Disección didáctica de fibra blanca en cerebelo humano en tres pasos: entrenamiento microneuroanatómico / 3-Step didactic white matter dissection of human cerebellum: Micro-neuroanatomical training

Objetivos: Un buen conocimiento anatómico del cerebelo es fundamental para llevar a cabo abordajes al IV ventrículo (frecuentes en la neurocirugía pediátrica) de forma segura, evitando secuelas como el mutismo cerebeloso. El propósito del presente trabajo es realizar una disección didáctica del cerebelo humano centrándonos especialmente en los pedúnculos cerebelosos y en los núcleos dentados (DN); estructuras en riesgo durante estos procedimientos. Material y métodos :Se disecó el órgano, siguiendo el método de Klingler para fibras blancas, usando material de microcirugía estándar y específico, bajo un microscopio D. F. Vasconcellos M900 con aumento x6-x40. Se utilizó una cámara Canon EOS T7 con un objetivo de 18-55 mm y se editaron las imágenes con Adobe Lightroom Classic CC y Keynote. Se emplearon métodos especiales como la iluminación endoscópica con luz LED para la obtención de algunas fotografías. Resultados: Se logró disecar con éxito los DN del cerebelo y describir su relación con los pedúnculos cerebelosos, vermis inferior y velos medulares. Mediante esta guía de tres pasos (1. cara tentorial; 2. cara suboccipital; 3. estructuras del IV ventrículo) se consiguió mostrar los elementos más importantes para el estudio del órgano y caracterizar sus implicaciones en los distintos abordajes al IV ventrículo. Conclusiones: La mejor forma de completar el estudio de neuroanatomía es la disección de especímenes, ya que aporta una visión 3 D. La transiluminación con luz LED se reveló como una herramienta útil para el registro fotográfico de estructuras del IV ventrículo, lo que mejora la visión espacial. Su principal aplicación la encontramos en los velos medulares y forámenes de la fosa romboide, ya que son permeables a la luz. La guía de disección en tres fases propuesta en este trabajo puede ayudar a los neurocirujanos, en cualquier etapa de su formación, a comprender mejor el cerebelo (AU)

Objectives: A thorough understanding of cerebellum anatomy is essential in 4th ventricle approaches (more frequent in pediatric neurosurgery), avoiding relevant complications such as cerebellar mutism. The aim of the present work is to show the feasibility of a didactic dissection of human cerebellum focusing on cerebellar peduncles and dentate nucleus (DN), which are structures at high risk during these surgical procedures. Material and methods: The cerebellum was dissected according to the Klingler method for white matter, using standard and specific microsurgery tools. Surgical microscope magnification (x6-x40) provided by a D.F. Vasconcellos M900 was required. A Canon EOS T7 18-55 mm digital camera was used and Adobe Lightroom Classic CC and Keynote were selected as photo enhancing software. Special methods such as LED light endoscopic transillumination were used for photographical reasons. Results: DN dissection was successfully achieved and the relations between these nucleus and the cerebellar peduncles, inferior vermis and medullary velums were described. Through this three steps dissection guide (1. tentorial surface; 2. suboccipital surface; 3. 4th ventricle structures), the most relevant anatomical structures were shown and its implications in different 4th ventricle approaches were characterised. Conclusion: 3 D perspective provided by real specimen anatomical dissection is critical for learning neuroanatomy. ED transillumination was shown as a useful technique for the 4th ventricle structures photographic documentation which improves spatial recognition. This benefit can be applied for the study of the relations between the medullary velums and the rhomboid fossa foramina, which are permeable to light. The proposed three-steps dissection guide helps to a better understanding of human cerebellum and to gain self-confidence, allowing safer practice for neurosurgeons in all stages of their career (AU)

Subluxación atlantoaxoidea rotacional no traumática en un varón de 6 años / Atlantoaxial rotary subluxation non-traumatic in a 6-year-old male

La subluxación atlantoaxoidea es una etiología que debemos tener presente en el diagnóstico diferencial de la tortícolis adquirida en pediatría. La etiopatogenia de este cuadro no es bien conocida y, aunque parece tener relación con traumatismos leves o afectación inflamatoria del cuello por infecciones respiratorias o cirugías faríngeas, es posible que se origine espontáneamente sin un antecedente. Debe sospecharse ante tortícolis resistente al tratamiento, realizando prueba de imagen y descartando patología infecciosa y tumoral. El manejo depende de la gravedad y duración del proceso.Presentamos el caso de un paciente de 6 años con subluxación atlantoaxoidea rotacional sin traumatismo (AU)

Atlantoaxoidea subluxation is an etiology that must be present in the differential diagnosis of torticollis in pediatrics. The pathogenesis of this disease is not well understood and, although it seems to be related to mild trauma or inflammatory involvement of the neck by respiratory infections or pharyngeal surgeries, possible arising spontaneously without a prior precedent. It should be suspected to torticollis treatment-resistant, making imaging test and discarding infectious and tumoral pathology. Management depends on the severity and duration of the process. We present the case of a 6 year old patient with subluxation rotational atlantoaxoidea without prior trauma, with favorable evolution with conservative treatment (AU)

Giant osteoma of the ethmoid sinus with orbital extension: craniofacial approach and orbital reconstruction.

Osteomas are the most common fibro-osseous lesions in the paranasal sinus. They are benign tumours characterized by slow growth and are often asymptomatic. Treatment is indicated in sphenoid osteomas that threaten the optic canal or orbital apex and in symptomatic cases. The choice of surgical management depends on the location, size and experience of the surgeon. An open approach allows tumour removal with direct visual control and remains the best option in large tumours, but the continued progression in endoscopic approaches is responsible for new indications in closed techniques. Immediate reconstruction allows aesthetic and functional restoration of neighbouring structures, which should one of the goals in the treatment of this benign entity. We report a case of a giant ethmoid osteoma with orbital invasion treated by a combined open craniofacial approach with reconstruction of the anterior cranial base and orbital walls. The literature is reviewed and aetiopathogenic theories, diagnostic procedures and surgical approaches are discussed.

Sinus pericranii. Serie de 5 casos / Sinus pericranii. A series of 5 cases

El sinus pericranii es una malformación vascular rara en la cual existe una comunicación anormal entre el sistema venoso extracraneal y los senos venosos durales. La historia natural, en la mayoría de casos, es la de una anomalía vascular en línea media craneal desde la nariz hasta el occipucio, que aumenta progresivamente de tamaño. Las opciones terapéuticas son diversas: desde la observación de la lesión hasta la embolización del componente intracerebral o la exéresis completa tanto del componente extra como intracraneal. En todas estas circunstancias pueden producirse complicaciones potencialmente letales, como son la trombosis y la hemorragia cerebrales. Describimos nuestra experiencia en el manejo del sinus pericranii, destacando la importancia del abordaje terapéutico multidisciplinar de esta infrecuente entidad (AU)

Sinus pericranii is a rare vascular anomaly in which an abnormal communication exists between the extracranial venous system and the dural venous sinuses. The natural history in most cases consists of a purplish nodule in the frontal region that may gradually increase in size. Different treatment options can be chosen: from observation of the lesion, to endovascular embolization of intracerebral component or a complete resection of both anomalous components (extra- and intra-cranial) by surgery. In this context, potential life-threatening complications including thrombosis and cerebral hemorrhage can occur. Here we present our experience in management of sinus pericranii, and emphasize the importance of a multidisciplinary therapeutic approach of this uncommon entity (AU)

[Sinus pericranii. A series of 5 cases]. / Sinus pericranii. Serie de 5 casos.

Sinus pericranii is a rare vascular anomaly in which an abnormal communication exists between the extracranial venous system and the dural venous sinuses. The natural history in most cases consists of a purplish nodule in the frontal region that may gradually increase in size. Different treatment options can be chosen: from observation of the lesion, to endovascular embolization of intracerebral component or a complete resection of both anomalous components (extra- and intra-cranial) by surgery. In this context, potential life-threatening complications including thrombosis and cerebral hemorrhage can occur. Here we present our experience in management of sinus pericranii, and emphasize the importance of a multidisciplinary therapeutic approach of this uncommon entity.

Tumoración hipofisaria secundaria a hipotiroidismo primario: un caso de hiperplasia tirotropa que simula un adenoma hipofisario / Hypophyseal tumour growth secondary to primary hypothyroidism: a case of a hypophyseal adenoma induced by thyrotropic hyperplasia

No disponible

[Aqueductal stenosis in the neurofibromatosis type 1. Presentation of 19 infantile patients]. / Estenosis del acueducto de Silvio en la neurofibromatosis tipo 1. Presentación de 19 pacientes infantiles.

AIM: To present a series of infantile patients with aqueductal stenosis associated with neurofibromatosis type 1 (NF1). PATIENTS AND METHODS: Nineteen patients with ages below 16 years, 11 girls and 8 boys, with NF1 presented hydrocephalus due to aqueductal stenosis. All patients, except one who died before the imaging study was performed and was diagnosed by autopsy, were studied by pneumoencephalography (since 1965 to 1974), computerized tomography (CT) (since 1975 to 1984), magnetic resonance (MR) or MR and CT (since 1985 to 2004) (two children had been studied by pneumoencephalography some years before) most times to discard optic pathway tumor and, in few patients, because of intracranial hypertension. RESULTS: All patients showed three ventricular hydrocephalus with aqueductal stenosis. Eleven patients showed optic pathway tumor. One patient had a benign aqueductal tumor that impaired the normal flow of cerebrospinal fluid. Neurological features of hydrocephalus occurred very rapidly in some patients and after several years of evolution in others. Two boys showed precocious puberty. All patients were treated with shunt. CONCLUSIONS: In our series, aqueductal stenosis occurred in about 5% of children with NF1. Aqueductal stenosis and hydrocephalus were identified at a short age because many patients were studied suspecting optic pathway tumor. Eleven patients (about 60%) associated optic pathway tumor and aqueductal stenosis.

Estenosis del acueducto de Silvio en la neurofibromatosis tipo 1. Presentación de 19 pacientes infantiles / Aqueductal stenosis in the neurofibromatosis type 1. presentation of 19 infantile patients

Objetivo. Presentar una serie de pacientes en edad infantil con estenosis del acueducto de Silvio asociada con neurofibromatosis tipo 1 (NF1). Pacientes y métodos. Son 19 pacientes, 11 niñas y 8 niños, con NF1, a los que se diagnosticó hidrocefalia por estenosis del acueducto de Silvio antes de cumplir los 16 años. Todos los pacientes, excepto uno, que falleció antes del estudio de imagen y fue diagnosticado tras la necropsia, fueron estudiados con neumoencefalografía (desde 1965 a 1974), tomografía computarizada (TC) (desde 1975 a 1984), con resonancia magnética (RM) o con RM y TC (desde 1985 a 2004) (dos niños habían sido estudiados previamente por neumoencefalografía), la mayoría de las veces para descartar tumor en vías ópticas y, en pocos pacientes, por signos de hipertensión intracraneal. Resultados. Todos los pacientes mostraron hidrocefalia triventricular con estenosis del acueducto. Once pacientes mostraban tumor de vías ópticas y en uno existía tumor benigno acueductal que bloqueaba la salida del líquido cefalorraquídeo. La descompensación de la hidrocefalia ocurría muy rápidamente en unos pacientes y, tras varios años de evolución, en otros. Dos pacientes, varones, presentaron pubertad precoz. Todos los pacientes precisaron tratamiento con shunt. Conclusiones. La presencia de estenosis del acueducto asociada con NF1 está alrededor del 5% en nuestra serie. La estenosis del acueducto y la hidrocefalia se descubrieron a muy temprana edad porque los pacientes fueron estudiados por sospecha de tumor de vías ópticas. Once pacientes (alrededor del 60%) asociaban tumor de vías ópticas y estenosis del acueducto (AU)

To present a series of infantile patients with aqueductal stenosis associated with neurofibromatosis type 1 (NF1). Patients and methods. Nineteen patients with ages below 16 years, 11 girls and 8 boys, with NF1 presented hydrocephalus due to aqueductal stenosis. All patients, except one who died before the imaging study was performed and was diagnosed by autopsy, were studied by pneumoencephalography (since 1965 to 1974), computerized tomography (CT) (since 1975 to 1984), magnetic resonance (MR) or MR and CT (since 1985 to 2004) (two children had been studied by pneumoencephalography some years before) most times to discard optic pathway tumor and, in few patients, because of intracranial hypertension. Results. All patients showed three ventricular hydrocephalus with aqueductal stenosis. Eleven patients showed optic pathway tumor. One patient had a benign aqueductal tumor that impaired the normal flow of cerebrospinal fluid. Neurological features of hydrocephalus occurred very rapidly in some patients and after several years of evolution in others. Two boys showed precocious puberty. All patients were treated with shunt. Conclusions. In our series, aqueductal stenosis occurred in about 5% of children with NF1. Aqueductal stenosis and hydrocephalus were identified at a short age because many patients were studied suspecting optic pathway tumor. Eleven patients (about 60%) associated optic pathway tumor and aqueductal stenosis (AU)

Sinus pericranii / Sinus pericranii

No disponible

No disponible

[Spinal epidural abscess caused by Acinetobacter baumannii mimicking a herniated lumbar disc]. / Absceso epidural vertebral por Acinetobacter baumanii que simula hernia discal lumbar.

INTRODUCTION: A vertebral epidural abscess usually offers a very varied clinical picture of systemic involvement with signs of infection, general malaise and neurological focus. It is diagnosed by means of magnetic resonance imaging, which reveals large lesions with frequent involvement of soft tissues and peripheral contrast enhancement. CASE REPORT: A 35-year-old male with lumbar-radicular pain in the right S1 with Lasègue's sign at 20 degrees on the right side and abolition of the Achilles' reflex. Magnetic resonance imaging showed an extradural lesion in L5-S1, dependent on the disc space, which suggested a herniated disc. The rest of the anamnesis, explorations and analyses were normal except for a slightly high erythrocyte sedimentation rate. The patient was submitted to surgery and an epidural abscess was observed from which an Acinetobacter baumanii was recovered. Treatment was established with antibiotics and a rigid lumbosacral orthosis. At three months clear signs of discitis were observed in magnetic resonance images; these were completely resolved at eight months, when the patient was asymptomatic. CONCLUSIONS: Epidural abscess must be included in the differential diagnosis of a herniated disc because in the early phases it can give rise to symptoms of lumbar-radicular pain that are identical to those caused by a herniated lumbar disc. This is the first case of an epidural abscess produced by A. baumanii.

Absceso epidural vertebral por Acinetobacter baumanii que simula una hernia discal lumbar / Spinal epidural abscess caused by acinetobacter baumanii mimicking a herniated lumbar disc

Introducción. El absceso epidural vertebral suele manifestarse con un cuadro clínico muy florido de afectación sistémica con signos de infección, mal estado general y focalidad neurológica. Se diagnostica mediante resonancia magnética, con la que se observan lesiones de gran tamaño con afectación frecuente de partes blandas y captación de contraste periférica. Caso clínico. Se trata de un varón de 35 años de edad que presentaba lumbociática en S1 derecha con signo de Lasègue derecho a 20 grados y abolición del reflejo aquíleo. La resonancia magnética mostró una lesión extradural en L5-S1, dependiente del espacio discal, sugestiva de una hernia discal. El resto de la anamnesis, exploraciones y analíticas fue normal, excepto una ligera elevación de la velocidad de sedimentación globular. Se intervino al paciente y se observó la presencia de un absceso epidural del cual se aisló un Acinetobacter baumanii. Se instauró un tratamiento antibiótico y ortesis lumbosacra rígida. A los tres meses se observaban signos claros de discitis en la resonancia magnética, que se habían resuelto completamente a los ocho meses, momento en el que el paciente se encontraba asintomático. Conclusiones. Entre el diagnóstico diferencial de la hernia discal debe incluirse el absceso epidural, que en sus fases precoces puede producir un cuadro clínico de lumbociática idéntico a la hernia discal lumbar. Se trata del primer caso de absceso epidural producido por A. baumanii

Objetivos. Presentar un paciente con síndrome de Klüver- Bucy causado por ceroidolipofuscinosis del adulto (enfermedad de Kufs) y revisar la literatura sobre a las causas de dicho síndrome. Caso clínico. Se trata de un varón de 38 años de edad valorado por cambios conductuales y deterioro cognitivo. La biopsia cerebral fue característica de ceroidolipofuscinosis del adulto. Este paciente cumplía los criterios de la enfermedad de Kufs definida, ya que presentaba características clínicas mixtas de los tipos A (alteraciones neuropsiquiátricas) y B (síndrome afasoapractoagnósico) de dicha enfermedad. Los síntomas iniciales incluyeron varias características clínicas del síndrome de Klüver-Bucy (probable agnosia visual, apatía, aumento de la actividad sexual, falta de inhibición sexual, hipermetamorfopsia, aumento de la conducta oral y cambios en los hábitos dietéticos). Conclusiones. La ceroidolipofuscinosis del adulto es una entidad infrecuente y de difícil diagnóstico dada la ausencia de marcadores biológicos periféricos y la necesidad de la confirmación de dicho diagnóstico mediante un estudio histopatológico

[Clinical characteristics of children with chronic pain in a pediatric pain unit: oncologic pain versus non-oncologic pain]. / Análisis de las características clínicas de los pacientes con dolor crónico tratados por la unidad de dolor infantil: dolor oncológico frente a no oncológico.

BACKGROUND: Despite undoubted scientific advances in the field of chronic pain in children, there is no evidence of clinical application of this knowledge. OBJECTIVE: To describe the experience of a pediatric pain unit (PPU) specifically dedicated to the treatment of chronic pain in children. MATERIAL AND METHODS: We performed an analytic, observational, retrospective, cohort study of the clinical features of the first 42 patients treated for chronic pain in the PPU during a two-year period. The patients were assigned to two groups: an oncologic group and a non-oncologic group. ANOVA was used to analyze quantitative variables and the Chi-square test was used to analyze qualitative variables. RESULTS: No significant differences were found between the two groups in the demographic variables studied (age and sex). Concerning the type of treatment used, no significant differences were found in effectiveness or compliance. However, treatment duration was significantly longer in the non-oncologic group than in the oncologic group (74.2 days vs 37.5 days, p(0.008). The duration of non-oncologic chronic pain before attending the PPU (mean: 557 days) influenced the effectiveness (r 5 0.781; p 5 0.0001) and duration of treatment (r 5 0.61; p 5 0.0051). However, the duration of previous chronic oncologic pain was significantly shorter (mean: 34 days) and showed no influence on treatment effectiveness or duration. CONCLUSIONS: The pediatric population presents chronic pain syndromes that can be appropriately treated in a PPU with conventional, easy to manage analgesics. We recommend the establishment of pediatric pain units similar to those for adults, using a multidisciplinary approach to mitigate children's suffering.

Análisis de las características clínicas de los pacientes con dolor crónico tratados por la unidad de dolor infantil: dolor oncológico frente a no oncológico / Clinical characteristics of children with chronic pain in a pediatric pain unit: oncologic pain versus non-oncologic pain

Antecedentes: A pesar de que en los últimos años se asiste a un innegable avance en los conocimientos científicos sobre el dolor crónico en el niño, estos avances no se han trasladado al campo asistencial. Objetivo: Describir la experiencia de una unidad de dolor infantil (UDI) dedicada específicamente al control del dolor crónico en el niño. Material y métodos: Se realizó un estudio analítico, observacional, retrospectivo y tipo cohortes de las características clínicas de los 42 primeros pacientes tratados de dolor crónico en una UDI durante un período de 2 años. Se dividió a los pacientes en 2 grupos según padeciesen dolor crónico oncológico o dolor crónico no oncológico, y se realizó un estudio de análisis de la varianza (ANOVA) para variables cuantitativas y chi cuadrado ( 2 ) para variables cualitativas. Resultados: No se apreciaron diferencias significativas entre los 2 grupos en las variables demográficas de edad y sexo estudiadas. En cuanto al tipo de tratamientos empleados, la efectividad y el grado de cumplimiento de éstos tampoco se observaron diferencias significativas; sólo se apreciaron en la duración del tratamiento, que fue mayor en el grupo de dolor crónico no oncológico (74,2 días frente a 37,5 días; p < 0,008).La duración del dolor crónico no oncológico antes de acudir a la UDI (media, 557 días) influyó en la efectividad del tratamiento (r 0,781; p 0,0001) y en la duración del mismo (r 0,61; p 0,0051). Sin embargo, la duración del dolor crónico oncológico (media, 34 días) fue significativamente menor (p < 0,0067) y no influyó ni en la efectividad ni en la duración del tratamiento. Conclusiones: La población pediátrica también presenta síndromes dolorosos crónicos que se pueden tratar correctamente en una UDI con fármacos analgésicos convencionales que son de fácil manejo. Se recomienda el desarrollo de unidades de tratamiento del dolor infantil específicas con un esquema asimilable al de las unidades de dolor crónico del adulto y con un abordaje multidisciplinario para contribuir a mitigar el sufrimiento en los niños (AU)

Hydrocephalus and secondary syndrome of inappropriate antidiuretic hormone due to rheumatoid vertical atlantoaxial subluxation.

We describe symptomatic hydrocephalus and secondary syndrome of inappropriate antidiuretic hormone as clinical manifestations of vertical atlantoaxial subluxation in a patient with severe rheumatoid arthritis. We found no reports of this association as a complication of rheumatoid cervical involvement. We discuss the difficulties of differential diagnosis and treatment in this patient.

Administration of bovine superoxide dismutase prevents sequelae of spinal cord ischemia in the rabbit.

The contribution of free radical-mediated reperfusion injury to the ischemic damage caused by total arterial occlusion has been investigated in a model of transient spinal cord ischemia in the rabbit. Spinal cord ischemia was produced in 20 anaesthetized rabbits by temporary luminal occlusion (20 min) of the abdominal aorta below the renal arteries. Superoxide dismutase (5 mg/kg) (10 animals) was infused before and during reperfusion below aortic occlusion using an infusion pump that infused the enzyme through the contralateral femoral artery. Control (10 animals) received sterile saline with the same procedure. In this later group, 4 animals developed paraplegia, 4 were paretic and only 2 were normal. However, in the treated group, 6 animals were normal while 3 were paretic and only one appeared paralyzed. We conclude that: a) oxygen free radicals generated during reperfusion are involved in producing the ischemic injury, and b) the ischemic spinal cord injury is prevented by superoxide dismutase.

Intraluminal thrombus and neointimal hyperplasia after microvascular surgery.

Despite advances in instrumentation, suture materials, and techniques, thrombosis and intimal hyperplasia due to myointimal cell proliferation are still problems in microvascular anastomosis. Platelet factors stimulate smooth-muscle cell proliferation and migration, but little is known about platelet-vessel wall interaction in microvascular surgery. This study evaluates the effect of the disposition of platelet or luminal thrombus, or both, in intimal evolution in autologous venous micrografts interposed in the common carotid artery of 30 rats. Three hours postoperatively, venous graft and suture line endothelium was completely denuded, and the host artery exhibited focal de-endothelialization. Thrombus deposition was observed on suture line and venous graft luminal surfaces, whereas host artery-denuded areas exhibited platelet adhesion. Two weeks postoperatively, intimal thickenings developed in venous graft and suture line, becoming narrower toward the venous graft. The distribution and size of intimal thickening did not change significantly at later observation periods (3-8 months). Intimal thrombus deposition and intimal hyperplasia, appearing in later stages of evolution, show a similar pattern of distribution.