Microsurgical clipping of previously coiled aneurysms.

OBJECTIVE: This study sought to show and analyze the main authors' experience (P.R. and J.M.C.) in previously coiled aneurysm surgery as an emerging challenge in today's neurosurgical practice. METHODS: Twelve female and 8 male patients, whose ages ranged from 32 to 56 years (average 43.5), underwent surgery between April 2009 and September 2012 in 2 centers. Reasons for surgery were 13 partially occluded aneurysms and 7 recanalized aneurysms. RESULTS: There was no mortality in this series. Aneurysmal sites were 5 anterior communicating artery aneurysms, 5 posterior communicating artery aneurysms, 3 middle cerebral artery aneurysms, 6 paraclinoid carotid artery aneurysms, and 1 aneurysm in the pericallosal artery. A patient sustained a postsurgical frontal infarction with mild neurological deficit. One of the aneurysms presented with an arterial branch at the level of the aneurysmal neck; therefore, partial clipping and packing was required. Microsurgical clipping in the remaining patients was performed successfully. Eight cases required partial coil removal before clipping. CONCLUSIONS: Surgical management of previously coiled aneurysms is an emerging challenge in neurosurgery. Incomplete or ineffective embolizations pose an increased risk for the patient, thus requiring surgical treatment. Although not advisable, coil removal might be necessary when in the vicinity of the aneurismal neck in order to place the clip correctly. The authors believe that adequate patient selection and careful preoperative planning are essential to reduce the incidence of patients with unsuccessful coils who will later need surgical treatment.

Identifying the trigeminal nerve branches for transovale radiofrequency thermolesion: "no pain, no stress".

BACKGROUND: Radiofrequency thermorhizotomy of the trigeminal nerve is a known treatment of trigeminal neuralgia. Analysis of verbal responses to electric stimulation of the trigeminal rootlets has been the only method available to localize the affected branch, but patient discomfort may lead to unreliable verbal responses, resulting in increased morbidity or even therapeutic failure. Orthodromically elicited evoked potentials of the trigeminal nerve have also been used, but their application is tedious and results may vary. OBJECTIVE: To develop an electrophysiological method for intraoperative localization of the trigeminal nerve branches. METHODS: A series of 55 patients under general anesthesia during radiofrequency thermorhizotomy were studied. The trigeminal nerve root was stimulated through the foramen ovale with the RF electrode. Antidromic responses were recorded from the 3 divisions of the trigeminal nerve in the face. Effectiveness rate, pain relief, recurrence, complications, and patient comfort after the procedure were analyzed. RESULTS: Reproducible and easily obtained antidromic responses were clearly recorded in every subdivision of the trigeminal nerve in all patients. Ninety-four percent of patients experienced immediate pain relief after the procedure. The recurrence rate was 12.72%, and the surgical morbidity was 20%. CONCLUSION: This method proved to be useful to determine the exact localization of individual subdivisions of the trigeminal nerve in anesthetized patients, making this procedure safer and more comfortable for them.

Clipado microquirúrgico de aneurismas parcialmente embolizados / Microsurgical clipping of partially embolized cerebral aneurisms

Objetivo: el manejo quirúrgico de los pacientes embolizados con coils plantea un problema ya que las cirugías en estos casos suelen ser más complejas. Material y métodos: presentamos siete pacientes embolicados, seis mujeres y un varón, operados entre abril del 2009 y septiembre de 2010, con un rango de edad entre 32 y 56 años (media 46) que requirieron posteriormente cirugía. Las cirugías fueron realizadas en el Hospital El Cruce y en otros tres centros quirúrgicos, por lo tanto el tratamiento endovascular fue realizado por diferentes equipos. Los aneurismas tratados fueron 2 comunicantes anteriores, 3 comunicantes posteriores y 2 Silvianos. Resultados: no hubo mortalidad en esta serie. Una paciente presentó un infarto frontal postoperatorio. Uno de los aneurismas presentó una rama a nivel del cuello aneurismático, por lo que solo fue posible reducir el cuello con un clip fenestrado y uno recto y empaquetar el aneurisma. En tanto que el clipado microquirúrgico en el resto de los aneurismas se logró con éxito. Conclusión: el manejo quirúrgico de los aneurismas previamente embolizados es un desafío emergente en la práctica neuroquirúrgica. La cirugía de un aneurisma embolizado es técnicamente más compleja y potencialmente más riesgosa para el paciente. Creemos que es fundamental una correcta selección de pacientes y una cuidadosa planificación del tratamiento para disminuir la incidencia de pacientes embolizados que requieran luego tratamiento quirúrgico.

Biopsia estereotáctica cerebral guiada tomográficamente: Análisis de una serie de 192 casos / Tomographically guided stereotactic brain biopsy: Review of a series of 192 cases

Objective. Stereotactic CT-guided biopsy is a safe procedure for the diagnosis of brain lesions unsuitable for surgical treatment because of their location, number, histology or poor medical status. The objective of this study is to analyze the indications,demography, topography, anatomopathologic diagnosis and complications in a series of stereotactic CT-guided brain biopsies. Method. 192 CT assisted stereotactic brain biopsies in 186 patients were retrospectively reviewed from june 1998 to june of 2008. Results. 186 patients, 101males (54.3%) and 85 females (45.7%), were analyzed. Mean age was 54.5 years. 144 (75%) of the biopsies were performed in hemispheric lesions, 43 (22.4%) in “deep seated” localization. The most frequent anatomopathologic diagnosis were glioblastoma (36,5%) and anaplasic astrocytoma (17%). 90,62% of the biopsies were positive, 7,3% were negative and 2,08% nondiagnostic. Morbility rate was 3,64% and mortality 2,08%. Conclusion.Stereotactic brain biopsy is a safe and effective procedure providing tissue for definitive anatomopathological diagnosis; it offers low morbidity and mortality rate. Our findings are similar to the literature.

Hemangioma capilar medular: Reporte de un caso y revisión de la literatura / Spinal cord capillary hemangioma: Report of a case and bibliographical review

Objective. To describe a rare case of intramedullary capillary haemangioma of the thoracic spinal cord asociated with extensive cord edema and review of the literature. Description. A 65-yeard-old male pacient presented a 4-months history of dorsal back pain, progressive 4/5 paraparesis and sensory abnormality of the lower extremities. MR studies of the thoracic spine show a well-defined intramedullary mass at the D6 level, isointense on T1, hiperintense on T2 and homogeneous, strong enhancement with gadolinium, compatible with vascular lesion, asociated with extensive cord edema from D8-C2. Intervention. A D6-D7 laminectomy was performed and the tumor was completly removed en bloc by using standard microneurosurgical technique. Conclusion. It is very important to know about the existence of intramedullary capillary haemangiomas. Despite of being extremely rare, they are benign vascular neoplasms with a good outcome after their complete resection. Therefore, it´s necessary to distinguish them of other malignant tumors, to avoid overtreatment of these benign lesions.

Tratamiento quirúrgico de la neuralgia del trigémino: Experiencia en 10 años / Surgical treatment of trigeminal neuralgia: A 10 years experience

Introduction. Surgical treatment of trigeminal neuralgia remains a matter of debate since there are no studies comparing long term effectiveness of the different surgical techniques. We present our 10 year experience. Description. Series: 40 patients. Period: 1998 - 2008. Surgical techniques: microvascular decompression, radiofrequency thermorhizotomy and balloon compression. Analyzed parameters: age, sex, nerve root involved, pain relief, recurrence, complications, need to restart medication and reintervention. Discussion. Microvascular decompression offers better long term results, radiofrequency is adequate for special cases (higher recurrence rate), and balloon compression is better for V1 neuralgia. Our sample is too small for statistics, yet our findings are coincident with the literature. Conclusion. Better patient selection criteria for each technique are needed. Microvascular decompression should be the treatment of choice when possible. How to treat recurrence remains unanswered.