Ventricular Access Utilizing Cutaneous Reference Points: Statistical Analysis and Proposal of a New Ventricular Entry Point.

OBJECTIVES: Perform radiologic measurements and analysis of normal brain computed tomography (CT) scans; delineate a new ventricular entry point from cutaneous landmarks, highlighting the potential surgical implications of these findings. METHODS: Six radiologic distances (AR; BR; AL; BL, C, and D) were measured in normal brain CT scans using Horos software. Statistical analysis of the measurements was performed with minitab18 software based on age, sex, and side. RESULTS: 132 brain CT scans were analyzed, yielding the following mean results: AR distance: 2.1 cm; BR distance: 7 cm; AL distance: 2.1 cm; BL distance: 7.1 cm; C distance: 12.4 cm; D distance: 7 cm; new ventricular entry point: 12.4 cm posterior to the nasion, and 2.1 cm lateral to the midline. CONCLUSIONS: The freehand technique for accessing the lateral ventricles is a common neurosurgical procedure but is often accompanied by complications. To address this, we suggest a novel entry point for ventricular access, determined by cutaneous reference points. This point is situated 12.4 cm posterior to the nasion along the midline and 2.1 cm lateral to the midline. Although our findings may play a role in presurgical planning for ventricular pathologies, future prospective studies are warranted.

Surgical approach to the treatment of pituicytoma. Report of five cases and a literature review.

Background: Pituicytoma (PTs) is a rare tumor of the sella and suprasellar region, derived from the pituicytes of the neurohypophysis, having distinct histological characteristics of glial neoplasms. We reported, the clinical data, neuroimaging studies, surgical approaches and pathology in five patients with PTs and also, we reviewed the literature. Methods: Retrospective chart from five consecutive patients with PTs treated at one University Hospital from 2016 to 2021 were reviewed. In addition, we conducted a search in PubMed/Medline databases using the term "Pituicytoma". Data regarding age, gender, pathological findings, and treatment modality applied were extracted. Results: All patients were female, aged 29-63, complaining of headaches, visual loss and field defects, dizziness and normal or abnormal levels of circulating pituitary hormones. Magnetic Resonance Imaging (MRI) showed in all patients a sellar and suprasellar mass, which was removed through an endoscopic transsphenoidal approach. Our third patient had a subtotal resection followed by close observation. Histopathology showed a glial non-infiltrative tumors with spindle cells, and a final diagnosis of pituicytoma was made. After surgery, visual field defects in all patients were normalized, and in two patients normal levels of plasma hormones were restored. After a mean of three years follow-up, the patients were managed post-operatively through close clinical observation and serial MRI. None of the patients had recurrence of the disease. Conclusion: PTs is a rare glial tumor of the sellar and suprasellar region that arises from neurohypophyseal pituicytes. Disease control may be achieved by total excision.

Risk Factors Related to Transient Diabetes Insipidus Development Following Transsphenoidal Pituitary Adenoma Resection: A Multicentric Study.

OBJECTIVE: To analyze and find risk factors associated with developing transient diabetes insipidus (DI) using a multicenter case series after trans-sphenoidal surgery. METHODS: Medical records of patients who underwent trans-sphenoidal surgery for pituitary adenoma resection between 2010 and 2021 at 3 different neurosurgical centers by 4 experienced neurosurgeons were retrospectively analyzed. The patients were divided into 2 groups (DI group or control group). Logistic regression analysis was conducted to identify risk factors associated with postoperative DI. Univariate logistic regression was performed to identify variables of interest. Covariates with a P value <0.05 were incorporated into multivariate logistic regression models to identify independently associated risk factors for DI. All statistical tests were conducted using RStudio. RESULTS: A total of 344 patients were included; 68% were women, the mean age was 46.5 years, and nonfunctioning adenomas were the most frequent (171, 49.7%). The mean tumor size was 20.3 mm. Covariates associated with postoperative DI were age, female gender, and gross total resection. The multivariable model showed that age (odds ratio [OR] 0.97, CI 0.95-0.99, P = 0.017) and female gender (OR 2.92, CI 1.50-6.03, P = 0.002) remained significant predictors of DI development. Gross total resection was no longer a significant predictor of DI in the multivariable model (OR 1.86, CI 0.99-3.71, P = 0.063), suggesting that this variable may be confounded by other factors. CONCLUSIONS: The independent risk factors for the development of transient DI were female and young patients.

Which biological pathways are responsible for the late appearance of brain metastases in renal cell carcinoma? Analysis of eight cases.

Background: Renal cell carcinoma (RCC) represents 1% of all cancers and its brain metastases amount to 8.1% of all metastatic tumors. Late brain metastases are defined as tumors that appear 10 years after diagnosis of the primary lesion. The objective of this work is to discuss which biological pathways are responsible for the late appearance of these metastases analyzing eight cases. Case Description: We report here eight cases of late brain metastases of RCC treated between 2018 and 2021. Patients consulted for different clinical complaints. Brain magnetic resonance imaging and computed tomography scan were performed on all patients. They were treated by complete surgical resection plus radiosurgery or by radiosurgery alone. The histology of most metastases showed clear cell RCC. Conclusion: In the presence of a patient with an intracranial tumor and a history of RCC with more than 10 years of evolution, the presence of late metastasis should always be considered. There are many theories described in the literature that try to explain the late appearance of brain metastases from RCC (low mitotic index, impaired immune system, cross talk, self-seeding, and among others).

Effects of time to chemoradiation on high-grade gliomas from the Buenos Aires Metropolitan Area.

High-Grade Gliomas (HGG) are the most frequent brain tumor in adults. The gold standard of clinical care recommends beginning chemoradiation within 6 weeks of surgery. Disparities in access to healthcare in Argentina are notorious, often leading to treatment delays. We conducted this retrospective study to evaluate if time to chemoradiation after surgery is correlated with progression-free survival (PFS). Our study included clinical cases with a histological diagnosis of Glioblastoma (GBM), Anaplastic Astrocytoma (AA) or High-Grade Glioma (HGG) in patients over 18 years of age from 2014 to 2020. We collected data on clinical presentation, type of resection, time to surgery, time to chemoradiation, location within the Buenos Aires Metropolitan Area (BAMA) and type of health insurance. We found 63 patients that fit our inclusion criteria, including 26 (41.3%) females and 37 (58.7%) males. Their median age was 54 years old (19-86). Maximal safe resection was achieved in 49.2% (n = 31) of the patients, incomplete resection in 34.9% (n = 22) and the other 15.9% (n = 10) received a biopsy, but no resection. The type of health care insurance was almost evenly divided, with 55.6% (n = 35) of the patients having public vs. 44.4% (n = 28) having private health insurance. Median time to chemoradiation after surgery was 8 (CI 6.68-9.9) weeks for the global population. When we ordered the patients PFS by time to chemoradiation we found that there was a statistically significant effect of time to chemoradiation on patient PFS. Patients had a PFS of 10 months (p = 0.014) (CI 6.89-13.10) when they received chemoradiation <5 weeks vs a PFS of 7 months (CI 4.93-9.06) when they received chemoradiation between 5 to 8 weeks and a PFS of 4 months (CI 3.76-4.26 HR 2.18 p = 0.006) when they received chemoradiation >8 weeks after surgery. Also, our univariate and multivariate analysis found that temporal lobe location (p = 0.03), GMB histology (p = 0.02) and biopsy as surgical intervention (p = 0.02) all had a statistically significant effect on patient PFS. Thus, time to chemoradiation is an important factor in patient PFS. Our data show that although an increase in HGG severity contributes to a decrease in patient PFS, there is also a large effect of time to chemoradiation. Our results suggest that we can improve patient PFS by making access to healthcare in Buenos Aires more equitable by reducing the average time to chemoradiation following tumor resection.

Psicoprofilaxis quirúrgica en neurocirugía: experiencia en el Hospital de Clínicas "José de San Martín" / Surgical psychoprophylaxis in neurosurgery: experience in the Hospital de Clínicas "José de San Martín"

Introducción: El presente estudio busca evaluar el rol del psicólogo en una unidad de neurocirugía a través de la psicoprofilaxis quirúrgica, una psicoterapia breve diseñada para el paciente quirúrgico durante su internación. Objetivo: Describir y analizar el trabajo realizado sobre psicoprofilaxis quirúrgica durante 8 años en la División Neurocirugía del Hospital de Clínicas José de San Martín de la Ciudad de Buenos Aires. Método: Se utilizó un protocolo de asistencia psicoterapéutica que consta de entrevistas clínicas al paciente y su familia durante la internación, asistencia del psicoterapeuta al pase de sala matinal diario, confección periódica de escalas de ansiedad, depresión y tests cognitivos, entrevistas con la familia por separado del paciente y reuniones informativas junto al equipo tratante y la familia. Se tomaron como parámetros de evaluación a la ansiedad, la depresión, la comunicación de la información, los miedos universales y la opinión de los pacientes sobre la utilidad de la misma. Resultados: Entre los años 2010 y 2018 recibieron psicoprofilaxis quirúrgica 1517 pacientes, todos ellos intervenidos quirúrgicamente por diferentes patologías. El 50% de los pacientes reportaban síntomas de ansiedad antes de la cirugía, dichos síntomas disminuyeron en un 83% después de la intervención psicológica. Lo mismo sucedió con los síntomas de depresión, del 36% del reporte inicial, un 52% mostró mejoría en sus síntomas después de recibir la psicoterapia durante la internación. En cuanto a la comunicación de la información y el tratamiento de los miedos básicos universales, el 84% de los pacientes pudieron recibir la información de forma pausada, con el tiempo suficiente para procesarla y acomodarla sumado al espacio de escucha a sus miedos universales, facilitando su procesamiento. El 82% de los pacientes asistidos calificaron como positiva la presencia de un profesional de la psicología durante la internación. Conclusión: El balance positivo entre los parámetros objetivos (ansiedad y depresión) y los subjetivos (comunicación de la información, miedos y opinión del paciente) muestran la utilidad de la presencia de un profesional de la psicología en un servicio de neurocirugía hospitalaria de alta complejidad.

Introduction: The present study evaluated the role of a psychologist in a neurosurgery unit practicing surgical psycho-prophylaxis, a brief psychotherapy intervention designed for surgical patients during hospitalization. Objective: To describe and analyze the usefulness of surgical psycho-prophylaxis over eight years in the Neurosurgery Division at Hospital de Clínicas José de San Martín. Method: A protocol of psychotherapeutic assistance was used, consisting of clinical interviews with patients and their families during hospitalization, assisting during morning rounds, evaluating patients anxiety and depression using standardized scales, cognitive testing, and arranging information meetings between the treatment team and patients' families. Evaluated parameters were anxiety, depression, how well information is communicated and universal fears addressed, and patients' opinions about the intervention's usefulness. Results: Between 2010 and 2018, 1517 patients received surgical psycho-prophylaxis, all of whom underwent surgery for different pathologies. Fifty percent of these patients reported symptoms of anxiety before surgery, which decreased by 83% post psychological intervention. Much the same transpired with symptoms of depression initially reported by 36% and improved in 52% after psychotherapy during hospitalization. Regarding information communication, 84% of patients were able to receive the information slowly, with enough time to process and accommodate it, in addition to affording them ears to hear their fears, facilitating their processing. Overall, 82% of the patients rated the presence of a psychology professional during hospitalization positively. Conclusion: Addressing both clinical parameters like anxiety and depression, and subtler parameters like the communication of information, and patients' fears and opinions, the presence of a psychology professional in the neurosurgery unit of a tertiary-care hospital was found to be both useful and appreciated by patients.

Hematoma cerebeloso a distancia / Far away cerebellar hematoma

Objetivo. Describir dos casos de hematoma cerebeloso después de cirugía supratentorial: un hematoma subdural (caso 1) y un higroma subdural (caso 2). Material y método. Análisis de las historias clínicas e imágenes de dos pacientes evaluadas en el Hospital de Clínicas y en el Hospital Español en 2009. Resultados. Caso 1: Paciente masculino de 70 años, con hemiparesia izquierda y lúcido que después de la evacuación de un hematoma subdural sufrió una hemorragia sobre las folias cerebelosas y presentó hematoma vermiano de 2,5 cm a las 72 horas de la cirugía. La evolución fue desfavorable con un súbito déficit neurológico e insuficiencia cardiorrespiratoria. Caso 2: Paciente femenino de 40 años, con un hematoma vermiano asintomático de 1 cm encontrado en la TAC de control a las 72 horas de la cirugía. Evoluciónsin déficit neurológico. Conclusión. La cirugía supratentorial con pérdida abundante de LCR sería el factor más importante de esta complicación. Elhiperdrenaje de LCR produce relajación del cerebelo con la consiguiente tracción y rotura de las venas puente que van a la tienda, provocando hematomas subdurales e infartos venosos hemorrágicos del cerebelo. Estos dos casos reportados fueron operados sin drenaje subdural aspirativo con pérdida abundante de LCR durante 72 y 48 horas respectivamente, que es el patrón etiológico más frecuente según la mayoría de los autores.

Metástasis de calota / Calvarial metastasis

Objective. To describe five cases of cranial vault metastasis. Materials and methods. Clinical records and images of five patients with cranial vault metastasis were reviewed at the “Hospital de Clinicas” and “Hospital Español” from Buenos Aires, between January 2009 to June 2010. Results. Case 1, 63 years old female, complains for headache with aleatory response to medical therapy; MRI: right occipital bone lession; Pathological Finding: breast carcinoma metastasis. Case 2, 70 years old female, complains for palpable lession of the scalp; MRI: right fronto-parietal intraxial lession and right parietal cranial vault lession; Pathological Finding: endometrial carcinoma metastasis (primary, diagnosed 4 months before). Case 3, 76 years old female, with palpable lession in the scalp; MRI: left parietal cranial vault lesion. Pathological Finding: kidney carcinoma metastasis (primary, diagnosed in 2008). Case 4, 50 years old female and Case 5, 78 years old male, both complains for bone pain; serological findings and marrow bone biopsy compatible with multiplemyeloma; screening of the long bones and cranial vault demonstrate evidence of bone infiltration. Conclusion. Metastasis at the cranial vault often presents with headache or pain upon inspection of a palpable scalp lession. Images of the CNS involves CT scan (delimitate lession and differentiates litic from blastic metastasis) and MRI (shows the degree of dural and brain infiltration). Prevalence of cranial vault metastasis is greater than brain metastasis, but this underdiagnosis is due that the first are frequently course without symptoms.

Hematoma cerebeloso a distancia / Far away cerebellar hematoma

Objetivo. Describir dos casos de hematoma cerebeloso después de cirugía supratentorial: un hematoma subdural (caso 1) y un higroma subdural (caso 2). Material y método. Análisis de las historias clínicas e imágenes de dos pacientes evaluadas en el Hospital de Clínicas y en el Hospital Español en 2009. Resultados. Caso 1: Paciente masculino de 70 años, con hemiparesia izquierda y lúcido que después de la evacuación de un hematoma subdural sufrió una hemorragia sobre las folias cerebelosas y presentó hematoma vermiano de 2,5 cm a las 72 horas de la cirugía. La evolución fue desfavorable con un súbito déficit neurológico e insuficiencia cardiorrespiratoria. Caso 2: Paciente femenino de 40 años, con un hematoma vermiano asintomático de 1 cm encontrado en la TAC de control a las 72 horas de la cirugía. Evoluciónsin déficit neurológico. Conclusión. La cirugía supratentorial con pérdida abundante de LCR sería el factor más importante de esta complicación. Elhiperdrenaje de LCR produce relajación del cerebelo con la consiguiente tracción y rotura de las venas puente que van a la tienda, provocando hematomas subdurales e infartos venosos hemorrágicos del cerebelo. Estos dos casos reportados fueron operados sin drenaje subdural aspirativo con pérdida abundante de LCR durante 72 y 48 horas respectivamente, que es el patrón etiológico más frecuente según la mayoría de los autores.(AU)

Metástasis de calota / Calvarial metastasis

Objective. To describe five cases of cranial vault metastasis. Materials and methods. Clinical records and images of five patients with cranial vault metastasis were reviewed at the ¶Hospital de Clinicas÷ and ¶Hospital Español÷ from Buenos Aires, between January 2009 to June 2010. Results. Case 1, 63 years old female, complains for headache with aleatory response to medical therapy; MRI: right occipital bone lession; Pathological Finding: breast carcinoma metastasis. Case 2, 70 years old female, complains for palpable lession of the scalp; MRI: right fronto-parietal intraxial lession and right parietal cranial vault lession; Pathological Finding: endometrial carcinoma metastasis (primary, diagnosed 4 months before). Case 3, 76 years old female, with palpable lession in the scalp; MRI: left parietal cranial vault lesion. Pathological Finding: kidney carcinoma metastasis (primary, diagnosed in 2008). Case 4, 50 years old female and Case 5, 78 years old male, both complains for bone pain; serological findings and marrow bone biopsy compatible with multiplemyeloma; screening of the long bones and cranial vault demonstrate evidence of bone infiltration. Conclusion. Metastasis at the cranial vault often presents with headache or pain upon inspection of a palpable scalp lession. Images of the CNS involves CT scan (delimitate lession and differentiates litic from blastic metastasis) and MRI (shows the degree of dural and brain infiltration). Prevalence of cranial vault metastasis is greater than brain metastasis, but this underdiagnosis is due that the first are frequently course without symptoms.(AU)

Diagnóstico diferencial en patología tumoral de la base de cráneo anterior / Differential diagnosis in tumor pathology of the anterior skull base

Objective. To describe a series of tumoral lesions of the anterior fossa that were treated at the Hospital de Clinicas during a determined lapse of time.Material and Methods. We evaluated the image archive and medical charts of all the patients operated on between January 2005 and May 2009 at the Neurosurgery Division of the Hospital de Clínicas. Results. From a total of 142 surgeries for expansive supratentorial lessions, 19 were for lessions of the anterior skull base (n=19) of which 7 were meningiomas (36%); four patients with gliomas (21%); one with GBM (5%); one with astrocitoma (5%); two with oligodendroglioma (10%); three patients presented tumors of the paranasal sinuses (15%); two had mucoceles (10%); one with squamous cell carcinoma (5%); three with orbital tumors; one with fibrous bone dysplasia (5%) and one with metastasis of a meduloblastoma of the posterior fossa (5%). Conclusion. The most frequent pathology found at this site is the meningioma, and secondly, gliomas. The third in frequency are the paranasal sinus tumors whose most malignant pathology is the squamous cell carcinoma. Our findings are statistically correspondent to other large series in literature.

Diagnóstico diferencial en patología tumoral de la base de cráneo anterior / Differential diagnosis in tumor pathology of the anterior skull base

Objective. To describe a series of tumoral lesions of the anterior fossa that were treated at the Hospital de Clinicas during a determined lapse of time.Material and Methods. We evaluated the image archive and medical charts of all the patients operated on between January 2005 and May 2009 at the Neurosurgery Division of the Hospital de Clínicas. Results. From a total of 142 surgeries for expansive supratentorial lessions, 19 were for lessions of the anterior skull base (n=19) of which 7 were meningiomas (36%); four patients with gliomas (21%); one with GBM (5%); one with astrocitoma (5%); two with oligodendroglioma (10%); three patients presented tumors of the paranasal sinuses (15%); two had mucoceles (10%); one with squamous cell carcinoma (5%); three with orbital tumors; one with fibrous bone dysplasia (5%) and one with metastasis of a meduloblastoma of the posterior fossa (5%). Conclusion. The most frequent pathology found at this site is the meningioma, and secondly, gliomas. The third in frequency are the paranasal sinus tumors whose most malignant pathology is the squamous cell carcinoma. Our findings are statistically correspondent to other large series in literature.(AU)