Refractory traumatic intracranial hypertension: the role of decompressive craniectomy.

Traumatic brain injury according to the World Health Organization estimates that by 2020 will be the third leading cause of morbidity and mortality worldwide. Intracranial hypertension refractory to medical management is the cause of increased mortality in neurotrauma. There are various measures to control intracranial hypertension, including surgical. Decompressive craniectomy has been routinely used to treat intracranial hypertension secondary to cerebral infarction, subarachnoid hemorrhage, intracerebral hemorrhage and trauma. We review the literature to describe the mechanisms, types and indications for this procedure.

El trauma craneoencefálico, según la Organización Mundial de la salud, se estima que para el año 2020 será la tercera causa de morbimortalidad en el mundo. La hipertensión intracraneal refractaria al manejo médico es la causante de la mayor mortalidad en esta población de pacientes. Existen diversas medidas para el control de la hipertensión intracraneal, entre ellas las quirúrgicas. La craniectomía descompresiva ha sido utilizada sistemáticamente para tratar la hipertensión intracraneal secundaria al infarto cerebral, la hemorragia subaracnoidea, la hemorragia intracerebral y el trauma. Se hace una revisión de la literatura para describir los mecanismos fisiopatológicos de la lesión cerebral traumática, así como también los tipos y las indicaciones de este procedimiento.

Intradiploic Pterional Epidermoid Tumor: A Case Report and Review of literature.

Intradiploic epidermoid cyst is an uncommonly occurring neoplasm, and only about 200 cases are reported in the form of isolated case report. It is presumed to occur due to ectodermal cells in inclusion in the bone tissue during embryonic life neural tube closure. It commonly remains asymptomatic or rarely presents as a bony lump in the skull bone. Authors report present an interesting case, which presented with swelling, and underwent successful surgical resection. Pertinent literature along with diagnosis and management is briefly reviewed. These lesions can erode the bone and involve the brain parenchyma due to their proximity to the brain. Radiological imaging is very helpful in accurate diagnosis of these lesions and in differentiating intradural from intradiploic varieties of epidermoid. We present an unusual case of this pathology.

[Type I Chiari malformation associated with cerebellar atrophy. Case report]. / Malformación de Chiari Tipo I asociado a atrofia cerebelosa. Reporte de caso.

Chiari malformation is characterized by caudal displacement of the cerebellar tonsils that penetrate into the spinal canal through the foramen magnum, achieving reach the atlas or axis. trunk and any drop of the fourth ventricle is observed. Typically is seen in young adults. In some cases scoliosis and Syringomyelic cavities may occur. The authors present (as far as they know) the first case in the literature with long term follow-up, of a caucasian woman with an unusual form of cerebellar atrophy and Chiari Type I malformation, suffering from weakness in his upper and lower extremities with rapidly progression. The patient was successfully treated with suboccipital decompression and C1 laminectomy.

La malformación de Chiari se caracteriza por un desplazamiento caudal de las amígdalas cerebelosas que penetran hacia el canal raquídeo por el foramen mágnum, logrando llegar hasta el atlas o el axis. No hay descenso del tronco y tampoco del cuarto ventrículo. Típicamente se observa en adultos jóvenes. En algunos casos hay escoliosis y cavidades siringomiélicas. Los autores presentan lo que a su conocimiento es el primer caso de la literatura con seguimiento a largo plazo de una mujer de raza blanca con una forma inusual de atrofia cerebelosa y malformación de Chiari tipo I, que sufre de debilidad en sus extremidades superiores e inferiores rápida y progresivamente. La paciente fue tratada con éxito mediante descompresión suboccipital y laminectomia C1.

Severe Cranioencephalic Trauma: Prehospital Care, Surgical Management and Multimodal Monitoring.

Traumatic brain injury is a leading cause of death in developed countries. It is estimated that only in the United States about 100,000 people die annually in parallel among the survivors there is a significant number of people with disabilities with significant costs for the health system. It has been determined that after moderate and severe traumatic injury, brain parenchyma is affected by more than 55% of cases. Head trauma management is critical is the emergency services worldwide. We present a review of the literature regarding the prehospital care, surgical management and intensive care monitoring of the patients with severe cranioecephalic trauma.

Symptomatic Chiari Malformation with Syringomyelia after Severe Traumatic Brain Injury: Case Report.

Chiari malformation Type I (CM-I) is a congenital disorder, which is basically a tonsillar herniation (≥ 5 mm) below the foramen magnum with or without syringomyelia. The real cause behind this malformation is still unknown. Patients may remain asymptomatic until they engender a deteriorating situation, such as cervical trauma. The objective of this case report is to give a broad perspective on CM-I from the clinical findings obtained in a patient with asymptomatic non-communicating syringomyelia associated with a CM-I exacerbated within 2 years of a TBI, and to discuss issues related to that condition.

Trauma craneoencefálico severo: atención prehospitalaria, manejo quirúrgico y monitoreo multomodal / Severe cranioencephalic trauma: prehospital care, surgical management and multimodal monitoring

El trauma craneoencefálico severo representa por lo menos la mitad de las muertes relacionadas con trauma, la patofisiología celular y clínica esta extensamente estudiada y documentada, las opciones de monitorización y tratamiento constituyen los paradigmas actualmente para la el progreso en la sobrevida disminuyendo la probabilidad de secuelas, junto con los principios de manejo general que incluyen entre otros el control de la temperatura, tensión arterial, sedación, ventilación, nutrición hacen posible la calidad en la atención de nuestros pacientes.

Severe brain trauma accounts for at least half of the deaths related to trauma, cellular pathophysiology and clinic it is extensively studied and documented , the monitoring and treatment options are currently paradigms for progress in decreasing the likelihood of survival sequels along with general management principles which include among others the temperature control, blood pressure, sedation, ventilation, nutrition enables quality care for our patients.

Seizure frequency reduction after posteromedial hypothalamus deep brain stimulation in drug-resistant epilepsy associated with intractable aggressive behavior.

OBJECTIVES: The aim of this study was to analyze the impact of deep brain stimulation (DBS) of the posteromedial hypothalamus (pHyp) on seizure frequency in patients with drug-resistant epilepsy (DRE) associated with intractable aggressive behavior (IAB). METHODS: Data were collected retrospectively from nine patients, who received bilateral stereotactic pHyp-DBS for the treatment of medically intractable aggressive behavior, focusing on five patients who also had DRE. All patients were treated at the Colombian Center and Foundation of Epilepsy and Neurological Diseases-FIRE (Chapter of the International Bureau for Epilepsy), in Cartagena de Indias, Colombia from 2010 to 2014. Each case was evaluated previously by the institutional ethical committee, assessing the impact of aggressive behavior on the patient's family and social life, the humanitarian aspects of preserving the safety and physical integrity of caregivers, and the need to prevent self-harm. Epilepsy improvement was measured by a monthly seizure reduction percentage, comparing preoperative state and outcome. Additional response to epilepsy was defined by reduction of the antiepileptic drugs (AEDs). Aggressive behavior response was measured using the Overt Aggression Scale (OAS). RESULTS: All the patients with DRE associated with IAB presented a significant decrease of the rate of epileptic seizures after up to 4 years follow-up, achieving a general 89.6% average seizure reduction from the state before the surgery. Aggressiveness was significantly controlled, with evident improvement in the OAS, enhancing the quality of life of patients and families. SIGNIFICANCE: In well-selected patients, DBS of the pHyp seems to be a safe and effective procedure for treatment of DRE associated with refractory aggressive behavior. Larger and prospective series are needed to define the pHyp as a target for DRE in different contexts.

Absceso cerebral en pacientes pediatricos / Brain abscess in pediatric patients

El absceso cerebral se constituye como un área central supurativa dentro del parénquima cerebral, dentro de una envoltura ampliamente vascularizada. Los patógenos ampliamente aislados en la patogénesis de esta entidad en niños son los Streptococos spp. A pesar del avance en la terapia antimicrobiana, las técnicas neuroquirúrgicas e imagenológicas, que permiten su diagnóstico y ubicación oportuna, el absceso cerebral aún se considera un problema de salud pública, con una importante incidencia, morbilidad y mortalidad en países en vía de desarrollo. Para el manejo de este tipo de infección del SNC, se requerirá de un abordaje multidisciplinario que involucre terapia médico quirúrgica. El objetivo de esta revisión es hacer un abordaje amplio sobre la patobiología del absceso cerebral relacionada con la labor concerniente al neurocirujano.

Brain abscess is formed as a central suppurativa area within the brain parenchyma, within an envelope extensively vascularized. Microorganisms largely isolated in the pathogenesis of this condition in children are Streptococos spp. Despite the progress in antimicrobial therapy, neurosurgical techniques and imagenologic support, which enabling timely diagnosis and location, brain abscess is still considered a public health problem and has an important incidence, morbidity and mortality in developing countries. To handle this type of CNS infection, will require a multidisciplinary approach involving surgical medical therapy. The aim of this review is to make a comprehensive approach on the pathobiology of brain abscess related to the work concerning the neurosurgeon.

Heridas por proyectil de arma de fuego en cráneo: revisión de la literatura / Firearm projectile wounds on skull: literature review

El trauma craneoencefálico es una de las principales causas de muerte en el mundo, y gran parte de estos se asocian a heridas por arma de fuego en cráneo. Conocer el manejo, las características y fisiopatología de la lesión nos permitirá saber abordar estos casos cuando se presenten a los diferentes centros asistenciales, al tiempo que nos permitirá tener en cuenta las posibles complicaciones, para evitar su aparición y así buscar mejorar la morbilidad por esta causa. Siempre acompañado de un manejo integral que permita abarcar todas las dimensiones afectadas.

Traumatic brain injury is a of the leading causes of death in the world, and many of these are associated with gunshot wounds in the skull. To know management the characteristics and pathophysiology of the lesion will tell as deal with these cases when presented to medical centers, while enabling us to take into account of possible complications, to prevent its occurrence and so try to improve morbidity from this cause. Always accompanied by an integrated management that can encompass all affected dimensions.

Hipotermia terapéutica en la lesión traumática cerebral / Therapeutic hypothermia in traumatic brain injury

El trauma craneoencefálico severo es una causa importante de mortalidad en pacientes jóvenes a nivel internacional. La hipertensión intracraneal es la causa de más del 80 por ciento de los pacientes con lesión traumática cerebral. Al presentar una traumática secundaria, se inician una seria de mecanismos metabólicos que incrementan la lesión al tejido cerebral, la inducción de hipotermia ha demostrado que puede alterar el curso natural del proceso patológico. Los fundamentos biológicos apuntan a que la hipotermia puede tener un potencial beneficio, aunque algunas publicaciones no han demostrado mejoría, es claro que en un grupo de pacientes principalmente jóvenes, la hipotermia temprana puede ser beneficiosa. Presentamos una práctica revisión de la literatura sobre esta temática.

The severe head trauma is a major cause of mortality in young patients worldwide. Intracranial hypertension is the cause of more than 80 percent of patients with traumatic brain injury. When a traumatic secondary presenter, begin a series of mechanisms that increase metabolic injury to brain tissue, induction of hypothermia has been shown to alter the natural course of the disease process. The biological foundations suggest that hypothermia may have a potential benefit, although some publications have not shown improvement, it is clear that in a group of mostly young patients, early hypothermia may be beneficial. We present a practical review of the literature on this subject.

Dystrophic thoracic spine dislocation associated with type-1 neurofibromatosis: Case report and rationale for treatment.

The authors report a rare case of spontaneous dystrophic thoracic spine dislocation in a 14-year-old boy with neurofibromatosis type 1 (NF-1). Anteroposterior and lateral standing radiographs showed a dysplastic kyphoscoliotic deformity, with the thoracic kyphosis and scoliosis measuring 75° and 69°, respectively. Three-dimensional reconstruction after computed tomography demonstrated spondyloptosis at T5-T6 with overlapping of T5 over T6 and T7. The patient underwent circumferential fusion with anterior fibular strut grafting mechanically secured between the inferior and superior endplates of T5 and T7 followed by an instrumented posterior fusion from T2 to L1 and thoracoplasty. There was satisfactory resolution of the deformity with stabilization at the last follow-up evaluation.

Management of Craniocerebral Gunshot Injuries: A Review.

Craniocerebral gunshot injuries (CGI) are increasingly encountered by neurosurgeons in civilian and urban settings. Unfortunately this is a prevalent condition in developing countries, with major armed conflicts which is not very likely to achieve a high rate of prevention. Management goals should focus on early aggressive, vigorous resuscitation and correction of coagulopathy; those with stable vital signs undergo brain computed tomography scan. Neuroimaging is vital for surgical purposes, especially for determine type surgery, size and location of the approach, route of extraction of the foreign body; however not always surgical management is indicated, there is also the not uncommon decision to choose non-surgical management. The treatment consist of immediate life salvage, through control of persistent bleeding and cerebral decompression; prevention of infection, through extensive debridement of all contaminated, macerated or ischemic tissues; preservation of nervous tissue, through preventing meningocerebral scars; and restoration of anatomic structures through the hermetic seal of dura and scalp. There have been few recent studies involving penetrating craniocerebral injuries, and most studies have been restricted to small numbers of patients; classic studies in military and civil environment have identified that this is a highly lethal or devastating violent condition, able to leave marked consequences for the affected individual, the family and the health system itself. Various measures have been aimed to lower the incidence of CGI, especially in civilians. It is necessarily urgent to promote research in a neurocritical topic such as CGI, looking impact positively the quality of life for those who survive.

[Pediatric Gliosarcoma: Case Report and Literature Review]. / Gliosarcoma pediatrico: Reporte de un Caso y Revisión de la Literatura.

Brain gliosarcoma is a rare variant of glioblastoma multiforme that occurs primarily between the sixth and seventh decades of life. Few cases have been reported in patients younger than nineteen years. We report a four-year-old male with clinical, imaging and pathology compatible with brain gliosarcoma. Beside surgery he was managed with adjuvant radiotherapy and after follow-up is free of recurrence or neurologic deficit. Brain gliosarcoma is highly aggressive and the median survival is related to the extent of surgical resection.

[Influence of armed conflict on mortality due to traumatic brain injury in children and adolescents]. / Influencia del conflicto armado en la mortalidad por trauma craneoencefálico en niños y adolescentes.

BACKGROUND: In the presence an armed conflagration, the mortality behavior of a country is expected to be affected. The aim of this investigation was to assess, in a country with internal warfare, the trend of mortality associated with traumatic brain injury in children and adolescents, which even under social peace conditions, is one of the most common causes of death and disability in this population groups. METHODS: A retrospective, population-based study was conducted, where the trend of mortality due to traumatic brain injury during the 1999 to 2008 period was assessed. A linear regression was performed to establish its correlation with mortality associated with warfare events of the armed conflict. RESULTS: Global mortality rate was 12.7 per 100 000 inhabitants. The temporary analysis showed a -9.67% annual decrease throughout the entire period of study (95 % CI = -9.25 % to -10.1 %; p < 0.001). The mortality rate was increased by 0.28 and 0.62 for each incremental unit in the armed conflict-related violent death rate and in civilian population, respectively. CONCLUSIONS: In an armed conflict scenario, mortality behavior varies according to the intensity of warfare actions. Mortality due to traumatic brain injury in children and adolescents can be used as an indicator of the impact of war on civilian population not involved with the armed conflict.

INTRODUCCIÓN: ante un conflicto bélico es de esperar que el comportamiento de la mortalidad de un país se vea afectado. El objetivo de esta investigación fue evaluar en un país en guerra interna, la tendencia de la mortalidad por trauma craneoencefálico en niños y adolescentes, que aún en condiciones de paz social constituye una de las causas más frecuentes de muerte y discapacidad en esos grupos poblacionales. MÉTODOS: se llevó a cabo un estudio poblacional y retrospectivo en el que se evaluó la tendencia de la mortalidad por trauma craneoencefálico durante el periodo de 1999 a 2008. Se realizó una regresión lineal para determinar su correlación con la mortalidad relacionada con los eventos bélicos del conflicto armado. RESULTADOS: la tasa de mortalidad global fue de 12.7 por 100 000 habitantes. El análisis temporal demostró una disminución anual de ­9.67 % durante todo el periodo de estudio (IC 95 % = ­9.25 % a ­10.1 %, p < 0.001]. La tasa de mortalidad se incrementó 0.28 y 0.62 por cada unidad de incremento en la tasa de muertes violentas relacionadas con el conflicto armado y en población civil, respectivamente. CONCLUSIONES: en un escenario de conflicto armado, el comportamiento de la mortalidad varía en función de la intensidad de las acciones bélicas. La mortalidad por trauma craneoencefálico en niños y adolescentes puede utilizarse como un indicador del impacto de la guerra sobre la población civil ajena al conflicto armado.

Sacroiliac screw fixation: A mini review of surgical technique.

The sacral percutaneous fixation has many advantages but can be associated with a significant exposure to X-ray radiation. Currently, sacroiliac screw fixation represents the only minimally invasive technique to stabilize the posterior pelvic ring. It is a technique that should be used by experienced surgeons. We present a practical review of important aspects of this technique.

[Endovascular management of skull base tumors. A practical review on literature]. / Manejo endovascular de tumores de la base del cráneo. Revisión práctica de la literatura.

Generally speaking, skull base tumors are very difficult-to-reach lesions. More or less, two thirds of those tumors correspond to meningiomas, which are highly vascular tumors. Tumors that are able to an embolization are juvenile nasopharyngeal angiofibromas, hemangiopericytomas, hemangioblastomas, meningiomas, metastatic lesions, paragangliomas, glomus tumors and other paragangliomas. Pre-operatory embolization of tumors arising in the skull base is a surgical strategy which allows to control probable hemorrhages secondary to the surgical resection of the tumor. The benefits of this sort of embolization have been partially demonstrated. However, there are concrete and objective results, as reduction in bleeding, time of surgery, post-operative hospital stay, and the use of blood transfusion; besides, another benefit reported is the lower morbimortality related to the surgical management of neural tissue and vascular structures. The aim of this article was to bring up to date the available information up to this moment, describe briefly the background of the pre-operative embolization of skull base tumors, and emphasize the knowledge related with the variables of this therapy, such as the types of hypervascular tumors, vascular anatomy related to this (according to type and position of the tumor), the types of embolization therapy in hypervascular tumors, as well as the materials that must be used.

Los tumores de la base del cráneo por lo general son lesiones a las que es difícil acceder. Un porcentaje que se aproxima a los dos tercios corresponde a meningiomas, los cuales son tumores altamente vasculares. Los tumores que pueden ser embolizados son los angiofibromas nasofaríngeos juveniles, los hemangiopericitomas, los hemangioblastomas, los meningiomas, las lesiones metastáticas, los paragangliomas, los tumores del glomus y demás paragangliomas. La embolización preoperatoria de tumores que aparecen en la base del cráneo es una estrategia quirúrgica que sirve para controlar probables hemorragias que son secundarias a la resección quirúrgica del tumor. Los beneficios de esto se han demostrado de manera parcial; sin embargo, hay resultados objetivos concretos, como la reducción del sangrado, del tiempo operatorio, de la estancia hospitalaria postoperatoria, y de la utilización de transfusiones sanguíneas, además de una menor morbimortalidad relacionada con la manipulación quirúrgica del tejido neural y las estructuras vasculares. El objetivo de esta revisión consistió en actualizar la información disponible hasta este momento, describir los antecedentes de la embolización preoperatoria de tumores de base de cráneo y enfatizar en el conocimiento de las variables relacionadas con esta terapia, tales como los tipos de tumores hipervasculares, la anatomía vascular relacionada (según el tipo y la localización del tumor), los tipos de terapia embolizante en tumores hipervasculares, así como los materiales que hay que utilizar.