Stereoelectroencephalography in the preoperative assessment of patients with refractory focal epilepsy: experience at an epilepsy centre.

OBJECTIVE: Stereoelectroencephalography (SEEG) is a technique for preoperative evaluation of patients with difficult-to-localise refractory focal epilepsy (DLRFE), enabling the study of deep cortical structures. The procedure, which is increasingly used in international epilepsy centres, has not been fully developed in Spain. We describe our experience with SEEG in the preoperative evaluation of DLRFE. MATERIAL AND METHODS: In the last 8 years, 71 patients with DLRFE were evaluated with SEEG in our epilepsy centre. We prospectively analysed our results in terms of localisation of the epileptogenic zone (EZ), surgical outcomes, and complications associated with the procedure. RESULTS: The median age of the sample was 30 years (range, 4-59 years); 27 patients (38%) were women. Forty-five patients (63.4%) showed no abnormalities on brain MR images. A total of 627 electrodes were implanted (median, 9 electrodes per patient; range, 1-17), and 50% of implantations were multilobar. The EZ was identified in 64 patients (90.1%), and was extratemporal or temporal plus in 66% of the cases. Follow-up was over one year in 55 of the 61 patients undergoing surgery: in the last year of follow-up, 58.2% were seizure-free (Engel Epilepsy Surgery Outcome Scale class I) and 76.4% had good outcomes (Engel I-II). Three patients (4.2%) presented brain haemorrhages. CONCLUSION: SEEG enables localisation of the EZ in patients in whom this was previously impossible, offering better surgical outcomes than other invasive techniques while having a relatively low rate of complications.

Estereoelectroencefalografía en la evaluación prequirúrgica de epilepsias focales refractarias: experiencia de un centro de epilepsia / Stereoelectroencephalography in the preoperative assessment of patients with refractory focal epilepsy: Experience at an epilepsy centre

Objetivo: La estereoelectroencefalografía (E-EEG) es una técnica de evaluación prequirúrgica en pacientes con epilepsia focal refractaria de difícil localización (EFRDL) que permite explorar con electrodos profundos regiones cerebrales de difícil acceso y la profundidad de la corteza. Esta técnica, en auge en centros internacionales, apenas se ha desarrollado en España. Describimos nuestra experiencia con la E-EEG en la evaluación de pacientes con EFRDL. Material y métodos: En los últimos 8 años, 71 pacientes con EFRDL fueron evaluados con E-EEG en nuestro centro. Analizamos prospectivamente los resultados obtenidos en la localización, los resultados quirúrgicos y las complicaciones asociadas a la técnica. Resultados: La mediana de edad fue de 30 años (rango 4-59 años), 27 pacientes eran mujeres (38%). La RM cerebral fue negativa en 45 pacientes (63,4%). Se implantaron 627 electrodos (mediana de 9 electrodos por paciente, rango 1-17), con un 50% de implantaciones multilobares. En 64 (90,1%) pacientes se localizó la zona epileptógena (ZE), siendo extratemporal o temporal plus en el 66% de los casos. En 55 pacientes de los 61 intervenidos el seguimiento fue superior al año: en el último año de seguimiento 32/55 pacientes (58,2%) estaban libres de crisis (Engel I) siendo los resultados favorables (Engel I-II) en el 76,4% de las intervenciones. Tres pacientes (4,2%) presentaron una hemorragia cerebral. Conclusión: La E-EEG permite localizar la ZE en pacientes en quienes anteriormente no era posible, ofreciendo unos resultados quirúrgicos superiores a otras técnicas invasivas y una tasa de complicaciones relativamente baja. (AU)

Objective: Stereoelectroencephalography (SEEG) is a technique for preoperative evaluation of patients with difficult-to-localise refractory focal epilepsy (DLRFE), enabling the study of deep cortical structures. The procedure, which is increasingly used in international epilepsy centres, has not been fully developed in Spain. We describe our experience with SEEG in the preoperative evaluation of DLRFE. Material and methods: In the last 8 years, 71 patients with DLRFE were evaluated with SEEG in our epilepsy centre. We prospectively analysed our results in terms of localisation of the epileptogenic zone (EZ), surgical outcomes, and complications associated with the procedure. Results: The median age of the sample was 30 years (range, 4-59 years); 27 patients (38%) were women. Forty-five patients (63.4%) showed no abnormalities on brain MR images. A total of 627 electrodes were implanted (median, 9 electrodes per patient; range, 1-17), and 50% of implantations were multilobar. The EZ was identified in 64 patients (90.1%), and was extratemporal or temporal plus in 66% of the cases. Follow-up was over one year in 55 of the 61 patients undergoing surgery: in the last year of follow-up, 58.2% were seizure-free (Engel Epilepsy Surgery Outcome Scale class I) and 76.4% had good outcomes (Engel I-II). Three patients (4.2%) presented brain haemorrhages. Conclusion: SEEG enables localisation of the EZ in patients in whom this was previously impossible, offering better surgical outcomes than other invasive techniques while having a relatively low rate of complications. (AU)

Stereoelectroencephalography in the preoperative assessment of patients with refractory focal epilepsy: Experience at an epilepsy centre. / Estereoelectroencefalografía en la evaluación prequirúrgica de epilepsias focales refractarias: experiencia de un centro de epilepsia.

OBJECTIVE: Stereoelectroencephalography (SEEG) is a technique for preoperative evaluation of patients with difficult-to-localise refractory focal epilepsy (DLRFE), enabling the study of deep cortical structures. The procedure, which is increasingly used in international epilepsy centres, has not been fully developed in Spain. We describe our experience with SEEG in the preoperative evaluation of DLRFE. MATERIAL AND METHODS: In the last 8 years, 71 patients with DLRFE were evaluated with SEEG in our epilepsy centre. We prospectively analysed our results in terms of localisation of the epileptogenic zone (EZ), surgical outcomes, and complications associated with the procedure. RESULTS: The median age of the sample was 30 years (range, 4-59 years); 27 patients (38%) were women. Forty-five patients (63.4%) showed no abnormalities on brain MR images. A total of 627 electrodes were implanted (median, 9 electrodes per patient; range, 1-17), and 50% of implantations were multilobar. The EZ was identified in 64 patients (90.1%), and was extratemporal or temporal plus in 66% of the cases. Follow-up was over one year in 55 of the 61 patients undergoing surgery: in the last year of follow-up, 58.2% were seizure-free (Engel Epilepsy Surgery Outcome Scale class I) and 76.4% had good outcomes (Engel I-II). Three patients (4.2%) presented brain haemorrhages. CONCLUSION: SEEG enables localisation of the EZ in patients in whom this was previously impossible, offering better surgical outcomes than other invasive techniques while having a relatively low rate of complications.

[Leptomeningeal spread of an intramedullary cervical pilocytic astrocytoma: case report and literature review]. / Diseminación leptomeníngea de un astrocitoma pilocítico cervical en el adulto:publicación de un caso y revisión de la literatura.

BACKGROUND. The rarest location of pilocytic astrocytoma is intramedullary. Gliomas represent up to 24 - 30% of intramedullary tumors in adulthood and are second only after ependymomas. Leptomeningeal dissemination through cerebrospinal fluid is unusual and occurs predominantly in medulloblastomas, ependymoblastomas, central neuroblastomas, ependymomas, germ cell tumors and high-grade gliomas. The majority of spinal cord gliomas reporting metastasis were anaplastic astrocytomas or glioblastomas multiforme and relatively few were low-grade gliomas. The incidence of leptomeningeal spread of low-grade tumors is rare. A rare cranial extension of brain leptomeningeal dissemination in an intramedullary pilocytic astrocytoma during adulthood is reported. CASE REPORT. A 51 year-old-man with a recurrent intramedullary mass at C5-C7 level operated 4 times with all pathological anatomy reports describing the lesion as Pilocytic Astrocytoma developed, after 15 years from the diagnosis, visual hallucinations and his level of consciousness worsened to Glasgow coma score 13/15. The MRI showed highly enhanced cranial and spinal leptomeninges and paquimeninges with a micro nodular-granulomatous aspect associated with intense affectation of basal cisterns, subarachnoid spaces and convexity of both cerebral hemispheres suggestive of leptomeningeal spread of the spinal mass. The patient expired after three days. CONCLUSION. Leptomeningeal spread is a rare phenomenon and when it happens usually doesn't change the primary tumor's behavior. In our case the aggressiveness could be explained by a potential malignization of the primary tumor that it was not documented because of the partial resections from the lasts surgeries or instead the tumor was actually a monomorphous pilomyxoid tumor.

Diseminación leptomeníngea de un astrocitoma pilocítico cervical en el adulto: publicación de un caso y revisión de la literatura / Leptomeningeal spread of an intramedullary cervical pilocytic astrocytoma: case report and literature review

Introducción. La localización menos frecuente de los astrocitomas pilocíticos es la intramedular. Los gliomas representan hasta el 24-30% de los tumores intramedulares en el adulto y son los segundos, sólo tras los ependimomas. La diseminación leptomeníngea a través del líquido cefalorraquídeo es inusual y sucede predominantemente en meduloblastomas, ependimoblastomas, neuroblastomas centrales, ependimomas, tumores de células germinales y gliomas de alto grado. La mayoría de las metástasis secundarias a gliomas medulares publicadas proceden de astrocitomas anaplásicos o glioblastomas multiformes y relativamente pocas de gliomas de bajo grado. La incidencia de diseminación leptomeníngea de gliomas de bajo grado es rara. Publicamos una rara diseminación a las leptomeninges cerebrales de un astrocitoma pilocítico intramedular en el adulto. Caso clínico. Describimos un varón de 51 años con masa intramedular recurrente a nivel de C5-C7 intervenido en 4 ocasiones con todos los informes de anatomía patológica describiendo la lesión como astrocitoma pilocítico. 15 años después del diagnóstico desarrolló alucinaciones visuales y deterioro del nivel de conciencia con escala de coma de Glasgow de 13/15. La resonancia magnética mostró importante realce de las leptomeninges y paquimeninges craneales y medulares con intensa afectación de las cisternas basales, espacio subaracnoideo y ambos hemisferios cerebrales sugerente de diseminación leptomeníngea de la masa medular. El paciente falleció a los 3 días.Conclusión. Este fenómeno es raro y cuando acontece no suele cambiar el comportamiento del tumor primario. En nuestro caso la agresividad se podría justificar o por una malignización del tumor primario no evidenciada debido a la resección parcial de las últimas cirugías o bien a que el tumor en realidad fuese un tumor pilomixoide monomorfo (AU)

Background. The rarest location of pilocytic astrocytoma is intramedullary. Gliomas represent up to 24 - 30% of intramedullary tumors in adulthood and are second only after ependymomas. Leptomeningeal dissemination through cerebrospinal fluid is unusual and occurs predominantly in medulloblastomas, ependymoblastomas, central neuroblastomas, ependymomas, germ cell tumors and high-grade gliomas. The majority of spinal cord gliomas reporting metastasis were anaplastic astrocytomas or glioblastomas multiforme and relatively few were low-grade gliomas. The incidence of leptomeningeal spread of low-grade tumors is rare. A rare cranial extension of brain leptomeningeal dissemination in an intramedullary pilocytic astrocytoma during adulthood is reported.Case report. A 51 year-old-man with a recurrent intramedullary mass at C5-C7 level operated 4 times with all pathological anatomy reports describing the lesion as Pilocytic Astrocytoma developed, after 15 years from the diagnosis, visual hallucinations and his level of consciousness worsened to Glasgow coma score 13/15. The MRI showed highly enhanced cranial and (..) (AU)

[Iatrogenic cervical epidural hematoma: case report and review of the literature]. / Heamtoma epidural ccervical yatrogenico. Presentacion de un caso clinico y revision de la literatura.

BACKGROUND: Around 600 spinal epidural hematoma cases have been previously reported. Incidence of paraplegia after epidural anesthesia varies between 0,0005 and 0,02%. Several possible etiologies have been described in the literature, including surgery, trauma, anticoagulant therapy, arteriovenous malformations, pregnancy and lumbar puncture. Spinal and epidural anesthesic procedures represent the tenth most common cause. But in combination with anticoagulant therapy, the forementioned procedures increase its incidence until reaching the fifth most common etiological group. We report the case of an 80 year-old-man with a cervical epidural hematoma who had a good outcome with conservative management. CASE REPORT: 80 year-old-man that developed intense cervicalgia with lower limbs weakness showing complete paraplegia and arreflexia 2 hours after analgesic treatment with epidural cervical infiltration for cervicoartrosis. Cervical MRI showed epidural cervical hematoma between C4 and T1 levels. The patient is transferred to our facilities in order to perform surgery. But after showing fast recovery, medical conservative management was elected. After one month, the patient's condition has improved showing no neurological deficits and complete resorption is seen in MRI. CONCLUSIONS: Nowadays, trend is to perform surgery in patients with spinal hematoma and significant neurological deterioration during the first hours. However, good neurological outcomes can be achieved with conservative management, in well selected patients with non progressive, incomplete and partial deficits. Presently, we can not predict which is the best treatment for each case.

[Forestier-Rotes-Querol's disease. Ossification of the anterior cervical longitudinal ligament as a cause of dysphagia]. / Enfermedad de Forestier-Rotes-Querol. Osificación del ligamento longitudinal cervical anterior como causa de disfagia.

Forestier's disease or diffuse idiophatic skeletal hyperostosis is a systemic reumathological abnormality of unknown etiology. It produces calcificationossification of the anterior longitudinal ligament. The low dorsal region is the most affected in the raquis. These patients are tipically asymptomatic or with few symptoms (minimal joint pain, spinal pain, stiffness). Dysphagia is the most common symptom when the disease affects the cervical spine; less frequent is dyspnea, both secondary to extrinsic compression of the esophagus and trachea. Neurological complaints are quite rare. In the 1970s Resnick described specific radiological criteria for the diagnosis of Forestier's disease that are still used today. It affects men more frequently than women (2:1); the peak occurrence is in patients in their 60s. We present two cases diagnosed by severe difficulty with deglution, a 84 years-old woman and a 54 years-old man; we operated on them for surgical decompression of the esophagus with resection of osteophytes C3-C4 and C5-C6 respectively through a conventional anterolateral neck approach. Relief of difficulty in swallowing was immediately ensued.

Delayed intracerebral hemorrhage after ventriculoperitoneal shunt insertion. Case report and literature review.

We present another case of delayed intracerebral hemorrhage after a ventriculoperitoneal (VP) shunting procedure. In this case, a right occipital intraparenchymal hematoma and associated intraventricular hemorrhage occurred six days after the operation for hydrocephalus secondary to subarachnoid hemorrhage in a 64 year old woman. It is a rare complication of VP shunting, with few cases reported previously in the literature. The presumed mechanism is the erosion of a cerebral blood vessel secondary to a close contact with the ventricular catheter; bleeding disorder, vascular malformation, head trauma or brain tumor were excluded in this patient.

[Leiomyosarcoma of the paranasal sinuses with intracranial involvement: report of a clinical case and review of the literature]. / Leiomiosarcoma de senos paranasales con extensión intracraneal: presentación de un caso clínico y revisión de la literatura.

We describe a 53 year old man with a two months history of frontal headache and right visual loss, with complete right blindness at the moment of diagnosis. Neither nasal obstruction nor endocrine symptoms were found. Computerized Tomography showed a neoplasm involving both paranasal sinuses and sellar region, with bilateral orbital extension. The patient underwent a bifrontal craniotomy with apparent complete excision. Histopathologic examination proved smooth muscle cells sarcoma (leiomyosarcoma). Clinical evolution was unfavorable, with rapid local recurrence. The patient died of cerebellar metastasis 4 months after the initial diagnosis and treatment. Leiomyosarcoma of the sinonasal tract is an unusual tumor, and we have found only 63 cases previously reported. The most frequent clinical presentation is nasal obstruction. Surgery is the treatment of choice, as far as radiotherapy or chemotherapy do not appear to slow disease progression. No relationship has been found between the aggressiveness of leiomyosarcoma of the sinonasal tract and morphologic parameters; instead, prognosis is dependent on the distribution of disease at clinical onset. Leiomyosarcoma of the sinonasal tract may be regarded as a locally aggressive neoplasm with only limited metastatic potential.

Leiomyosarcoma metastatic to the brain with prolonged survival.

A case of uterine leiomyosarcoma with cerebral and pulmonary metastasis is presented. The patient underwent chemotherapy and multiple surgical procedures, including three craneotomies for resecting cerebral metastasis. More than four years of survival with good quality of life were obtained. An aggressive surgical therapy in the rare cases of cerebral metastasis of leiomyosarcoma may be justified.