Bilateral Radioscopically Guided Erector Spinae Plane Block for Postoperative Analgesia in Spine Surgery: A Randomized Clinical Trial.

BACKGROUND: We compare two perioperative pain management procedures(a radioscopicallyguided erector spinae plane [ESP] block versus the standard wound infiltration technique with local anesthetics) in patients undergoing lumbosacral spine surgery. METHODS: A randomized, double-blind clinical trial was performed, in which adults at our hospital undergoing lumbosacral surgery without fixation were randomly assigned to receive either the standard wound infiltration technique, employing long-term anesthetics, or a radioscopicallyguided ESP block. Postoperative pain severity, morphine consumption, number of patients immobilized due to wound pain, length of hospitalization, and complications were recorded. RESULTS: Over the first 7 postoperative hours, pain relief was superior in the ESP block group among patients who underwent diskectomies or one-level decompression (p< 0.0001). Using an ESP block also was statistically superior at decreasing all postoperative variables recorded in patients scheduled for multilevel decompression: visual analog scale (VAS) pain severity over the first 7 hours after the procedure (p = 0.0004); number of patients with wound pain 1 (p = 0.049), 7 (p< 0.0001), and 24 hours (p = 0.007) after surgery; length of hospitalization (p = 0.0007), number of patients immobilized for wound pain (p = 0.0004) and rescue morphine consumption (p< 0.0001). CONCLUSION: The ESP block is a safe procedure that seems to outperform the infiltration wound technique for postoperative pain management in patients undergoing open spinal surgery. Future studies are needed to verify its effectiveness for arthrodesis/fixation and minimallyinvasive procedures, and for chronic spine pain relief.

Safety margin for the preservation of the nasoseptal artery during trans-nasal endoscopic approach.

BACKGROUND: The introduction of the nasoseptal flap for the reconstruction of extended endoscopic approaches decreased the incidence of postoperative fistula. In order to preserve the septal vascular pedicles, many have started to prepare the flap systematically, prior to the opening of the sphenoid rostrum. The aim of this study is to obtain an average measure of the location of the posterior septal artery using the upper edge of the choana as a landmark. METHODS: Ten cadaveric heads, fixed with formaldehyde and injected with colored silicone, were studied. The course, branching pattern and dominance of the branches of the posterior septal artery were recognized, as well as the distance in of its superior and lower branches respect to the medial upper edge of the choana. RESULTS: In all cases, the posterior septal artery enters as an only vessel through the sphenopalatine foramen. In its sphenoid segment, over the sphenoid rostrum, the posterior septal artery divides into its upper and lower branches, in most cases, laterally to the sphenoid ostium (70%, N.=14). The lower branch was dominant in 60% of the cases (N.=12). Regarding the mean distance in millimeters from the medial upper edge of the choana to the superior branch, it was 14.45±0.4102 (18-11.5) and, to the lower branch, 10.9±0.4682 (14-7). CONCLUSIONS: A rostrum opening to 15 mm over the upper edge of the choana is safe to avoid vascular complications, and to be able to prepare a viable nasoseptal flap only if it is necessary.

Relationship between the posterior septal artery and the upper edge of the choana.

BACKGROUND: The pedicled nasoseptal flap has been a key element in advancing the endoscopic transnasal approach (ETA) for the treatment of skull base lesions from the anterior cranial fossa to the occipitocervical junction. To preserve vascular supply, an anatomical knowledge of the location of the posterior septal artery (PSA) is essential. The objective of this work is to establish the relationship between PSA and the superior edge of the choana to define a safety margin during the opening of the sphenoidal rostrum preserving PSA. METHODS: One hundred and eighty angiotomographies of the brain were assessed. The sphenopalatine artery (SPA) was evaluated in the pterygopalatine fossa and PSA at its entrance into the nasal cavity and on the sphenoidal rostrum. RESULTS: PSA was found in all 3 tomographic planes (axial, coronal and sagittal) in 100 patients (200 PSAs). Thirty-five were male and 65 were females. Average age was 62 years with a range of 19-90 years. Total average distance between PSA and the superior edge of the choana was 8.5 mm with a range of 2.5-18 (12.45 90th percentile). CONCLUSION: Although the distance between the choanal edge and PSA is 8.5 mm on average, due to its variability, a distance of at least 12.45 mm for the opening of the sphenoidal sinus in the ETA approach should be considered as a safety margin.

Bloqueo perioperatorio interfascial del plano del erector espinal lumbosacro para el manejo del dolor postoperatorio en cirugía de columna espinal: estudio prospectivo, randomizado / Interfascial perioperative block of the lumbosacral erector spinae plane for the management of postoperative pain in spinal column surgery: prospective, randomized study

Objetivo: Comparar dos técnicas perioperatorias, el bloqueo del plano del erector espinal y la infiltración de la herida con analgésicos de vida media larga, para el control del dolor de herida postquirúrgico en pacientes operados de cirugía abierta de columna. Material y métodos: Ensayo clínico prospectivo, simple ciego, realizado en el Hospital de Clínicas, desde julio de 2018 hasta marzo de 2019, donde se randomizaron pacientes sometidos a cirugía de columna lumbosacra abierta sin fijación. Se compararon dos técnicas de infiltración perioperatoria para el manejo del dolor de la herida postoperatorio: la infiltración pre y postoperatoria con analgésicos de vida media larga con el bloqueo del plano del erector espinal. Se evaluó el dolor (VAS promedio), el uso de opioides, los días de inmovilización postoperatorios, los días de internación y las complicaciones. Se consideró como estadísticamente significativo una p<0,05. Resultados: 40 pacientes cumplieron con los criterios de inclusión. 20 (50%) fueron sometidos a la técnica de infiltración estándar y 20 (50%) al bloqueo del plano del erector espinal. De los pacientes operados de discectomías y recalibrajes de 1 nivel se mostró que el bloqueo del erector espinal fue superior en el descenso del VAS postoperatorio en las primeras 7 horas (p=0,000). En los recalibrajes de más de 2 niveles, la técnica nueva demostró ser superior en todas las variables analizadas en forma estadísticamente significativa: VAS (p=0,0004) y número de pacientes con dolor de la herida a las 7 horas de la cirugía (p=0,000), horas de internación (p=0,0007), días de inmovilización (p=0,0004) y consumo de opioides (p=0,000). Conclusión: El bloqueo del plano del erector espinal es superior a la técnica de infiltración estandarizada para la disminución del dolor en la herida en pacientes sometidos a cirugía abierta de columna.

Objective: To compare two perioperative techniques, the erector spinae plane block with the infiltration of the wound with long lasting local analgesics, for the management of postoperative wound pain in spinal surgery. Material and methods: Prospective, single-blind clinical trial was performed at the Hospital de Clínicas, from July 2018 to March 2019. Patients undergoing spinal lumbosacral surgery without fixation were enrolled. Two perioperative infiltration techniques were compared for postoperative wound pain management: pre and postoperative infiltration with long lasting analgesics with the interfascial spinae plane erector block. Postoperative results were analyzed in terms of pain relief (VAS), need for opioids, days of immobilization in bed, hours of hospitalization and complications. A p <0.05 was considered statistically significant. Results: 40 patients were included. 20 (50%) underwent the standard infiltration technique and 20 (50%) the interfascial spinae plane erector block. The spinae plane erector block was superior in pain wound relief in the first 7 postoperative hours in patients who underwent discectomies or one level decompressions (p=0,000). In all the patients with decompressions of 2 or more levels, the new technique proved to be statistically significant superior in all the postoperative variables analyzed: VAS (p = 0.0004) and number of patients with wound pain after 7 hours of the surgery (p = 0.000), hours of hospitalization (p = 0.0007), days of immobilization in bed (p = 0.0004) and use of opioids (p = 0.000). Conclusion: The interfascial spinae erector plane is a better technique compare with the standardized infiltration of the wound for postoperative wound pain relief in patients undergoing open spinal surgery.

[Usefulness of minimally invasive spine surgery for the management of thoracolumbar spinal metastases]. / Utilidad de la cirugía espinal mínimamente invasiva en el manejo de las metástasis espinales toraco-lumbares.

OBJECTIVE: To describe the surgical results and evolution of patients who underwent minimally invasive spine surgery (MISS) for the treatment of thoracolumbar spinal metastases, using the NOMS (Neurological, Oncological, Mechanical, Systemic) assessment for the therapeutic decision. METHODS: Patients who underwent MISS technique for the treatment of thoracolumbar spinal metastases were prospectively enrolled at the Hospital Italiano de Buenos Aires, from June 2014 to June 2017. In all cases, the NOMS assessments were performed for therapeutic decision making. Surgical results were analyzed in terms of improvements in Karnofsky performance status, pain relief (VAS - visual analog scale), Frankel, blood loss, need for transfusions, complications, use of opioids and hospitalization length. A P < 0.05 value was considered statistically significant. RESULTS: During the study period 26 patients were included, 13 of them were women. The average age was 57-year-old (27-83 years). Breast cancer was the most frequent primary tumor (27%). The main symptom was pain (96%), although 12 patients presented with myelopathy (46%). High-grade epidural spinal cord compression requiring decompression was observed in 17 cases (65%). According to the SINS (spinal instability neoplastic score), most lesions were potentially unstable or unstable (89%) requiring MISS stabilization. After surgery, pain relief (VAS) and neurological recovery (Frankel) improved significantly in the 77% and 67% of the cases, respectively, with low intraoperative blood loss and without any transfusions. Only one minor surgical complication was presented (4%). The average of hospital stay was 5.5 days. CONCLUSION: In our series and using the NOMS as a therapeutic algorithm, MISS was effective for decompression and spinal stabilization, with a low rate of complications and rapid postoperative recovery.

Flow Diverter for the Treatment of Pseudoaneurysms of the Extracraneal Vertebral Artery: Report of Two Cases and Review of the Literature.

BACKGROUND: Pseudoaneurysms (PAs) of the extracranial vertebral artery (VA) are rare lesions, representing less than 1% of all aneurysms. Although these lesions may resolve spontaneously, they present a high rupture rate, so early preventive treatment is advised. CASE DESCRIPTION: Case 1: A 48-year-old woman presented with pain and cervical rigidity. An angiotomography showed a PA of the left VA at the level of the C2 transverse foramen, with mural thrombosis and bone remodeling of the left lateral mass. The PA was treated with the endovascular placement of a flow diverter stent. The patient was discharged 3 days after the procedure without complications. The last vascular imaging follow-up was performed 6 years after the procedure showing a patent left VA, with complete resolution of the aneurysm. Case 2: A 57-year-old woman was admitted referring cervicalgia after a polytraumatism. An angiotomography revealed a fracture of the C1 posterior arch, lateral mass, and left transverse foramen, on top of a left VA thrombosis due to a vascular dissection. Eleven months after the trauma, a left VA V3 segment arteriovenous fistula developed. It was treated with hydrocoils, with no complications. One month after the embolization, a left VA V3 segment PA was observed and treated with a flow diverter stent. An angiographic follow-up 2 years after the procedure showed a patent left VA, with complete resolution of the PA. CONCLUSION: The use of flow diverters seems to be a safe and effective therapeutic option for the treatment of PAs of the extracranial VAs.

Relación entre la arteria septal posterior y el borde superior de la coana / Relationship between the posterior septal artery and the superior border of the choana

Introducción: El colgajo pediculado nasoseptal (CPNS) ha sido un elemento fundamental en el avance del abordaje transnasal endoscópico (TNE) para tratar lesiones de la base de cráneo desde la fosa anterior hasta el clivus y la unión occipitocervical. El CPNS provee un tejido viable, vascularizado, extenso y versátil el cual es capaz de adherirse al hueso y sellar el defecto dural disminuyendo así el riesgo de fístula de líquido cefalorraquídeo (LCR) en el postoperatorio, del más del 20% a menos del 5%. Tanto para el CPNS primario como para colgajo de rescate es necesario preservar el pedículo vascular por lo que es fundamental el conocimiento anatómico de la localización de la arteria septal posterior y sus ramas, así como los reparos anatómicos para reconocerla en el intraoperatorio. Objetivo: Establecer la relación entre la arteria septal posterior (ASP) y el borde superior de la coana para definir un margen de seguridad durante la apertura del rostro esfenoidal preservando la ASP y sus ramas. Material y métodos: Estudio observacional, descriptivo, retrospectivo de corte transversal. Angiotomografía cerebral (ATC) con contraste endovenoso realizadas en pacientes mayores a 18 años de ambos sexos para el estudio de lesiones vasculares intracraneales. Las ATC fueron realizadas en un tomógrafo Aquilion ONE 320 (Toshiba, Japan). Para la visualización y medición de las imágenes se utilizó el software Alma Workstation V4.2.0.2 (Alma IT Systems). Se documentaron las variaciones anatómicas y se realizaron mediciones entre el borde superior de la coana y la arteria septal posterior en ambas fosas nasales (Fig 2 a y b). Resultados: De los 98 pacientes estudiados, 32 eran varones y 66 mujeres. La edad media fue de 62,6 con un rango de 19 a 90 años (Tabla 1). Se realizaron mediciones en ambos lados (196 ASP). La distancia media entre la ASP y el borde superior de la coana fue de 14,8 mm del lado izquierdo y 14,7 mm del lado derecho. La distancia media total fue de 14,82 (Tabla 1, Fig 4). Discusión: El borde superior de la coana es un reparo confiable por su constancia en la práctica quirúrgica. Otros autores han medido la distancia entre la rama superior de la ASP y el ostium esfenoidal en 8.2 ± 0.5 mm con un rango de 6.6 a 12.2 mm. Sin embargo el ostium no es un reparo tan confiable por su variable localización en el rostro esfenoidal. La distancia entre la ASP o su rama inferior y el arco de la coana, está descrita a 6.72 ± 2.64 mm con un rango de 2.34­12.64. Sin especificar entre la ASP o su rama inferior. Conclusión: La ASP se encuentra en promedio a aproximadamente 15 mm cefálico al borde superior de la coana. Esta distancia puede ser considerada como un margen de seguridad para evitar lesionar el pedículo vascular durante la confección del CPNS o bien para preservarlo durante la apertura del rostro esfenoidal en caso de requerirse un CPNS de rescate.

[Optical coherence tomography as a predictor of visual recovery in patients with pituitary macroadenomas]. / Tomografía de coherencia óptica como predictor de recuperación visual en pacientes con macroadenomas hipofisarios.

BACKGROUND: With pituitary macroadenomas, there is a high incidence of visual loss from optic pathway compression. Surgical removal of the tumor usually prevents progression and allows visual recovery. Our objective was to evaluate if optical coherence tomography (OCT) predicts visual outcomes after surgical decompression. METHODS: Patients with pituitary macroadenomas were prospectively recruited between February 2015 and November 2016. We evaluated preoperative and postoperative visual acuity, automated perimetry, and OCT. We compared the results 6-12 weeks and 6-9 months after surgical removal of the tumor. Dependent and independent continuous variables were analyzed by Student's t-test, linear regression analysis, and Pearson's correlation coefficients, considering P < 0.05 as statistically significant. RESULTS: Visual acuity and visual field defects were much worse in patients with a thin preoperative retinal nerve fiber layer (RNFL). Both patients with normal RNFL thickness and patients with thin RNFL experienced significant improvement in postoperative visual perimetry 6-12 weeks after surgery. OCT values correlated inversely with pre- and postoperative visual fields, which means that, if the nerve was thicker, the visual field was better. Patients with a normal OCT had greater recovery because their preoperative perimetry values were better. The correlation between OCT values and visual field improvement was weak, suggesting that patients' visual fields improved after decompressive surgery independent of the nerve's thickness. CONCLUSION: The computerized visual field continues to be the gold standard in the evaluation of patients with pituitary macroadenomas with optic pathway compression. Our results suggest that OCT might not be an accurate predictor of visual outcomes.

Utilidad de la cirugía espinal mínimamente invasiva (MISS) en el manejo de las metástasis espinales toraco-lumbares / Utility of minimally invasive spinal surgery (MISS) in the management of thoraco-lumbar spinal metastases

Objetivo: Describir los resultados quirúrgicos y evolución de pacientes con metástasis espinales toraco-lumbares operadas con técnica mínimamente invasiva (MISS) utilizando para la decisión terapéutica la evaluación: Neurológica, Oncológica, Mecánica y Sistémica (NOMS). Material y Métodos: Se incluyeron en forma prospectiva pacientes con metástasis espinales toraco-lumbares operados con técnica MISS por el Servicio de Neurocirugía del Hospital Italiano de Buenos Aires, entre junio de 2014 y junio de 2017. Se utilizó en todos los casos el algoritmo de evaluación NOMS para la decisión terapéutica. Se analizaron los resultados quirúrgicos postoperatorios como el Karnofsky Performance Status (KPS), dolor (VAS: Visual Analogue Scale), Frankel, pérdida sanguínea, necesidad de transfusiones, complicaciones, uso de opioides y días de internación. Se consideró como estadísticamente significativo una p<0,05. Resultados: Durante el período de estudio 26 pacientes cumplieron los criterios de inclusión, de los cuales 13 fueron mujeres. La edad promedio fue 57 (27-83) años. El origen más frecuente de las lesiones fue cáncer de mama (27%). El síntoma más constante fue el dolor (96%), aunque 12 pacientes manifestaron inicialmente mielopatía (46%). Se observaron grados avanzados de invasión del canal con requerimiento de descompresión en el 65% de los casos. Acorde al Spinal Instability Neoplastic Score (SINS), 23 pacientes (89%) presentaron lesiones potencialmente inestables o inestables, requiriendo estabilización. Se evidenció una mejoría estadísticamente significativa del VAS en el 77% y del Frankel en el 67% de los casos tras la cirugía. No hubo necesidad de transfusiones. Se registró sólo una complicación quirúrgica leve (4%). La media de internación fue de 5,5 días. Conclusión: En nuestra serie y utilizando como algoritmo terapéutico el NOMS, la cirugía MISS resultó efectiva tanto para la descompresión para la estabilización espinal, con baja tasa de complicaciones y rápida recuperación postoperatoria.

Objective: To describe the surgical results and evolution of patients who undergo minimally-invasive spinal surgery (MISS) to treat thoracolumbar metastases, using the NOMS (Neurological, Oncological, Mechanical, Systemic) assessment tool to aid therapeutic decisions. Methods: Patients who underwent MISS to treat thoracolumbar metastases were prospectively enrolled at the Hospital Italiano de Buenos Aires, from June 2014 to June 2017. In all cases, the NOMS assessment tool was employed for therapeutic decision-making. Surgical results were analyzed, in terms of improvements in Karnofsky Performance Status (KPS), pain severity (VAS), and the Frankel neurological scale; also measured were blood loss and the need for transfusions, complications, use of opioids, and the length of hospitalization. P values <0.05 were considered statistically significant. Results: Twenty-six patients were enrolled (13 women) of mean age 57 years old (27-83). Breast cancer was the most frequent primary tumor (27%). The main presenting symptom was pain (96%), although 12 patients presented with myelopathy (46%). High-grade epidural spinal cord compression requiring decompression was observed in 17 patients (65%). According to the SINS (Spinal Instability Neoplastic Score), most lesions were either potentially unstable or unstable (89%), requiring stabilization. After surgery, pain severity and neurological status improved significantly in 77% and 67% of patients, respectively, with low intraoperative blood loss and no need for transfusions. Only one minor surgical complication occurred (4%). The average hospital stay was 5.5 days. Conclusion: In our series, using the NOMS instrument as the therapeutic algorithm, MISS was effective for spinal decompression and stabilization, with a low rate of complications and rapid postoperative recovery.

Tratamiento endoscópico de quistes coloideos del tercer ventrículo / Third ventricle colloid cysts endoscopic approach

Introducción: los quistes coloideos (QC) son tumores benignos de crecimiento lento, que comprenden menos del 1% de los tumores intracraneales. Se presentan en adultos jóvenes y se ubican más frecuentemente en el techo del tercer ventrículo. El objetivo de este trabajo es presentar una serie de pacientes con QC del tercer ventrículo operados por vía endoscópica, analizar la técnica quirúrgica, ventajas y desventajas. Desarrollo: se realizó una búsqueda retrospectiva de pacientes operados por vía endoscópica, en el Servicio de Neurocirugía del Hospital Italiano de Buenos Aires, de tumores del tercer ventrículo en un período de 2 años (2013-2015), con diagnóstico de QC confirmado por anatomía patológica . Se identificaron cinco pacientes, tres mujeres y dos hombres, cuyo promedio de edad fue de 50 años. No hubo complicaciones perioperatorias y ninguno mostró recidiva en el lapso de observación. Conclusión: la vía endoscópica es una vía técnicamente simple y con muy baja morbilidad. Si bien no siempre puede realizarse una exéresis completa, los trabajos prospectivos permitirán definir si esto resulta suficiente para el control de la enfermedad. (AU)

Colloid cysts are benign, slow-growing tumors, comprising less than 1% of intracranial tumors. They occur in young adults and are more frequently located on the roof of the third ventricle. The objective of this study is to present a series of patients with Colloid cysts operated endoscopically and analyze advantages and disadvantages of this surgical technique. We performed a retrospective review of Colloid Cysts operated on endoscopically, at the Neurosurgical Department of Hospital Italiano de Buenos Aires in a period of 2 years (2013-2015). Five patients were identified, three women and two men whose average age was 50 years. No perioperative complications were observed, with no recurrences during the follow up period. Conclusion: the endoscopic approach is technically simple and has very low morbidity. Although a complete excision can not always be performed, prospective studies will allow us to define whether if is sufficient to control the disease. (AU)

[Relevance of Simpson's grades in the resection of grade I meningiomas]. / Relevancia de los grados de Simpson en la resección de meningiomas grado I.

OBJECTIVE: Compare the number of recurrences in patients with WHO Grade I meningiomas that underwent microsurgical resection. INTRODUCTION: In 1957 Simpson established five grades for surgical resection for intracranial meningiomas and recurrence rate. He thought that an aggressive removal of these tumors with dura and bone was necessary to cure them. Development of new diagnostic methods, advances in anatomopathology and microsurgical technique lead us to question if this scale has a value nowadays. METHODS: A retrospective analysis was performed. All patients operated from grade I meningiomas between February 2006 to December 2015 were included. Pre and postoperative MRI as well as histology were analyzed. A multivariate analysis was performed, a P < 0.05 was considered statistically significant. RESULTS: There was no statistical significant difference between patients undergoing Simpson Grade I, II, III or IV resection (P = 0,3117). This could be best stated for Simpson Grade I and II resection, where the number of patients included in the study was higher. When we analyze tumor location there was not significant difference in recurrence between groups (P = 0,2203). CONCLUSION: For grade I meningiomas there is no significant difference in the recurrence between patients with a Simpson Grade I or II resection, thus increasing morbidity of the surgery is not justified. A new resection scale should be designed taking into account the WHO classification.

Tratamiento endoscópico de 140 tumores de hipófisis, resultados y complicaciones / Endoscopic treatment of 140 pituitary tumors, results and complications

Objetivo: Presentar los resultados y las complicaciones de 140 pacientes con adenomas hipofisarios operados por vía transnasal endoscópica en un período de 4 años. Material y métodos: Se realizó un análisis retrospectivo desde marzo del 2011 hasta diciembre del 2014. Se analizaron las imágenes, los estudios oftalmológicos y hormonales, tanto pre como postoperatorios, así como también la morbimortalidad asociada al procedimiento quirúrgico. Resultados: Se registró un 57,9% de pacientes con tumores funcionantes (n = 81), siendo la patología más frecuente la acromegalia (29,3%). El 78,6% fueron macroadenomas (n = 110), de los cuales el 56,4% (n = 62) presentaban invasión del seno cavernoso; 61 presentaron alteración en el campo visual computarizado (44%). Tras la intervención, el 50,8% de los pacientes obtuvo mejoría. En un 60% de los casos se alcanzó una resección completa. De los pacientes con patología funcionante (81 casos), un 25% persistió con enfermedad activa tras la cirugía. Se registró un 15% de pacientes complicados (n = 21) y un solo fallecimiento (0,7%). Conclusión: Según los resultados obtenidos, esta técnica presenta baja morbimortalidad y elevado éxito terapéutico. La principal limitante para la resección quirúrgica completa es la invasión del seno cavernoso

Objective: To present the clinical and radiographic outcomes of 140 patients with pituitary adenomas treated by an endoscopic endonasal approach (EEA) over a period of 4 years. Material and methods: A retrospective analysis was performed between 2011 and 2014. Pre and post operative MRI, ophtalmological assessment, endocrinological laboratory evaluation and surgical morbidity and mortality were assessed. Results: 57,9% of the patients had functional tumors (n = 81), acromegaly being the most frequent sub-type (29.3%). 78.6% of the lesions were macroadenomas (n = 110) of which 56.4% (n = 62) involved the cavernous sinus, 61 patients presented with visual field defects (44%) of which 50.8% of patients showed improvement after surgery. Gross total removal was achieved in 60% of the cases. Hormonal remission was achieved in the 75% of the patients with functional tumors. The morbidity rate was 15% and one patient died after surgery (mortality 0.7%). Conclusion: EEA is a safe and effective tool to treat pituitary adenomas. The main limitation for complete surgical resection is the cavernous sinus invasion

[Endoscopic treatment of 140 pituitary tumors, results and complications]. / Tratamiento endoscópico de 140 tumores de hipófisis, resultados y complicaciones.

OBJECTIVE: To present the clinical and radiographic outcomes of 140 patients with pituitary adenomas treated by an endoscopic endonasal approach (EEA) over a period of 4 years. MATERIAL AND METHODS: A retrospective analysis was performed between 2011 and 2014. Pre and post operative MRI, ophtalmological assessment, endocrinological laboratory evaluation and surgical morbidity and mortality were assessed. RESULTS: 57,9% of the patients had functional tumors (n=81), acromegaly being the most frequent sub-type (29.3%). 78.6% of the lesions were macroadenomas (n=110) of which 56.4% (n=62) involved the cavernous sinus, 61 patients presented with visual field defects (44%) of which 50.8% of patients showed improvement after surgery. Gross total removal was achieved in 60% of the cases. Hormonal remission was achieved in the 75% of the patients with functional tumors. The morbidity rate was 15% and one patient died after surgery (mortality 0.7%). CONCLUSION: EEA is a safe and effective tool to treat pituitary adenomas. The main limitation for complete surgical resection is the cavernous sinus invasion.

Meningioma cordoide: reporte de dos casos y revisión de la literatura / Cordoid meningioma: report of two cases and review of the literature

El meningioma cordoide es un subtipo infrecuente de meningioma. La mayoría es de gran tamaño y de localización supratentorial. Suelen presentarse clínicamente con síntomas inespecíficos. La Resonancia Magnética de Cerebro muestra una lesión extraaxial compatible con meningioma, siendo la histología y las pruebas de inmunohistoquímica necesarias para realizar el diagnóstico definitivo. La anatomía patológica remeda a la del cordoma ya que se encuentran constituidos por células vacuoladas, epiteloides o fusiformes, dispuestas en cordones o islas dentro de una matriz mixoide. La importancia de conocer esta variante de meningioma radica en su alta tasa de recurrencia, principalmente si la exéresis es incompleta, por lo que son considerados como tumores de mayor agresividad y peor pronóstico. Se presentan dos casos de meningioma cordoide operados en nuestro centro.

Chordoid meningiomas are a rare form of meningioma that, as with most meningiomas, typically present as a bulky, supratentorial tumor. Otherwise, their clinical presentation is non-specific. Brain MRI shows an extra-axial lesion compatible with a meningioma; however, the diagnosis must be confirmed by histopathology and immunohistochemistry. Microscopically, these tumors are composed of spindle or epithelioid, partly-vacuolated cells arranged in nests or cords in a myxoid matrix, resembling a chordoma. Recurrence rates are high following subtotal resection. As such, these tumors are considered a more aggressive variant associated with poorer outcomes. Two patients with a chordoid meningioma treated surgically at our centre, using microsurgical techniques, are presented.