RESUMEN
BACKGROUND: Repairing bone defects generated by craniectomy is a major therapeutic challenge in terms of bone consolidation as well as functional and cognitive recovery. Furthermore, these surgical procedures are often grafted with complications such as infections, breaches, displacements and rejections leading to failure and thus explantation of the prosthesis. OBJECTIVE: To evaluate cumulative explantation and infection rates following the implantation of a tailored cranioplasty CUSTOMBONE prosthesis made of porous hydroxyapatite. One hundred and ten consecutive patients requiring cranial reconstruction for a bone defect were prospectively included in a multicenter study constituted of 21 centres between December 2012 and July 2014. Follow-up lasted 2 years. RESULTS: Mean age of patients included in the study was 42±15 years old (y.o), composed mainly by men (57.27%). Explantations of the CUSTOMBONE prosthesis were performed in 13/110 (11.8%) patients, significantly due to infections: 9/13 (69.2%) (p<0.0001), with 2 (15.4%) implant fracture, 1 (7.7%) skin defect and 1 (7.7%) following the mobilization of the implant. Cumulative explantation rates were successively 4.6% (SD 2.0), 7.4% (SD 2.5), 9.4% (SD 2.8) and 11.8% (SD 2.9%) at 2, 6, 12 and 24 months. Infections were identified in 16/110 (14.5%): 8/16 (50%) superficial and 8/16 (50%) deep. None of the following elements, whether demographic characteristics, indications, size, location of the implant, redo surgery, co-morbidities or medical history, were statistically identified as risk factors for prosthesis explantation or infection. CONCLUSION: Our study provides relevant clinical evidence on the performance and safety of CUSTOMBONE prosthesis in cranial procedures. Complications that are difficulty incompressible mainly occur during the first 6 months, but can appear at a later stage (>1 year). Thus assiduous, regular and long-term surveillances are necessary.
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Craneotomía/normas , Durapatita/normas , Procedimientos de Cirugía Plástica/métodos , Prótesis e Implantes/normas , Implantación de Prótesis/normas , Cráneo/cirugía , Adulto , Autoinjertos/trasplante , Craneotomía/efectos adversos , Craneotomía/métodos , Durapatita/administración & dosificación , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Prótesis e Implantes/efectos adversos , Implantación de Prótesis/efectos adversos , Procedimientos de Cirugía Plástica/efectos adversos , Reproducibilidad de los ResultadosAsunto(s)
Acreditación , Neurocirugia/educación , Acreditación/legislación & jurisprudencia , Selección de Profesión , Competencia Clínica/legislación & jurisprudencia , Competencia Clínica/normas , Curriculum/normas , Francia , Humanos , Programas Nacionales de Salud , Neurocirugia/legislación & jurisprudencia , Neurocirugia/estadística & datos numéricos , Procedimientos Neuroquirúrgicos/educación , Procedimientos Neuroquirúrgicos/legislación & jurisprudencia , Procedimientos Neuroquirúrgicos/normas , Complicaciones Posoperatorias/prevención & control , Garantía de la Calidad de Atención de Salud/legislación & jurisprudencia , Garantía de la Calidad de Atención de Salud/normas , Factores de Riesgo , Sociedades MédicasRESUMEN
INTRODUCTION: Dural tears are a dreaded surgical incident because they are difficult to anticipate and may lead to serious complications. MATERIALS AND METHODS: The French College of Neurosurgery analyzed 100 cases of dural tears declared on the physicians accreditation website from the Haute Autorité de santé (Regional Health Authority). A questionnaire on drainage, type of dural repair and bed rest duration was sent to 87 French neurosurgeons. RESULTS: Thirty-six percent of patients with dural tears had a history of previous spinal surgery and the most common cause of tear was surgical fibrosis into the operative field for 30% of cases. Sixty-four percent had no history of spinal surgery and, in 33% of cases, the dural tear occurred during a surgery for herniated disc. Drainage was proposed case by case in 76% of cases, the patient was allowed to stand up at day 1 in 48% of cases. The treatment of dural tears combined different techniques including in situ injection of biological glue in 86% of cases. The most common complication was the need of wound repair procedure in 59.5% of cases, which was complicated by meningitis in 21.5% of cases. CONCLUSION: This study shows the lack of formal consensus about the procedure of repair, the method of drainage or the need to keep the patient bed ridden. This study highlights a relatively high frequency of dural tears, its potentially serious complications and stresses the need for prospective studies in order to define the appropriate action to undertake when faced with this type of incident.
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Descompresión Quirúrgica , Duramadre/cirugía , Complicaciones Intraoperatorias/etiología , Vértebras Lumbares/cirugía , Procedimientos Neuroquirúrgicos , Adulto , Descompresión Quirúrgica/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Neuroquirúrgicos/efectos adversos , Estudios Prospectivos , Adulto JovenRESUMEN
Surgical excision of brain metastases has been well evaluated in unique metastases. Two randomized phase III trial have shown that combined with adjuvant whole brain radiotherapy, it significantly improves overall survival. However, even in the presence of multiple brain metastases, surgery may be useful. Also, even in lesions amenable to radiosurgery, surgical resection is preferred when tumors displayed cystic or necrotic aspect with important edema or when located in highly eloquent areas or cortico-subcortically. Furthermore, surgery may have a diagnostic role, in the absence of histological documentation of the primary disease, to rule out a differential diagnosis (brain abscess, lymphoma, primary tumor of the central nervous system or radionecrosis). Finally, the biological documentation of brain metastatic disease might be useful in situations where a specific targeted therapy can be proposed. Selection of patients who will really benefit from surgery should take into account three factors, clinical and functional status of the patient, systemic disease status and characteristics of intracranial metastases. Given the improved overall survival of cancer patients partially due to the advent of effective targeted therapies on systemic disease, a renewed interest has been given to the local treatment of brain metastases. Surgical resection currently represents a valuable tool in the armamentarium of brain metastases but has also become a diagnostic and decision tool that can affect therapeutic strategies in these patients.
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Neoplasias Encefálicas/secundario , Procedimientos Neuroquirúrgicos , Neoplasias Encefálicas/diagnóstico , Neoplasias Encefálicas/radioterapia , Neoplasias Encefálicas/cirugía , Ensayos Clínicos Fase I como Asunto , Terapia Combinada , Irradiación Craneana , Craneotomía , Diagnóstico Diferencial , Progresión de la Enfermedad , Supervivencia sin Enfermedad , Humanos , Microcirugia , Pronóstico , Radioterapia Adyuvante , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del TratamientoRESUMEN
The incidence of deep vein thrombosis (DVT) is between 20 and 35% using contrast venography, with a rate of symptomatic DVT between 2.3 and 6% in neurosurgery without any prophylaxis. The risk of DVT is poorly evaluated in head injured patients but is around 5%. Specific risk factors in neurosurgery are: a motor deficit, a meningioma or malignant tumour, a large tumour, age over 60 years, surgery lasting more than 4 hours, a chemotherapy. The benefit of mechanical methods or low molecular weight heparin (LMWH) for the prevention of DVP in neurosurgery is demonstrated (grade A). Each method decreases the risk by about 50%. A postoperative prophylaxis with a LMWH does not seem to increase the risk of intracranial bleeding (grade C). There is no demonstrated benefit to begin a prophylaxis with LMWH before the intervention. The duration of the prophylaxis is 7 to 10 days but this has not been scientifically determined.
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Traumatismos Craneocerebrales/complicaciones , Procedimientos Neuroquirúrgicos , Tromboembolia/prevención & control , Traumatismos Craneocerebrales/terapia , Humanos , Medición de RiesgoRESUMEN
The risk of deep vein thrombosis (DVT) after spinal cord injury is very high. Without prophylaxis the incidence of DVT using venography is 81% and the risk of symptomatic DVT is between 12 and 23%. The risk is much lower in elective spine surgery. After discectomy or laminectomy on less than two spine levels, the risk of DVT is less than 1%. After spinal fusion or extended laminectomy, the risk can be estimated between 0.3 and 2.2%. A prophylaxis is recommended for all patients after spinal cord injury (grade A). The association of a mechanical method and heparin is recommended (grade B). The duration of prophylaxis is 3 months in patients with a motor deficit (grade C). No prophylaxis is recommended after discectomy or limited laminectomy in patients without additional risk factors. Mechanical methods are recommended after spinal fusion or extended laminectomy. For patients with additional risk factors a low molecular weight heparin is recommended.
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Procedimientos Neuroquirúrgicos , Traumatismos de la Médula Espinal/complicaciones , Médula Espinal/cirugía , Tromboembolia/prevención & control , Procedimientos Quirúrgicos Ambulatorios , Humanos , Medición de Riesgo , Traumatismos de la Médula Espinal/terapiaRESUMEN
There are few studies of poor methodological quality on the risk of thromboembolism in head and neck surgery. The incidence of symptomatic deep vein thrombosis is estimated between, 0.1% and 0.6%. The patient's risk factors (cancer, alcoholism, smoking, malnutrition) determine for the assessment of the potential benefit of thromboembolism prophylaxis. No method can be recommended based on the literature. In patients receiving anticoagulant therapy undergoing superficial head and neck surgery or dental extraction, the literature suggest to continue anticoagulation throughout the perioperative period.
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Procedimientos Quirúrgicos Orales , Procedimientos Quirúrgicos Otorrinolaringológicos , Tromboembolia/prevención & control , Humanos , Medición de RiesgoRESUMEN
A 48-year-old woman was admitted to the Neurosurgery Department for a large frontal lobe tumor revealed by partial seizures. The patient was conscious and alert. Neurological examination was normal. MRI study showed a right frontal lobe tumor compounded of an anterior solid mass strongly enhanced after gadolinium injection and a posterior voluminous cyst with important mass effect. The cerebral blood volume (CBV) map showed no area of elevated CBV within the tumor consistent with a low-grade tumor. The patient was operated on with a presumed diagnosis of anaplastic oligodendroglioma. Postoperative course was uneventful. Histopathological examination was consistent with a benign ganglioglioma. The patient did not undergo an additional treatment. One year later, the patient was healthy and neurological and neuropsychological examination were normal. MRI study did not show any recurrence. This case emphazises the relevance of perfusion MR imaging in the preoperative workup of glioneuronal and glial tumors.
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Lóbulo Frontal/patología , Ganglioglioma/patología , Imagen por Resonancia Magnética/métodos , Neoplasias Supratentoriales/patología , Diagnóstico Diferencial , Epilepsias Parciales/etiología , Femenino , Lóbulo Frontal/cirugía , Gadolinio , Ganglioglioma/complicaciones , Ganglioglioma/diagnóstico , Ganglioglioma/cirugía , Humanos , Persona de Mediana Edad , Oligodendroglioma/diagnóstico , Oligodendroglioma/patología , Radiofármacos , Sensibilidad y Especificidad , Neoplasias Supratentoriales/complicaciones , Neoplasias Supratentoriales/diagnósticoRESUMEN
The sitting position in neurosurgery may lead to complications such as air embolism and neurological complications. We report the case of a 16-year-old male who suffered from post-operation paraplegia after surgery for Arnold Chiari disease. This patient had several risk factors and serious morphological spinal abnormalities. We propose to include monitoring of somatosensory evoked potentials (SSEP) during this surgery in order to detect this type of devastating incident.
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Procedimientos Neuroquirúrgicos/efectos adversos , Paraplejía/etiología , Complicaciones Posoperatorias/etiología , Postura/fisiología , Adolescente , Malformación de Arnold-Chiari/cirugía , Potenciales Evocados Somatosensoriales/fisiología , Humanos , Masculino , Monitoreo Intraoperatorio , Columna Vertebral/anomalíasRESUMEN
Forty-four patients (22 males and 22 females) were admitted to our institution for an intracranial epidermoid cyst between 1980 and 2000. Their mean age was 39.9 years. The duration of the disease at admission varied between a few days and 30 years. CT-scan was performed in all cases, MRI in 33 cases with a diffusion sequence in 3. Most of the 26 patients with posterior fossa lesions were treated surgically in the sitting position, with resection of the tonsils in four cases in order to minimize cerebellar retraction. The other supratentorial tumors were operated using a fronto-temporo-pterional approach in 13 cases (with temporo-polar lobectomy in 6 cases), or a parietal transparenchymal approach in the parieto-occipital lesions (2 cases). The resection was total or subtotal (residual capsule) in 79.5% of cases. Post-operative morbidity was 13.6% and mortality 8.9%. The median follow-up was 8 years, with a recurrence rate of 4.5%. Epidermoid cysts are benign, slowly but ineluctably growing tumors which require surgical treatment. Their diagnosis has become easier, especially with the development of MRI diffusion sequences. Morbidity and mortality (morbi-mortality) reported in the literature as well as found in our series seems to be unrelated to classical aseptic meningitis (22.7% in our series) or hydrocephalus (2 cases in our series). For many authors, it may be the consequence of systematic resection of the tumor capsule. This does not seem to be the case in our series in which only 25% of the patients underwent a complete resection. Prolonged cerebral retraction could be one of the responsible factors. One of the technical proposals could be to perform a transparenchymal approach in selected patients.
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Encefalopatías/cirugía , Quiste Epidérmico/cirugía , Adulto , Daño Encefálico Crónico/etiología , Encefalopatías/complicaciones , Encefalopatías/diagnóstico por imagen , Encefalopatías/patología , Quiste Epidérmico/complicaciones , Quiste Epidérmico/diagnóstico por imagen , Quiste Epidérmico/patología , Femenino , Estudios de Seguimiento , Humanos , Imagen por Resonancia Magnética , Masculino , Meningitis Aséptica/epidemiología , Meningitis Aséptica/etiología , Persona de Mediana Edad , Procedimientos Neuroquirúrgicos/métodos , Complicaciones Posoperatorias/epidemiología , Pronóstico , Recurrencia , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: Improvement of neurosurgical techniques with a more detailed description of brain tumors and their functional environment. METHODS: We performed: (1) anatomical magnetic resonance imaging (MRI) for reference, (2) functional sequences dedicated to the adjacent cortical structures (sensorimotor, visual, language paradigms), and (3) thallium 201 cerebral tomoscintigraphy to visualize active tumor invasion. Data were transferred to a workstation for automatic registration. RESULTS: All data were combined into one synthetic image showing the foci of high proliferative activity, which have to be completely resected, and the peritumoral functional structures, which have to be spared in order to minimize postoperative sequelae. This trimodal image is entered into a surgical neuronavigation computer for preoperative planning in order to outline tumoral target and functional risk areas. All this information is displayed in the operative microscope (Zeiss MKM) optically linked to MR images. This multimodality technique diminishes operative time by reducing electrocorticography and improves the operative short-term outcome. CONCLUSION: Multimodal imaging is useful for optimization of neurosurgical tumor resection.
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Neoplasias Encefálicas/cirugía , Encéfalo/diagnóstico por imagen , Glioblastoma/cirugía , Oligodendroglioma/cirugía , Tomografía Computarizada de Emisión de Fotón Único , Adulto , Anciano , Encéfalo/metabolismo , Encéfalo/patología , Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/patología , Neoplasias Encefálicas/secundario , Femenino , Estudios de Seguimiento , Lóbulo Frontal/diagnóstico por imagen , Lóbulo Frontal/metabolismo , Lóbulo Frontal/patología , Glioblastoma/diagnóstico , Glioblastoma/diagnóstico por imagen , Glioblastoma/patología , Humanos , Procesamiento de Imagen Asistido por Computador , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Lóbulo Occipital/diagnóstico por imagen , Lóbulo Occipital/metabolismo , Lóbulo Occipital/patología , Oligodendroglioma/diagnóstico por imagen , Oligodendroglioma/patología , Lóbulo Temporal/diagnóstico por imagen , Lóbulo Temporal/metabolismo , Lóbulo Temporal/patología , Radioisótopos de TalioRESUMEN
BACKGROUND AND PURPOSE: The usual onset of intramedullary spinal cord metastases at an advanced stage of cancer disease explains that surgical removal of such lesions is rarely performed. We tried to define the place for surgery in the management of such lesions. METHODS: We report the observation of a 52-year-old male patient presenting with a metastasis of the conus medullaris revealing a lung cancer. Surgical excision of the lesion led to pain relief and improvement of bladder dysfunction. We present a review of pertinent literature. RESULTS: Surgery allows histological diagnosis in case of isolated, revealing tumor. In other selected cases, radical removal of intramedullary metastases could improve the quality and comfort of life although it does not seem to affect the duration of survival.
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Adenocarcinoma/secundario , Adenocarcinoma/cirugía , Médula Renal/patología , Médula Renal/cirugía , Neoplasias Renales/secundario , Neoplasias Renales/cirugía , Neoplasias de la Médula Espinal/patología , Neoplasias de la Médula Espinal/cirugía , Adenocarcinoma/complicaciones , Humanos , Neoplasias Renales/complicaciones , Masculino , Microcirugia/métodos , Persona de Mediana Edad , Enfermedades de la Vejiga Urinaria/etiología , Enfermedades de la Vejiga Urinaria/fisiopatologíaRESUMEN
OBJECTIVE: Surgery of the insula represents a technical challenge, because of the proximity of the internal capsule to the lenticulostriate arteries and the lack of certainty concerning its functionality. Using intraoperative direct cerebral stimulation, combined with neuronavigation, the authors operated on 12 insular gliomas. On the basis of this experience, the physiopathological and surgical implications are discussed. METHODS: A low-grade insular glioma, revealed by seizures, was diagnosed in 12 right-handed patients with a normal neurological status. Preoperative magnetic resonance imaging showed that, according to Yasargil's classification system, three patients harbored Type 3 lesions and nine patients had Type 5 lesions (10 tumors on the right side and 2 on the left dominant side). All patients underwent surgery using direct cerebral stimulation, under general anesthesia in nine patients (motor mapping) and under local anesthesia in three patients (sensorimotor and language mapping). Ultrasonography and/or neuronavigation was used in all cases. Preoperative angio-computed tomographic scanning showed the lenticulostriate arteries in two patients. RESULTS: The internal capsule was systematically detected, and the language areas were identified within the left insula in the awake patients. The lenticulostriate arteries were seen in two patients. Seven patients presented an immediate postoperative deficit; six of them recovered completely within 3 months. Four resections were total, six were subtotal, and two were partial (left insula). CONCLUSION: The use of intraoperative direct cerebral stimulation and neuronavigation allows surgery of the insula with minimization of the risk of sequelae, but its use is still limited with regard to the dominant hemisphere, owing to the essential role of this structure in language.
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Neoplasias Encefálicas/fisiopatología , Neoplasias Encefálicas/cirugía , Corteza Cerebral/fisiopatología , Corteza Cerebral/cirugía , Glioma/fisiopatología , Glioma/cirugía , Adulto , Neoplasias Encefálicas/diagnóstico , Neoplasias Encefálicas/patología , Estimulación Eléctrica , Electrofisiología , Femenino , Glioma/diagnóstico , Glioma/patología , Humanos , Periodo Intraoperatorio , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Terapia Asistida por Computador , UltrasonografíaAsunto(s)
Antígenos de Neoplasias/análisis , Neoplasias Encefálicas/química , Neoplasias Encefálicas/patología , Neoplasias Neuroepiteliales/química , Neoplasias Neuroepiteliales/patología , Adulto , Anciano , Neoplasias Encefálicas/ultraestructura , Femenino , Humanos , Microscopía Electrónica , Neoplasias Neuroepiteliales/ultraestructuraRESUMEN
OBJECT: The goal of this study was to determine the somatotopical structure-function relationships of the primary motor cortex in individual patients by using functional magnetic resonance (fMR) imaging. This was done to assess whether there is a displacement of functional areas compared with anatomical landmarks in patients harboring brain tumors close to the central region, and to validate these findings with intraoperative cortical stimulation. METHODS: One hundred twenty hemispheres in 60 patients were studied by obtaining blood oxygen level-dependent fMR images in patients while they performed movements of the foot, hand, and face on both sides. There was a good correspondence between anatomical landmarks in the deep portion of the central sulcus on axial slices and the somatotopical organization of primary motor areas. Pixels activated during hand movements were centered on a small characteristic digitation; those activated during movements in the face and foot areas were located in the lower portion of the central sulcus (lateral to the hand area) and around the termination of the central sulcus, respectively. In diseased hemispheres, signal-intensity changes were still observed in the projection of the expected anatomical area. The fMR imaging data mapped intraoperative electrical stimulation in 92% of positive sites. CONCLUSIONS: There was a high correspondence between the somatotopical anatomy and function in the central sulcus, which was similar in normal and diseased hemispheres. The fMR imaging and electrical stimulation data were highly concordant. These findings may enable the neurosurgeon to locate primary motor areas more easily during surgery.
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Neoplasias Encefálicas/fisiopatología , Estimulación Eléctrica , Imagen por Resonancia Magnética , Monitoreo Intraoperatorio , Corteza Motora/fisiopatología , Adulto , Anciano , Astrocitoma/patología , Astrocitoma/fisiopatología , Astrocitoma/cirugía , Mapeo Encefálico , Neoplasias Encefálicas/patología , Neoplasias Encefálicas/cirugía , Cara/fisiología , Pie/fisiología , Mano/fisiología , Humanos , Procesamiento de Imagen Asistido por Computador , Persona de Mediana Edad , Actividad Motora/fisiología , Corteza Motora/patología , Oligodendroglioma/patología , Oligodendroglioma/fisiopatología , Oligodendroglioma/cirugía , Oxígeno/sangre , Estudios RetrospectivosAsunto(s)
Mapeo Encefálico , Neoplasias Encefálicas/cirugía , Epilepsia/cirugía , Adulto , Encéfalo/fisiopatología , Encéfalo/cirugía , Daño Encefálico Crónico/fisiopatología , Daño Encefálico Crónico/prevención & control , Neoplasias Encefálicas/fisiopatología , Estimulación Eléctrica , Epilepsia/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/fisiopatología , Complicaciones Posoperatorias/prevención & controlRESUMEN
Indications of surgical treatment for lesions in the central nervous system depend on the risk of a definitive neurological deficit, related to the benefit of resection. Detection of eloquent areas is then necessary because of major individual variability. Neuro-imaging functional techniques are in development and are beginning to be efficient for cortical sensorymotor mapping, but still lack sensitivity and specificity for language mapping, and remain unable to give real-time data during surgery and to perform sub-cortical mapping. The more precise and reliable method of functional mapping is represented by the intra-operative direct electrical stimulations (DES), which allow identification and preservation of essential pathways for motricity, sensibility and language, at each level of the central nervous system (cortico-subcortical). We report our experience of DES in the surgery of tumours and vascular malformations located in supra-tentorial brain eloquent areas, with a consecutive series of 60 patients operated on under general or local anaesthesia, from November 1996 until May 1999 in our department at La Salpêtrière Hospital. Presenting symptoms in the 60 subjects (39 males, 21 females, mean age: 45 years) were seizures in 37 cases with normal clinical examination, and mild neurological deficit in 29 cases. MRI showed 60 supra-tentorial brain lesions: 30 precentral, 12 postcentral, 14 perisylvian in the dominant hemisphere, 4 deep-seated. All subjects underwent surgical resection using DES, with supratentorial cortico-subcortical mapping under general anaesthesia for motor areas detection in 43 cases and under local anaesthesia for sensori-motor and/or language tasks in 17 cases. The final histological diagnosis was 44 gliomas (31 low-grade and 13 high-grade), 9 metastasis, 3 cavernomas, 4 arteriovenous malformations (AVM). Resection was total or subtotal in 52 cases (87%) and partial in 8 cases (13%). 29 patients had no post-operative deficit, while the other 31 patients were impaired post-operatively, with in all cases, except 3, a complete recovery delayed for 15 days to 3 months (overall morbidity: 5%). The median follow up was 14 months. Intra-operative direct electrical stimulations of the central nervous system constitute a reliable, precise and safe method, allowing the realization of a functional mapping useful for all operations of lesions located in eloquent areas. This technique allows a minimization of definitive post-operative neurological deficit, and concurrently an improvement in the quality of resection.
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Daño Encefálico Crónico/diagnóstico , Mapeo Encefálico/instrumentación , Neoplasias Encefálicas/cirugía , Estimulación Eléctrica/instrumentación , Glioma/cirugía , Malformaciones Arteriovenosas Intracraneales/cirugía , Monitoreo Intraoperatorio/instrumentación , Complicaciones Posoperatorias/diagnóstico , Adulto , Encéfalo/fisiopatología , Encéfalo/cirugía , Daño Encefálico Crónico/fisiopatología , Neoplasias Encefálicas/fisiopatología , Dominancia Cerebral/fisiología , Diseño de Equipo , Femenino , Estudios de Seguimiento , Glioma/fisiopatología , Humanos , Malformaciones Arteriovenosas Intracraneales/fisiopatología , Trastornos del Lenguaje/diagnóstico , Trastornos del Lenguaje/fisiopatología , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/fisiopatología , Pronóstico , Trastornos Psicomotores/diagnóstico , Trastornos Psicomotores/fisiopatologíaRESUMEN
Indications of surgical treatment for lesions in functional cerebral areas depend on the ratio between the definitive neurological deficit and the beneficial effect of resection. Detection of eloquent cortex is difficult because of important individual variability. Peroperative direct cortical and subcortical electrical stimulations (DCS) provide the most precise and reliable method currently available allowing identification and preservation of neurons essential for motricity, sensitivity++ and language. We report our preliminary experience with DCS in surgery of intracerebral infiltrative tumors with a consecutive series of 15 patients operated from November 96 through September 97 in our institution. Presenting symptoms in the 15 patients (8 males, 7 females, mean age 43 years) were seizures in 11 cases (73%) and neurological deficit in 4 cases (27%). Clinical examination was normal in 11 patients and revealed hemiparesia in 4. Magnetic resonance imaging (MRI) with three-dimensional reconstruction showed a precentral tumor in 10 cases, central lesion in one patient, postcentral lesion in two cases, right insular tumor (non-dominant hemisphere) in one case. All patients underwent surgical resection using DCS with detection in 13 cases of motor cortex and subcortical pathways under genera anesthesia, in one case of somatosensory area under local anesthesia, and in one case of language areas also under local anesthesia. The tumor was recurrent in two patients had been operated earlier but without DCS. Resection, verified by postoperative MRI, was total in 12 cases (80%) and estimated at 80% in 3 patients. Histological examination revealed an infiltrative glioma in 12 cases (8 low grade astrocytomas, 3 low grade oligodendrogliomas, and one anaplastic oligodendroglioma), and metastases in 3 cases. Eight patients had no postoperative deficit, while the other 7 patients were impaired, with, in all cases except one, complete recovery in 15 days to 2 months. Direct cortical and subcortical electrical stimulations offer a reliable, precise and safe method, allowing functional mapping especially useful in case of infiltrative cerebral tumors in eloquent areas. This technique allows improvement in the quality of tumoral resection and concurrently a minimization of the risk of definitive postoperative neurological deficit.
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Corteza Cerebral/fisiología , Corteza Cerebral/cirugía , Estimulación Eléctrica , Procedimientos Neuroquirúrgicos , Cuidados Preoperatorios , Adulto , Anestesia General , Anestesia Local , Neoplasias Encefálicas/cirugía , Femenino , Humanos , Procesamiento de Imagen Asistido por Computador , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Corteza Motora/fisiologíaRESUMEN
Local control of brain metastases is better with first treatment by stereotactic radiosurgery than with radiosurgery for recurrence. We reported a retrospective analysis of the influence of clinical and technical factors on local control and survival after radiosurgery realised in first intention. From January 1994 to December 1997, 26 patients presenting with 43 metastases underwent radiosurgery. The median age was 61 years and the median Karnofsky index 70. Primary sites included: lung (12 patients), kidney (7 patients), breast (2 patients), colon (1 patient), melanoma (2 patients), osteosarcoma (1 patient), it was unknown for one patient. Seven patients had extracranial metastases. Twenty-one sessions of radiosurgery have been realized for one metastase, and 9 for two, three or four lesions. The median diameter was 21 mm and the median volume 1.8 cm3. The median peripheral dose to the lesion was 14 Gy, and the median dose at the isocenter 20 Gy. Forty-two metastases were evaluable for response analysis. The overall local control rate was 90.5% and the 1-year, 2- and 3-year actuarial rates were 85% and 75%. In univariate analysis, theorical radioresistance was significantly associated with better local control (100% versus 77%, p < 0.05). All patients were evaluable for survival. The median survival rate was 15 months. Four patients had a symptomatic oedema (RTOG grade II). Two lesions have required a surgical excision. In conclusion, low dose radiosurgery (14 Gy delivered at the periphery of metastasis) can be proposed in first intention for brain metastases, in particularly for theorical radioresistant lesions.