Accidente cerebrovascular pediátrico secundario a displasia fibromuscular / Pediatric cerebrovascular accident secondary to fibromuscular dysplasia

Presentamos el caso de un varón de 13 años diagnosticado de displasia fibromuscular (DFM) por estudio angiográfico, con imagen “arrosariada” de la carótida interna, tras presentar 2 ictus isquémicos en 9 días. Se decidió tratamiento conservador con ácido acetilsalicílico en dosis antiagregantes. Veinte meses después, la evolución clínica es favorable, sin que haya presentado nuevos episodios. La DFM es una causa muy poco frecuente de ictus en la infancia. Se conoce poco acerca de su etiología. A pesar de tratarse de una entidad habitualmente asintomática, debemos pensar en su existencia ante ictus repetidos o no explicables por otra causa. Su pronóstico y tratamiento son controvertidos debido al escaso número de pacientes en edad pediátrica con esta enfermedad (AU)

We present the case of a 13 year-old patient diagnosed with fibromuscular dysplasia (FMD) by angiographic study, with “string of beads” image of internal carotid, after undergoing two ischemic strokes in nine days. Conservative treatment with acetylsalicylic acid at antiaggregant doses was decided. Twenty months later the clinical progress is favorable without presenting any new episodes. FMD is a very uncommon cause of stroke in childhood. Little is known about its etiology. In spite of it usually being an asymptomatic disease, it must be considered in cases of repeated or inexplicable strokes. Its prognosis and treatment is controversial, due to the limited number of pediatric patients with this pathology (AU)

[Pediatric cerebrovascular accident secondary to fibromuscular dysplasia]. / Accidente cerebrovascular pediátrico secundario a displasia fibromuscular.

We present the case of a 13 year-old patient diagnosed with fibromuscular dysplasia (FMD) by angiographic study, with "string of beads" image of internal carotid, after undergoing two ischemic strokes in nine days. Conservative treatment with acetylsalicylic acid at antiaggregant doses was decided. Twenty months later the clinical progress is favorable without presenting any new episodes. FMD is a very uncommon cause of stroke in childhood. Little is known about its etiology. In spite of it usually being an asymptomatic disease, it must be considered in cases of repeated or inexplicable strokes. Its prognosis and treatment is controversial, due to the limited number of pediatric patients with this pathology.

[Clinical and radiologic assessment of vertebroplasty]. / Valoración clínico-radiológica de las vertebroplastias.

INTRODUCTION: Percutaneous vertebroplasty consists of the injection of acrylic cement into weakened vertebral bodies to achieve pain relief and mechanical stability of the spine. OBJECTIVE: To evaluate the characteristics and effectiveness of the vertebroplasties performed at the Hospital Universitario Miguel Servet in Zaragoza. PATIENTS AND METHODS: This is a retrospective study of 147 vertebroplasties performed in 95 patients (60 women and 35 men; age range: 19 to 84 years). The oblique transpedicular approach, which achieves adequate cement injection with a single puncture, is currently used. A visual analogue scale (VAS) was used to evaluate pain before and after the procedure. RESULTS: The osseous lesion most often treated by vertebroplasty is fracture secondary to osteoporosis, accounting for 65% of the cases in this series, followed by hemangiomas (23%), and osteolytic metastases, traumatic fractures, lymphomas, and myelomas. Prior to vertebroplasty, the mean VAS score was 8.88 versus 2.78 after the treatment. Only 7.3% of the patients had symptomatic complications. CONCLUSION: Vertebroplasty is safe and efficacious; it is the treatment of choice for vertebral pain refractory to medication. It enables patients to return to their habitual lifestyle quickly and thus helps reduce hospital stays and costs.

Valoración clínico-radiológica de las vertebroplastias / Clinical and radiologic assessment of vertebroplasty

Introducción. La vertebroplastia percutánea consiste en la inyección de cemento acrílico en los cuerpos vertebrales debilitados, con el fin de obtener un efecto analgésico y la estabilización mecánica de la columna vertebral. Objetivo. Valorar las características y efectividad de las vertebroplastias realizadas en el Hospital Universitario Miguel Servet de Zaragoza. Pacientes y métodos. Se han estudiado, de forma retrospectiva, 147 vertebroplastias efectuadas entre 1994 y 2003, a 95 pacientes (60 mujeres y 35 hombres), con un rango de edad entre 19 y 84 años. La vía de abordaje utilizada actualmente es la transpedicular oblicua, que con una sola punción consigue una buena expansión del cemento dentro del cuerpo vertebral. Resultados. La lesión ósea más frecuentemente tratada con vertebroplastia es la fractura secundaria a osteoporosis, con un 65% de los casos, le sigue con un 23% los hemangiomas y, en menor proporción, las metástasis osteolíticas, fracturas traumáticas, linfomas y mielomas. Para valorar la reducción del dolor empleamos la escala analógica visual (VAS), pasando de un VAS previo a la vertebroplastia de 8,88 a un VAS de 2,78 después del tratamiento. Solamente el 7,4% de los pacientes tuvieron complicaciones sintomáticas. Conclusión. La vertebroplastia es un procedimiento seguro y eficaz, de elección en el tratamiento del dolor vertebral refractario a la medicación, que permite una rápida incorporación del paciente a su vida habitual y una reducción de los costes hospitalarios

Introduction. Percutaneous vertebroplasty consists of the injection of acrylic cement into weakened vertebral bodies to achieve pain relief and mechanical stability of the spine. Objective. To evaluate the characteristics and effectiveness of the vertebroplasties performed at the Hospital Universitario Miguel Servet in Zaragoza. Patients and methods. This is a retrospective study of 147 vertebroplasties performed in 95 patients (60 women and 35 men; age range: 19 to 84 years). The oblique transpedicular approach, which achieves adequate cement injection with a single puncture, is currently used. A visual analogue scale (VAS) was used to evaluate pain before and after the procedure. Results. The osseous lesion most often treated by vertebroplasty is fracture secondary to osteoporosis, accounting for 65% of the cases in this series, followed by hemangiomas (23%), and osteolytic metastases, traumatic fractures, lymphomas, and myelomas. Prior to vertebroplasty, the mean VAS score was 8.88 versus 2.78 after the treatment. Only 7.3% of the patients had symptomatic complications. Conclusion. Vertebroplasty is safe and efficacious; it is the treatment of choice for vertebral pain refractory to medication. It enables patients to return to their habitual lifestyle quickly and thus helps reduce hospital stays and costs

[Progression following the embolisation of 100 intracranial arteriovenous malformations]. / Evolución tras la embolización de 100 malformaciones arteriovenosas intracraneales.

INTRODUCTION: We analysed the characteristics, progression and outcomes observed following the embolisation of 100 intracranial arteriovenous malformations (AVM) that were performed in order to achieve complete obliteration of the AVM, the elimination of associated vascular risk factors and also to reduce their size with a view to increasing the effectiveness of later treatments. PATIENTS AND METHODS: The demographic and anatomical characteristics of 110 patients with AVM were analysed over a period of 13 years, and embolisation was performed in 100 of them. In all, 203 embolisation sessions were carried out with an average of 3 embolisations per patient. Of the 100 AVM that were embolised, 36 were AVM which were treated by embolisation with no later therapy, 48 required radiosurgery after the embolisation and the other 16 were submitted to surgery following the embolisation. The type of materials used included liquid adhesive embolic agents (Hystoacryl, Glubran), non-adhesive embolic agents (Onyx) and polyvinyl alcohol particles. Patients were examined clinically and arteriographically. RESULTS: Of the 100 AVM that were embolised, complete eradication was accomplished with just embolisation in 27 cases of AVM (27%). Of the 48 AVM in which radiosurgery was carried out at a later date, the average rate of obliteration was 78% and of the 16 AVM in which surgery was carried out some time later, the average rate of obliteration was 70%. Of the 100 AVM that were embolised, some residue remained in 16 cases. Embolisation eliminated most of the associated vascular risk factors, as can be seen by the fact that associated risk factors disappeared in 28 (65%) out of the 43 AVM with such factors. The morbidity and mortality rates with embolisation were 8% and 2%, respectively. CONCLUSIONS: Embolisation eliminated most of the vascular risk factors, with complete obliteration in 27 cases and size was satisfactorily reduced for later treatment; at the same time, morbidity and mortality rates were acceptable.

Evolución tras la embolización de 100 malformaciones arteriovenosas intracraneales / Progression following the embolisation of 100 intracranial arteriovenous malformations

Introducción. Analizamos las características, evolución y resultados tras la embolización de 100 malformaciones arteriovenosas (MAV) intracraneales con el objetivo de conseguir la obliteración completa de la MAV, la eliminación de los factores de riesgo vascular asociados y disminuir su tamaño para la efectividad de posteriores tratamientos. Pacientes y métodos. Analizamos las características demográficas y anatómicas de 110 pacientes portadores de MAV durante 13 años, y se realizó una embolización a 100de éstos. Se practicaron 203 sesiones de embolización con una media de 3 embolizaciones/paciente. De las 100 MAV embolizadas, hubo 36 MAV a las que sólo se realizó embolización sin otro tratamiento posterior, a 48 se les realizó radiocirugía postembolización y a los 16 restantes cirugía postembolización. El tipo del material usado fueron agentes embólicos líquidos adhesivos (Hystoacril, Glubran®), agentes embólicos no adhesivos (Onyx) y partículas de polivinil alcohol. Se revisó a los pacientes clínica y arteriográficamente. Resultados. De las 100 MAV embolizadas, hubo una erradicación completa con sólo embolización en 27 MAV (27%). De las48 MAV a las que se les realizó radiocirugía posterior, hubo una obliteración media del 78%. De las 16 MAV a las que se realizó cirugía posterior, hubo una obliteración media del 70%. De las 100MAV embolizadas, hubo 16 en las que quedaron restos. La embolización eliminó la mayoría de los factores de riesgo vascular asociados: de 43 MAV con factores de riesgo asociados, desaparecieron en 28 MAV (65%). Con la embolización se produjo una morbilidad del 8% y mortalidad del 2%. Conclusión. La embolización eliminó la mayoría de los factores de riesgo vascular, con una obliteración completa en 27 casos y se redujo el tamaño para posteriores tratamientos de manera satisfactoria, y todo ello con una morbimortalidad aceptable (AU)

Introduction. We analysed the characteristics, progression and outcomes observed following the embolisation of 100intracranial arteriovenous malformations (AVM) that were performed in order to achieve complete obliteration of the AVM, the elimination of associated vascular risk factors and also to reduce their size with a view to increasing the effectiveness of later treatments. Patients and methods. The demographic and anatomical characteristics of 110 patients with AVM were analysed over a period of 13 years, and embolisation was performed in 100 of them. In all, 203 embolisation sessions were carried out with an average of 3 embolisations per patient. Of the 100 AVM that were embolised, 36 were AVM which were treated by embolisation with no later therapy, 48 required radiosurgery after the embolisation and the other 16 were submitted to surgery following the embolisation. The type of materials used included liquid adhesive embolic agents (Hystoacryl, Glubran ®), non adhesiveembolic agents (Onyx) and polyvinyl alcohol particles. Patients were examined clinically and arteriographically. Results. Of the 100 AVM that were embolised, complete eradication was accomplished with just embolisation in 27 cases of AVM (27%). Of the 48 AVM in which radiosurgery was carried out at a later date, the average rate of obliteration was 78% and of the 16 AVM in which surgery was carried out some time later, the average rate of obliteration was 70%. Of the 100 AVM tha twere embolised, some residue remained in 16 cases. Embolisation eliminated most of the associated vascular risk factors, as can be seen by the fact that associated risk factors disappeared in 28 (65%) out of the 43 AVM with such factors. The morbidity and mortality rates with embolisation were 8% and 2%, respectively. Conclusions. Embolisation eliminated most of the vascular risk factors, with complete obliteration in 27 cases and size was satisfactorily reduced for later treatment; at the same time, morbidity and mortality rates were acceptable (AU)

[A clinico radiological study of patients with cavernous angiomas of the spinal cord]. / Estudio clinicorradiológico de pacientes con angiomas cavernosos medulares.

AIM: To define the spectrum of signs, symptoms and radiological features in patients with spinal intramedullary cavernous angioma. We analyze surgical management and clinical follow up in these patients. PATIENTS AND METHODS: 16 adult patients, 9 women and 7 men, were studied in our hospital each with one cavernous angioma of the spinal cord. All patients were diagnosed with magnetic resonance imaging. The lesion location was intramedullary in all patients, 6 patients cervical level and 10 thoracic level. RESULTS: In 12 patients surgical resection of the malformation was performed and histological results confirmed the spinal cavernous diagnostic. In 10 patients, the clinical outcome had improved in Frankel grade. In the four nonoperated cases, successive monitoring studies demonstrated no radiological progression and the clinical symptomatology has remained stable. CONCLUSION: Women in the fertile period appear to be predisposed to develop spinal cavernous angioma. The bleeding risk, in our study, didn t have any relation with CMA level. Magnetic resonance imaging features cannot predict the CMA evolution.

Estudio clinicorradiológico de pacientes con angiomas cavernosos medulares / A clinico-radiological study of patients with cavernous angiomas of the spinal cord

Objetivos. El propósito de este estudio es definir el espectro de síntomas y signos clínicos junto con los hallazgos radiológicos que se presentan en pacientes con cavernomas intramedulares (ACM); se analiza el tratamiento y la evolución clínica en estos pacientes. Pacientes y métodos. Presentamos 16 casos de pacientes, nueve mujeres y siete hombres, con ACM únicos estudiados en nuestro hospital clínicamente, y que se diagnosticaron radiológicamente mediante una resonancia magnética (RM) medular. La localización de las lesiones era en todos los casos intramedular, en seis pacientes en la región cervical, y en 10, en la dorsal. Resultados. Fueron intervenidos 12 de los pacientes. En ellos, se resecó la lesión y se comprobó anatomopatológicamente el diagnóstico de presunción. En cuanto a la evolución clínica posquirúrgica, en 10 mejoró su estado, según la escala de valoración de Frankel. Se ha controlado la evolución de los otros cuatro pacientes, no operados por rechazo voluntario de la intervención, y no se han presentado modificaciones clínicas o radiológicas reseñables. Conclusiones. Encontramos esta patología con mayor frecuencia en mujeres, con inicio de la sintomatología en la edad fértil de la vida. No observamos en nuestra serie una predilección de localización en cuanto al riesgo de sangrado. No hay un patrón de RM claro de predicción evolutiva de los ACM (AU)

Aim. To define the spectrum of signs, symptoms and radiological features in patients with spinal intramedullary cavernous angioma. We analyze surgical management and clinical follow-up in these patients. Patients and methods. 16 adult patients, 9 women and 7 men, were studied in our hospital each with one cavernous angioma of the spinal cord. All patients were diagnosed with magnetic resonance imaging. The lesion location was intramedullary in all patients, 6 patients cervical level and 10 thoracic level. Results. In 12 patients surgical resection of the malformation was performed and histological results confirmed the spinal cavernous diagnostic. In 10 patients, the clinical outcome had improved in Frankel grade. In the four nonoperated cases, successive monitoring studies demonstrated no radiological progression and the clinical symptomatology has remained stable. Conclusion. Women in the fertile period appear to be predisposed to develop spinal cavernous angioma. The bleeding risk, in our study, didn’t have any relation with CMA level. Magnetic resonance imaging features cannot predict the CMA evolution (AU)

[Selective ophthalmic artery fibrinolysis in acute central retinal artery occlusion]. / Fibrinolisis selectiva de arteria oftálmica en la oclusión aguda de la arteria central de la retina.

PURPOSE: To evaluate efficacy and reliability of local intra-arterial fibrinolysis (LIF) in Retinal Central Artery Occlusion (RCAO). MATERIAL AND METHOD: We have studied 12 patients with RCAO. Seven patients (group I) were treated with conventional therapy and 5 patients (group II) underwent treatment with urokinase via transcutaneous femoral catheter into the ophthalmic artery. Thereafter patients received heparin sulfate for 3 days. RESULTS: Mean follow up was 14 months and mean time from onset of symptoms to the beginning of therapy was 11 hours. One patient in group I showed improvement of visual acuity (from counting fingers to 0.1). In all patients in group II there was angiographic evidence of improved perfusion of retinal arteries and 4 patients (80%) showed improvement in visual acuity. The best results were obtained when LIF was performed before 10 hours after onset of symptoms. No complications were observed after the fibrinolysis treatment. CONCLUSION: LIF in ophtalmic arteries for the treatment of RCAO reduces dosage of fibrinolytic agents and becomes a safe and useful treatment during the first hours post RCAO.

Fibrinolisis selectiva de arteria oftálmica en la oclusión aguda de la arteria central de la retina / Selective ophthalmic artery fibrinolysis in acute central retinal artery occlusion

Objetivo: Evaluar la eficacia y seguridad de la fibrinolisis local intrarterial (FLI) en la oclusión aguda de la arteria central de la retina (OACR).Material y métodos: Estudiamos 12 pacientes con OACR clasificados en dos grupos. El grupo I (7 pacientes) recibió un tratamiento conservador. El tratamiento del grupo II (5 pacientes) consistió en la infusión de urokinasa intrarterial, mediante la colocación de un microcateter en la arteria oftálmica por vía transcutánea femoral, seguida de heparinización durante 3 días. Resultados: La media de seguimiento fue de 14 meses. El período de latencia medio entre el inicio de la clínica y el tratamiento fue de 11 horas. En el grupo I sólo un paciente mejoró su agudeza visual de contar dedos a 0,1. En el grupo II se observó la perfusión del árbol retiniano en todos los pacientes y mejoró la AV de 4 de ellos (80 por ciento). Esta mejoría fue mayor en los pacientes con una evolución menor de 10 horas. No se observaron complicaciones postfibrinolisis. Conclusiones: La FLI en la arteria oftálmica, permite reducir la dosis de fibrinolítico en el tratamiento de la oclusión aguda de la arteria central de la retina. Esto hace que sea una técnica segura y eficaz si se realiza en las primeras horas del cuadro (AU)

[The contribution of an intraarterial electroencephalographic study in patients with deep epileptogenic foci]. / Aportación del estudio electroencefalográfico intrarterial en pacientes con focos epileptógenos profundos.

OBJECTIVES: To evaluate the diagnostic efficacy of an intra-arterial electroencephalographic recording and determine which patients obtain most benefit from this technique, to compare the results obtained using other recording techniques and to establish a standard for recording. PATIENTS AND METHODS: We made 64 intra-arterial recordings in 30 patients from one of three groups: persons with drug-resistant temporal epilepsy; patients with epileptic seizures of any type who required cerebral arteriography and patients whose illness required selective anteriography for any reason. We used a Seeker 10 guide-wire, the end of which acted as an electrode and a 2 minute recording was made. The position of the electrode varied depending on the site of the patients disorder. Activity was simultaneously measured with surface electrodes. Using the chi squared non-parametric test, we analysed the efficacy of the test. The paired t test was used to establish the concordance between observers. We compared the results obtained from the intra-arterial EEG with the simultaneous surface recording. RESULTS: We found three types of electroencephalographic patterns. The commonest was defined by the presence of high-voltage multi-spiked acute waves. The sensitivity of the test was 93.33%, the specificity was 80% and the overall value of the test was 86.66%. The chi squared test showed its reliability in the diagnosis of deep epileptogenic foci. There was high concordance between the observers in the study. No complications were seen in the patients in this study. CONCLUSION: The intra-arterial EEG recording is a semiinvasive test which may be useful in a selected group of patients and has high sensitivity and specificity.

Aportación del estudio electroencefalográfico intrarterial en pacientes con focos epileptógenos profundos / The contribution of an intra-arterial electroencephalographic study in patients with deep epileptogenic foci

Objetivos. Valorar la eficacia diagnóstica del registro electroencefalográfico intrarterial y conocer qué pacientes se benefician más de esta técnica; comparar los resultados obtenidos con los de otras técnicas de registro y establecer una pauta de registro. Pacientes y métodos. Se realizan 64 registros intrarteriales en 30 pacientes pertenecientes a uno de estos tres grupos: individuos con epilepsia temporal resistente a farmacoterapia; enfermos con crisis epilépticas de cualquier tipo que requieran arteriografía cerebral, y pacientes cuya dolencia precise la realización de arteriografía selectiva por cualquier motivo. Se emplea una guía Seeker 10, cuyo extremo distal se comporta como electrodo, y se realiza un registro de 2 minutos de duración. La situación del electrodo varía según la localización de la enfermedad del paciente. Simultáneamente se registra la actividad con electrodos superficiales. Mediante la prueba no paramétrica de la ji al cuadrado, se analiza la eficacia de la prueba y, con el test de la t pareada, la concordancia entre observadores. Se comparan los resultados obtenidos a través del EEG intrarterial y el registro de superficie simultáneo. Resultados. Se han encontrado tres tipos de patrones electroencefalográficos, el más frecuente de los cuales es el definido por la existencia de ondas agudas hipervoltadas y polipuntas. La sensibilidad de la prueba fue del 93,33 por ciento, la especificidad del 80 por ciento y el valor global de la prueba del 86,66 por ciento. La prueba de la ji al cuadrado demostró su fiabilidad en el diagnóstico de focos epileptógenos profundos. La concordancia entre observadores fue elevada. No se han descrito complicaciones en los pacientes de la muestra. Conclusión. El registro EEG intrarterial es una prueba diagnóstica seminvasiva que puede ser útil en un grupo seleccionado de pacientes y que presenta sensibilidad y especificidad elevadas (AU)

Neurological impairment in alpha-mannosidosis: a longitudinal clinical and MRI study of a brother and sister.

Neurological development over a period of 25 years and MRI findings are reported in two members of the same family affected by mannosidosis type II. Progressive axial and appendicular cerebellar syndrome, moderate hearing loss and deterioration of gait were present in both patients. Neuropsychological deficiency was severe, but progression over the years was not observed except in the woman's speech capacity. Neither of the patients showed clinical improvement. A progressive corticosubcortical atrophy stands out in the brain neuroimaging studies, especially at the vermian cerebellar level. The osseous cranial deformities are very characteristic and include brachycephaly, thickening of the calvaria at the expense of the diploe, and poor pneumatization of the sphenoid. Neither of our cases showed an empty sella turcica.

[Preoperative percutaneous++ vertebroplasty in hemangioma compression]. / Vertebroplastia percutánea preoperatoria en hemangioma compresivo.

INTRODUCTION: Vertebroplasty is a new procedure used in interventional neuroradiology, involving percutaneous introduction of acrylic cement. CLINICAL CASE: We present the case of a D10 vertebral hemangioma, which had progressed so as to cause compression of the spinal cord. We used combined treatment. Vertebroplasty was done with acrylic cement, using transpedicular percutaneous puncture, with subsequent bilateral laminectomy to decompress the spinal cord. One year later the clinical condition is completely satisfactory. The signs of paraparesia and dorsalgia have disappeared. Posterior fixation was not necessary. CONCLUSIONS: Vertebroplasty is effective since the vertebral body is consolidated and pain avoided. We give details of the methodology, indications and possible complications of the technique of percutaneous vertebroplasty.

Technical Aspects of Intra-arterial Electroencephalogram Recording.

SUMMARY: The purpose of this prospective study is to show a technique for recording electroencephalographic activity via an endovascular approach in presurgical evaluation of epileptic patients. Technical aspects and insertion strategy are outlined. Advantages of intra-arterial electroencephalography have been demonstrated. It is a semi-invasive procedure that provides information in temporal lobe and extratemporal epilepsy. It allows a dynamic electroencephalographic recording and patient tolerance is excellent. Risks are practically absent. Disadvantages are: in comparison to ovale electrodes, chronic and multicontact recording is not possible and the recording is only intercritical.

[Wegener's granulomatosis with meningeal involvement: clinic-radiological correlations]. / Granulomatosis de Wegener con afectación meníngea: correlación clinicorradiológica.

INTRODUCTION: Wegener's granulomatosis is a systemic vasculitis which, in its classical form, is characterized by involvement of the superior and inferior respiratory tract and the kidneys. The vasculitis may be multisystemic. Ophthalmic and neurological involvement are common (22% and 54% of those affected respectively). When considering involvement of the nervous system, the commonest finding is peripheral neuropathy, particularly in the form of multiple mononeuritis. Meningeal involvement is exceptional. CLINICAL CASE AND CONCLUSIONS: We present a case of Wegener's granulomatosis with meningeal involvement, studied using CT and MR. The findings using imaging techniques are described, and conditions which should be considered in the differential diagnosis are discussed.

[Spontaneous intracranial hypotension: findings of cerebral NMR]. / Hipotensión intracraneal espontánea: hallazgos en RMN cerebral.

INTRODUCTION: The intracranial hypotension syndrome is characterized by a cerebrospinal fluid (CSF) pressure of less than 60 mmH2O and presents as postural hypotension which is often accompanied by nausea, vomiting, cervicalgia and some degree of neck rigidity. It is considered to be spontaneous when there is no known precipitating factor. It is believed that there is a CSF leak across the subarachnoid space, although it is not always possible to detect this. In recent years several authors have described different pathological findings on magnetic resonance (MR) studies. CLINICAL CASE: We present the radiological studies of a patient with clinical evidence of headache which was worse on standing and improved when lying down. The outflow pressure of CSF was 6 mmH2O when lying down. On isotopic cisternography using Tc DTPA-99m there was no detectable CSF leak. On cerebral MR there was diffuse pachymeningeal thickening with increased signals in T1 sequences. This was more pronounced in T2 with lineal dural uptake of contrast at infra and supratentorial levels. The brain stem meninges were intact. In parallel with a favorable clinical course, following clinical resolution the radiological images were seen to have returned to normal. CONCLUSIONS: Radiological findings, together with a compatible clinical condition, help to establish the diagnosis of spontaneous intracranial hypotension and avoids the use of unnecessary clinical investigations.

[Idiopathic hypophyseal hyperplasia: diagnosis by magnetic resonance]. / Hiperplasia hipofisaria idiopática: diagnóstico por resonancia magnética.

INTRODUCTION: Hypophyseal hyperplasia is an uncommon disorder in which the gland increase in size due to excessive proliferation of strings of normal cells, which usually secrete prolactin. Different aetiologies may cause this disorder of the hypophyseal gland. However, in a small number of cases the hyperplasia is not due to any of these aetiologies and is therefore known as idiopathic hypophyseal hyperplasia. There are few references in the literature to idiopathic hypophyseal hyperplasia with hyperprolactinaemia. Usually diagnosis is reached after treatment for a hypophyseal adenoma, since the clinical features are similar. CLINICAL CASES: We present three cases seen in our department, in which hormone and endocrine studies were done to exclude known causes of hyperplasia, together with CT and MR scans. We analyzed the behaviour of hypophyseal hyperplasia by using imaging techniques, and the differential aspects with regard to hypophyseal adenomas. Firm diagnosis is only made on anatomopathological study of the hypophysis. However, we consider that sound knowledge of the characteristics of this condition may help to establish the correct diagnosis and thus avoid unnecessary surgery. CONCLUSIONS: We review the information published in the literature on this subject, emphasizing the importance of differential diagnosis by means of imaging techniques.

[Epilepsy as the first sign of multiple sclerosis]. / Epilepsia como primera manifestación de esclerosis múltiple.

INTRODUCTION: Epileptic crises are uncommon in patients with multiple sclerosis. However, epilepsy is commoner in these patients than in the general population. An epileptic crisis as the presenting feature of multiple sclerosis is even rarer. The lesions involved in the pathogenesis of these crises are plaques of demyelinization which affect the cortical or subcortical areas. Other factors, some of which are still not clearly understood, such as the fibre, electrolytic changes, size of the plaque, reactive gliosis and the enzyme (Na(+)-K+)ATPase, seem also to play a part in the production mechanism. Magnetic resonance is a very sensitive technique used in the detection of demyelinating lesions during the acute phase. The sensitivity is further increased by the use of gadolinium. CLINICAL CASES AND CONCLUSIONS: We present two cases of multiple sclerosis which presented as epileptic crises. In one there were generalized tonic-clonic crises and in the other partial sensitive crises. We mention the EEG findings, CSF analysis and neuroimaging diagnostic techniques.