Predictors of poor functional outcomes in adults with type I Chiari Malformation: Clinical and surgical factors assessed with the Chicago Chiari Outcome Scale over long-term follow-up.

OBJECTIVE: This study aimed to identify clinical and surgical features associated with poor long-term postoperative outcomes in patients diagnosed with Type I Chiari Malformation (CMI) treated with posterior fossa decompression with duroplasty (PFDD), with or without tonsillar coagulation. METHODS: This retrospective, single-center study included 107 adult patients with CMI surgically treated between 2010 and 2021. The surgical technique involved a midline suboccipital craniectomy, C1 laminectomy, durotomy, arachnoid dissection, duroplasty, and tonsillar coagulation until 2014, after which tonsillar coagulation was discontinued. Postoperative outcomes were assessed using the Chicago Chiari Outcome Scale (CCOS) at a median follow-up of 35 months. Clinical, surgical, and neuroimaging data were analyzed using the Wilcoxon signed-rank test, Cox regression analysis, and Kaplan-Meier survival curves to identify predictors of poor functional outcomes. RESULTS: Of the 107 patients (mean age 43.9 years, SD 13), 81 (75.5 %) showed functional improvement, 25 (23.4 %) remained unchanged, and 1 (0.9 %) experienced worsened outcomes. Cephalalgia, bilateral motor weakness, and bilateral paresthesia were the most frequent initial symptoms. Tonsillar coagulation was performed in 31 cases (28.9 %) but was clinically associated with higher rates of unfavorable outcomes. The Wilcoxon signed-rank test indicated that long-term follow-up CCOS was significantly higher than postoperative CCOS (Z = -7.678, p < 0.000). Multivariate Cox analysis identified preoperative bilateral motor weakness (HR 6.1, 95 % CI 1.9-18.9; p = 0.002), hydrocephalus (HR 3.01, 95 % CI 1.3-6.9; p = 0.008), and unilateral motor weakness (HR 2.99, 95 % CI 1.1-8.2; p = 0.033) as significant predictors of poor outcomes on a long-term follow-up. CONCLUSION: This study highlights the high rate of functional improvement in CMI patients following PFDD. Preoperative motor weakness and hydrocephalus were significant predictors of poor long-term outcomes. Tonsillar coagulation did not demonstrate a clear clinical benefit and may be associated with worse outcomes. Our findings suggest that careful preoperative assessment and selection of surgical techniques are crucial for optimizing patient outcomes.

Surgical treatment of pituitary neuroendocrine tumors with coexisting intracranial lesions: A case series and review of the literature.

Background: Pituitary neuroendocrine tumors (PitNETs) are a diverse group of benign neoplasms that account for a significant proportion of intracranial tumors (13%). The coexistence of PitNET with other intracranial lesions, such as meningiomas and intracranial aneurysms, has been constantly reported in the literature; yet, the pathophysiological mechanisms remain unknown, and the appropriate management is controversial. This study aims to describe the clinical characteristics, surgical treatment, and outcomes of patients with PitNET with coexisting intracranial lesions in a single healthcare center. Methods: A retrospective analysis was conducted on 12 patients who underwent surgical treatment for PitNET and another intracranial lesion at our single tertiary referral center over 15 years from January 2008 to May 2023. Results: Among these coexisting lesions, aneurysms were the most commonly found (41.67%), followed by meningiomas (33.33%). Surgical intervention for both lesions was performed in a single-stage procedure for most cases (75%), employing transcranial, endoscopic endonasal, and combined approaches. We found low preoperative Karnofsky Performance Scale scores in three patients, with significant differences in functional outcomes. Conclusion: These findings contribute to the limited knowledge about PitNET coexisting with other intracranial lesions and emphasize the importance of patient-tailored, multidisciplinary management in these unusual scenarios.

Poorly differentiated sinonasal neuroendocrine carcinoma with skull base invasion: A case report.

Background: Sinonasal neuroendocrine carcinoma is a rare head and neck tumor that represents only 5% of sinonasal neoplasms. This lesion has a high risk of invasion to adjacent structures such as the orbit, skull base, and soft tissues, with symptoms usually being nonspecific. Most cases are diagnosed in late stages, decreasing overall survival without treatment. To date, there is no consensus on management given its low prevalence; however, it has been shown that multimodal therapy, with the correct surgical approach as the mainstay, offers a better disease-free prognosis. Case Description: A 46-year-old woman presented with a 1 year history of nasal symptoms, characterized by obstruction and epistaxis. Imaging studies showed an extra-axial mass causing skull base erosion and displacement of the right fronto-orbital region, without invasion of brain parenchyma or meninges. A biopsy was performed and an unresectable poorly differentiated sinonasal neuroendocrine carcinoma was diagnosed. Treatment with radio and chemotherapy was initiated and, as the tumoral volume decreased, she was referred for neurosurgical intervention; an endonasal endoscopic approach was performed. Gross total resection was achieved and the patient was discharged without postoperative complications and no residual lesion on imaging. Conclusion: We describe the evolution of a rare advanced-stage neoplasm. It highlights that despite receiving an initial diagnosis of an unresectable mass, multimodal therapy, and an adequate surgical approach deemed the entire lesion to be resected. Despite the favorable clinical evolution, the follow-up of neuroendocrine carcinoma is prioritized as a neoplasm with a high rate of recurrence and metastasis.

Intra-aneurysmatic thrombectomy in a distal anterior cerebral artery aneurysm.

Thrombectomy procedures following intra-aneurysmatic lesions are extremely rare, and few cases have been reported. This article describes a microsurgical intra-aneurysmatic thrombectomy (MIaT) for a distal anterior cerebral artery (DACA) aneurysm. We present the case of a 48-year-old female that was admitted to the emergency room, showing neurologic deterioration with focal deficits. A computed tomography angiography (CTA) scan revealed an aneurysm located in the distal segment of the left anterior cerebral artery. During the surgical procedure, after clipping, a wellformed clot was visualized through the aneurysm's wall obstructing the left DACA flow. We proceeded to open the aneurysm's dome to remove the thrombus and clip the aneurysm neck, re-establishing the flow of the left DACA. Intra-aneurysmatic thrombosis can occur as a complication during clipping, obstructing the distal flow of vital arteries and causing fatal results in the patient's postoperative status. MIaT is a good technique for restoring the flow of the affected vessel and allows a secure aneurysm clipping after thrombus removal.

Motor outcome after resective surgery for the central lobe gliomas.

Background: Extent of resection (EOR) plays a major role in the prognosis on patients with gliomas, although the postoperative functionality of the patient is of great importance as well. It is why many surgeons advocate to not operate extensively on tumors that involve eloquent regions such as the central lobe. Recent series have demonstrated that it is possible to achieve extensive resections in this area without significantly affecting the functional outcome for these patients. We illustrate this issue with the experience obtained at the National Institute of Neurology and Neurosurgery in Mexico City. Methods: This is an observational and retrospective study that included patients that received surgical resection for intracranial gliomas that involved the central lobe at the National Institute of Neurology and Neurosurgery of Mexico, between January 2017 and May 2020. Demographic and clinical variables of the patients at the time of diagnosis were collected as well as tumor morphological variables, surgical adjuncts, and clinical outcomes. Statistical analysis was performed with SPSS software. Results: A total of 28 patients were included in the study with 43% of patients having a motor deficit before surgery. The average EOR was 88.6%. Patients presented with worsening of their motor status in the immediate postoperative period in 21% of the cases, although most of the patients recovered within the 1st month of follow-up. After analyzing all variables, not having a presurgical motor deficit was a statistically significant risk factor for developing a new motor deficit in the immediate postoperative period (P: 0.02). Conclusion: A resective surgery for gliomas near or within the central lobe can be performed safely and a satisfactory motor outcome for patients can be achieved without sacrificing the EOR. An intact presurgical motor status is a risk factor for developing a new deficit after surgery.

Endoport-assisted microsurgical treatment for a ruptured posterior cerebral artery aneurysm: A technical note.

Posterior Cerebral Artery aneurysms are scarce, yet its territory is frequently associated to large and giant aneurysms. Treatment is mostly a binary option between microsurgical clipping and endovascular coiling. Hybrid approaches are an option too, whereas innovation with less frequent techniques such as endoscope-controlled and endoscope-assisted procedure may provide a safer surgical approach with same successful results. Hereby we report a case of a 53 years old male examined at the ER after presenting generalized seizures and altered state of consciousness. Upon arrival, neurological evaluation revealed homonymous right hemianopia. Computed tomography (CT) scan revealed a subarachnoid hemorrhage and left parieto-occipital intraparenchymal hemorrhage with intraventricular extension; computed tomography angiogram (CTA) revealed an aneurysm at the left posterior cerebral artery (PCA) in its P4 segment. We performed a vascular exploration with drainage of the occipital and intraventricular hematoma through a single endoscopic port through transulcal approach guided by neuronavigation, in addition to clipping and aneurysmectomy. The combination of microsurgical clipping with previous Endoport-guided endoscopic procedure may be a surgical-operative option that not only may facilitate the approach to the desired lesion, but also provides a safer surgical scenario.

Current Approach of Functioning Head and Neck Paragangliomas: Case Report of a Young Patient with Multiple Asynchronous Tumors.

Introduction. Pheochromocytomas (Pheo) and paragangliomas (PGL) are rare neuroendocrine tumors arising from chromaffin cells of the adrenal medulla and from the extra-adrenal autonomic paraganglia, respectively. Only 1-3% of head and neck PGL (HNPGL) show elevated catecholamines, and at least 30% of Pheo and PGL (PCPG) are associated with genetic syndromes caused by germline mutations in tumor suppressor genes and proto-oncogenes. Clinical Case. A 33-year-old man with a past medical history of resection of an abdominal PGL at the age of eleven underwent a CT scan after a mild traumatic brain injury revealing an incidental brain tumor. The diagnosis of a functioning PGL was made, and further testing was undertaken with a PET-CT with 68Ga-DOTATATE, SPECT-CT 131-MIBG, and genetic testing. Discussion and Conclusion. The usual clinical presentation of functioning PCPG includes paroxistic hypertension, headache, and diaphoresis, sometimes with a suggestive family history in 30-40% of cases. Only 20% of PGL are located in head and neck, of which only 1-3% will show elevated catecholamines. Metastatic disease is present in up to 50% of cases, usually associated with a hereditary germline mutation. However, different phenotypes can be observed depending on such germline mutations. Genetic testing is important in patients with PCPG since 31% will present a germline mutation. In this particular patient, an SDHB gene mutation was revealed, which can drastically influence the follow-up plan and the genetic counsel offered. A multidisciplinary approach is mandatory for every patient presenting with PCPG.SDHB gene mutation was revealed, which can drastically influence the follow-up plan and the genetic counsel offered. A multidisciplinary approach is mandatory for every patient presenting with PCPG.

[Donor/recipient age index (DoRAIn) as an independent predictor of long-term living-donor renal graft function]. / Índice de edad donador/receptor (DoRAIn) como un predictor independiente de la función del injerto de donante vivo renal a largo plazo.

PROBLEM: The effect of donor/recipient age disparity on living-donor renal graft function is controversial. The objective of this study is to find new clinical predictors of renal graft function and evaluate the effect of donor/recipient age disparity in our series. METHODS: A retrospective review of our institutional renal transplantation database was performed. We calculated the glomerular filtration rate of our patients with the Chronic Kidney Disease Epidemiology Collaboration formula. Our receptors were categorized using a cut-off of 60 ml/min calculated glomerular filtration rate. An index called "Donor/Recipient Age Index" was created based on the interaction between donor/recipient ages. Univariable and multivariable regression analysis were performed. The Mantel-Cox model was used for statistical analysis. RESULTS: A total of 220 donor/recipient pairs were selected from January 2005 to August 2013. Only 186 pairs completed the one-year follow-up. The mean age of the donors was 35.3 ± 10.4 years and 31.6 ± 11.7 years for the recipients. The Donor/Recipient Age Index significantly predicted a glomerular filtration rate < 60 ml/min at one-year follow-up in univariable (p = 0.02) and multivariable (p = 0.033) regression models. CONCLUSION: We propose the Donor/Recipient Age Index as a significant predictor of long-term graft function.

[The impact of donor-to-recipient gender match and mismatch on the renal function of living donor renal graft recipients]. / Compatibilidad de género entre donador y receptor puede ser un factor pronóstico en la funcióndel injerto de trasplante renal de donador vivo.

INTRODUCTION: Donor-to-recipient gender match and mismatch may be a potential prognostic factor for living donor renal graft function. METHODS: A retrospective review of donor-to-recipient pairs undergoing living donor kidney transplantation was done. They were classified according to gender match as: male-to-male, female-to-female, male-to-female, and female-to-male. Serum creatinine was recorded during one year for donors and for up to four years for recipients. Renal function was evaluated by estimating the glomerular filtration rate with the Chronic Kidney Disease-Epidemiology Collaboration formula. A comparative statistical analysis was performed. RESULTS: The analysis included 217 donor-to-recipient pairs. No significant differences across the four groups in estimated glomerular filtration rate and serum creatinine at any cut-off time point except at day one serum creatinine were found. Recipients had a significant difference in serum creatinine up to the first year of follow-up, with higher values for male recipients; no significant differences were found during the second through fourth year of follow-up. A significant difference was observed in estimated glomerular filtration rate throughout all follow-ups among the four groups, favoring female recipients of male kidneys. CONCLUSIONS: Donor-recipient mismatch may have a deleterious effect over long-term graft function. Female recipients of male kidneys have the best prognosis.