[Aneurysmal subarachnoid hemorrhage: group of study of cerebrovascular pathology of the Spanish society of neurosurgery management guideline]. / Hemorragia subaracnoidea aneurismática: guía de tratamiento del grupo de patología vascular de la sociedad Española de neurocirugía.

An actualized revision of the most important aspects of aneurismal subarachnoid hemorrhage is presented from the guidelines previously published by the group of study of cerebrovascular pathology of the Spanish Society of Neurosurgery. The proposed recommendations should be considered as a general guide for the management of this pathological condition. However, they can be modified, even in a significant manner according to the circumstances relating each clinical case and the variations in the therapeutic and diagnostic procedures available in the center attending each patient.

Idiopathic subarachnoid hemorrhage: a multicentre series of 220 patients.

BACKGROUND. The Spanish neurosurgical society created a multicentre data base on spontaneous SAH to analyze the real problematic of this disease in our country. This paper focuses on the group of patients with idiopathic SAH (ISAH). METHODS. 16 participant hospitals collect their spontaneous SAH cases in a common data base shared in the internet through a secured web page, considering clinical, radiological, evolution and outcome variables. The 220 ISAH cases collected from November 2004 to November 2007 were statistically analyzed as a whole and divided into 3 subgroups depending on the CT blood pattern (aneurysmal, perimesencephalic, or normal). RESULTS. The 220 ISAH patients constitute 19% of all 1149 spontaneous SAH collected in the study period. In 46,8% of ISAH the blood CT pattern was aneurysmal, which was related to older age, worse clinical condition, higher Fisher grade, more hydrocephalus and worse outcome, compared to perimesencephalic (42.7%) or normal CT (10.4%) pattern. Once surpassed the acute phase, outcome of ISAH patients is similarly good in all 3 ISAH subgroups, significantly better as a whole compared to aneurysmal SAH patients. The only variable related to outcome in ISAH after a logistic regression analysis was the admission clinical grade. CONCLUSIONS. ISAH percentage of spontaneous SAH is diminishing in Spain. Classification of ISAH cases depending on the blood CT pattern is important to differentiate higher risk groups although complications are not negligible in any of the ISAH subgroups. Neurological status on admission is the single most valuable prognostic factor for outcome in ISAH patients.

[Spontaneous Subarachnoid Haemorrhage multicenter database from the Group for the Study of Vascular Pathology of the Spanish Society for Neurosurgery: presentation, inclusion criteria and development of an internet-based registry]. / Base de datos multicéntrica de hemorragia subaracnoidea espontánea del Grupo de Trabajo de Patología Vascular de la Sociedad Española de Neurocirugía: presentación, criterios de inclusión y desarrollo de una base de datos en internet.

INTRODUCTION: Subarachnoid haemorrhage is one of the most severe neurosurgical diseases. Its study is crucial for improving the care of these patients in our environment. With this goal the Group for the Study of Neurovascular Pathology of the Spanish Society for Neurosurgery (SENEC) decided to create a multicenter registry for the study of this disease. MATERIALS AND METHODS: In this database we have prospectively included all cases with spontaneous subarachnoid haemorrhage admitted to the participant hospitals from November 2004 to November 2007. The fields to be included in the database were selected by consensus, including age, past medical history, clinical characteristics at admission, radiological characteristics including presence or absence of an aneurysm and its size and location, type and complications of the aneurysm treatment, outcome assessed by the Glasgow Outcome Scale (GOS) at discharge and six months after the bleeding as well as the angiographic result of the aneurysm treatment. All fields were collected by means of an electronic form posted in secure web page. RESULTS: During the three years of study a total of 1149 patients have been included by 14 Hospitals. The time needed to fill in a patient in the registry is approximately 3.4 minutes. This series of patients with spontaneous SAH is similar to other non-selected in-hospital series of SAH. The mean age of the patients is 55 years and there is a 4:3 female to male ratio. In relation to the severity of the bleeding 32% of the patients were in poor clinical grade at admission (WFNS 4 or 5). 5% of the patients died before angiography could be performed. An aneurysm was confirmed as the origin of the bleeding in 76% of the patients (aSAH), while in 19% of the patients no lesion was found in the angiographic studies and were thus classified as idiopathic subarachnoid hemorrhage (ISAH). Of those patients with aSAH, 47% were treated endovascularly, 39% surgically, 3% received a combined treatment and 11% did not receive any treatment for their aneurysm because of early death. Regarding outcome, there is a 22% mortality in the series. Only 40% of the patients with aSAH reached a good outcome at discharge (GOS = 5). CONCLUSIONS: Spontaneous SAH continues to be a disease with high morbidity and mortality. This database can be an ideal instrument for improving the knowledge about this disease in our environment and to achieve better results. It would be desirable that this database could in the future be the origin of a national registry of spontaneous SAH.

[Spontaneous spinal cord herniation]. / Hernia medular espontánea.

Spontaneous spinal cord herniation through a dural defect is an unusual condition. This entity has been probably underestimated before the introduction of MRI. We report a case of a 49-year-old man with a progressive Brown-Sequard syndrome. MRI and CT myelogram showed a ventrally displaced spinal cord at level T6-T7 and expansion of the posterior subarachnoid space. Through a laminectomy, a spinal cord herniation was identified and reduced. The anterior dural defect was repaired with a patch of lyophilized dura. The patient recovered muscle power but there was no improvement of the sensory disturbance. The diagnosis of spontaneous spinal cord herniation must be considered when progressive myelopathy occurs in middle-aged patients, without signs of spinal cord compression and typical radiological findings. Surgical treatment may halt the progressive deficits and even yield improvement in many cases.

Oligodendroglioma and multiple sclerosis. A case report.

BACKGROUND: The concurrence of multiple sclerosis (MS) and glioma is uncommon. Approximately 30 cases have been reported, but in only six of them the tumour was pure or mixed oligodendroglioma. The appearance of new neurological symptoms and signs in a patient with multiple sclerosis is usually attributed to a relapse of this disease and neuroradiological studies are not always performed. When done, the finding of a new focal mass lesion is usually interpreted as a pseudotumoural plaque. CASE REPORT: A 37-year-old man was admitted because of partial simple seizures and an enlarging intracranial mass. He had been diagnosed of MS eleven years earlier. A MRI study performed eight years before admission showed a large mass in the right frontal lobe which was thought to be a pseudotumoural plaque. Two years later, he developed simple partial motor seizures that were initially controlled with valproic acid. He remained well until three months before admission, when seizures reappeared with a poor response to valproic acid. A new MRI study showed an heterogeneous right frontal enlarging mass lesion. A primary neoplasm was suspected and a subtotal removal was performed. The pathological diagnosis was oligodendroglioma with a periferic demyelinating area. CONCLUSION: Atypical MRI lesions in a patient with MS must be carefully interpreted. Pseudotumoural plaques have been described both clinically and radiologically to be hardly distinguishable from a tumoural lesion and histological confirmation is often required. The association between MS and glioma is uncommon but it must be kept in mind when a mass lesion develops in a patient with MS.

[Treatment of central neurocytoma. Experience at a single institution]. / Tratamiento neurocitoma central. Experiencia en nuestro centro.

Central neurocytomas are classically considered as a rare, intraventricular benign tumours with neuronal differentiation derived from precursor cells of subventricular matrix. However some patients with neoplasms with histologic atypia and elevated proliferation potential may have a poor outcome. Treatment of choice is complete surgical excision. Adjuvant therapy is reserved for patients with residual or recurrent lesions including reoperation, radiotherapy or chemotherapy. We review our experience with the treatment of this neoplasm. Five patients with an intraventricular mass studied with magnetic resonance imaging underwent craniotomy for tumour resection. All cases were reviewed retrospectively. Histopathological analysis confirmed central neurocytoma in all cases. Proliferation index was assessed by Ki-67 immunohistochemistry. Complete radiological tumor resection through transcortical approach was achieved in all except one patient. In this case adjuvant therapy with radiosurgery was given with important reduction in tumor size. All the tumours had a proliferation index below 2% except one with 5%. Follow-up in four patients ranged from 12 to 36 months. There were no tumour recurrences in this period. Complete surgical excision of central neurocytoma provides better local control and survival compared with other treatments. Radiosurgery as adjuvant therapy in incomplete resections may eliminate the need of reoperation and avoid long-term side effects from conventional radiotherapy.

[Idiopathic subarachnoid hemorrhage; comparison of different bleeding patterns and long-term outcome]. / Hemorragia subaracnoidea no filiada: comparación de diferentes patrones de sangrado y evolución a largo plazo.

INTRODUCTION: Idiopathic subarachnoid haemorrhage (ISAH) represents approximately 15-30% of all subarachnoid haemorrhages. On the basis of the diagnostic CT and depending on the location of the subarachnoid bleeding, patients with ISAH may be classified into three groups: a) Patients with normal CT and diagnosis made by lumbar puncture (ISAHNCT); b) patients with a pure perimesencephalic pattern (ISAHPM) and c) patients with a bleeding pattern resembling that of aneurismatic rupture (ISAHA). This classification could permit the establishment of differences in the management and prognosis. OBJECTIVES: To describe the clinical and radiological characteristics of these three classes of patients and analyse their medium and long term outcome and moreover, compare these with those observed in patients suffering aneurysmal subarachnoid haemorrhage (ASAH). MATERIAL AND METHODS: A series of 122 patients consecutively admitted to Hospital 12 de Octubre Madrid between 1990 and 2000 with the diagnosis of ISAH were retrospectively reviewed. Patients were considered to have suffered ISAH when the first complete four vessel angiography did not show the presence of any aneurysm or vascular lesion responsible for the bleeding. Patients were classified depending on the pattern of bleeding into ISAHNCT, ISAHPM as described by Van Gijn et al., and ISAHA. The angiography study was repeated when: a) the first study was incomplete or had poor quality, b) vasospasm was present, c) in those patients who had an aneurysmal pattern of bleeding in the initial CT. Different clinical and radiological characteristics were recorded as well as complications that occurred during the hospital stay. Final outcome was evaluated by means of the Glasgow Outcome Score (GOS). With the purpose of comparing these clinical and radiological characteristics and the outcome of patients with ISAH with those suffering aneurysmal subarachnoid haemorrhage (ASAH), 294 patients diagnosed with ASAH during the same study period were also reviewed. RESULTS: 27% of patients admitted to our hospital with the diagnosis of non-traumatic subarachnoid hemorrhaged were diagnosed as ISAH. Of these, 41% presented with a ISAHA pattern, 39% ISAHPM and 20% ISAHNCT. The average age was similar in the different subgroups of SAH, being around 55 years. There was a greater frequency of male patients in the ISAHNCT and ISAHPM groups. In comparison with ASAH, ISAH characterises by patients presenting with less frequency a bad clinical grade and also loss of consciousness at stroke. There are fewer complications in patients with ISAH than ASAH, with a frequency of rebleeding and ischemia much less (5 and 6% respectively). Within the ISAH group, patients with ISAHA pattern of bleeding present more complications. Outcome is excellent for patients with ISAHNCT and ISAHPM, and rather worse for patients with ISAHA (median followup 5.8 years). CONCLUSIONS: This study confirms that the frequency of ISAH in our environment reaches the higher limit of that shown previously in the literature, replicating the results previously published by our group. Patients with ISAH have a better prognosis and a smaller risk of complications than patients with ASAH, the prognosis of patients with ISAHCTN and ISAHPM being particularly good. Patients with ISAHA present initially with a severe clinical situation, probably related to the bigger amount of bleeding, as well as a higher frequency of systemic complications, cerebral ischemia and hydrocephalus. However, if the absence of vascular lesions is confirmed, the long term prognosis is similar to that of the other subgroups of ISAH.

[Parasplenial arteriovenous malformations. Report of 15 surgically treated cases]. / Malformaciones arteriovenosas paraesplénicas. A propósito de 15 casos tratados quirúrgicamente.

INTRODUCTION: Yasargil called paraesplenial those AVMs located at the confluence of the hippocampus, the isthmus of the cingulate girus and the girus occipitotemporalis medialis. Large AVMs at this location are among the most difficult to delineate and to treat. OBJECTIVE: Analyze the clinical presentation, the findings in the imaging studies, the surgical management and the final outcome in 15 patients with paraesplenial AVMs treated with embolization (the last 4 cases), and microsurgical removal. RESULTS: Nine patients (60%) were female and 6 males of ages between 15 and 39 years (mean = 24 yrs). Eleven (75%) presented with hemorrhage, (intraventricular in most cases) and the remaining with epilepsy. The Spetzler-Martin grade was II in one Case, III in 5 cases, IV in 8 cases and V in one case. Preoperative embolization clearly improved surgical management. All the patients had complete resection of the lesion, 13 in a single stage and 2 in two stages. The final outcome was good but four patients developed defects of the visual field not seen preoperatively. CONCLUSIONS: The authors comment the peculiarities of paraesplenial AVMs which can be safely and completely removed with microsurgery and the aid of preoperative embolization.

Intratumoural bleomycin as a treatment for recurrent cystic craniopharyngioma. Case report and review of the literature.

INTRODUCTION: The majority of craniopharyngioma (CF) have a cystic component and only 10% are completely solid. In tumors with a large cystic component, stereotactic drainage or instillation of radioctive and/or chemotherapeutic agents have been used. Only several authors have reported the use of bleomycin for the treatment of cystic CF. CASE REPORT: The authors present the case of a nineteen years old patient with a recurrent cystic CF who was treated with intratumoral injections of bleomycin. The patient had been operated on three times before because of regrowth of the tumor. This last time he had a severe disturbance of his visual acuity and a huge regrowth of the cystic CF. An intracystic catheter stereotactically placed was connected to an Ommaya reservoir and, after assuring the impermeability of the cyst, bleomycin was administered through the reservoir up to a total dose of 45mg distributed in six doses. No complications were detected during and after the procedure. A MR performed 4 months after treatment showed a clear reduction in the size of the cyst but 10 months later a new regrowth of the cyst was detected by MR with no new signs or symptoms. A total dose of 30 mg divided in six doses was administered. No complications occurred. The MR 18 months after the first treatment showed the reduction in size of the tumor. The ophtalmological study showed almost normal visual acuity in both eyes. DISCUSSION: Although there is not an stablished protocol for the indication and the form of application of intracystic bleomycin, results with this treatment for cystic CF seem good in the literature. However, the risk of local complications after the administration of intratumoural bleomycin in these patients is around 10%, and some fatal toxic reactions have been recently reported. CONCLUSION: Intracystic administration of bleomycin is a valid option as adjuvant therapy for CF in patients with recurrences that are not surgical candidates because of the high risk of complications. The role of bleomycin as a primary treatment for CF and treatment protocols remain to be stablished with additional studies.

Ganglioglioma of the brainstem: report of three cases and review of the literature.

BACKGROUND: Brainstem gangliogliomas are rare low-grade tumors that usually have a long clinical history. However, they may cause sudden death. There are only 31 cases of brainstem ganglioglioma reported in the literature, and only one has been studied with magnetic resonance (MR). We present three new cases of brainstem ganglion cell tumor studied with computed tomography (CT) (3 cases) and MR (2 cases) and discuss the clinical presentation, diagnostic imaging and treatment of these tumors. CASE DESCRIPTION: Age at presentation ranged from 19 to 59 years old. Two patients were female and 1 male. Duration of symptoms before diagnosis ranged from 1 year to nearly 14 years. Presenting complaints included syncope spells, cranial nerve deficits, headache, and gait instability. Imaging studies revealed well-circumscribed lesions involving the brainstem; the lesion was cystic in one case and calcified in one. They were iso- or hyperdense on CT scan, isodense on T1-weighted and hyperdense on T2-weighted MRI and frequently showed contrast enhancement. All tumors were operated through a posterior fossa craniectomy. Using microsurgical techniques only partial resection could be achieved, as there was no sharp delineation from the surrounding tissue in any case. Two of our patients had increased neurological deficits after surgery. Radiotherapy was not given. Follow-up of tumoral remnants has not shown clear tumor growth after 1, 3.5, and 10 years. CONCLUSIONS: Imaging characteristics of brainstem gangliogliomas do not seem to differ from those in other locations and are not specific. Radical surgery is rarely if ever possible, nor is it advisable because of the risk of functional deterioration. However, because of their benign histology, partial resection seems to carry a similar prognosis as tumors in other locations that are amenable to complete resection.

[Meningioma of the olfactory groove: review of a series of 27 cases]. / Meningiomas del surco olfatorio: revisión de una serie de 27 casos.

OBJECTIVE: To describe our experience with olfactory groove meningiomas, analysing their clinical and radiological form of presentation and their surgical treatment. METHODS: The clinical records of 27 patients diagnosed of olfactory groove meningioma, extracted from the series of meningiomas operated on in our department since 1973, were retrospectively reviewed. Demographical data, the clinical presentation and duration of the symptoms before diagnosis were collected. Several radiological characteristics were also reviewed such as the tumour size, associated brain edema, type of contrast enhancement, presence of endostosis and invasion of the cranial base. The surgical resection grade, the histological type and the presence of recurrences in the follow-up were also analysed. RESULTS: The average age at presentation was 59 years. Average duration of symptoms prior to diagnosis was 39 months. The most frequent symptom at presentation was higher function impairment (52%), The average maximum tumoral diameter was 6.2 cm. 61% of the patients presented moderate or severe brain edema, which was quite frequently bilateral (74%). Radiological endostosis was present in 37% of the cases, but there were no signs of bone invasion in any case. The approach used was the basal frontal, uni or bilateral. In all cases the grade of resection was Simpson II. The majority of the cases presented a typical histology. Over 80% of the cases presented a good recovery at discharge. None of the patients presented with a tumoral recurrence after an average radiological follow-up of 74 months. CONCLUSIONS: The olfactory groove is an infrequent location for intracranial meningiomas, accounting for only 4.5% of all meningiomas in our experience. These tumours reach a big size due to the delay in diagnosis. Drilling of the cranial base does not seem necessary for preventing tumoral recurrence.

[Tentorial meningiomas. A study of 14 surgically verified cases]. / Meningiomas del tentorio: análisis de 14 casos operados.

OBJECTIVE: Complete surgical resection is considered to be the elective treatment for tentorial meningiomas. The objective of this work is to describe the clinical and radiological characteristics of these tumours, the best surgical approach, complications related to surgery and long term outcome of patients harbouring a meningioma at this location. MATERIALS AND METHODS: A series of 14 patients with tentorial meningiomas consecutively operated at our department between 1977 and 1999 is analyzed. Twelve patients were studied with CT and the last 8 with MR. Arteriography or angio-MR were performed in some patients when dural sinuses involvement was suspected. Tumoral resection was evaluated by means of Simpson Scale and final outcome according to the Glasgow Outcome Scale (GOS). RESULTS: Nine patients were female and 5 male. Mean age was 64 years (41-82). The average duration of presenting symptoms was 17 months. Headache was the most frequent presenting symptom. The tumour was implanted at the tentorial free edge in 4 cases, at the lateral region in 9 and at the falcotentorial region in 1 case. Complete surgical resection (Simpson I-II) was achieved in 10 cases. Final outcome was good recovery in 9 cases, moderate disability in 1, severe disability in 2 and two patients died. CONCLUSIONS: Surgery is the elective treatment for tentorial meningiomas. In most cases, complete surgical resection should be the objective. Subtotal resection may be considered when the tumour invades a patent dural sinus or the cavernous sinus or when the tumour is closely adherent to the brain stem. In these cases a close follow up is needed and reoperation or radiosurgical treatment may be contemplated if residual tumour growth occurs.

Cerebral lymphoma presenting as a leukoencephalopathy.

Cerebral lymphoma is infrequent in immunocompetent patients. This tumour usually appears on CT and MRI as a single lesion or as multiple lesions with mass effect and homogeneous enhancement after contrast administration. A patient is described with a cerebral lymphoma, confirmed by histopathological examination, who presented as a progressive leukoencephalopathy.

Basal ganglia hematomas in severely head injured patients: clinicoradiological analysis of 37 cases.

OBJECT: The authors analyzed the clinicoradiological presentation of traumatic basal ganglia hematomas (TBGHs) in severely head injured (SHI) patients. METHODS: The records of 37 patients (28 male and nine female patients with a mean age of 28 years) in whom computerized tomography (CT) scans revealed TBGHs 2 ml or more in volume were retrospectively reviewed. These cases represented 2.4% of the total series of 1526 SHI patients admitted to the authors' institution between 1979 and 1998. Thirty-five patients (94%) were involved in traffic accidents and only two exhibited a period of lucidity. Associated extracranial injuries were seen in 21 patients (57%) and coagulation disorders in 32 (86%). Skull fracture was present in 10 (43%) of the 23 patients in whom skull x-ray films were obtained. Computerized tomography findings indicated diffuse axonal injury in 27 patients (73%), intraventricular hemorrhage in 22 patients (59%), and subarachnoid hemorrhage in 16 patients (43%). In all but two patients, the TBGHs were visible on the initial CT scan, and in 28 cases (76%) these hematomas were contralateral to the side of impact. Hematoma enlargement over the first few posttraumatic days was noted in 65% of the patients in whom control CT scans had been obtained (22 of 34 patients). Four patients (11%) underwent surgery to remove their TBGHs. Final outcomes were poor: 22 patients (59%) died, two (5%) became vegetative, seven (19%) experienced severe disabilities, and only six patients (16%) made a favorable recovery. CONCLUSIONS: Traumatic basal ganglia hematomas are dynamic lesions that tend to enlarge during the acute posttraumatic period. The overall prognosis in this series was poor. Patients in whom the volume of the hematoma was larger than 25 ml and those in whom hematoma volume enlargement or raised intracranial pressure occurred had the worst outcomes, perhaps indicating the need for a more aggressive surgical treatment.

Parosteal osteosarcoma of the skull.

Parosteal osteosarcoma of the skull is a distinct surface bone tumor, with a better prognosis than conventional osteosarcoma. The most common location is on the surface of the distal femur which accounts for 46-66% of the cases. The presentation in the skull is uncommon and there are few cases reported in the literature. We describe the case of a man who developed a parosteal osteosarcoma arising from the occipital bone with extension to the parietal bone. The patient was operated and had a complete tumor resection.

Age and outcome after severe head injury.

The authors analyzed the relationship between patient age and the final outcome in a series of 810 patients aged 14 years or older who were consecutively admitted between 1987 and 1996 after suffering a severe closed head injury. The most relevant clinico-radiological variables were prospectively collected in a Data Bank. Stratified and logistic regression analyses were performed in order to assess the influence of age on adverse outcome and the interaction between patient age and other prognostic indicators. Our results reaffirm that the adverse outcome rate increases steadily with age in severe head injured patients and that age effect on outcome is independent of other prognostic variables. The odds of having an adverse outcome increases significantly over 35 years of age being 10 times higher in patients older than 65 years as compared to those aged 15-25 years (reference age group). The adverse influence of an advanced age on the final outcome has not yet been satisfactorily explained but an older brain may have an impaired ability to recover after a pathological insult as compared to a younger one.