Survival following vertebral compression fractures in population over 65 years old.

BACKGROUND: Lower mortality has been demonstrated when vertebral compression fractures (VCFs) are treated surgically (vertebral augmentation) vs. conservatively. AIMS: To analyze the overall survival in patients over 65 who suffer a VCF, to review the principal causes of death, and to detect which factors are associated with a greater risk of mortality. METHODS: Patients over 65 years old diagnosed with acute, non-pathologic thoracic or lumbar VCF, treated consecutively from January 2017 to December 2020, were retrospectively selected. Those patients with follow-ups under 2 years or who required arthrodesis were excluded. Overall survival was estimated by the Kaplan-Meier method. Differences in survival were tested through the log-rank test. Multivariable Cox regression was used to assess the association of covariates and time to death. RESULTS: A total of 492 cases were included. Overall mortality was 36.2%. Survival rate at 1-, 12-, 24-, 48-, and 60-month follow-up was 97.4%, 86.6%, 78.0%, 64.4%, and 59.4%, respectively. Infection was the leading cause of death. The independent factors associated with a higher mortality risk were age, male, oncologic history, non-traumatic mechanism, and comorbidity during hospitalization. No statistical difference was found when comparing the two survival curves by treatment (vertebral augmentation vs. conservative) over time. CONCLUSION: Overall mortality rate was 36.2% after a median follow-up of 50.5 months (95% CI 48.2; 54.2). Age, male sex, history of oncological disease, non-traumatic mechanism of the fracture, and any comorbidity during hospitalization were identified as variables independently associated with a higher risk of mortality following a VCF in the elderly.

Oral extrusion of a vertebral body replacement device after chordoma tumor growth and radiation: case report and review.

BACKGROUND: Screw migration following anterior cervical discectomy and fusion is a very rare complication and it is often related to device failure. Even more exceptional is the extrusion of an intervertebral graft. CASE PRESENTATION: We report the second case of migration and extrusion through the oral cavity of a cervical vertebral body replacement device (expandable cylinder) in a patient that had undergone cervical corpectomy due to a vertebral chordoma. CONCLUSION: The antecedent of radiation therapy as well as progressive tumor re-growth may have favored the development of this complication. A literature review is added.

Normal perfusion pressure breakthrough phenomenon: experimental models.

One of the most life-threatening complications after the obliteration of intracranial arteriovenous malformations is the development of oedema and/or multifocal haemorrhage. Two main theories have been postulated so far in order to explain this situation. On one hand, "normal perfusion pressure breakthrough phenomenon" is based on the loss of cerebral vessel autoregulation due to the chronic vasodilation of perinidal microcirculation. On the other hand, the "occlusive hyperaemia" deals with thrombotic and venous obstruction phenomena that may also generate such manifestations. The aim of this study is to resume the main concepts of the "normal perfusion pressure breakthrough phenomenon" theory as well as the related animal models described up to date, their advantages and disadvantages, and the main conclusions obtained as a result of the experimental research.

Long-term quality of life after decompressive craniectomy.

Introduction: This study aims to assess the quality of life (QoL) in patients who have undergone decompressive craniectomy (DC) for any pathology that has caused life-threatening intracranial hypertension. Similarly, it aims to evaluate QoL perceived by caregivers or external informants. In addition to that, the last purpose is to determine which clinical or therapeutic factors could correlate with a better QoL. Methods: A single-center cross-sectional study was designed. All patients over 18 years old who underwent a supratentorial DC at our department due to intracranial hypertension of any etiology, from January 2015 to December 2021, were retrospectively selected. Patients with incomplete follow-up (under 1 year from the event or those who died) or who declined to participate in the study were excluded. QoL was assessed with SF-36 and CAVIDACE scales. The correlation between clinical and therapeutic variables and SF-36 subscales was studied with Spearman's correlation and the Mann-Whitney U-test. Results: A total of 55 consecutive patients were recruited: 22 patients had died, three were missed for follow-up, and 15 declined to participate, thus 15 subjects were finally included. The mean follow-up was 47 months (IQR 21.5-67.5). A significant reduction in the "role physical" and "role emotional" subscales of SF-36 was observed compared with the general population. According to caregivers, a significant reduction was assigned to the "physical wellbeing" and "rights" domains. The "physical functioning" score was poorer in women, older patients, those with dominant hemisphere disease, those who required tracheostomy, and those with poor outcomes in the modified Rankin scale. A strong correlation was found between the QoL index at the CAVIDACE scale and the SF-36 subscales "physical functioning" and "role physical". Conclusion: Most patients and caregivers reported acceptable QoL after DC due to a life-threatening disease. A significant reduction in SF- 36 subscales scores "role limitation due to physical problems" and "role limitation due to emotional problems" was referred by patients. According to caregivers' QoL perception, only 25% of the survey's participants showed low scores in the QoL index of the CAVIDACE scale. Only 26.7% of the patients showed mood disorders.

Sinking bone flap due to overdrainage of a ventriculoperitoneal shunt. A case report and review of the literature.

The widespread use of decompressive craniectomy and subsequent cranioplasty has led to a better understanding of its complications. However, cases of a sunken bone flap have hardly ever been described. We present the eighth case reported up to date and perform a review of the literature of this sporadic complication. A 40-year-old Caucasian male suffered a traumatic brain injury that required a decompressive craniectomy. One month after initial trauma autologous cranioplasty was performed. A ventriculoperitoneal shunt was also placed. Neurological status progressively improved but his therapist noted cognitive status decline 8 months later. Follow-up computed tomography showed a progressive sinking bone flap. The patient underwent bone flap removal and a custom-made calcium phosphate-based implant was inserted, leading to symptoms resolution. Bone resorption has been described as the main cause of sinking bone flap following cranioplasty. This entity may manifest with symptoms of overdrainage in patients with cerebrospinal fluid shunt devices.

Volumetric Study of Nonfunctioning Pituitary Adenomas: Predictors of Gross Total Resection.

OBJECTIVE: Despite the efforts made to determine the achieved resection grade after pituitary adenoma surgery, there is a high level of disagreement among all the available classifications and measurement methods used. Our objective is to identify the factors that preoperatively could predict a gross total resection (GTR) of a clinically nonfunctioning pituitary adenoma through an endoscopic endonasal approach. METHODS: Across 100 surgeries, we analyzed epidemiologic and clinical data, radiologic relevant data, extent of resection (EOR), and postoperative outcomes. The EOR was measured objectively through an accurate volumetric analysis. RESULTS: The median presurgical volume was 8.58 cm3 (range, 0.5-58 cm3), the median maximum diameter was 27.3 mm (range, 7-67 mm), and the Knosp grade was 0 in 1 patient, 1 in 23%, 2 in 31%, 3 in 23% and 4 in 22% of patients. In the multivariate logistic regression analysis, we found 3 factors that significantly predicted the chances of a successful GTR: previous sellar surgery, Knosp grade, and tumor signal in the T2-weighted magnetic resonance imaging scan. Another 10 radiologic variables were analyzed and had no effect on the EOR. CONCLUSIONS: Knosp grade (P < 0.001; odds ratio [OR], 25.65; 95% confidence interval, 7.19-91.52) is the most predictive factor for performing a GTR of nonfunctioning pituitary adenoma. Previous pituitary surgery (P = 0.023; OR, 5.81) and an isointense T2-weighted signal (P = 0.034; OR, 3.75) also negatively influenced the chances of GTR. We highlight the influence of T2-weighted signal in the chances of GTR.

Neuroprotective effect of indomethacin in normal perfusion pressure breakthrough phenomenon.

Loss of cerebral autoregulation in normal perfusion pressure breakthrough (NPPB) phenomenon has been reported in other Central Nervous System diseases such as neonatal intraventricular haemorrhage. Several studies have demonstrated that low-dose indomethacin prevents this latter condition. A previous rat model was used to resemble NPPB phenomenon. Study animals were distributed in 4 groups that received 3 doses of indomethacin at different concentrations prior to fistula occlusion 60 days after its creation. Control animals received saline solution. Intracranial pressure (ICP) increased in all groups following fistula creation, whereas mean arterial pressure (MAP) and cerebral perfusion pressure (CPP) decreased as a manifestation of cerebral hypoperfusion and intracranial hypertension. The administration of indomethacin was associated with raised MAP and CPP, as well as decreased ICP. Sodium fluorescein extravasation was slight in study animals when comparing with control ones. Histological analysis evidenced diffuse ischaemic changes with signs of neuronal apoptosis in all brain layers in control animals. These findings were only focal and slight in study animals. The results suggest the usefulness of indomethacin to revert, at least partially, the haemodynamic effects of NPPB phenomenon in this experimental model, as well as to reduce BBB disruption and histological ischemia observed in absence of indomethacin.

Free Mucosal Graft for Reconstruction after Nonfunctional Pituitary Adenoma Surgery.

BACKGROUND: In the search for an effective closure without nasosinusal morbidity, we have studied the efficacy of free mucosal graft as a reconstructive technique of the sellar floor after the resection of nonfunctioning pituitary adenomas (NFPA). METHODS: In 100 endonasal endoscopic surgeries, we analyzed the personal history, radiological and intraoperative aspects that could have an impact on the risk of postoperative cerebrospinal fluid (CSF) leak. They were divided into three groups: no mucosa flap/graft, mucosal free graft, and nasoseptal pedicled flap. RESULTS: The characteristics of the patients and adenomas were the same in all three groups. Intraoperative CSF leak was observed in 1/13 cases of the group without graft/flap (7%), in 16/50 of the free mucosal graft (32%) and 12/37 (32%) of pedicle flap. The proportion of cases in which other means of reconstruction were used in addition (fat, collagen matrix, and sealant) was similar in the different groups. No CSF leaks were observed, except for a doubtful one in the free mucosal graft group, which resolved spontaneously within 24 h, without receiving any type of treatment. CONCLUSIONS: The middle turbinate free mucosal graft can be of great value in endonasal surgery: It achieves a hermetic closure in cases of low-flow CSF leaks, it can be useful as a rescue for cases where nasoseptal mucosa is not available to perform a pedicled nasoseptal flap, minimizes the nasosinusal complications of the pedicled flap by leaving a smaller surface area of the nasal cavity devoid of the mucosa, and achieves greater nasosinusal functionality because proper reepithelialization occurs in the area.

Experimental rat model of chronic cerebral hypoperfusion-reperfusion mimicking normal perfusion pressure breakthrough phenomenon.

BACKGROUND: Normal perfusion pressure breakthrough (NPPB) phenomenon is a major life-threatening complication that restricts the treatment of complex intracranial arteriovenous malformations. The aim of the study it to develop a rat model mimicking NPPB phenomenon that enables the evaluation of any therapy to prevent such complication. METHODS: Twenty Wistar male rats were randomly assigned to either a study or a control group. Study animals underwent an end-to-side left external jugular vein-common carotid artery anastomosis and ligation of bilateral external carotid arteries. Control animals only underwent ligation of bilateral external carotid arteries. All animals were sacrificed sixty days after the procedure. Hemodynamic parameters [mean arterial pressure (MAP), intracranial pressure (ICP) and cerebral perfusion pressure (CPP)], blood-brain barrier (BBB) permeability (measured by fluorescein staining) and histological features were then compared between both groups. RESULTS: A significant decrease in MAP and CPP was confirmed in the study group. An increase in ICP was also observed. A significant decrease in MAP and CPP was also present in the study group when comparing preoperative values with those recorded on days 0 (postoperative), 7 and 60. Fluorescein staining findings were consistent with signs of BBB disruption in study animals. Histological analysis demonstrated an increased number of pyknotic neurons in the ipsilateral hemisphere of rat brains included in the study group. CONCLUSION: These results confirm that this model mimics a vascular steal state with chronic cerebral hypoperfusion comparable to patients with AVMs behavior and disruption of the BBB after fistula closure comparable to NPPB phenomenon disorders.

Intraventricular haemorrhage caused by the rupture of a dural arteriovenous malformation of the middle cranial fossa.

Dural arteriovenous malformations of the middle cranial fossa are very rare. Venous drainage flows either through superficial leptomeningeal veins or through the sphenoparietal, sphenopetrous and/or sphenobasilar sinuses. They often have an aggressive course and therefore poor outcome. It is essential to analyse and understand the angioarchitecture of the dural arteriovenous malformations in order to select and plan the correct treatments. We describe an exceptional case of intraventricular haemorrhage caused by the rupture of a dural arteriovenous malformation of the middle cranial fossa. To our knowledge, this is the first case report of such characteristics described in the literature.

Penetrating brain injury by drill bit.

Non-missile low velocity penetrating brain injuries are unusual among civilian population. They show specific characteristics different from missile wounds. In this paper we describe a rare case of self-inflicted penetrating head trauma by electric drill. We document neuroimaging studies and review the management concerning this pathology. To our knowledge, this is the first case of intracranial retained drill bit with such radiological findings reported in the literature. An 80-year-old male with no previous psychiatric disorder presented at our hospital after suffering an accident while working with an electric drill. Physical examination revealed right lower extremity plegia and three penetrating scalp wounds to the left parasagittal region. Skull X-ray and computed tomography demonstrated an intracranial metallic foreign body located in the left parietal lobe and an intraparenchymal hematoma with no mass effect close to the foreign body. The patient was taken to the operating room to remove the drill bit fragment. Antibiotic and antiseizure prophylaxis were administered. Postoperative computed tomography confirmed no residual metallic fragments and functional recovery was excellent. After psychiatric assessment, suicide attempt was confirmed and antidepressive therapy was then started. On follow-up, no complication was documented. It is essential to exclude penetrating brain trauma whenever a scalp wound is noticed in order to provide proper treatment and prevention care. The permanent neurological deficit in low velocity injuries is related to the degree and location of the primary injury. It also depends on an early diagnosis and treatment and the absence of delayed complications.

Retropharyngeal pseudomeningocele formation as a traumatic atlanto-occipital dislocation complication: case report and review.

Retropharyngeal pseudomeningocele after atlanto-occipital dislocation is a rare complication, with only five cases described in the literature. It develops when a traumatic dural tear occurs allowing cerebrospinal fluid outflow, and it often appears associated with hydrocephalus. We present a case of a 29-year-old female who suffered a motor vehicle accident causing severe brain trauma and spinal cord injury. At hospital arrival the patient scored three points in the Glasgow Coma Scale. Admission computed tomography of the head and neck demonstrated subarachnoid hemorrhage and atlanto-occipital dislocation. Three weeks later, when impossibility to disconnect her from mechanical ventilation was noticed, a magnetic resonance imaging of the neck showed a large retropharyngeal pseudomeningocele. No radiological evidence of hydrocephalus was documented. Given the poor neurological status of the patient, with spastic quadriplegia and disability to breathe spontaneously due to bulbar-medullar injury, no invasive measure was performed to treat the pseudomeningocele. Retropharyngeal pseudomeningocele after atlanto-occipital dislocation should be managed by means of radiological brain study in order to assess for the presence of hydrocephalus, since these two pathologies often appear associated. If allowed by neurological condition of the patient, shunting procedures such as ventriculo-peritoneal or lumbo-peritoneal shunt placement may be helpful for the treatment of the pseudomeningocele, regardless of craniocervical junction management.

[Effect of antibiotic-impregnated catheters on the incidence of infection after cerebrospinal fluid shunting]. / Efecto de los catéteres impregnados con antibiótico en la incidencia de infección tras procedimientos de derivación de líquido cefalorraquídeo.

BACKGROUND AND OBJECTIVE: Infection is a major complication after cerebrospinal fluid (CSF) shunt systems insertion. Antibiotic-impregnated (AI) catheters seem to reduce infection rate in clinical practice. The objective of this study was to determine if the use of AI catheters reduces Staphylococcus spp. infection rate, as it is the most commonly isolated organism. PATIENTS AND METHOD: Authors retrospectively reviewed all patients who underwent rifampin-impregnated and clindamycin-impregnated catheters at our hospital. These included external ventricular catheters (inserted from January 2006 to January 2007) and internalized shunts (inserted from January 2004 to January 2007). They also reviewed patients who underwent insertion of non-impregnated external catheters and internalized shunts during the same periods. Overall infection rate, Staphylococcus spp. infection rate and gram negative bacilli infection rate were compared in both groups by means of chi2 test. RESULTS: Sixty-five procedures with AI catheters and 66 procedures with non-AI catheters were performed. Overall infection rate as well as Staphylococcus spp. infection rate were significantly lower in the AI catheters cohort (p = 0.046 and p = 0.029, respectively), without increasing gram negative bacilli infections. CONCLUSIONS: The use of rifampin and clindamycin-impregnated catheters is a useful tool to reduce Staphylococcus spp. infections after CSF shunting procedures. However, future clinical trials are required to confirm these results.

Genetic alterations of IDH1 and Vegf in brain tumors.

BACKGROUND: This study evaluates the presence of R132H mutation in isocitrate dehydrogenase (IDH1) gene and the vascular endothelial growth factor (VEGF) +936 C/T polymorphism in brain tumors. The impact of these genetic alterations on overall survival (OS) and progression free survival (PFS) was evaluated. METHODS: A cohort of 80 patients surgically treated at Hospital Clínico San Carlos, Madrid, between March 2004 and November 2012, was analyzed. Tumors were distributed in 73 primary brain tumors (gliomas, meningiomas, hemangiopericytomas and hemangioblastomas) and seven secondary tumors evolved from a low grade glioma, thus providing a mixed sample. RESULTS: IDH1R132H gene mutation was found in 12 patients (15%) and appears more frequently in secondary tumors (5 (71.4%) whereas in 7 (9.7%) primary tumors (p < .001)). The mutation is related to WHO grade II in primary tumors and a supratentorial location in secondary tumors. The OS analysis for IDH1 showed a tendency towards a better prognosis of the tumors containing the mutation (p = .059).The IDH1R132H mutation confers a better PFS (p = .025) on primary tumors. The T allele of VEFG +936 C/T polymorphism was found in 16 patients (20%). No relation was found between this polymorphism and primary or secondary tumor, neither with OS or PFS. CONCLUSIONS: IDH1R132H gene mutation is exclusive in supratentorial tumors and more frequent in secondary ones, with a greater survival trend and better PFS in patients who carry it. The T allele of VEGF +936 C/T polymorphism is more common in primary tumors, although there is no statistical relation with survival.

Adenomas hipofisarios no funcionantes: epidemiología, clínica y evolución posquirúrgica / Non-functioning pituitary adenomas: epidemiology, clinical and postoperative outcome

INTRODUCCIÓN: Los adenomas hipofisarios no funcionantes son el grupo tumoral más frecuente en la región selar. Suelen ser neoplasias benignas diagnosticadas por síntomas visuales u hormonales, aunque no es infrecuente detectarlos como un hallazgo casual. OBJETIVO: Analizar los aspectos clínicos hallados en esta enfermedad y su respuesta tras el tratamiento quirúrgico. PACIENTES Y MÉTODOS: En una serie de 100 casos, se analizaron datos epidemiológicos, clínicos, endocrinológicos, visuales y radiológicos antes y después del tratamiento quirúrgico, y se recogen las complicaciones relacionadas con la cirugía y el seguimiento a largo plazo. RESULTADOS: El síntoma más frecuente en el momento del diagnóstico fue la afectación del campo visual (62%), y sólo el 7% de los adenomas se trataba de un hallazgo casual. El déficit hormonal más frecuente era el hipogonadismo hipogonadótropo (48%). Tras la cirugía se observó recuperación completa del defecto campimétrico en el 54,8% de los pacientes, con sólo un 1% de empeoramiento tras la cirugía, y la incidencia de diabetes insípida fue del 4%. La resección fue superior al 95% en el 63% de los casos, a pesar de que el porcentaje de adenomas con invasión del seno cavernoso en grados altos fue elevado (45%). CONCLUSIONES: Aunque el síntoma más frecuente de los adenomas hipofisarios no funcionantes es la afectación campimétrica, ésta tiene una excelente respuesta a la cirugía si se realiza dentro del tiempo adecuado. El grado de invasión del seno cavernoso parece el factor más limitante para una resección quirúrgica completa

INTRODUCTION: Non-functioning pituitary adenomas are the most frequent tumor group in the sellar region. They are usually benign neoplasms diagnosed after visual or hormonal symptoms, although it is not uncommon to detect them as a casual finding. AIM: To analyze the clinical aspects found in this disease and its response after surgical treatment. PATIENTS AND METHODS: In a series of 100 cases, epidemiological, clinical, endocrinological, visual and radiological data were analyzed before and after surgical treatment, as well as the complications related to surgery and long-term follow-up. RESULTS: The most frequent symptom at the time of diagnosis was visual field involvement (62%), and only the 7% of adenomas were a casual finding. The most common hormonal deficit was hypogonadotropic hypogonadism (48%). After surgery, complete recovery of the visual field defect was observed in 54.8% of the patients, only 1% worsening after surgery, and the incidence of diabetes insipidus was 4%. The resection was superior to 95% in 63% of cases, although the percentage of adenomas with invasion of the cavernous sinus in Knosp grades 3 and 4 it was high (45%). CONCLUSIONS: Although the most frequent symptom of non-functioning pituitary adenomas is campimetric involvement, it has an excellent response to surgery if it is performed within the appropriate time. The grade of invasion of the cavernous sinus is the most limiting factor for a complete surgical resection

Sinking bone flap due to overdrainage of a ventriculoperitoneal shunt. A case report and review of the literature / Hundimiento de colgajo óseo por sobredrenaje de una derivación ventriculoperitoneal. Caso clínico y revisión de la literatura

The widespread use of decompressive craniectomy and subsequent cranioplasty has led to a better understanding of its complications. However, cases of a sunken bone flap have hardly ever been described. We present the eighth case reported up to date and perform a review of the literature of this sporadic complication. A 40-year-old Caucasian male suffered a traumatic brain injury that required a decompressive craniectomy. One month after initial trauma autologous cranioplasty was performed. A ventriculoperitoneal shunt was also placed. Neurological status progressively improved but his therapist noted cognitive status decline 8 months later. Follow-up computed tomography showed a progressive sinking bone flap. The patient underwent bone flap removal and a custom-made calcium phosphate-based implant was inserted, leading to symptoms resolution. Bone resorption has been described as the main cause of sinking bone flap following cranioplasty. This entity may manifest with symptoms of overdrainage in patients with cerebrospinal fluid shunt devices (AU)

El uso extendido de la craniectomía descompresiva y la consiguiente craneoplastia ha propiciado un mejor conocimiento de sus complicaciones. Sin embargo, esporádicamente se han descrito casos de hundimiento del colgajo óseo. Describimos el octavo caso descrito hasta la fecha y realizamos una revisión de la literatura de esta infrecuente complicación. Un varón de 40 años sufrió un traumatismo craneoencefálico que requirió craniectomía descompresiva. Un mes después se sometió a la reposición de su colgajo óseo, junto con la implantación de una derivación ventriculoperitoneal. Presentó mejoría neurológica progresiva que se frenó y empeoró ocho meses después. La tomografía computarizada de control mostró hundimiento progresivo del colgajo óseo. El paciente se sometió a la retirada del colgajo óseo y cranioplastia con implante a medida, con resolución de los síntomas. La resorción ósea se ha descrito como la principal causa del hundimiento del colgajo óseo tras cranioplastia. Sin embargo, esta entidad puede manifestarse como síntomas de sobredrenaje en pacientes con derivación de líquido cefalorraquídeo (AU)