Anterior Interhemispheric Approach for the Surgical Treatment of Azygos Anterior Cerebral Artery Aneurysms: A Case Series.

The azygos artery is an uncommon vascular variant of the anterior cerebral artery (ACA). This anomaly is associated in a high percentage with aneurysms. Management of azygos ACA aneurysms represents a surgical challenge. We present five patients who underwent microsurgical treatment for distal azygos ACA aneurysms with complex morphology. Four patients showed subarachnoid hemorrhage (SAH) and one complained of sentinel headache. Early preoperative digital subtraction angiography (DSA) or computerized tomography angiography (CTA) was performed. All patients were treated by surgical clipping via an anterior interhemispheric approach. During follow-up, all patients had a satisfactory outcome, with postoperative angiograms showing complete resolution of aneurysms.

Evaluación comparativa de descompresión lumbar primaria por técnica mínima invasiva versus convencional / Comparative evaluation of primary lumbar decompression by minimally invasive vs conventional technique

Resumen Introducción La descompresión lumbar es una de las principales cirugías programadas en ortopedia, es necesario identificar los beneficios y complicaciones de cada tipo de abordaje. Objetivo Comparación del abordaje convencional y mínimamente invasivo (MI). Material y métodos Estudio transversal, descriptivo y comparativo de descompresión lumbar primaria mínima invasiva vs. convencional. Resultados 36 pacientes divididos en dos grupos, 28 (77.7%) fueron abordaje convencional y ocho (22.3%) por mínima invasión, edad promedio de siete años menor en MI (MI media de 52.2 ± 8 años contra 59.8 ± 9, t Student p = 0.04), la disfunción medida similar. Inician deambulación 24 horas antes (mediana de 24 horas contra 48 horas en convencional, U de Mann Whitney p = 0.012), reducción de 1.5 días de estancia (mediana de 2.5 contra = cuatro días en convencional, p = 0.017), y del dolor postquirúrgico en la MI. Pérdida hemática menor en MI (medianas de 200 en convencional contra 65 mL, U de Mann Whitney p = 0.09), complicaciones, una infección del sitio quirúrgico, un hematoma de lecho quirúrgico, una inadecuada colocación de implantes y una lesión de dura. Conclusiones Se demostró la superioridad de la MI en varios aspectos, y la eficacia del test de Oswestry para la evaluación funcional del canal lumbar estrecho.

Abstract Introduction Lumbar decompression is one of the main surgeries scheduled in orthopedics, it is necessary to identify the benefits and complications of each type of approach. Objective Comparison of conventional and minimally invasive (MI) approaches. Material and methods Cross-sectional, descriptive, comparative study of minimally invasive versus conventional primary lumbar decompression. Results 36 patients divided into 2 groups, 28 (77.7%) were conventional and 8 (22.3%) were minimally invasive, average age 7 years younger in MI (MI average 52.2 ± 8 years versus 59.8 ± 9, t Student p = 0.04), similarly measured dysfunction. They begin wandering 24 hours before (median of 24 hours against 48 hours in conventional, Mann Whitney U p = 0.012), reduction of 1.5 days of stay (median of 2.5 versus = five days in conventional, p = 0.017), and post-surgical pain in MI. Minor blood loss in MI (median of 200 in conventional versus 65 mL, Mann Whitney U p = 0.09), complications, 1 surgical site infection, 1 surgical site hematoma, 1 inadequate implant placement and 1 dura mater lesion. Conclusions It was demonstrated the superiority of the MI in several aspects, and the effectiveness of the Oswestry test for the functional evaluation of the strait lumbar channel.

[Surgical management of paraclinoid aneurysms]. / Manejo neuroquirúrgico de aneurismas paraclinoideos.

BACKGROUND: Paraclinoid aneurysms arise from C5 clinoid segment and C6 ophthalmic segment, within the internal carotid artery. Brain aneurysms have a frequency ranging from 5 to 11 %. A successful surgery requires knowledge of the anatomic region and the aneurysm. The objective was to show the surgical management of paraclinoid aneurysms. METHODS: From January 2009 to January 2015, we carried out a retrospective study in the Neurosurgery Department at Centro Médico Nacional Siglo XXI. We included 66 patients with the diagnosis of paraclinoid aneurysm. We obtained the clinical characteristics, evolution, complications, and outcomes from the clinical and radiological records. RESULTS: 61 patients (92.4 %) were female; 65 underwent neurosurgical clipping, and one underwent cerebral bypass surgery with exclusion of the aneurysm. Forty six patients presented subarachnoid hemorrhage due to aneurysmal rupture. By reason of their location, 35 paraclinoid aneurysms (53 %) were superior, 20 medial (30.3 %) and 4 inferior (6 %). Thirty three patients had small aneurysms, 23 large aneurysms, and 10 patients presented giant aneurysms. After surgery, 51 patients had good results, since they scored 4 and 5 in the Glasgow Outcome Score. Three patients presented amaurosis as a surgery-related complication. CONCLUSION: Microsurgical management is still the best treatment for these aneurysms, due to its ability to exclude them entirely; besides, is the best method to decompress the optic nerve.

Introducción: los aneurismas paraclinoideos se originan en los segmentos clinoideo C5 y oftálmico C6 de la arteria carótida interna. Su frecuencia aproximada es del 5 al 11 %. Para su manejo microquirúrgico se requiere de un conocimiento anatómico de la región y del aneurisma. El objetivo es mostrar el manejo neuroquirúrgico de los aneurismas paraclinoideos. Métodos: se hizo un estudio retrospectivo en un servicio de neurocirugía, de enero de 2009 a enero de 2015. Se incluyeron 66 pacientes con aneurisma paraclinoideo. Se obtuvieron las características clínicas, la evolución, las complicaciones y los resultados de los pacientes al revisar los expedientes clínicos y radiológicos. Resultados: 61 pacientes (92.4 %) pertenecieron al sexo femenino; a 65 se les realizó clipaje neuroquirúrgico y a uno se le realizó bypass cerebral con exclusión del aneurisma. Tuvieron ruptura del aneurisma con hemorragia subaracnoidea 46 pacientes. Por su localización 35 aneurismas paraclinoideos (53 %) fueron superiores, 20 mediales (30.3 %) y cuatro inferiores (6 %). Tuvieron aneurismas pequeños 33 pacientes (50 %), 23 grandes (34.8 %) y 10 gigantes (15.5 %). Presentaron buenos resultados 51 pacientes después del manejo quirúrgico, dado que sacaron calificaciones de 4 y 5 según el Glasgow Outcome Score (GOS). La amaurosis fue la complicación funcional más seria atribuible a la cirugía (tres pacientes). Conclusión: la microcirugía sigue siendo el tratamiento para estos aneurismas debido a su capacidad de excluirlos totalmente, además de que es el mejor método para descomprimir el nervio óptico.

Plasma cell tumor of the clivus: report of two cases.

BACKGROUND: Plasma cell tumor only rarely affects the cranium and may be found as an isolated lesion or as a part of multiple myeloma. In this review we present the clinical and radiological characteristics and analyze the evolution of two cases of this tumor located at the skull base, specifically in the clivus and sellar region. We also present a brief review of the literature. CLINICAL CASES: Case #1: The patient was a 66-year-old female with a solitary plasmacytoma of the bone (the isolated form of plasma cell tumor) that was totally removed. Case #2: The patient was a 61-year-old male with the diffuse form of this disease who was submitted to subtotal removal. In both patients, adjuvant treatment based on radiotherapy and chemotherapy was proposed; however, only one patient (Case #2) accepted adjuvant treatment and had a very favorable result. Most clinical symptoms disappeared and the patient is currently alive and with a very good quality of life (>3-year follow-up). The other patient (Case #1), despite the presence of the localized form of the disease, died 3 months after diagnosis. CONCLUSION: Early diagnosis and removal of as much of the tumor as possible, but mainly the opportune indication of adjuvant treatment with radiotherapy and chemotherapy, are the keys to management of these cases.

[Sellar remodeling: a surgical option for primary empty sella syndrome]. / Remodelación selar: una opción quirúrgica para el síndrome de la silla turca vacía primaria.

BACKGROUND: The empty sella is an entity that only rarely presents signs and symptoms. When noted, visual field deficits are an indication for surgical management. MATERIAL AND METHODS: We studied twenty patients with primary empty sella and visual field deficits surgically treated with a technique termed by us as "sellar remodeling." We treated 19 females and 1 male. Aside from visual deficits, all participants reported headache. We reported an increase in prolactin serum level in three cases. Patients with an increase in cerebrospinal fluid pressure were excluded. The surgical procedure involved placing through a transsphenoidal route an autologus graft formed by fat, aponeurosis and two bone lamina, with precise dimensions according to each patient's sella turcica. RESULTS: After surgery, visual deficits improved in 18 patients and headache in 17. Two patients displayed normal prolactin levels. No serious complications were reported during surgery. CONCLUSIONS: Sellar remodeling is a precise, simple, safe and inexpensive technique that significantly improves symptoms such as visual deficits and headache observed in primary empty sella syndrome.

Remodelación selar: una opción quirúrgica para el síndrome de la silla turca vacía primaria / Sellar remodeling: a surgical option for primary empty sella syndrome

Antecedentes: La silla turca vacía es una entidad que sólo en raras ocasiones presenta signos y síntomas, dentro de los cuales la afección en el campo visual es una indicación para el manejo quirúrgico. Materiales y Metodos: Se analizaron 20 pacientes con silla turca vacía primaria y alteraciones en los campos visuales, que fueron manejados quirúrgicamente con una técnica que denominamos remodelación selar. Fueron 19 mujeres y un hombre; todos ellos, además del déficit visual presentaban cefalea y tres casos elevación en el nivel sérico de prolactina. Se excluyeron los que mostraron aumento en la presión del líquido cefalorraquídeo. El procedimiento quirúrgico consistió en la colocación, por vía transesfenoidal, de un injerto autólogo formado por grasa, aponeurosis y dos láminas de hueso, con dimensiones precisas de acuerdo al tamaño de la silla turca del paciente. Resultados: Con la cirugía se logró mejorar el déficit visual en 18 pacientes y la cefalea en 17; finalmente, dos de ellos normalizaron su nivel de prolactina. No se presentaron complicaciones serias. Conclusiones: La remodelación selar es una técnica precisa, sencilla, segura y barata que permite mejorar los síntomas del síndrome de la silla turca vacía primaria, en especial las alteraciones visuales y la cefalea.

BACKGROUND: The empty sella is an entity that only rarely presents signs and symptoms. When noted, visual field deficits are an indication for surgical management. MATERIAL AND METHODS: We studied twenty patients with primary empty sella and visual field deficits surgically treated with a technique termed by us as [quot ]sellar remodeling.[quot ] We treated 19 females and 1 male. Aside from visual deficits, all participants reported headache. We reported an increase in prolactin serum level in three cases. Patients with an increase in cerebrospinal fluid pressure were excluded. The surgical procedure involved placing through a transsphenoidal route an autologus graft formed by fat, aponeurosis and two bone lamina, with precise dimensions according to each patient's sella turcica. RESULTS: After surgery, visual deficits improved in 18 patients and headache in 17. Two patients displayed normal prolactin levels. No serious complications were reported during surgery. CONCLUSIONS: Sellar remodeling is a precise, simple, safe and inexpensive technique that significantly improves symptoms such as visual deficits and headache observed in primary empty sella syndrome.

[Cerebellar amygdalopexy in the management of Chiari I malformation]. / Amigdalopexia cerebelosa en el manejo de la malformación de chiari de tipo I.

BACKGROUND: The treatment of Chiari I malformation associated with syringomyelia is controversial. OBJECTIVE: We describe a series of patients with this disease treated during a twelve-year period. We also present clinical, surgical and radiological findings. MATERIAL AND METHODS: Forty eight patients were included; a non significant female predominance was found. Clinical course was characterized by headache, cerebellar signs and symptoms, neck pain and involvement of lower cranial nerves and pyramidal tract. The degree of tonsillar descent and syringomyelia size varied and a correlation between them was not found. Surgery consisted in an occipital craniectomy, C1 laminectomy and tonsillar elevation through bipolar coagulation and duraplasty. RESULTS: The best results were observed in pain and cerebellar symptoms, while a deficit of lower cranial nerves and pyramidal tract were observed. However, in most patients we were able to slow symptom progression. No adverse effects were documented. CONCLUSIONS: The surgicalprocedureproposed herein is an effective and safe treatment alternative for this malformation, and its results are comparable to other riskier procedures.

Amigdalopexia cerebelosa en el manejo de la malformación de chiari de tipo I / Cerebellar amygdalopexy in the management of Chiari I malformation

Antecedentes. El tratamiento de la malformación de Chiari de tipo I asociada a siringomielia es controvertido. En este trabajo se presenta un análisis clínico, quirúrgico y radiológico de los pacientes con esta afección que fueron manejados durante un periodo de doce años. Material y métodos. Se incluyeron 48 pacientes, donde se encontró un discreto predominio en el sexo femenino. El cuadro clínico estuvo dominado por cefalea, dolor cervical, signos y síntomas cerebelosos, afección de nervios craneales bajos y lesión de la vía piramidal. Resultados. Tanto el grado de descenso amigdalino como el tamaño de la siringomielia fueron muy variables, sin encontrar correlación entre ambos. La cirugía consistió en una craniectomía occipital, laminectomía de C1, ascenso de amígdalas cerebelosas mediante coagulación bipolar y plastía de duramadre. Los mejores resultados clínicos se obtuvieron en el dolor y los síntomas cerebelosos, mientras que los peores fueron en la afección de los nervios craneales bajos y de la vía piramidal, sin embargo, en la gran mayoría de los pacientes se logró detener la progresión de los síntomas. No se presentaron complicaciones serias en el presente estudio. Conclusión. El procedimiento propuesto ofrece una alternativa segura, efectiva y comparable con otros métodos más riesgosos para el manejo de esta malformación.

BACKGROUND: The treatment of Chiari I malformation associated with syringomyelia is controversial. OBJECTIVE: We describe a series of patients with this disease treated during a twelve-year period. We also present clinical, surgical and radiological findings. MATERIAL AND METHODS: Forty eight patients were included; a non significant female predominance was found. Clinical course was characterized by headache, cerebellar signs and symptoms, neck pain and involvement of lower cranial nerves and pyramidal tract. The degree of tonsillar descent and syringomyelia size varied and a correlation between them was not found. Surgery consisted in an occipital craniectomy, C1 laminectomy and tonsillar elevation through bipolar coagulation and duraplasty. RESULTS: The best results were observed in pain and cerebellar symptoms, while a deficit of lower cranial nerves and pyramidal tract were observed. However, in most patients we were able to slow symptom progression. No adverse effects were documented. CONCLUSIONS: The surgicalprocedureproposed herein is an effective and safe treatment alternative for this malformation, and its results are comparable to other riskier procedures.

[Soft palate transnasal retractor]. / Retractor transnasal del paladar blando.

INTRODUCTION: An anterior transoral approach allows the surgeon to access the lower portion of the clivus; to the first, second or third thoracic vertebra. It is indispensible that the teeth, lips, cheeks and tongue be retracted to avoid interposition on the surgical field. This retraction is carried out by means of a Dingman separator. Nevertheless, generally the soft palate is elevated with sutures through the nasal fossa. Because this invasive method could damage soft tissues, we have designed a basket to separate the soft palate from the surgical field, thus allowing the surgeon to maneuver with comfort and without damaging structures. TECHNIQUE: A 30-cm segment of 22 gauge wire is passed through each end of a thin sheet of silicon (4 x 3 x 1.5 cm) forming a basket. With the patient under general anesthesia, both free ends of the wire are introduced into the buccal cavity in the same manner nasal packing is used to control epistaxis. Each end of the wire is slid from the mouth through the nasal fossa to bring them outside the face. Traction is placed on both ends of the wire allowing the intraoral band of silicon to elevate and hold the soft palate. CLINICAL CASE: We present the case of a 64-year-old woman with spastic quadriparesis and hyperreflexia predominantly of the upper extremities, in addition to trophic changes due to arthritis of long duration. Imaging studies demonstrated nonreducible subluxation of the atlantoaxial joint with ventral compression of the bulbomedullar union by the odontoid apophysis. Resection of the anterior arch of the atlas and apophyses was made via the transoral route, where retraction of the soft palate by means of the described basket was employed. The patient did not experience significant sequelae as a result of the technique utilized.