Empiema epidural espinal. Análisis de 14 casos / Spinal epidural empiema. Analysis of 14 cases

Objetivos. Realizar un estudio sobre los casos de empiema epidural espinal atendidos en los últimos 20 años y practicar una revisión de la literatura sobre la patogenia, diagnóstico y tratamiento de estas lesiones. Pacientes y métodos. Se trata de un estudio retrospectivo descriptivo sobre 14 casos de empiemas epidurales espinales. Se analizaron las características epidemiológicas básicas, manifestaciones clínicas, datos analíticos, técnicas de diagnostico, actitudes terapéuticas usadas y los resultados obtenidos. Resultados. La serie esta formada por 7 varones y 7 mujeres con edades que oscilaron entre 8 y 76 años (media 48.9). En 12 casos el síntoma de presentación fue la presencia de dolor vertebral local, siempre en relación con la localización del empiema, siendo la duración media de la sintomatología de 9.3 días. La velocidad de sedimentación globular (VSG) estaba elevada en todos los casos y existía leucocitosis en trece paicentes (92,9%). En 11 casos (78,5%), la localización del empiema fue en la región dorsal. Trece pacientes fueron tratados mediante cirugía y uno recibió exclusivamente tratamiento antibiótico. Conclusiones: En paicentes con factores de riesgo (inmunosupresión, diabestes), la presencia de dolor espinal asociado a fiebre y alteraciones analíticas (leucocitosis / elevación de la VSG), deben ser con resonancia magnética espinal, ante el riesgo de desarrollar un empiema epidural. El tratamiento exclusivamente médico debe sólo reservarse para pacientes con elevado riesgo quirúrgico o que no presenten afectación neurológica (AU)

Objective. The goal of this study was to review our series of spinal epidural empiema diagnosed in the last 20 years and review the literatura regarding the pathogenesis, diagnosis and treatment of these lesions. Patints and methods. This is a retrospective study over 14 patients diagnosed of spinal epidural empyema. We review the epidemiological data, clinical symptoms, laboratory and imaging data, the treatment regimen and the results. Results. Fourteen patients, 7 males and 7 females, with an age range form 8 to 76 years (mean 48.9) were identified. The first symptom was localized back/neck pain in 12 patients and the mean duration of symptoms was 9.3 days. Erythrocyte sedimentation rate (ESR) was elevated in 13 cases (92,9%). Site of sipinal epidural empyemas was distributed along the axis but in 11 cases the location was thoracic. Thirteen patients had surgery for debridement and spinal decompression and one patient was treated successfully with antibiotics alone. Conclusions: Patients with localized back pain and fever who are at risk for developing such empyemas with elevation of white blood cells and increased ESR, should have an immediate magnetic resonance imaging sean. Urgent surgical drainage and antibiotic use are the treatment of choice in order to prevent irreversible neurological deficits. Nonsurgical treatment should be reserved for poor surgical candidates and patients without neurological deficits (AU)

[Acute spontaneous subdural haematoma of arterial origin]. / Hematoma subdural agudo espontáneo de origen arterial.

INTRODUCTION: An acute subdural hematoma is often regarded as a complication of head trauma. Occasionally subdural bleeding from the rupture of a cerebral aneurysm or an arteriovenous malformations is described. Spontaneous subdural hematoma is, however, very rare and it commonly has an arterial origin and their aetiology is still a matter of controversy. OBJECTIVE: The purpose of this paper is to present eight cases of spontaneous subdural hematoma seen at our department during the last 19 years. The etiological possibilities of spontaneous subdural hematoma are discussed. PATIENTS AND METHODS: We analyzed 8 cases of acute spontaneous subdural hematoma among a total number of 321 patients with subdural hematoma is presented. RESULTS: There were six males and 2 females with a mean age of 52 years (range 20-66). All patients developed progressive neurological deficits, until become comatose. All eight patients were operated on and surgical mortality was 25%. CONCLUSIONS: Spontaneous subdural hematoma is a rare condition and the prognosis is mainly dependent on the pre-operative neurological state regardless of its origin or cause.

[Atypical and malignant intracranial meningiomas]. / Meningiomas intracraneales atípicos y malignos.

INTRODUCTION: Meningiomas are one of the most common tumours of the central nervous system, with an incidence of 15% to 20% of all primary brain tumours. Meningiomas are generally slowly growing, benign tumours attached to the dura-mater and composed of neoplastic meningothelial cells. Most of meningiomas are benign and can be graded into WHO grade I. However certain histological subtypes are associated with a poor clinical outcome and correspond to WHO grades II and III. OBJECTIVE: To review the epidemiology, clinical, surgical, and histological aspects of multiple intracranial meningiomas. PATIENTS AND METHODS: The authors report 12 cases of malignant intracranial meningioma, consecutively operated on at our hospital between 1985-2002. All the patients were studied with CT and the last 9 with MRI. All patients showed no manifestations of von Recklinghausen disease. RESULTS: The age at diagnosis ranged from 39 to 87 (mean 64.3 years). There were 6 males and 6 females. The predominant site for the meningioma was the parasagittal region (5 cases), followed by the cerebral convexity (3 cases). All meningiomas were treated with surgical extirpation and in 8 cases the treatment was radiotherapy. The more common histological subtype was atypical meningiomas (5 cases). The median time survival was 48 months (range 16-168). CONCLUSIONS: Malignant meningiomas constitute 1% to 10% of all meningiomas. They affect men and women almost equally, in contrast, benign meningiomas are more commonly found in women. Complete surgical resection and administration of adjuvant irradiation following initial resection is crucial to long term control.

[Spinal epidural empyema. Analysis of 14 cases]. / Empiema epidual espinal. Análisis de 14 casos.

OBJECTIVE: The goal of this study was to review our series of spinal epidural empyema diagnosed in the last 20 years and review the literature regarding the pathogenesis, diagnosis and treatment of these lesions. PATIENTS AND METHODS: This is a retrospective study over 14 patients diagnosed of spinal epidural empyema. We review the epidemiological data, clinical symptoms, laboratory and imaging data, the treatment regimen and the results. RESULTS: Fourteen patients, 7 males and 7 females, with an age range from 8 to 76 years (mean 48.9) were identified. The first symptom was localized back/ neck pain in 12 patients and the mean duration of symptoms was 9.3 days. Erythrocyte sedimentation rate (ESR) was elevated in all patients; peripheral leukocyte count was elevated in 13 cases (92.9%). Site of spinal epidural empyemas was distributed along the axis but in 11 cases the location was thoracic. Thirteen patients had surgery for debridement and spinal decompression and one patient was treated successfully with antibiotics alone. CONCLUSIONS: Patients with localized back pain and fever who are at risk for developing such empyemas with elevation of white blood cells and increased ESR, should have an immediate magnetic resonance imaging sean. Urgent surgical drainage and antibiotic use are the treatment of choice in order to prevent irreversible neurological deficits. Nonsurgical treatment should be reserved for poor surgical candidates and patients without neurological deficits.

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[Multiple intracranial meningiomas]. / Meningiomas intracraneales múltiples.

AIMS: Multiple meningiomas is a condition in which the patient had more than one meningioma in several intracranial locations in the same patient without signs of neurofibromatosis. The incidence of multiple intracranial meningiomas varies from 1 to 10% in different series. In this article we report our experience with the diagnosis and treatment of multiple meningioma. PATIENTS AND METHODS: The authors report 13 cases of multiple intracranial meningioma, consecutively operated on at our hospital between 1983-2003. All the patients were studied with CT and the last 10 with MRI. In 8 patients all of the tumours were found at the first admission. In the other five the diagnosis was not established until years after removal of the first meningioma. All the patients showed no manifestations of von Recklinghausen disease. RESULTS: The overall average age at diagnosis was 53.3 years: 7 were females and 6 males. The predominant site for the meningioma was the parasagittal and falcine region, followed by the cerebral convexity. Thirty-two meningiomas were treated with surgical extirpation and in four cases the treatment was radiotherapy. CONCLUSIONS: Multiple meningiomas are not a specific disease entity and have no distinctive clinical, pathological or surgical features. Despite the multiplicity of sites, multiple meningiomas do not differ in prognosis from benign solitary meningiomas.

[Malignant fibrous histiocytoma of the duramater]. / Histiocitoma fibroso maligno de duramadre.

Malignant fibrous histiocytoma is the most common soft tissue sarcoma in adults with the majority of cases that occur in patients between 50-70 years and most of cases occurs in male. Seventy percent originate from extremities. Primary MFH involving the central nervous system is a rare occurrence with most cases originating from the dura or leptomeninges. A case of primary intracranial malignant fibrous histiocytoma in a 60-year-old man is presented. The tumor was successfully excised and the patient remained well at follow-up of 12 months. The clinical features of this case and the therapeutic prognosis of 24 cases reported previously in the literature were reviewed.

[De novo arachnoid cyst treated with a cystoperitoneal shunt]. / Quiste aracnoideo de novo tratado con derivación cistoperitoneal.

INTRODUCTION: Arachnoid cysts (AC) are benign pathological structures that are typically found during childhood, and represent approximately 1% of all intracranial lesions. Unlike cases of secondary cysts with a known causation, which can be attributed to inflammatory processes or traumatic brain injuries, the causation of the primary cysts is unknown. In the cases reported to date, the cysts present from the first imaging study conducted, which is why they are considered to be of a prenatal origin. CASE REPORT: A boy who, at the age of 5 months, is found to have an AC of considerable dimensions that did not appear in a transfontanellar echographic study carried out for other reasons at the age of 2 months. CONCLUSION: The importance of this case lies in the fact that it has been possible to show the appearance of a cyst after birth in a sequence of images in the case of a pathology which, according to all the theories and tests, is considered to have a congenital causation.

Histiocitoma fibroso maligno de duramadre / Malignant fibrous histiocytoma of the duramater

El histiocitoma fibroso maligno es el sarcoma de partes blandas más frecuente en el adulto, con una mayor incidencia entre los 40 y 60 años, afectando mayoritariamente a los varones. El 70 por ciento de los casos se sitúan en las extremidades. La localización intracraneal del HFM es muy poco frecuente y la mayoría de las veces se originan en la duramadre o las leptomeninges. Presentamos el caso clínico de un paciente de 60 años afecto de un histiocitoma fibroso maligno, originado en la duramadre craneal, que fue extirpado completamente, y con un seguimiento de 12 meses tras el diagnóstico. Realizamos una revisión de los 24 casos recogidos en la literatura y analizamos las características clínicas y terapéuticas. (AU)

Quiste aracnoideo de novo tratado con derivación cistoperitoneal / De novo arachnoid cyst treated with a cystoperitoneal shunt

Introducción. Los quistes aracnoideos (QA) son estructuras patológicas de características benignas típicas de la infancia, donde representa aproximadamente el 1 por ciento de las lesiones intracraneales. Si se excluyen los casos de quistes secundarios de etiología conocida, atribuibles a procesos inflamatorios o traumatismos craneoencefálicos, los quistes primarios son de etiología desconocida; en los casos presentados hasta ahora, los quistes se presentaban desde el primer estudio de imagen practicado, por lo que se les atribuía un origen prenatal. Caso clínico. Niño al que a los 5 meses de edad se le descubre un voluminoso QA que no se presentaba en una ecografía transfontanelar realizada, por otras causas, a los 2 meses de edad. Conclusión. La importancia de este caso radica en la posibilidad de demostrar en imágenes seriadas la aparición de un quiste después del nacimiento, en una patología a la que todas las teorías y pruebas atribuyen un origen congénito (AU)

[Chronic subdural hematoma in patients over 80 years of age]. / Hematoma subdural crónico en el paciente mayor de 80 años.

INTRODUCTION: Chronic subdural hematoma (CSH) represents one of the most frequent types of intracranial hemorrhage. Most occur in elderly patients causing a variety of therapeutic problems associated to systemic diseases. PATIENTS AND METHODS: A retrospective study of 90 patients older than 80 years of age with chronic subdural hematoma treated in the last 15 years was undertaken. For clinical evaluation on admission and at discharge we used the classification of Markwalder. Surgical treatment was performed in all patients and a burr hole craniostomy with closed drainage system was used. RESULTS: On admission, 73 patients (80%) were in satisfactory condition (grades 0-2); 17 (20%) were grade 3 or 4. Seven (7.7%) patients died but none due to surgery. In 6 (6.6%) of the patients, surgical reintervention was required to remove a recurring CSH. In 76.6% of the patients, the results achieved were graded 0 or 1. CONCLUSIONS: In our experience CSH in elderly patients should be treated with minimal surgery with a simple drainage of the subdural space. The good results suggest that the procedure could be considered as a first procedure in these patients and that age or concomitant diseases do not appear to be poor prognostic factors.

[Acute inter-hemispheric subdural hematoma]. / Hematoma subdural agudo interhemisférico.

Interhemispheric subdural hematoma in adults is a rare complication of head injury with no more than 100 cases reported since 1940. The classical presentation of this disorder is a contralateral monoparesis of the leg or a hemiparesis more pronounced in the leg. We report three cases of interhemispheric subdural hematoma following closed head injuries and the review of the literature with an analysis and of the therapeutic possibilities. Conservative management under close supervision may be a proper attitude in those patients without alterations of consciousness. Surgical treatment is necessary in patients with progressive deterioration.

Ependimomas intracraneales / Intracranial ependymomas

Introducción. Los ependimomas son tumores de origen ependimario que se localizan en las cavidades ventriculares y la médula espinal. Los ependimomas intracraneales representan entre el 2 y 6 por ciento de los tumores del sistema nervioso central y la mitad de ellos aparecen en las dos primeras décadas de la vida. Desarrollo. Realizamos una revisión sobre la epidemiología, clínica, hallazgos histopatológicos, diagnóstico neurorradiológico y tratamiento de los ependimomas intracraneales. Conclusiones. Los ependimomas infratentoriales son más frecuentes en niños mientras que los supratentoriales predominan en el adulto. Del análisis de la literatura se concluye que la cirugía radical es el tratamiento de elección en estos tumores. La supervivencia guarda relación con la extensión de la exéresis practicada, el grado histológico y la edad del paciente (AU)

[Choroid plexus tumors]. / Tumores de plexos coroideos.

INTRODUCTION AND OBJECTIVE: Tumors of the choroid plexus are rare tumors of neuro ectodermal origin, accounting for less 1% of intracranial tumors in all ages. Most cases present in children less than 2 years of age. These tumors have been classified according to histopathological criteria into papilloma and carcinoma. DEVELOPMENT: We review the epidemiological, clinical, neuropathological details, neuroradiological aspects and treatment of choroid plexus tumors. CONCLUSIONS: Choroid plexus tumors may present with overt intracranial hypertension with or without focal neurological signs. In the adult population, headaches are the most commonly encountered symptom. The CT characteristics of CPT are well characterized. On non enhanced studies the tumor appears as a smooth or lobulated mass, hyperdense in relation to surrounding brain parenchyma. With intravenous contrast, there is marked, homogeneous enhancement. With MRI these tumors showed an iso intensity in T1 weighted images and iso hypo intensity in T2 weighted images, with marked enhancement after gadolinium. The treatment of choice is total surgical excision with minimal damage to the surrounding neural elements. For carcinomas, adjuvant treatment in the form of chemotherapy supplemented by radiation therapy in older children.

Tumores de plexos coroideos / Choroid plexus tumors

Introducción. Los tumores de los plexos coroideos son neoplasias poco frecuentes de origen neuroectodérmico que representan menos del 1 por ciento de todos los tumores intracraneales. La mayoría se presentan en niños menores de 2 años. Histológicamente pueden ser de dos tipos: papilomas y carcinomas. Desarrollo. Revisamos la epidemiología, clínica, neuropatología, aspectos neurorradiologicos y tratamiento de los tumores de plexos coroideos. Conclusiones. Clínicamente se manifiestan con signos de hipertensión intracraneal que pueden acompañarse de signos de focalidad. En los adultos, la cefalea es el síntoma más frecuente. Las características tomodensitométricas son constantes, y se manifiestan como tumores hiperdensos, uniformes o lobulados que se realzan de forma importante con la administración de contraste. Con resonancia magnetica se manifiestan como isointensos en T1 e isohipointensos en T2, con un gran realce tras la admisnistración de gadolinio. El tratamiento de elección es la resección quirúrgica completa, procurando el mínimo daño en las estructuras adyacentes. En los carcinomas de plexos es preciso complementar el tratamiento con quimioterapia y radioterapia en los niños mayores de 3 años (AU)

[Intracranial ependymomas]. / Ependimomas intracraneales.

INTRODUCTION: Ependymomas are tumours derived from ependymal cells, found lining the cerebral ventricles and central canal of spinal cord. Intracranial ependymomas account for 2 6% of all neoplasms of the central nervous system and at least half present in the first two decades of life. DEVELOPMENT: We review the epidemiological, clinical, neuropathological details, neuroradiological aspects and treatment of intracranial ependymomas. CONCLUSIONS: Ependymomas of the posterior fossa predominate in children, while supratentorial tumours are more common in adults. This analysis of the literature further highlight that total tumour removal is the treatment of choice for intracranial ependymomas. Postoperative survival was predominantly dependent on the histological grade of malignancy, the extension of surgery and the age of the patient.

[Spinal meningiomas]. / Meningiomas espinales.

OBJECTIVE: Meningiomas account for 15 to 45% of spinal cord tumors. They are more frequent in females and have low recurrence rate due both to their low tendency for regrowth and to their prevalence in the aged population. METHODS: We reviewed retrospectively the clinical records of 37 patients operated on for spinal meningioma in our Neurosurgical Service from 1982 to 1998. Duration and type of symptoms, radiological and surgical results are analyzed. RESULTS: Our spinal meningiomas account for about 26% of all spinal cord tumors operated on during a 19-year period. They accounted for 11% of all meningiomas operated during the same period. We observed a higher prevalence in females between 50 to 70 years of age. Weakness and localized pain were the most common presenting symptoms. The tumors were located in the thoracic region in 33 patients and only one case was found to be completely extradural. All the patients were operated on by laminectomy and total removal was achieved in all cases. CONCLUSIONS: The use magnetic resonance to make an early diagnosis and microsurgical techniques appeared as the most relevant factors for further improvement of the surgical results.