism for this complication and suggest that this occurrence must be taken into account at the time of evaluating a patient with shunt malfunction.

"Benign" shaken baby syndrome. Case report.

The authors report an infant with clinical and neuroimaging findings of shaken baby syndrome. The pitfalls encountered in the assessment on the cause of the bilateral frontal and interhemispheric subdural hematomas in this child are also briefly discussed. We have called this condition "benign" shaken baby syndrome and emphasize that not always acute subdural hematomas are of non-accidental nature.

[Postoperative delirium in patient neurosurgical: evaluation by means of the Abbreviated Mental Test]. / Delirio postoperatorio en pacientes neuroquirúrgicos: evaluación mediante el Test Mental Abreviado.

OBJECTIVES: To assess the incidence and characteristics of postoperative changes in the higher cerebral functions after elective intracranial surgery under general anesthesia. PATIENTS AND METHODS: This is a prospective study of 60 patients, aged 18-81 years, submitted to neurosurgical operations, allocated into two groups of 30 patients each: intracranial surgery group, patients submitted to craniotomy, and extracranial surgery group or control group, patients submitted to spinal procedures. All patients were given the Abbreviated Mental Test (AMT) on the day before to the operation, and then 2 and 24 hours after the end of the procedure. All individuals were managed with the same anesthetic technique. RESULTS: No differences in regard to demographics, duration of the operation, ASA physical state, and habits were found between the two groups. No differences in the pre-surgical and post-surgical AMT mean score were encountered between patients submitted to intracranial 9.87 +/- 0.35 or to spinal surgeries 9.80 +/- 0.41. Similarly, there were no significant differences between the two groups in the results of the AMT performed at 2 and 24 hours after the end of the surgeries. Only two subjects undergoing spinal procedures had a score of < or = 8 in the AMT performed 2-hours after the operation, while none showed a decrease in the 24-hour test score. CONCLUSIONS: Patients submitted to intracranial surgery did not show any changes in cognitive or attention functions during the first postoperative 24 hours as assessed by the AMT.

Meningiomas after radiation-therapy for benign astrocytomas.

A 4.5 year-old-girl was submitted to subtotal removal of a benign astrocytoma of the left temporal lobe with basal ganglia extension and given radiotherapy. At age 27, she was found to harbor a right posterior frontal meningioma that was totally removed. A recurrence of the right convexity meningioma was again excised after a 4-year interval. The authors report this case to illustrate the possibility of the appearance of radiation-induced meningiomas after an interval of 22 years and briefly discuss 16 previous reports on this occurrence in benign astrocytomas.

[Syndromes of overdrainage of ventricular shunting in childhood hydrocephalus]. / Síndromes de hiperdrenaje de las válvulas en hidrocefalia infantil.

Overdrainage in ventricular shunting constitutes a difficult to prevent and to treat complication. The authors reviewed a retrospective series of 512 children submitted to a ventricular shunting procedure aimed at analysing factors influencing this type of complication. The causes for the hydrocephalus were congenital (n=172), post-myelomeningocele (n=123), posthemorrhagic (n=103), tumoral (n=64), postmeningitis (n=40) and posttraumatic (n=10). Eighty-eight children (17.8%) evolved with a complication related to the excessive function of the valve. The authors investigated the relationship between hydrocephalus' etiology and type of overdrainage syndromes. The most frequent complication was ventricular catheter block (n=50), followed by symptomatic slit ventricle syndrome (SVS) (n=19), subdural hematoma (n=10) and trapped fourth ventricle (n=9). There were no statistical differences regarding complications for each etiologic subset of hydrocephalus. SVS occurred in 19 children (3.71%), a low rate according to the current literature. Posthemorrhagic and postinfectious hydrocephalus grouped together showed a higher rate of SVS (p=0.005), a feature that we attributed to the cerebral destruction caused by these two conditions. Treatment of SVS was complex and required diverse procedures, applied in an escalated way, which included five decompressive craniectomies. The authors suggest avoiding, as much as possible, the use of ventricular shunts, and recommend the alternative use of new technology valves and neuroendoscopic procedures.

Iatrogenic Creutzfeldt-Jakob disease: an example of the interplay between ancient genes and modern medicine.

We tested DNA from 15 centrally infected cases of iatrogenic Creutzfeldt-Jakob disease (CJD) (dura mater or corneal homografts and stereotactic EEG electrodes), 11 peripherally infected cases (native human growth hormone or gonadotrophin), and 110 control individuals for the presence of mutations in the chromosome 20 amyloid gene. No patient or control had any of the known pathogenic point or insert mutations found in familial disease, but allelic homozygosity at polymorphic codon 129 was present in all but two (92%) of the 26 patients, compared with 54 (50%) of the 110 controls (p < 0.001). Pooled data from all identified and tested cases of iatrogenic disease yielded a worldwide total of 56 patients, of whom all but four were homozygous at codon 129 (p < 0.001). These findings support the thesis that homozygosity at codon 129 enhances susceptibility to iatrogenic infections of both central and peripheral origin, with evident implications for the population of dura mater homograft and pituitary hormone recipients whose lives have been complicated by the possibility of exposure to the infectious agent of CJD.

Motor complications associated with chronic levodopa therapy in Parkinson's disease.

Fluctuations and dyskinesias are the 2 main motor complications associated with chronic levodopa therapy. Striatal denervation following degeneration of the substantia nigra dopaminergic projections is probably the major pathophysiologic mechanism underlying motor fluctuations. In addition, pathologic modification of striatal receptors, partially related to the nonphysiologic delivery of levodopa in a discontinuous pulsatile mode, may be responsible for the various types of dyskinesias and sudden "off" episodes. Drugs capable of providing a stable dopaminergic stimulation should be particularly useful for preventing the development of motor complications in patients not yet treated. At the other end of the clinical spectrum, patients with complex fluctuations are the least likely to improve with slow-release levodopa preparations.

Incidence of dementia and major subtypes in Europe: A collaborative study of population-based cohorts. Neurologic Diseases in the Elderly Research Group.

The authors examined the association of incident dementia and subtypes with age, sex, and geographic area in Europe. Incidence data from eight population-based studies carried out in seven European countries were compared and pooled. The pooled data included 835 mild to severe dementia cases and 42,996 person-years of follow-up. In all studies a higher proportion of cases were diagnosed with AD (60 to 70% of all demented cases) than vascular dementia (VaD). The incidence of dementia and AD continued to increase with age up to age 85 years, after which rates increased in women but not men. There was a large variation in VaD incidence across studies. In the pooled analysis, the incidence rates increased with age without any substantial difference between men and women. Surprisingly, higher incidence rates of dementia and AD were found in the very old in northwest countries than in southern countries. This study confirms that AD is the most frequent dementing disorder in all ages, and that there is a higher incidence of dementia, specifically AD, in women than men among the very old. Finally, there may be regional differences in dementia incidence.