Classification of structural lesions in magnetic resonance imaging. Surgical implications in drug-resistant epilepsy patients.

INTRODUCTION: The presence of a structural lesion in the preoperative magnetic resonance imaging (MRI) of drug-resistant epilepsy patients has been usually associated with a favourable surgical outcome. We present our experience in our Epilepsy Surgery Unit. PATIENTS AND METHODS: Clinical records from 265 patients, operated on from 1990-2010 in our institution, were reviewed. Patients were classified, according to MRI findings, into three groups: surgical lesion (SL), tumors or vascular malformations requiring surgery 'per se'; orientative lesion (OL), dysplasia, atrophy or mesial temporal sclerosis; and (NL) group, with normal MRI. Seizure outcomes were analysed in relation to this classification. RESULTS: Period 1990-2000, 151 patients: 87% of SL, 65% of OL and 57% of NL patients were in Engel class I or II at the two-year follow-up. Among temporal lobe epilepsy cases (TLE), 87% of SL, 67% of OL and 56% of NL patients achieved seizure control. Differences were statistically significative. Period 2001-2010, 114 patients: 100% of SL, 90% of OL, and 81% of NL patients were in Engel's class I or II. Both TLE and extratemporal (ETLE) SL patients obtained a 100% seizure control. Among the OL patients, 95% with TLE and 43% of ETLE achieved seizure control. In the NL group, the percentages were 88% in TLE, and 50% in ETLE. CONCLUSIONS: In our series, SL was a predictor of a favorable outcome. In TLE patients, good results were achieved despite normal MRI. Patients with ETLE and NL did not have a worse outcome than those with OL. A classification in SL, OL and NL seems more helpful for predicting the surgical outcome than the traditional classification lesion versus non-lesion MRI. Radiological findings must be carefully evaluated in the context of a complete epilepsy surgery evaluation.

TITLE: Clasificacion de las lesiones estructurales en resonancia magnetica. Implicaciones quirurgicas en pacientes con epilepsia farmacorresistente.Introduccion. En la seleccion quirurgica del paciente con epilepsia farmacorresistente, el papel de la resonancia magnetica (RM) no se ha cuantificado hasta el momento. Presentamos la experiencia en nuestra Unidad de Cirugia de la Epilepsia. Pacientes y metodos. Se estudiaron retrospectivamente los pacientes intervenidos por epilepsia farmacorresistente. Distinguimos dos periodos: 1990-2000 (RM de 0,5 T) y 2001-2008 (RM de 1,5 T). La RM preoperatoria se clasifico en tres grupos: RM con lesion quirurgica (LQ), RM orientativa (LO) y RM normal (NL). Tambien se efectuo una clasificacion anatomopatologica similar. Se correlacionaron las distintas clasificaciones y los resultados quirurgicos. Resultados. Periodo 1990-2000: 151 pacientes. El 70% quedo en las clases de Engel I o II. Segun la RM, los resultados fueron: LQ, 87%; LO, 65%; y NL, 57%. Las diferencias fueron estadisticamente significativas. Periodo 2001-2008: 114 pacientes. El 89% quedo en las clases de Engel I o II. Segun la RM: LQ, 100%; LO, 90%; y NL, 81%. Las diferencias fueron estadisticamente significativas. Los pacientes con epilepsia del lobulo temporal y extratemporal con LQ tuvieron un 100% de control; con LO, el 95% con epilepsia del lobulo temporal y el 43% con estado epileptico; en aquellos pacientes sin lesion (NL), el 88% con epilepsia del lobulo temporal se controlo frente al 50% con estado epileptico. Conclusiones. La RM es una herramienta eficaz en la seleccion de candidatos quirurgicos en la epilepsia. La LQ asocia muy buen pronostico. En la epilepsia del lobulo temporal se pueden obtener muy buenos resultados (80-90% de control) a pesar de una RM normal. En el estado epileptico, las LO pueden tener peor resultado que la NL en la RM.

Electrocorticographic evidence and surgical implications of different physiopathologic subtypes of temporal epilepsy.

OBJECTIVE: Mesial temporal lobe epilepsy (MTLE) might have a focal or a network physiopathology. Therefore, the objective of this study was to demonstrate that changes in the spiking activity during electrocorticography (ECoG) could reflect changes in the epileptic network, and the resection of the epileptogenic zone could eliminate the mesial spikes. METHODS: Twenty-five MTLE patients were intraoperatively evaluated by ECoG and the mesial strip was maintained until the lateral cortectomy (LC) was completed. Total spiking activity (TSA, mean spikes/min for all the mesial channels) was computed off-line before and after LC. Either a tailored anterior medial temporal resection or LC was carried out based on the TSA changes. RESULTS: The outcome at 19.1±1.4 months was Engel's class I, 84%; II, 8%; or III, 8%. During the LC, the TSA recorded from the mesial strip did not change in 14 patients, increased in three patients, and decreased in eight patients. In 20% of patients, the mesial activity completely disappeared, and the mesial structures were spared. All of these patients were Engel's class IA. CONCLUSIONS: Our results strongly suggest the existence of physiopathologic differences in MTLE. The identification of these subtypes is fundamental for an individualized surgical approach. SIGNIFICANCE: ECoG would be needed to offer a better surgical approach.

New insights on culture and calcium signalling in neurons and astrocytes from epileptic patients.

Primary brain cell cultures are a useful tool for understanding the physiopathology of epilepsy and for searching new potential antiepileptic drugs. These cell types are usually prepared from murine species and few human models have been described. The main goal of this study is the establishment of experimental conditions to isolate and culture neurons and astrocytes from human brain and to test its functionality. The tissues came from antiepileptic drug-resistant epileptic patients undergoing surgery. Human neurons and astrocytes were isolated following an enzymatic and mechanical dissociation protocol. Cultures were viable for 3-6 weeks. Cytological characterization was performed by immunocytochemistry using specific antibodies against both neuron (anti-NeuN) and astrocyte (anti-GFAP) protein markers. In order to test their viability and functionality, cells were loaded with the fluorescent calcium probe fura-2 and variations in cytosolic calcium concentrations ([Ca2+]c) were measured by cell imaging. [Ca2+]c increases were evoked upon cell stimulation with high K+ (KCl 75 mM), glutamate (500 µM) or bicuculline (100 µM). Interestingly, spontaneous [Ca2+]c transients were also observed in some neuron-like cells. A novel unreported finding in this study has been the incorporation of human serum that was critical for cell functionality. The setting of these human cultures open the opportunity to new insights on culture and calcium signalling studies on the mechanism(s) of cell resistance to antiepileptic drugs, as well as to studies on plasticity, maturation and possible neurite emission for graft studies.

[Cavernous haemangioma of the skull]. / Hemangioma cavernoso intraóseo craneal.

INTRODUCTION: Cavernous haemangiomas are benign tumours that rarely affect the skull. A correct suspicion diagnosis is seldom obtained when typical radiological signs are lacking. In this way a definite diagnosis is only obtained after a surgical procedure in most cases. CASE REPORT: A 52-year-old female presented a painless, slow-growing tumoration in her right forehead. Skull CT showed an osteolytic lesion located within the right frontal bone. On suspicion of a metastatic origin of the lesion, a systemic research for a primary tumour was performed without significative findings. Finally, en bloc resection of the lesion was performed followed by cranioplasty. Microscopically, the lesion proved to be a cavernous haemangioma of the frontal bone. CONCLUSION: Despite their low frequency, cavernous haemangiomas must be included in the differential diagnosis of slow-growing osteolytic lesions located within the skull. The elective treatment of this tumours includes a complete resection by craniectomy, with safe bony margins.

Hemangioma cavernoso intraóseo craneal / Cavernous haemangioma of the skull

Introducción. Los hemangiomas cavernosos sontumores benignos que excepcionalmente afectan loshuesos craneales. En ausencia de signos radiológicostípicos, frecuentemente son intervenidos bajo la sospechade otro tipo de neoplasia ósea, obteniéndose el diagnósticoúnicamente tras el procedimiento quirúrgico.Caso clínico. Presentamos el caso de una pacientede 52 años con una tumoración indolora del huesofrontal derecho, de lento crecimiento y característicasosteolíticas desde el punto de vista neurorradiológico.Para descartar un origen metastásico, se llevó a cabo unestudio oncológico sistémico, sin hallazgo de neoplasiaprimaria. Finalmente, la lesión fue extirpada en bloquemediante craniectomía, seguido de craneoplastia.El diagnóstico anatomo-patológico fue hemangiomacavernoso intraóseo.Conclusión. A pesar de su baja frecuencia, el diagnósticode hemangioma cavernoso intraóseo debe serconsiderado ante la presencia de una tumoración cranealde lento crecimiento y características osteolíticasen las pruebas de neuroimagen. El tratamiento deelección consiste en la resección completa de la lesiónmediante craniectomía, incluyendo márgenes de seguridadde hueso sano (AU)

Introduction. Cavernous haemangiomas are benigntumours that rarely affect the skull. A correct suspiciondiagnosis is seldom obtained when typical radiologicalsigns are lacking. In this way a definite diagnosis is onlyobtained after a surgical procedure in most cases.Case report. A 52-year-old female presented a painless,slow-growing tumoration in her right forehead.Skull CT showed an osteolytic lesion located within theright frontal bone. On suspicion of a metastatic originof the lesion, a sistemic research for a primary tumourwas performed without significative findings. Finally,en bloc resection of the lesion was performed followedby cranioplasty. Microscopically, the lesion proved to bea cavernous haemangioma of the frontal bone.Conclusion. Despite their low frequency, cavernoushaemangiomas must be included in the differentialdiagnosis of slow-growing osteolytic lesions locatedwithin the skull. The elective treatment of this tumoursincludes a complete resection by craniectomy, with safebony margins (AU)

[Refractory epilepsy as the presenting symptom of a brucellar brain abscess]. / Epilepsia refractaria como presentacioón de absceso cerebral brucelósico.

INTRODUCTION: Brucellosis is a zoonotic disease that is occasionally transmitted to human beings from infected animal reservoirs. It is an important condition in endemic areas. One infrequent complication of systemic brucellosis is the infection of the central or the peripheral nervous systems. CASE REPORT: A 54-year-old male who was being studied prior to surgery for refractory epilepsy, with clinical expression in the form of complex partial seizures. Neuroimaging findings revealed an expansive lesion in the right temporal lobe, which direct serological, histopathological and microbiological evidence showed to be a chronic brucellar abscess. After combined treatment involving complete surgical resection followed by a cycle of standard antimicrobial therapy, the patient was seizure-free at one year of follow-up. CONCLUSIONS: Despite its low frequency, infection by Brucella must be considered in the differential diagnosis of intracranial expansive lesions, as well as in the case of patients whose presenting symptoms are epileptic seizures. To perform the diagnosis it is especially important to be aware of the wide range of clinical and radiological manifestations that can be produced, and which do not always correlate. Identification of risk factors on the patient record is also a crucial step.

Epilepsia refractaria como presentación de absceso cerebral brucelósico / Refractory epilepsy as the presenting symptom of a brucellar brain abscess

Introducción. La brucelosis es una enfermedad zoonósicaque se transmite de forma ocasional al ser humano desde reservoriosanimales infectados. Representa una entidad de relevanciaen áreas endémicas. Una complicación poco frecuente de la brucelosissistémica es la infección del sistema nervioso, tanto centralcomo periférico. Caso clínico. Varón de 54 años en estudio prequirúrgicode epilepsia refractaria, con expresión clínica en forma decrisis parciales complejas, en el cual se demostró mediante técnicasde neuroimagen una lesión expansiva en el lóbulo temporal derecho,filiada como absceso crónico brucelósico mediante demostraciónserológica, histopatológica y microbiológica directa. Tras eltratamiento combinado mediante resección quirúrgica completa,seguido de un ciclo de tratamiento antimicrobiano, el paciente quedólibre de crisis tras un año de seguimiento. Conclusiones. A pesarde su baja frecuencia, la infección por Brucella debe considerarseen el diagnóstico diferencial de las lesiones expansivas intracraneales,así como en los pacientes cuya forma de presentación son lascrisis epilépticas. Para la realización del diagnóstico es de especialimportancia el conocimiento de la amplia variedad de manifestacionesclínicas y radiológicas a las que puede dar lugar, y que nosiempre encuentran correlato, así como la identificación de factoresde riesgo en la historia clínica

Introduction. Brucellosis is a zoonotic disease that is occasionally transmitted to human beings from infectedanimal reservoirs. It is an important condition in endemic areas. One infrequent complication of systemic brucellosis is theinfection of the central or the peripheral nervous systems. Case report. A 54-year-old male who was being studied prior tosurgery for refractory epilepsy, with clinical expression in the form of complex partial seizures. Neuroimaging findingsrevealed an expansive lesion in the right temporal lobe, which direct serological, histopathological and microbiologicalevidence showed to be a chronic brucellar abscess. After combined treatment involving complete surgical resection followedby a cycle of standard antimicrobial therapy, the patient was seizure-free at one year of follow-up. Conclusions. Despite itslow frequency, infection by Brucella must be considered in the differential diagnosis of intracranial expansive lesions, as wellas in the case of patients whose presenting symptoms are epileptic seizures. To perform the diagnosis it is especially importantto be aware of the wide range of clinical and radiological manifestations that can be produced, and which do not alwayscorrelate. Identification of risk factors on the patient record is also a crucial step

[Pharmacoresistant temporal-lobe epilepsy. Exploration with foramen ovale electrodes and surgical outcomes]. / Epilepsia farmacorresistente del lóbulo temporal. Exploración con electrodos del foramen oval y resultados quirúrgicos.

AIM: To report our experience in the surgical treatment of temporal-lobe epilepsy. PATIENTS AND METHODS: An analysis was performed of the outcomes of 137 patients submitted to surgery between 1990 and 2001, with a follow-up of more than two years. A study was conducted of the percentages of successful detection by the different complementary tests--MRI, EEG, interictal SPECT, video-EEG with foramen ovale electrodes (FOE), neuropsychological study (NPS)--and the precision with which they reported the epileptogenic focus. RESULTS AND CONCLUSIONS: Successful surgical outcomes (Engel grades I-II): 73.4%. No surgical mortality occurred, although some mild, reversible morbidity was observed. Surgical outcomes were not affected by sex, age, age of onset and the length of time the patient had had the disease, or the frequency of the seizures. No association was found between seizures in the immediate post-operative period and a poorer long term control of the epilepsy. MR images were normal in 25% of patients; in these cases the surgical outcomes (Engel grades I-II at two years: 62%) were significantly poorer than in cases of tumours/cavernomas (86%); RMI studies of other types of lesions gave intermediate results (72%). With respect to the capacity of the different tests to lateralise/locate the epileptogenic focus, video-EEG-FOE proved to be the best, followed by MRI, SPECT, EEG and NPS.

Epilepsia farmacorresistente del lóbulo temporal. Exploración con electrodos del foramen oval y resultados quirúrgicos / Pharmacoresistant temporal-lobe epilepsy. Exploration with foramen ovale electrodes and surgical outcomes

Objetivo. Presentar nuestra experiencia en el tratamiento quirúrgico de la epilepsia del lóbulo temporal. Pacientes y métodos. Se analizan resultados en 137 pacientes, intervenidos quirúrgicamente entre 1990 y 2001, con seguimiento mayor de dos años. Se estudia el porcentaje de aciertos de las pruebas complementarias-RM, EEG, SPECT interictal, vídeo-EEG con electrodos del foramen oval (EFO), estudio neuropsicológico (NPS)- y la precisión con que informaron del foco epileptógeno. Resultados y conclusiones. Éxitos quirúrgicos (grados I-II de Engel): 73,4%. No hubo mortalidad quirúrgica, aunque sí escasa morbilidad, leve yreversible. No modificaron los resultados quirúrgicos ni el sexo, edad, edad de comienzo y tiempo de desarrollo de la enfermedad, ni la frecuencia de las crisis. No encontramos asociación entre crisis en el postoperatorio inmediato y peor control de la epilepsia alargo plazo. La RM fue normal en el 25% de los pacientes; en ellos, los resultados quirúrgicos (grados I-II de Engel a los dos años: 62%) fueron significativamente peores que en los casos detumor/cavernoma (86%); ante otras lesiones en la RM, el resultado fue intermedio (72%). En relación a la capacidad lateralizadora/localizadora del foco epileptógeno de las diferentes pruebas, destaca el vídeo-EEG-EFO, seguido de la RM, SPECT, EEG y NPS

Aim. To report our experience in the surgical treatment of temporal-lobe epilepsy. Patients and methods. Ananalysis was performed of the outcomes of 137 patients submitted to surgery between 1990 and 2001, with a follow-up of more than two years. A study was conducted of the percentages of successful detection by the different complementary tests - MRI,EEG, interictal SPECT, video-EEG with foramen ovale electrodes (FOE), neuropsychological study (NPS) - and the precision with which they reported the epileptogenic focus. Results and conclusions. Successful surgical outcomes (Engel grades I-II):73.4%. No surgical mortality occurred, although some mild, reversible morbidity was observed. Surgical outcomes were not affected by sex, age, age of onset and the length of time the patient had had the disease, or the frequency of the seizures. No association was found between seizures in the immediate post-operative period and a poorer long term control of the epilepsy.MR images were normal in 25% of patients; in these cases the surgical outcomes (Engel grades I-II at two years: 62%) were significantly poorer than in cases of tumours/cavernomas (86%); RMI studies of other types of lesions gave intermediate results (72%). With respect to the capacity of the different tests to lateralise/locate the epileptogenic focus, video-EEG-FOE proved to be the best, followed by MRI, SPECT, EEG and NPS

[Reconstruction of thoracolumbar spine instability: clinical and neuroradiological results of a surgical challenge]. / Reconstrucción de la columna toracolumbar inestable: resultados clínicos y neurorradiológicos de un desafío quirúrgico.

INTRODUCTION: Surgical treatment for thoracolumbar union instability represents a challenge, due to the difficult access to this area of the spine, and to the extreme variability of morphological and biomechanical lesions observed. AIM: To describe the indications and clinical and neuroradiological results obtained with procedures of anterior or combined spinal fusion-instrumentation used for the treatment of instable thoracolumbar lesions. PATIENTS AND METHODS: 17 patients with thoracolumbar instability were treated surgically, being followed-up at least for one year. Causes of instability were classified in three groups: (i) fractures or fracture-luxations (n = 7), (ii) pathologic fractures following tumoral invasion (n = 6) and (iii) infectious or degenerative spondylodiscitis (n = 5). In order to carry out the substitution of the injured vertebral body an anterior approach to the thoracolumbar union was performed in all cases, using a modified technique of thoracophrenolaparotomy in which the diaphragmatic dome was not incised. Depending on the number of columns of Denis damaged, the vertebral corpectomy was followed by either an anterolateral or a combined spinal fusion-instrumentation. RESULTS: Pain in standing position was eliminated postoperatively in 83%. Neurological deficits were improved in 50% of cases. Surgical mortality was null and transient postoperative complications occurred in 11.7% of patients, but no lung atelectasis or respiratory infections were observed. CONCLUSIONS: Chronic pain associated to thoracolumbar instability can be treated successfully by substitution of the damaged vertebral body followed by anterior or combined spinal fusion-instrumentation. Thoracophrenolaparotomy without division of the diaphragm is feasible and it reduces the morbidity associated to postoperative respiratory complications.

Reconstrucción de la columna toracolumbar inestable: resultados clínicos y neurorradiológicos de un desafío quirúrgico / Reconstruction of thoracolumbar spine instability: clinical and neuroradiological results of a surgical challenge

Introducción. El tratamiento de la inestabilidad de la unión toracolumbar constituye un desafío quirúrgico, por el difícil acceso anatómico a este segmento vertebral y por la gran variabilidad de alteraciones morfológicas y biomecánicas existentes. Objetivo. Describir las indicaciones y los resultados clínicos y neurorradiológicos de las técnicas de fusión-instrumentación anterior o combinada, empleadas en el tratamiento de la inestabilidad toracolumbar. Pacientes y métodos. Se ha tratado quirúrgicamente a 17 pacientes con inestabilidad toracolumbar, con un seguimiento posoperatorio mínimo de un año. Las causas de inestabilidad se clasificaron en tres grupos: 1. Fracturas o fracturas-luxación de origen traumático (n = 7); 2. Fracturas patológicas por invasión tumoral vertebral (n = 6), y 3. Espondilodiscitis de origen infeccioso o degenerativo (n = 5). En todos los casos se empleó un abordaje por vía anterior a la unión toracolumbar mediante toracofrenolaparotomía sin sección de la cúpula diafragmática, con sustitución del segmento vertebral y fusión-instrumentación anterolateral o combinada según el número de columnas de Denis dañadas. Resultados. El tratamiento quirúrgico de reestabilizar la unión toracolumbar logró la desaparición del dolor en bipedestación en el 83% de los casos y mejoró el déficit neurológico en el 50%. La mortalidad quirúrgica fue nula y la morbilidad posquirúrgica del 11,7%, sin que se produjeran atelectasias pulmonares o infecciones respiratorias. Conclusiones. El tratamiento de la inestabilidad toracolumbar mediante la sustitución del cuerpo vertebral dañado y fusión-instrumentación anterior o combinada permite eliminar satisfactoriamente el dolor crónico en posición erguida. La técnica de toracofrenolaparotomía sin sección del diafragma reduce la morbilidad asociada a las alteraciones respiratorias posquirúrgicas

Introduction. Surgical treatment for thoracolumbar union instability represents a challenge, due to the difficult access to this area of the spine, and to the extreme variability of morphological and biomechanical lesions observed. Aim. To describe the indications and clinical and neuroradiological results obtained with procedures of anterior or combined spinal fusion-instrumentation used for the treatment of instable thoracolumbar lesions. Patients and methods. 17 patients with thoracolumbar instability were treated surgically, being followed-up at least for one year. Causes of instability were classified in three groups: (i) fractures or fracture-luxations (n = 7), (ii) pathologic fractures following tumoral invasion (n = 6) and (iii) infectious or degenerative spondylodiscitis (n = 5). In order to carry out the substitution of the injured vertebral body an anterior approach to the thoracolumbar union was performed in all cases, using a modified technique of thoracophrenolaparotomy in which the diaphragmatic dome was not incised. Depending on the number of columns of Denis damaged, the vertebral corpectomy was followed by either an anterolateral or a combined spinal fusion-instrumentation. Results. Pain in standing position was eliminated postoperatively in 83%. Neurological deficits were improved in 50% of cases. Surgical mortality was null and transient postoperative complications occurred in 11.7% of patients, but no lung atelectasis or respiratory infections were observed. Conclusions. Chronic pain associated to thoracolumbar instability can be treated successfully by substitution of the damaged vertebral body followed by anterior or combined spinal fusion-instrumentation. Thoracophrenolaparotomy without division of the diaphragm is feasible and it reduces the morbidity associated to postoperative respiratory complications

[Island of Reil and pharmacoresistance in epilepsy]. / Insula de Reil y epilepsia farmacorresistente.

INTRODUCTION: Over the last few years surgery has been developing, with promising results, methods to treat an important number of cases of partial epilepsy that are related, to different extents, with the lobe of the insula and display pharmacoresistance. Better knowledge of the anatomofunctional particularities of this region of the cortex, new neuroimaging and neurophysiological techniques, together with the use of the surgical microscope, stereotactic support and neuronavigation, have had a strong influence on the development of this type of surgery. CASE REPORT: In this paper we report three cases of patients with epilepsy and who were diagnosed as suffering from structural lesions of the insular region: two cavernomas and an oligodendroglioma. The preoperative study was carried out using magnetic resonance imaging, angiography and video EEG. The surgical procedure consisted in a transsylvian approach with electrocorticography, which provided us with the clinical results we have studied. CONCLUSIONS: The correct approach to the diagnosis of the epileptogenic insular lesions must include a complete neurophysiological study and preoperative planning with angiography. This allows their surgical resection through the transsylvian approach and enables us to obtain, with a very low degree of morbidity, clearly satisfactory results as regards the decrease in the number of seizures in these patients

[Clinical and surgical aspects of meningiomas of the base of the skull. 1. Meningiomas of the anterior fossa]. / Aspectos clínicos y quirúrgicos de los meningiomas de la base del cráneo. I. Meningiomas de la fosa anterior.

INTRODUCTION AND OBJECTIVE: Meningiomas are usually benign, slow growing tumours. They form around 15% of all intracranial tumours and approximately a third are found at the base of the skull. In this paper we describe the clinical and surgical characteristics of meningiomas of the anterior fossa and our experience in treating them surgically. PATIENTS AND METHODS: We present 25 patients who were operated on for meningiomas of the olfactory sulcus, orbit and sella and suprasella meningiomas, and the results obtained. RESULTS AND CONCLUSIONS: The results showed: 1. Female predominance at all sites. 2. Age did not determine whether surgery was performed. 3. In most cases macroscopically complete resection of the tumour was achieved. 4. The size of the tumour worsened the preoperative clinical situation and postoperative morbidity and mortality.

[Clinical and surgical aspects of the meningiomas of the base of the skull. III. Meningiomas of the posterior fossa]. / Aspectos clínicos y quirúrgicos de los meningiomas de la base del cráneo. III. Meningiomas de la fosa posterior.

INTRODUCTION AND OBJECTIVE: The close relationship between the meninges of the posterior fossa and major vascular structures, the possible involvement of many cranial nerves and proximity of the brainstem means that surgery of lesions in this region is difficult. Minimal differences in the site of origin of the tumour and its anatomical relations may affect the surgical approach and postoperative results. In this study three basic sites were distinguished (clival and petroclival, petrous or pontocerellar angle and foramen magnum meningiomas). Significant differences were observed in the three types. PATIENTS AND METHODS: We present 26 successive patients whose meningiomas of the posterior fossa were resected and the results obtained. RESULTS AND CONCLUSIONS: 1. The patients operated on included 24 women and 2 men. 2. Age was not decisive when deciding on surgery. 3. The average time between onset of symptoms and diagnosis was 14 months. 4. The petroclival meningiomas were the most difficult to excise. 5. The size of the tumours worsened the preoperative clinical situation and postoperative morbidity.

[Clinical and surgical aspects of meningiomas at the base of the skull. II. Meningiomas of the middle fossa]. / Aspectos clínicos y quirúrgicos de los meningiomas de la base del cráneo. II. Meningiomas de la fosa media.

INTRODUCTION and objective. In spite of the advances made over the past two decades in neuro anesthesia, neuro radiology and neurosurgical microsurgery, meningiomas of the base of the skull are still a challenge in the field of neurosurgery. In this paper we describe the clinical and surgical characteristics of meningiomas of the middle fossa and our experience in their surgical treatment. PATIENTS AND METHODS. We describe 24 patients who were operated on consecutively for meningiomas of the temporal fossa, lesser wing of the sphenoid and cavernous sinus and the surgical results obtained. RESULTS and conclusions. The results obtained included: 1. Predominance of women for all sites. 2. Age was not a decisive factor when deciding whether to operate or not. 3. The average period between onset of symptoms and diagnosis was two years. 4. In most cases resection of the tumour was total, as confirmed on macroscopy studies. 5. There was a significant increase on the Kamofsky scale postoperatively whatever the site of the tumour resected. 6. The tumours of the cavernous sinus were technically the most difficult to resect surgically. 7. The size of the tumour worsened the preoperative clinical condition and postoperative morbidity.

Aspectos clínicos y quirúrgicos de los meningiomas de la base del cráneo II. Meningiomas de la fosa media / Clinical and surgical aspects of meningiomas at the base of the skull. II. Meningiomas of the middle fossa

Introducción y objetivo. A pesar de los avances realizados en las dos últimas décadas, tanto de la neuroanestesia, como de la neurorradiología y de la microcirugía neuroquirúrgica, los meningiomas de la base del cráneo continúan ofreciendo un reto en el campo de la neurocirugía. En el presente trabajo se exponen las características clínicas y quirúrgicas de estos tumores localizados en la fosa media, así como nuestra experiencia en el tratamiento quirúrgico de los mismos. Pacientes y métodos. Se presentan 24 pacientes que han sido intervenidos consecutivamente de meningiomas de la fosa temporal, del ala menor del esfenoides y del seno cavernoso, así como los resultados quirúrgicos. Resultados y conclusiones. Entre los resultados obtenidos se destaca lo siguiente: 1. Predominio del sexo femenino en todas las localizaciones. 2. La edad no constituye un factor determinante en cuanto a la decisión quirúrgica. 3. La media del tiempo transcurrido desde el inicio de los síntomas y el diagnóstico ha sido de dos años. 4. En la mayoría de los casos se obtuvieron resecciones macroscópicamente totales del tumor. 5. En todas las localizaciones se ha observado un incremento significativo en la escala de Karnofsky postoperatoria. 6. Los tumores localizados en el seno cavernoso ofrecieron una mayor dificultad para la resección quirúrgica. 7. El tamaño tumoral influye negativamente en la situación clínica preoperatoria, así como en la morbilidad postoperatoria (AU)

Aspectos clínicos y quirúrgicos de los meningiomas de la base del cráneo III. Meningiomas de la fosa posterior / Clinical and surgical aspects of the meningiomas of the base of the skull. III. Meningiomas of the posterior fossa

Introducción y objetivo. La estrecha relación que mantienen los meningiomas de fosa posterior con estructuras vasculares importantes, la posible afectación de múltiple nervios craneales y la proximidad con el tronco encefálico ponen de manifiesto la dificultad de la cirugía en este tipo de lesiones. Mínimas diferencias en cuanto al lugar de implantación tumoral y sus relaciones anatómicas pueden condicionar tanto el tipo de abordaje quirúrgico como los resultados postoperatorios. En este estudio se han distinguido tres localizaciones básicas (meningiomas clivales y petroclivales, petrosos o del ángulo pontocerebeloso, y del agujero magno) y se contemplan a su vez diferencias significativas en cada una de ellas. Pacientes y métodos. Se presentan 26 pacientes que se han intervenido consecutivamente de meningiomas de la fosa posterior, así como los resultados quirúrgicos. Resultados y conclusiones. Entre los resultados obtenidos se destaca: 1. De los pacientes intervenidos 24 fueron mujeres y dos fueron hombres. 2. La edad no constituye un factor determinante en cuanto a la decisión quirúrgica. 3. La media del tiempo transcurrido desde el inicio de los síntomas y el diagnóstico fue de 14 meses. 4. Los meningiomas petroclivales fueron los más difíciles de extirpar. 5. El tamaño tumoral influye negativamente en la situación clínica preoperatoria, así como en la morbilidad postoperatoria (AU)

Aspectos clínicos y quirúrgicos de los meningiomas de la base del cráneo I. Meningiomas de la fosa anterior / Clinical and surgical aspects of meningiomas of the base of the skull. 1. Meningiomas of the anterior fossa

Introducción y objetivo. Los meningiomas son por lo general tumores benignos y de lento crecimiento; constituyen alrededor del 15 por ciento de todos los tumores intracraneales y, de ellos, aproximadamente un tercio se localiza en la base del cráneo. En el presente trabajo se exponen las características clínicas y quirúrgicas de aquellos localizados en la fosa anterior, así como nuestra experiencia en el tratamiento quirúrgico de estos tumores. Pacientes y métodos. Se presentan 25 pacientes que han sido intervenidos consecutivamente de meningiomas del surco olfatorio, de la órbita, tanto selar como supraselar, así como los resultados quirúrgicos. Resultados y conclusiones. Entre los resultados obtenidos destaca lo siguiente: 1. Predominio del sexo femenino en todas las localizaciones. 2. La edad no constituye un factor determinante en cuanto a la decisión quirúrgica. 3. En la mayoría de los casos se obtuvieron resecciones microscópicamente totales del tumor. 4. El tamaño tumoral influye negativamente en la situación clínica preoperatoria, así como en la morbilidad y mortalidad postoperatoria (AU)

Tratamiento quirúrgico de la espondilodiscitis en la espondilitisanquilosante. Presentación de dos casos / Surgical treatment of spondylodiscitis in ankylosing spondylitis. Two cases report

Introducción. La espondilodiscitis en la espondilitis anquilosante tiene una prevalencia del 5 por ciento. En su patogenia están implicados factores mecánicos e inflamatorios. La intervención neuroquirúrgica es necesaria cuando aparecen complicaciones neurológicas o inestabilidad vertebral. Es una cirugía compleja por la mayor fragilidad de la columna, el estadio avanzado de la enfermedad en estos pacientes y las graves complicaciones pulmonares. Casos clínicos. Presentamos dos pacientes con más de 20 años de evolución de espondilitis anquilosante. Ambos se presentaron con una clínica de varios meses de evolución de dolor lumbar junto con afectación medular. Los hallazgos de imagen revelaron signos de discitis junto con destrucción de los cuerpos vertebrales adyacentes a nivel D11-12 y D12-L1 en uno y otro paciente, respectivamente. En ambos casos se realizó, mediante abordaje anterior, discectomía y resección de los platillos vertebrales adyacentes. A continuación se interpuso injerto autólogo de costilla y se realizó una fijación anterolateral con placa y tornillos sobre los cuerpos vertebrales adyacentes. Evolucionan favorablemente con desaparición del dolor y la clínica neurológica a los 5 y 1 años de evolución. Discusión y conclusiones. Se desconoce la prevalencia de los pacientes intervenidos de espondilodiscitis en el contexto de espondilitis anquilosante. El dolor dorsolumbar de características inflamatorias de nueva aparición en pacientes con espondilitis anquilosante de larga evolución debe hacer sospechar la presencia de espondilodiscitis. Aunque puede estar en relación con un trauma previo, la discitis es el mecanismo fundamental. La RM es la prueba de imagen más sensible. Puede existir una osteoporosis importante y estenosis de canal, además de una grave osificación de todos los ligamentos paraespinales lo que dificulta el abordaje a los cuerpos vertebrales y su posterior fijación. La descompresión del canal medular mediante un abordaje anterior (toracotomía o toracofrenolaparotomía) y fijación espinal anterior es el tratamiento de elección en los casos con afectación neurológica o afectación de la columna anterior y media de Denis (AU)