Relationship between the posterior septal artery and the upper edge of the choana.

BACKGROUND: The pedicled nasoseptal flap has been a key element in advancing the endoscopic transnasal approach (ETA) for the treatment of skull base lesions from the anterior cranial fossa to the occipitocervical junction. To preserve vascular supply, an anatomical knowledge of the location of the posterior septal artery (PSA) is essential. The objective of this work is to establish the relationship between PSA and the superior edge of the choana to define a safety margin during the opening of the sphenoidal rostrum preserving PSA. METHODS: One hundred and eighty angiotomographies of the brain were assessed. The sphenopalatine artery (SPA) was evaluated in the pterygopalatine fossa and PSA at its entrance into the nasal cavity and on the sphenoidal rostrum. RESULTS: PSA was found in all 3 tomographic planes (axial, coronal and sagittal) in 100 patients (200 PSAs). Thirty-five were male and 65 were females. Average age was 62 years with a range of 19-90 years. Total average distance between PSA and the superior edge of the choana was 8.5 mm with a range of 2.5-18 (12.45 90th percentile). CONCLUSION: Although the distance between the choanal edge and PSA is 8.5 mm on average, due to its variability, a distance of at least 12.45 mm for the opening of the sphenoidal sinus in the ETA approach should be considered as a safety margin.

Minimally invasive asterional approach for microvascular decompression in trigeminal neuralgia.

OBJECTIVE: Trigeminal neuralgia (TN) is a neuropathic disorder that can be treated surgically. This study aimed to present the surgical findings and the clinical outcomes of 26 patients with TN treated by minimally invasive asterional surgery. METHODS: Longitudinal descriptive study. Twenty-six patients with TN underwent minimally invasive asterional surgery. The medical history, surgical findings, therapeutic response, and complications were registered. They were followed for 36 months. RESULTS: Nineteen cases were associated with vascular compression; five were associated with arachnoiditis. The two remaining cases were associated with multiple sclerosis and post-herpetic neuralgia. The pain was substantially reduced in all patients in the immediate postoperative period. At 36 months, in 25 patients, total or acceptable pain control was achieved. In the long term, 22 patients evolved with no permanent complications. CONCLUSION: The microvascular decompression surgery by an asterional approach is an alternative with similar results to the classic retrosigmoid approach to treat TN, but that adds the benefits of the principles of minimally invasive surgery. Constant efforts need to be made to optimize minimally invasive surgical techniques for TN.

[Abordaje asterional mínimamente invasivo para descompresión microvascular en neuralgia del trigémino].

OBJECTIVE: Trigeminal neuralgia (TN) is a neuropathic disorder that can be treated surgically. This study aimed to present the surgical findings and the clinical outcomes of 26 patients with TN treated by minimally invasive asterional surgery. METHODS: Longitudinal descriptive study. Twenty-six patients with TN underwent minimally invasive asterional surgery. The medical history, surgical findings, therapeutic response, and complications were registered. They were followed for 36 months. RESULTS: Nineteen cases were associated with vascular compression; five were associated with arachnoiditis. The two remaining cases were associated with multiple sclerosis and post-herpetic neuralgia. The pain was substantially reduced in all patients in the immediate postoperative period. At 36 months, in 25 patients, total or acceptable pain control was achieved. In the long term, 22 patients evolved with no permanent complications. CONCLUSION: The microvascular decompression surgery by an asterional approach is an alternative with similar results to the classic retrosigmoid approach to treat TN, but that adds the benefits of the principles of minimally invasive surgery. Constant efforts need to be made to optimize minimally invasive surgical techniques for TN.

OBJETIVO: La neuralgia del trigémino (NT) es un trastorno neuropático susceptible de tratamiento quirúrgico. El objetivo es presentar los hallazgos quirúrgicos y resultados obtenidos en 26 pacientes con NT, tratados mediante un abordaje asterional mínimamente invasivo para descompresión vascular trigeminal. MÉTODOS: Estudio longitudinal descriptivo. Se intervino mediante abordaje asterional a 26 pacientes. Se registró el historial médico, hallazgos quirúrgicos, respuesta al tratamiento y complicaciones. Se les dio seguimiento durante 36 meses. RESULTADOS: Diecinueve casos se asociaron a compresión vascular, cinco casos a aracnoiditis y los dos restantes se relacionaron con esclerosis múltiple y neuralgia postherpética. El dolor se controló significativamente en todos los pacientes durante el postoperatorio inmediato. A 36 meses de seguimiento, en 25 pacientes se alcanzó un control total o aceptable del dolor. A largo plazo 22 pacientes evolucionaron sin complicaciones permanentes. CONCLUSIONES: La cirugía de descompresión microvascular a través de un abordaje asterional mínimamente invasivo para el tratamiento de la NT es una alternativa con resultados similares al abordaje retrosigmoideo clásico, pero que suma las bondades de una técnica quirúrgica que se rige con los principios de la mínima invasión. Se requieren esfuerzos constantes para optimizar las técnicas quirúrgicas en el tratamiento de la NT.

[IgG4 related disease presenting as panhypopituitarism and perimacular scotoma]. / Panhipopituitarismo y escotoma perimacular como presentación de enfermedad relacionada a IgG4.

IgG4-related disease (IgG4-RD) is a recently described systemic entity of unknown origin. It predominantly affects older men and has distinctive histopathologic features as storiform fibrosis, obliterative phlebitis, dense lymphoplasmacytic infiltrate with immunostaining for IgG4, and it may be associated with elevated serum levels of IgG4. Although any organ can be affected, pituitary gland is rarely involved. We describe the case of a 36-year-old man who presented with headaches, impaired vision, panhypopituitarism with diabetes insipidus and an infiltrative lesion mainly of infundibulum and pituitary. We arrived at diagnosis of IgG4-RD by pituitary biopsy. A successful response to treatment with immunosuppressive doses of corticosteroids was achieved.

[Endoscopic treatment of 140 pituitary tumors, results and complications]. / Tratamiento endoscópico de 140 tumores de hipófisis, resultados y complicaciones.

OBJECTIVE: To present the clinical and radiographic outcomes of 140 patients with pituitary adenomas treated by an endoscopic endonasal approach (EEA) over a period of 4 years. MATERIAL AND METHODS: A retrospective analysis was performed between 2011 and 2014. Pre and post operative MRI, ophtalmological assessment, endocrinological laboratory evaluation and surgical morbidity and mortality were assessed. RESULTS: 57,9% of the patients had functional tumors (n=81), acromegaly being the most frequent sub-type (29.3%). 78.6% of the lesions were macroadenomas (n=110) of which 56.4% (n=62) involved the cavernous sinus, 61 patients presented with visual field defects (44%) of which 50.8% of patients showed improvement after surgery. Gross total removal was achieved in 60% of the cases. Hormonal remission was achieved in the 75% of the patients with functional tumors. The morbidity rate was 15% and one patient died after surgery (mortality 0.7%). CONCLUSION: EEA is a safe and effective tool to treat pituitary adenomas. The main limitation for complete surgical resection is the cavernous sinus invasion.

Pathological changes of the hippocampus and cognitive dysfunction following frontal lobe surgery in a rat model.

BACKGROUND: Postoperative cognitive dysfunction (POCD) is a known complication after intracranial surgery. Impaired hippocampal neurogenesis has been associated with cognitive dysfunction in animal models. METHODS: In order to assess hippocampal changes after brain surgery, a frontal lobe corticectomy was performed in ten adult Wistar rats (group 4). Three different control groups (n = 10 each) included no treatment (G1), general anesthesia alone (G2), and craniectomy without dural opening (G3). Twenty-four hours after surgery, half of the animals were killed, and the mRNA levels for IL-6, TNF-α, and brain-derived growth factor (BDNF) in the contralateral hippocampus were assessed by qPCR. Seven days later, the remaining animals underwent anxiety and memory testing. Afterwards, the number of immature neurons in the hippocampal cortex was measured by doublecortin (DCX) staining. RESULTS: Twenty-four hours after surgery, mRNA levels of IL-6 and TNF-α increased and BDNF decreased in both surgical groups G3 and G4 (p = 0.012). Cognitive tests demonstrated an increase in anxiety levels and memory impairment in surgical groups compared with non-surgical animals. These changes correlated with an inhibition of hippocampal neurogenesis evidenced by a decreased number of new neurons (mean ± SD for G1-4: 66.4 ± 24; 57.6 ± 22.2; 21.3 ± 3.78; 5.7 ± 1.05, p < 0.001, non-parametric ANOVA). CONCLUSIONS: Intracranial surgery was demonstrated to induce an inflammatory reaction within the hippocampus that compromised neurogenesis and impaired normal cognitive processing. Corticectomy had a greater effect than craniotomy alone, indicating a central trigger for hippocampal inflammatory changes. POCD after craniotomy may originate from a central inflammatory response resulting from surgical trauma to the brain parenchyma.

The Coexistence of Carotico-Clinoid Foramen and Interclinoidal Osseous Bridge: An Anatomo-Radiological Study With Surgical Implications.

BACKGROUND AND OBJECTIVES: The coexistence of complete carotico-clinoid bridge (CCB), an ossification between the anterior (ACP) and the middle clinoid (MCP), and an interclinoidal osseous bridge (ICB), between the ACP and the posterior clinoid (PCP), represents an uncommonly reported anatomic variant. If not adequately recognized, osseous bridges may complicate open or endoscopic surgery, along with the pneumatization of the ACP, especially when performing anterior or middle clinoidectomies. METHODS: According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews guidelines, a systematic scoping review was conducted up to June 5, 2023. PubMed, Scopus, Web of Science databases, and additional citations were searched. Two hundred high-resolution noncontrast computed tomography (CT) scans (400 sides) and 41 dry skulls (82 sides) were analyzed to identify the different morphology of sellar bridges, focusing on the coexistence of complete CCF and ICB. Two embalmed latex-injected heads with coexisting CCF and ICB were dissected step-by-step to show the anatomic relationship with the surrounding structures from an endoscopic and microscopic perspective. RESULTS: A total of 19 articles were included. The review identified a complete CCF and ICB rate ranging from 4.92% to 6.3%. The analysis of 200 CT scans revealed a rate of coexistence in 4% of the cases, all encountered in White women. Two different types of interclinoid bridges were identified based on the degree of bone mineralization. Both endoscopic and macroscopic step-by-step dissections highlighted variability in morphology and consistency of the sellar bridges and the close relationship with the cavernous sinus neurovascular structures. CONCLUSION: The coexistence of CCF and ICB is an anatomic variation found in 4% of cases. Preoperative knowledge of the degree of mineralization and its relationship with surrounding structures is essential to performing safe surgery and minimizing cranial nerve and vascular injuries. Preoperative high-resolution CT scans can adequately identify these anatomic variations.

Polyetheretherketone interbody cages versus autogenous iliac crest bone grafts with anterior fixation for cervical disc disease.

OBJECTIVE: The aim of this study was to compare the fusion rate, operation time, recovery of disc space height, clinical duration and improvement, return to activities of daily living, and complication rate associated with anterior cervical discectomy with interbody fusion by using polyetheretherketone cages or autogenous iliac crest bone grafts as disc replacement in a series of 60 patients. MATERIALS AND METHODS: Between November 2006 and February 2010 a retrospective analytical observational cohort study was carried out in 60 consecutive patients surgically treated with anterior cervical discectomy with interbody fusion for degenerative disc desease at the Neurosurgical Department of the Hospital Italiano de Buenos Aires. The patients were divided into 2 groups for the assessment of clinical characteristics, demographics, fusion rates, duration of surgical procedure, neurological and functional outcomes, imaging results, and complications. Group A included patients treated with autogenous iliac crest bone grafts, and group B included patients treated with polyetheretherketone cages. RESULTS: The mean age of the patients was 50.8 years. Female patients comprised the majority in both groups (63.3%). Cervicobrachialgia was the most common presentation. Clinical improvement, fusion rates, and recovery of disc space height were similar in both groups. The operation time was significantly shorter in the polyetheretherketone group (P<0.001). Twenty percent (n=6) of the patients in group A suffered complications, >80% of which were associated with iliac crest bone graft harvesting. Patients in group B had no complications (P<0.05). CONCLUSIONS: Although outcomes were very successful in both groups in terms of fixation stability, recovery of disc space, return to activities of daily living and work, and remission of symptoms, operation time was considerably shorter for patients in the polyetheretherketone group, who had none of the complications associated with iliac crest bone graft harvesting, both differences being statistically significant.

Microsurgical free flaps for skull base reconstruction following tumor resection: Available techniques and complications.

INTRODUCTION: Resection of malignant tumors located in the anterior and middle fossae of the skull base requires thorough anatomical knowledge, as well as experience regarding the possible reconstructive options to resolve the resulting defects. The anatomical and functional relevance of the region, the complexity of the defects requiring reconstruction and the potential complications that can occur, represent a true challenge for the surgical team. The goal of this study is to describe the microsurgical reconstructive techniques available, their usefulness and postoperative complications, in patients with malignant tumors involving the skull base. MATERIALS AND METHOD: This observational, retrospective study, included all patients who underwent surgery for malignant craniofacial tumors from January 1st, 2009 to January 1st, 2019 at a University Hospital in Argentina. Only patients who required reconstruction of the resulting defect with a free flap were included. RESULTS: Twenty-four patients required reconstruction with FF; 14 were male (58.3%) and mean age was 54.9 years. Sarcoma was the most frequent tumor histology. Free flaps used were the following: anterolateral thigh, rectus abdominis, radial, latissimus dorsi, iliac crest and fibular. Complications occurred in 6 cases and no deaths were reported in the study group. CONCLUSION: Free flaps are considered one of the preferable choices of treatment for large skull base defects. In spite of the complexity of the technique and the learning curve required, free flaps have shown to be safe, with a low rate of serious complications. For these patients, the surgical resolution should be performed by a multidisciplinary team.

Multidisciplinary approach to anaplastic and metastatic meningioma: A case report and review of the literature.

Background: Meningiomas are slow-growing neoplasms, accounting for 20% of all primary intracranial neoplasms and 25% of all intraspinal tumors. Atypical and anaplastic meningiomas are infrequent, representing fewer than 5% of all meningiomas. Unusually, they can show aggressive behavior, and extracranial metastases are extremely rare, representing approximately 0.1% of all reported cases. Case Description: Fifty-six-year-old male patient diagnosed with atypical basal frontal meningioma with multiple resections, both endoscopic endonasal and transcranial. After hypofractionated radiosurgery, the patient showed new tumor recurrence associated to right cervical level II ganglionic metastasis. We opted for complete resection of the meningioma and reconstruction with anterior rectus abdominis muscle flap, as well as selective cervical ganglionectomy. Anatomical pathology showed neoplastic proliferation of meningothelial cells in syncytial cytoplasm, oval or spherical nuclei with slight anisocariosis and hyperchromasia, and intranuclear vacuoles, all compatible with anaplastic meningioma. Conclusion: Due to a lack of consensus on how to treat a metastatic malignant meningioma, this pathology requires a multidisciplinary approach, and treatment needs to be adapted to each particular case. Complete resection of the lesion is the primary goal, and this requires complex procedures involving endocranial as well as extracranial surgeries, which result in composite defects difficult to resolve. Microvascular free flaps are considered the gold standard in reconstructions of large skull base defects, with high success rates and few complications.

Supratentorial and infratentorial brain abscesses: surgical treatment, complications and outcomes--a 10-year single-center study.

OBJECTIVE: To analyze the variables determining morbidity, mortality and outcome in subjects with brain abscesses treated at a single center over a 10-year period. METHODS: A retrospective study was conducted on a series of 59 patients with brain abscesses surgically treated with stereotactically guided aspiration or open craniotomy excision. Such variables as age, gender, clinical presentation, number of days to diagnosis, location, number of lesions, predisposing factors, mechanism of infection, etiological agent, and therapy were analyzed independently. Complications were defined as any deviation from the normal postoperative course occurring within 30 days of surgery, and classified according to a four-point gradual severity scale. Postoperative outcome was appraised through the Glasgow Outcome Scale (GOS) 6 months after surgery, 0-4 points were considered poor outcome and 5 points good outcome. RESULTS: Eighty abscesses were diagnosed and surgically managed in 59 patients. The mean age was 44.69 years (range: 0.16-77); 59.3% were female. The median number of days to diagnosis was 7. Most frequent clinical presentations included fever (52.5%), headache (42.4%), and focal neurologic deficits (39%). Mechanism of infection was mainly hematogenous spread (32.2%). Stereotactically guided aspiration was the treatment of choice for 74.6% of the patients, whereas 25.4% of the cases were managed through open craniotomy excision. Outcome was favorable in 81.35% (n = 48) of the subjects. General morbidity was 27.1%, and mortality stood at 10.16%. Out of a total 38.98% (n = 23) of complications, two-thirds were due to medical causes. The analysis of variables revealed that only age (p = 0.02), immunosuppression (OR 5.83; p = 0.012) and hematogenous spread (p < 0.01) were associated with poor outcomes. CONCLUSIONS: Immunosuppression, hematogenous spread and advanced age were predictors of poor prognosis. Most of the complications following brain abscess management were not directly related to surgery or surgical technique.

Surgical management of atypical trigeminal neuralgia secondary to tentorial meningioma: 2D video.

Background: Tentorial meningiomas (TM) are complex entities with distinguished clinical, radiological and surgical considerations. They comprise approximately 3 - 6% of all intracranial meningiomas1. TM have been classified in 5 subgroups according to the modified Yasargil's classification, based on their location 2 and 3. Those located at the free margin of the tentorium are still challenging for neurosurgeons, with high morbidity and mortality. Atypical trigeminal neuralgia (ATN) is a type of trigeminal neuralgia that is identified by the constancy of symptoms. They experience less intense pain, but a constant dull aching or burning pain, and it is frequently misdiagnosed. Although it is well known that typical trigeminal (TN) neuralgia responds very well to medical treatment and are related with posterior fossa tumors, ATN is less likely. In this video we demonstrate the microsurgical resection of group 1 tentorial meningioma in the treatment of atypical trigeminal neuralgia. Case Description: A previously healthy 63-year-old female came to our service complaining of long lasting, intermittent, right facial pain for two years. On neurological examination, the patient had hypoesthesia in the territory of maxillae (V2) branch of the right trigeminal nerve. She had no other complaints on the physical examination. Initial treatment with carbamazepine and pregabalin was performed, however, it could not be further increased because of the maximal doses and side effects. Radiological investigation was carried out with cranial computed tomography (CT) and magnetic resonance image (MRI), which showed a high signal density mass lesion in the free margin of the tentorium, with extension to the right cerebello pontine angle (CPA), compressing the trigeminal nerve, that exhibited homogeneous contrast enhancement, suggestive of tentorial meningioma. Given the size, the location of the mass, and no response to the medical treatment, microsurgical resection was performed. Conclusion: The postoperative period was excellent, without any neurological deficit. The patient consented with publication of her images and videos.

Minimally Invasive Drainage of Intracerebral Hemorrhage. A South American Experience with the MISTIE Procedure.

BACKGROUND: Intracerebral hemorrhage (ICH) is the second most common subtype of stroke but is associated with greater rates of disability or mortality. One of the factors of a poor prognosis is large hematoma volume. The MISTIE III trial with the aim of decreasing clot size showed that the greater the ICH reduction, the higher likelihood of lower mortality without a net increase in the proportion of patients with severe disability. Our aim is to describe our experience with treating selective patients with ICH per the MISTIE trial protocol in a university hospital in Argentina during 4 years. METHODS: A retrospective analysis was performed of consecutive patients with ICH treated at a single university tertiary-care center from 2017 to 2021 with the MISTIE protocol. RESULTS: We deployed this procedure in 7 patients with a median age of 61 years, median National Institutes of Health Stroke Scale score of 14, an ICH volume of 35 mL and median ICH score of 2. Five of 7 patients achieved the target goal of hematoma reduction; 4 of the patients had a total independence level and 1 needed minimal help at 12 months after discharge. Five patients had a good functional outcome (modified Rankin Scale score 0-3 and extended Glasgow Outcome Scale score 4-8) and 2 patients had died but neither because of consequences of thrombolysis of the intracerebral hemorrhage. We did not find bleeding complications during catheter placement, alteplase infusion, or after catheter removal. CONCLUSIONS: The procedure can be carried out safely in Latin American centers that have experience in managing neurocritical patients.

Safety margin for the preservation of the nasoseptal artery during trans-nasal endoscopic approach.

BACKGROUND: The introduction of the nasoseptal flap for the reconstruction of extended endoscopic approaches decreased the incidence of postoperative fistula. In order to preserve the septal vascular pedicles, many have started to prepare the flap systematically, prior to the opening of the sphenoid rostrum. The aim of this study is to obtain an average measure of the location of the posterior septal artery using the upper edge of the choana as a landmark. METHODS: Ten cadaveric heads, fixed with formaldehyde and injected with colored silicone, were studied. The course, branching pattern and dominance of the branches of the posterior septal artery were recognized, as well as the distance in of its superior and lower branches respect to the medial upper edge of the choana. RESULTS: In all cases, the posterior septal artery enters as an only vessel through the sphenopalatine foramen. In its sphenoid segment, over the sphenoid rostrum, the posterior septal artery divides into its upper and lower branches, in most cases, laterally to the sphenoid ostium (70%, N.=14). The lower branch was dominant in 60% of the cases (N.=12). Regarding the mean distance in millimeters from the medial upper edge of the choana to the superior branch, it was 14.45±0.4102 (18-11.5) and, to the lower branch, 10.9±0.4682 (14-7). CONCLUSIONS: A rostrum opening to 15 mm over the upper edge of the choana is safe to avoid vascular complications, and to be able to prepare a viable nasoseptal flap only if it is necessary.

Surgical Management of a Superior Orbital Fissure Cavernous Hemangioma.

Background: Cavernous sinus hemangiomas (CSHs) are intracranial extradural benign, well-demarcated neoplasms arising within dural sinuses. The orbital apex and superior orbital fissure (SOF) are common locations for these lesions. Because of the complex anatomy of this area and potential morbidity, SOF CSH surgical management is challenging. Objective: Describe a case of a SOF CSH and review of literature. Material and Methods: We present the case of a 44-year-old female with a 2-month history of right eye visual disturbances. A contrast-enhanced magnetic resonance imaging showed a right orbital apex nodular formation. A pterional craniotomy with a middle fossa mini peeling was performed. Results: Gross total resection was accomplished. No recurrences were observed 2 years after surgery. Conclusion: SOF CSH should be included in a differential diagnosis in cases of space-occupying orbital apex lesions with atypical features. Surgery is the gold standard treatment. Radiosurgery is a valid option for tumor remnants.

Morphometric analysis of posterior cranial fossa and surgical implications.

BACKGROUND: Posterior cranial fossa (PCF) is an important area in terms of anatomy and surgery. It is a common site of many neoplastic, vascular, and degenerative lesions. Craniovertebral surgeries require special attention regarding detailed information about the morphology and morphometry of this region. The aim of this study was to analyze the morphometric characteristics of PCF and distances between the inner base of the skull. MATERIALS AND METHODS: An observational, retrospective cross-sectional study was made. Fifty-five dry human skulls of unknown sex were measured ascertained using digital Vernier caliper with 0.01 mm precision. RESULTS: The morphometric analysis of the mean length and width of the FM was 34.51 mm and 29.85 mm, respectively. We found a significant difference (P < 0.05) among the distance between the posterior tip of occipital condyle and basion of the right and left sides. CONCLUSION: According to our observations, the present study yielded detailed morphometry of the PCF and neurovascular relationship. It can facilitate successful instrumentation and minimize neurovascular injuries. Furthermore, it provides safe and suitable data for guiding neurosurgical procedures. The major limitation of this study was the lack of knowledge regarding the age and gender of the participants whose skull base was studied.

[Collision sellar lesions: pituitary adenoma and Rathke cleft cyst]. / Lesiones sincrónicas selares: adenoma hipofisario y quiste de la bolsa de Rathke.

Rathke's cleft cyst (RCC) are a slow-growing, benign, cystic lesions that arises from the remnants of the primitive ectoderm and Rathke's pouch. They present a common origin with pituitary adenomas (PA), however, the concomitant presentation of a PA and a RCC rarely occur. We present a case of a 41-year-old female with Cushing's disease. Magnetic resonance imaging (MRI) showed two synchronic lesions in the sellar region. An endoscopic transnasal approach was performed, with complete excision of both. The histological studies revealed an ACTH secreting PA and a RCC. The patient presented clinical and endocrinological remission six months after surgery. With the presence of cystic lesion at the sellar region, and the concomitant finding of a pituitary adenoma, RCC should be considered.

El quiste de la bolsa de Rathke (QBR) es una entidad benigna de crecimiento lento que proviene del remanente del ectodermo primitivo. Presenta un origen común con los adenomas hipofisarios (AH), sin embargo, la presentación sincrónica de un AH y un QBR es infrecuente. Presentamos el caso de una mujer de 41 años con enfermedad de Cushing. Se realizó resonancia magnética con el hallazgo de dos lesiones en región selar. Se hizo un abordaje transnasal endoscópico, con exéresis completa de ambas. El informe de anatomía patológica reveló un AH corticotropo y un QBR. Tuvo una remisión clínica analítica endocrinológica a los seis meses postquirúrgicos. Ante el hallazgo de una imagen quística a nivel selar concomitante con un adenoma hipofisario, debe ser considerada la posibilidad diagnóstica de un QBR.

Surgical Indication Optimization of Brain Metastases Based on the Evolutionary Analysis of Karnofsky Performance Status.

BACKGROUND AND OBJECTIVE: Surgical resection of brain metastases (BM) offers the highest rates of local control and survival; however, it is reserved for patients with good functional status. In particular, the presence of BM tends to oversize the detriment of the overall functional status, causing neurologic deterioration, potentially reversible following symptomatic pharmacological treatment. Thus, a timely indication of surgical resection may be dismissed. We propose to identify and quantify these variations in the functional status of patients with symptomatic BM to optimize the indication of surgical resection. PATIENTS AND METHODS: Historic, retrospective cohort analysis of adult patients undergoing BM microsurgical resection, consecutively from January 2012 to May 2016, was conducted. The Karnofsky performance status (KPS) variation was recorded according to the symptomatic evolution of each patient at specific moments of the diagnostic-therapeutic algorithm. Finally, survival curves were delineated for the main identified factors. RESULTS: One hundred and nineteen resection surgeries were performed. The median overall survival was 243 days, while on average it was 305.7 (95% confidence interval [CI]: 250.6-360.9) days. The indication of surgical resection of 10% of the symptomatic patients in our series (7.5% of overall) could have been initially rejected due to pharmacologically reversible neurologic impairment. Survival curves showed statistically significant differences when KPS was stratified following pharmacological symptomatic treatment (p < 0.0001), unlike when they were estimated at the time of BM diagnosis (p = 0.1128). CONCLUSION: The preoperative determination of the functional status by KPS as an evolutive parameter after the nononcologic symptomatic pharmacological treatment allowed us to optimize the surgical indication of patients with symptomatic BM.

Morphologic Variations in the Circle of Willis as a Risk Factor for Aneurysm Rupture in the Anterior and Posterior Communicating Arteries.

BACKGROUND: Intracranial aneurysms are acquired abnormal vascular dilations. The most dangerous complication of a cerebral aneurysm is its rupture, with a high rate of mortality. This study aimed to determine whether there is an association between anatomic variations in the circle of Willis and ruptured aneurysms in the anterior and posterior communicating arteries. METHODS: A cross-sectional study of adult patients with a diagnosis of intracranial aneurysm was carried out between March 2015 and March 2019. The patients were divided into groups of ruptured or unruptured aneurysm in the anterior and posterior communicating arteries. RESULTS: A total of 132 patients with anterior and posterior communicating artery aneurysms were included. The presence of anatomic variation in the circle of Willis presented a statistically significant association with ruptured aneurysms (odds ratio [OR], 2.28; 95% confidence interval [CI], 1.11-4.65; P = 0.024). There was a statistically significant difference between the presence of nonspherical aneurysm and rupture (OR, 6.9; 95% CI, 3.12-15.48; P < 0.0001). Multivariate logistic regression observed smoking (OR, 2.4; 95% CI, 1.01-5.9; P = 0.4), anterior complex variations (OR, 2.68; 95% CI, 1.01-7.18; P < 0.04), and nonspherical morphology (OR, 4.7; 95% CI, 1.93-11.45; P = 0.001) presented a statistically significant association with the rupture. CONCLUSIONS: Our results suggest that the studied variations of the circle of Willis and nonspherical morphology, in addition to playing a role in the development of cerebral aneurysms, may contribute to their rupture.

Restricted diffusion in a ring-enhancing mucoid metastasis with histological confirmation: case report.

We present a case of restricted diffusion in a ring-enhancing cerebellar metastasis in a 58-year-old man. Diffusion imaging showed restriction with low apparent diffusion coefficient values within the cavity. Diagnosis of abscess was suggested based on radiological findings. A suspicious lung nodule was found in the systemic evaluation, and histological examination of the brain lesion confirmed metastatic adenocarcinoma with mucoid content confirmed by further specific pathological tests. We discuss the reason of diffusion findings and the importance of the correct interpretation of this technique in a clinical situation. Our case confirms previous hypothesis about restricted diffusion related to mucoid content in metastasis.