Risk Factors Associated With Inadequate Brain Relaxation in Craniotomy for Surgery of Supratentorial Tumors.

INTRODUCTION: Cerebral swelling often occurs during craniotomy for cerebral tumors. Poor brain relaxation can increase the risk of cerebral ischemia, possibly worsening the outcome. The surgical team should identify any risk factors that could cause perioperative brain swelling and decide which therapies are indicated for improving it. The present investigation aimed to elucidate the risk factors associated with brain swelling during elective craniotomy for supratentorial brain tumors. METHODS: This prospective, nonrandomized, observational study included 52 patients scheduled for elective supratentorial tumor surgery. The degree of brain relaxation was classified upon the opening of the dura according to a four-point scale (brain relaxation score: 1, perfectly relaxed; 2, satisfactorily relaxed; 3, firm brain; and 4, bulging brain). Moreover, hemodynamic and respiratory parameters, arterial blood gas, and plasma osmolality were recorded after the removal of the bone flap. RESULTS: This study showed that the use of preoperative dexamethasone was associated with a brain relaxation score of ≤2 (p = 0.005). The median midline shift of 6 (3-0) mm and median hemoglobin level of >13 g/dL were associated with a brain relaxation score of ≥3 (p = 0.02 and p = 0.01, respectively). The dosage of mannitol (0.25 g/kg versus 0.5 g/kg), physical status, intraoperative position, tumor diameter and volume, peritumoral edema and mass effect, World Health Organization (WHO) grading, mean arterial pressure, PaCO2, osmolality, and core temperature were not identified as risk factors associated with poor relaxation. CONCLUSION: The use of preoperative dexamethasone was associated with improved brain relaxation, whereas the presence of a preoperative midline shift and a higher level of hemoglobin were associated with poor brain relaxation.

Calidad de vida tras el tratamiento quirúrgico del infarto maligno de la arteria cerebral media / Quality of life following surgical treatment of malignant middle cerebral artery infarction

Introducción. Son escasas las publicaciones que valoran la capacidad de adaptación a la enfermedad de pacientes con infarto maligno de la arteria cerebral media sometidos a cirugía descompresiva. El propósito del trabajo es analizar la calidad de vida final y el grado de satisfacción de pacientes y familiares. Pacientes y métodos. Analizamos 21 pacientes al año de ser intervenidos. Para evaluar la calidad de vida, empleamos la versión española del Sickness Impact Profile. Para conocer el grado de satisfacción retrospectiva, preguntamos a familiares y pacientes si, conociendo las secuelas actuales del afectado, habrían estado igualmente de acuerdo con realizar la craniectomía descompresiva. Resultados. La esfera física se percibe como más perturbada que la relativa a aspectos emocionales. No existen diferencias en la calidad de vida entre pacientes con afectación del hemisferio derecho o izquierdo. Los pacientes con mejor situación funcional refieren una mejor calidad de vida. El 81% de los pacientes se encuentra satisfecho. Conclusión. A pesar de que todos los pacientes muestran una reducción en la calidad de vida después de la craniectomía descompresiva, la mayoría parecen satisfechos con el tratamiento recibido, incluso en afectación del hemisferio dominante o aquéllos con una discapacidad moderada-grave (AU)

Introduction. Little work has been published on the capacity to adapt to the disease of patients with malignant middle cerebral artery infarction who have undergone decompressive surgery. The purpose of this study is to analyse the final quality of life and the degree of satisfaction of patients and their relatives. Patients and methods. We analysed 21 patients one year after their operation. The quality of life was evaluated using the Spanish version of the Sickness Impact Profile. In order to determine the degree of retrospective satisfaction, we asked relatives and patients whether, now that the patient’s current sequelae are known, they would have still agreed to a decompressive craniectomy. Results. The physical sphere is felt to be more disrupted than that concerning emotional aspects. There are no differences in the quality of life between patients who have the right or the left hemisphere affected. Patients with a better functional situation report a better quality of life. Altogether, 81% of patients said they were satisfied. Conclusions. Despite the fact that all the patients show a loss of quality of life after a decompressive craniectomy, most of them seem to be satisfied with the treatment they have received, even in cases in which the dominant hemisphere is compromised or in those with a moderate-severe disability (AU)

Bases patogénicas de la epileptogénesis en los cavernomas cerebrales / Pathogenetic bases of epileptogenesis in cerebral cavernomas

Introducción. Los cavernomas cerebrales son un tipo de malformación arteriovenosa que cursa clínicamente con crisis epilépticas, déficits neurológicos focales y hemorragias intraparenquimatosas. Se cree que las situaciones de hipoxia, neovascularización y algunas endoproteasas están implicadas en la fisiopatología de las crisis. Nuestro estudio pretende valorar esta posible relación, analizando con métodos inmunohistoquímicos la presencia de la subunidad 1α del factor inducible por hipoxia (HIF-1α) y la metaloproteasa de matriz 9 (MMP-9). Pacientes y métodos. Se seleccionaron 17 muestras consecutivas con diagnóstico anatomopatológico de cavernoma en un período de nueve años sobre las que se realizó una tinción inmunohistoquímica para HIF-1α y MMP-9, valorando la relación con las crisis epilépticas según el grado de captación del anticuerpo de los diferentes tejidos encontrados alrededor de las muestras de cavernoma. Resultados. En aquellos pacientes que presentaron crisis, se observó tinción inmunohistoquímica para HIF-1α en el 31% de las muestras en el endotelio vascular, el 17% en el tejido fibroso y el 34% en el tejido inflamatorio. También se observó tinción positiva para MMP-9 en el 86% del endotelio vascular, el 100% del tejido fibroso y el 43% del tejido cerebral. Analizando la muestra, se observa una tendencia positiva en presencia de crisis epilépticas en los pacientes que muestran la presencia de HIF-1α y MMP-9 en el endotelio vascular, tejido fibroso y tejido cerebral, no siendo así para el tejido inflamatorio. Conclusión. La expresión de HIF-1α y MMP-9, evaluada por métodos inmunohistoquímicos, se relaciona positivamente con la presencia de complicaciones de tipo epiléptico (AU)

Introduction. Brain cavernoma are a type of arteriovenous malformation that clinically presenting seizures, neurological deficit or bleeding. Hypoxia, neoangiogenesis and metalloproteasas seems to be involved in seizures physiopathology. Our study aims to assess this potential relation by immunohistochemical methods, analyzing hypoxia inducible factor (HIF-1alpha) and metalloproteasa (MMP-9) in tissue surrounding cavernoma. Patients and methods. We selected 17 consecutive cases anatomopathologically diagnosed as cavernoma during 9 years. Immunohistochemical staining was performed for HIF-1alpha and MMP-9. We evaluated the relation between seizures and the scale of uptake of different tissues surrounding cavernoma. Results. Cases with seizures had HIF-1alpha positive uptake in vascular endothelium in 31%, 17% in fibrous tissue and 34% in inflammatory tissue. Besides, it also shows MMP-9 positive uptake in vascular endothelium in 86%, 100% in fibrous tissue and 43% of brain tissue. Statistical analysis by chi-square and odds ratio shows a positive trend towards seizures and the presence of HIF-1alpha and MMP-9 in vascular tissue, fibrous tissue and brain tissue, but no for inflammatory tissue. Conclusion. HIF-1alpha and MMP-9, valued by immunohistochemical methods, are related to complications as seizures (AU)

[Quality of life following surgical treatment of malignant middle cerebral artery infarction]. / Calidad de vida tras el tratamiento quirúrgico del infarto maligno de la arteria cerebral media.

INTRODUCTION: Little work has been published on the capacity to adapt to the disease of patients with malignant middle cerebral artery infarction who have undergone decompressive surgery. The purpose of this study is to analyse the final quality of life and the degree of satisfaction of patients and their relatives. PATIENTS AND METHODS: We analysed 21 patients one year after their operation. The quality of life was evaluated using the Spanish version of the Sickness Impact Profile. In order to determine the degree of retrospective satisfaction, we asked relatives and patients whether, now that the patient's current sequelae are known, they would have still agreed to a decompressive craniectomy. RESULTS: The physical sphere is felt to be more disrupted than that concerning emotional aspects. There are no differences in the quality of life between patients who have the right or the left hemisphere affected. Patients with a better functional situation report a better quality of life. Altogether, 81% of patients said they were satisfied. CONCLUSIONS: Despite the fact that all the patients show a loss of quality of life after a decompressive craniectomy, most of them seem to be satisfied with the treatment they have received, even in cases in which the dominant hemisphere is compromised or in those with a moderate-severe disability.

Multiple involvement of the central nervous system in Rosai-Dorfman disease.

Rosai-Dorfman disease is a rare, benign, idiopathic histio-proliferative disorder. Only 5% of cases involve the central nervous system. We describe a 10-year-old girl with pain in her lower limbs and back. Spinal magnetic resonance imaging revealed an intradural extramedullary lesion at T9-T10. We decided on surgical treatment. An anatomic/pathologic examination revealed histiocytic-like cells and extensive fibrosis. Immunohistochemistry revealed positivity for CD68 protein and negativity for CD1a protein. Craniospinal magnetic resonance imaging demonstrated an extra-axial lesion in the right frontal region, a small nodule in the left middle cerebellar peduncle, and another small lesion in the right ventral pons. We performed a complete removal of the frontal lesion. The histologic examination produced results compatible with Rosai-Dorfman disease. Most lesions in intracranial Rosai-Dorfman disease mimic meningioma. The definitive diagnosis relies on pathologic and immunohistochemical characteristics. Surgical removal is generally regarded as the treatment of choice. Disease progression after surgical resection is uncommon. Surgical treatment is not recommended until clear disease progression is detected, or focal disease causes neurologic compression. This disease must be included in the differential diagnosis of lesions that mimic meningioma.

Lead Fractures in Deep Brain Stimulation during Long-Term Follow-Up.

The purpose was to determine the incidence of lead fracture in patients with DBS over a long period of time. We present a retrospective study of 208 patients who received 387 DBS electrodes. Fourteen patients had sixteen lead fractures (4% of the implanted leads) and two patients suffered from 2 lead fractures. Of all lead fractures, five patients had the connection between the leads and the extension cables located in mastoids region, ten in cervical area and one in thoracic region. The mean distance from the connection between the electrode and the extension cable and the lead fracture was 10.7 mm. The lead fracture is a common, although long-term complication in DBS surgery. In our experience, the most common site of electrode cable breakage is approximately between 9 and 13 mm from the junction between the lead and the extension cable. The most important cause of lead fracture is the rotational movement of the lead-extension cable system. If we suspect lead fracture, we must check the impedance of the electrode and to evaluate the side effects of voltage. Finally, we must conduct a radiological screening.