How I do it? Cranial setup for cranial settling.

BACKGROUND: Expanded endonasal endoscopic techniques allow us to treat several pathologies related to the odontoid process and craniocervical junction. Cases such as giant basilar invagination represent a surgical challenge. METHODS: The authors provide technical nuances and describe how to complete an endoscopic endonasal odontoidectomy and release the craniocervical junction with the aim of restoring a correct sagittal balance in cases with giant basilar invagination. The study of cadaveric specimens adds clarifying dissections. CONCLUSIONS: Endonasal endoscopic odontoidectomy and craniocervical junction joint release allow the treatment of irreducible basilar invagination and restoration of better sagittal balance before posterior cervical occipitocervical fusion.

99mTc-HDP SPECT/MRI in isolated xanthoma of the temporal bone / 99mTc-HDP SPECT/RM en xantoma único del hueso temporal

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Intradural extramedullary spinal hydatidosis: case report.

The parasitic tapeworm Echinococcus granulosis causes hydatid disease, which is rarely encountered in nonendemic regions. It is a progressive disease with serious morbidity risks. Rarely, these cysts are found in the spine. They are mainly found epidurally, originating from direct extension from pulmonary, abdominal or pelvic infestation. Nevertheless, the main mechanism for intradural involvement is not yet clear. Antihelminthic treatment should be administered for a long period following early decompressive surgery. We report a case of recurrent hydatid disease that presented unusual intradural dissemination. Prognosis for spinal hydatid disease remains very poor and comparable to that of a malignant neoplasm.

Intradural extramedullary spinal hydatidosis: case report

The parasitic tapeworm Echinococcus granulosiscauses hydatid disease, which is rarely encountered innonendemic regions. It is a progressive disease withserious morbidity risks. Rarely, these cysts are foundin the spine. They are mainly found epidurally, originatingfrom direct extension from pulmonary, abdominalor pelvic infestation. Nevertheless, the main mechanismfor intradural involvement is not yet clear. Antihelminthictreatment should be administered for a long periodfollowing early decompressive surgery. We report a caseof recurrent hydatid disease that presented unusualintradural dissemination. Prognosis for spinal hydatiddisease remains very poor and comparable to that of amalignant neoplasm (AU)

El Equinococcus granulosis es el parásito causantede la hidatidosis, que se encuentra de forma muy pocofrecuente en regiones no endémicas. Es una enfermedadquística progresiva con riesgo de causar morbilidadimportante, afectando principalmente al hígado y alpulmón. Muy raramente se encuentran quistes a nivelespinal. La hidatidosis espinal afecta sobre todo al espacioepidural por extensión directa de infección existentea nivel pulmonar, abdominal o pélvico. No obstante,el mecanismo para la afectación intradural todavíano está aclarado. El tratamiento antihelmíntico ha deser administrado durante largo tiempo tras la cirugíadescompresiva. Presentamos el caso de una hidatidosisespinal recurrente que presentó una diseminación intradural inusual. El pronóstico de la hidatidosisespinal continúa siendo muy pobre, comparable al deuna enfermedad neoplásica maligna (AU)

Haemangiopericytoma presenting with acute intracerebral haemorrhage.

Clinical presentation of brain tumour by acute haemorrhage is well known and occurs in around 5% of the cases. Haemangiopericytoma (HPC) is a richly vascularized tumour, but its clinical manifestation is most frequently related to tumour mass effect or seizures. We present the eighth case reported of a patient with acute intracerebral bleeding caused by HPC. Though HPC represents only about 2% of intracranial meningeal neoplasms it must be included in the differential diagnosis of intracranial haemorrhage.

[Magnetic resonance in moderate and severe head injury: comparative study of CT and MR findings. Characteristics related to the presence and location of diffuse axonal injury in MR]. / Resonancia magnética en trauma craneal moderado y grave: estudio comparativo de hallazgos en TC y RM. Características relacionadas con la presencia y localización de lesión axonal difusa en RM.

INTRODUCTION: Cranial CT has been the most extended evaluation means for patients suffering head trauma. However, it has low sensitivity in the identification of diffuse axonal injury and posterior fossa lesions. Cranial MR is a potentially more sensitive test but difficult to perform in these patients, a fact that has hampered its generalised use. OBJECTIVE: To compare the identification capability of traumatic intracranial lesions by both diagnostic tests in patients with moderate and severe head injury and to determine which radiological characteristics are associated with the presence of diffuse injury in MR and their clinical severity. MATERIAL AND METHODS: 100 patients suffering moderate or severe head injury to whom a MR had been performed in the first 30 days after trauma were included. All clinical variables related to prognosis were registered, as well as the data from the initial CT following Marshall et al., classification. The MR was blindly evaluated by two neuroradiologists that were not aware of the initial CT results or the clinical situation of the patient. All lesions were registered as well as the classification following the classification of lesions related to DAI described by Adams et al. CT and MR findings were compared evaluating the sensitivities of each test. Factors related to the presence of diffuse injury in MR were studied by univariate analysis using chi2 test and simple correlations. RESULTS: MR is more sensitive than CT for lesions in cerebral white matter, corpus callosum and brainstem. It also detects a greater number of cerebral contussions. The presence of diffuse axonal injury depends on the mechanism of the trauma, being more frequent in higher energy trauma, specially in traffic accidents. Among the radiological characteristics associated to DAI the most clearly related is intraventricular haemorrhage. The presence of a deeper injury and a higher score in the scales of Adams is associated with a lower score in the GCS and motor GCS, and so with a worse level of consciousness and bigger severity of injury, confirming Ommaya's model.

Resonancia magnética en trauma craneal moderado y grave: estudio comparativo de hallazgos en TC y RM. Características relacionadas con la presencia y localización de lesión axonal difusa en RM / Magnetic Resonance in moderate and severe head injury: comparative study of CT and MR findings. Characteristics related to the presence and location of diffuse axonal injury in MR

Introducción. La TC craneal ha sido el método más extendido en la evaluación de enfermos que han sufrido trauma craneal. Sin embargo, es poco sensible en la identificación de lesión axonal difusa y lesiones en fosa posterior. La RM craneal es una prueba potencialmente más sensible pero de difícil realización en estos enfermos, hecho que ha impedido la generalización de su uso. Objetivos. Comparar la capacidad de identificación de lesiones intracraneales postraumáticas por parte de las dos pruebas diagnósticas en enfermos con TCE grave y moderado, y determinar qué características radiológicas en la TC se asocian a la presencia de LAD en RM y su gravedad clínica. Material y métodos. Se incluyen en el estudio 100enfermos con TCE moderado y grave a los que se ha realizado RM craneal dentro de los primeros 30 días tras el trauma craneal. Se recogieron todas las variables clínicas potencialmente relacionadas con el pronóstico de los enfermos, así como los datos del TC inicial según la clasificación de Marshall y cols. La RM fue evaluada de manera ciega por dos neurorradiólogos que ignoraban al resultado de la TC inicial y la situación clínica inicial del paciente. Se recogieron todas las lesiones que presentaban, así como su clasificación según la clasificación de lesiones asociadas con LAD, descrita por Adams. Se compararon los hallazgos en TC y RM, evaluando la sensibilidad de cada prueba con respecto a los diferentes hallazgos. Se estudiaron los hallazgos relacionados con la presencia de LAD en RM, mediante estudio univariable, usando la prueba de χ2 y correlaciones simples. Resultados. La RM es más sensible que la TC para las lesiones en sustancia blanca cerebral, cuerpo calloso y tronco. Además, detecta mayor número de contusiones. La presencia de lesión axonal difusa depende del mecanismo de producción del trauma, siendo más frecuente en traumas de mayor energía, sobre todo en los accidentes de tráfico, bien sea con automóvil o moto/bici. En cuanto a las características radiológicas asociadas a LAD la más claramente relacionada es la hemorragia intraventricular. La presencia de daño cada vez más profundo y mayor puntuación en la escala de Adams se asocia a menor puntuación en la GCS y GCS motora, y por consiguiente peor nivel de conciencia y mayor gravedad del trauma inicial, confirmando el modelo de Ommaya

Introduction. Cranial CT has been the most extended evaluation means for patients suffering head trauma. However, it has low sensitivity in the identification of diffuse axonal injury and posterior fossa lesions. Cranial MR is a potentially more sensitive test but difficult to perform in these patients, a fact that has hampered its generalised use. Objective. To compare the identification capability of traumatic intracranial lesions by both diagnostic tests in patients with moderate and severe head injury and to determine which radiological characteristics are associated with the presence of diffuse injury in MR and their clinical severity. Material and methods. 100 patients suffering moderate or severe head injury to whom a MR had been performed in the first 30 days after trauma were included. All clinical variables related to prognosis were registered, as well as the data from the initial CT following Marshall et al., classification. The MR was blindly evaluated by two neuroradiologists that were not aware of the initial CT results or the clinical situation of the patient. All lesions were registered as well as the classification following the classification of lesions related to DAI described by Adams et al. CT and MR findings were compared evaluating the sensitivities of each test. Factors related to the presence of diffuse injury in MR were studied by univariate analysis using χ2 test and simple correlations. Results. MR is more sensitive than CT for lesions in cerebral white matter, corpus callosum and brainstem. It also detects a greater number of cerebral contussions. The presence of diffuse axonal injury depends on the mechanism of the trauma, being more frequent in higher energy trauma, specially in traffic accidents. Among the radiological characteristics associated to DAI the most clearly related is intraventricular haemorrhage. The presence of a deeper injury and a higher score in the scales of Adams is associated with a lower score in the GCS and motor GCS, and so with a worse level of consciousness and bigger severity of injury, con-firming Ommaya’s model

[Value of serial CT scanning and intracranial pressure monitoring for detecting new intracranial mass effect in severe head injury patients showing lesions type I-II in the initial CT scan]. / Utilidad de la TAC secuencial y la monitorización de la presión intracraneal para detectar nuevo efecto masa intracraneal en pacientes con traumatismo craneal grave y lesión inicial Tipo I-II.

OBJECTIVE: To determine the incidence of pathological and intracranial pressure (ICP) changes during the acute posttraumatic period in severe head injury patients presenting with lesions Types I-II (TCDB classification) in the admission CT scan with the aim of defining the most appropriate strategy of sequential CT scanning and ICP monitoring for detecting new intra-cranial mass effect and improving the final outcome. MATERIAL AND METHODS: 56 patients (ages 15-80 years) consecutively admitted during a 2 years period were included. All had the initial CT scan < 24 hours after injury (mean interval = 150 min), several CT controls within the first days of the course and ICP monitoring after admission. Different epidemiological, clinical and radiological variables were recorded and deterioration defined as the development of sustained ICP over 20 mmHg requiring aggressive medical and/or surgical treatment was considered the dependent variable. Uni and multivariate analyses were made for determining the correlation between different parameters and the occurrence of deterioration and the final outcome as assessed with the GOS. RESULTS: The mean GCS score was 5 and 37% of the patients showed pupillary changes; 52.3% had peritraumatic hypotension-hypoxemia, 16.1% anemia and 12.3% coagulation changes. 50% of the patients showed petechial hemorrhages in the white matter or the brainstem, 66% SAH, 40% HIV, 39.3% brain contusion and 21.4% small extraaxial hematomas. 57.1% of the patients showed CT changes through the acute post-traumatic period consisting of new contusion (26.8% of the cases), growing of previous contusion (68.2%) or previous extraaxial hematoma (10.7%), and generalized brain swelling (10.7%). 64.9% of the patients made a favourable and 35.7% an unfavourable outcome. Overall, 27 (48.9%) patients developed deterioration, 21 (37.5%) with concurrent CT changes and 6 (10.7%) without new pathology as seen by the CT control. The remaining 29 (51.7%) patients in this series did not develop deterioration in spite that 11(19.6%) showed CT changes. The age, the initial score, the occurrence of peritraumatic hypotension-hypoxemia and coagulation disorders did not correlate with the risk of deterioration. By contrast, the presence of contusion at the initial CT scan (p= 0.01) and the occurrence of CT change (only generalized brain swelling, p= 0.003) significantly correlated with the risk of deterioration; in his turn deterioration increased by a factor of 10 (OR = 9.8) the risk of death and 7 out of the 8 patients who died developed intractable intracranial hypertension. The 8 (14.2%) patients requiring surgery showed simultaneous ICP deterioration and CT changes, but another 11 patients in a similar condition could be managed without surgery. With or without ICP deterioration, patients showing CT changes had a worse outcome than those without new pathologies, but the difference did not reach statistical significance, DISCUSSION AND CONCLUSIONS: Over 50% of the patients with initial Type I-II lesions developed new CT changes and nearly 50% showed intracranial hypertension during the acute posttraumatic period. Considering the high incidences of ICP and CT deterioration through the course, along with the absence of strong predictors and the discordances between CT and ICP changes (which were seen in 30.3% of the cases) we recommend ICP monitoring after admission in all patients and serial CT scanning at 2-4, 12, 24, 48 and 72 hours after injury with additional controls as indicated by clinical or ICP changes in all cases. Though it is clear that the presence of severe intra-cranial hypertension significantly increased the risk of death, the small size of the sample in this series prevented to assess to what extent the occurrence of new mass effect and/or raised ICP contributed to the development of moderate and severe disability in the survivors which were mainly due to the occurrence of diffuse axonal injury. Finally, demonstrating that sequential CT scanning and ICP monitoring improve the final outcome in this type of patients would require a prospective randomized trial which is impracticable for different reasons, among them the ethical ones.

Utilidad de la TAC secuencial y la monitorización de la presión intracraneal para detectar nuevo efecto masa intracraneal en pacientes con traumatismo craneal grave y lesión inicial Tipo I-II / Value of serial CT scanning and intracranial pressure monitoring for detecting new intracranial mass effect in severe

Objetivo. Analizar los cambios en la patología y presión intracraneal (PIC) durante el periodo agudo postraumático en una serie de pacientes con trauma craneal grave y lesiones Tipos I-II en la TAC inicial (clasificación del Traumatic Coma Data Bank) con el objetivo de diseñar la pauta mas adecuada de uso de TAC secuencial y monitorización de la PIC para detectar nuevo efecto masa intracraneal y tratar así de mejorar la evolución final de pacientes. Material y métodos. Se analiza una serie de 56 pacientes (edades = 15-80 años) admitidos consecutivamente en un periodo de dos años que fueron sometidos a TAC inicial < 24 horas tras el impacto, (intervalo medio = 150 minutos), TACs control en los primeros días del curso, y monitorización de la PIC. Se recogieron diferentes variables epidemiológicas, clínicas, radiológicas y se consideró como variable dependiente el desarrollo de deterioro definido como elevación mantenida de la PIC por encima de 20 mmHg que requiriera tratamiento agresivo médico y/o quirúrgico. Mediante análisis bi y multivariante se determinaron las correlaciones entre las diferentes variables y la aparición de deterioro. Para estimar la afectación neurológica y el resultado final se emplearon las escalas de coma y evolución de Glasgow, respectivamente. Resultados. El "score " medio en la serie fue de 5, y 37% de los pacientes tuvieron cambios pupilares, 52,3% hipotensión-hipoxemia, 16.1% anemia peritraumáticas y 12,3% alteraciones de la coagulación. 50% de los pacientes mostraron petequias en sustancia blanca y/o tronco cerebral en la TAC inicial, 66% HSA, 40% HIV, 39,3% contusión y 21,4% hematomas extraaxiales. 57,1% de los pacientes mostraron cambios en la TAC de control consistentes en nueva contusión en 26,8% de los casos, crecimiento de contusión previa en 68,2%, crecimiento de hematoma previo en 10,7% y swelling cerebral generalizado en 10,7%. 64% de los pacientes experimentaron una evolución final favorable y 35,7% desfavorable. 27 pacientes (48,9%) desarrollaron deterioro PIC, de los que 21 (37,5%) presentaron cambios concurrentes en la TAC, y 6 (10,7%) no los mostraron. Los restantes 29 (51,7%) pacientes no presentaron deterioro PIC, aunque 11 (19,6%) de ellos mostraron cambio TAC. La edad, el "score", la presencia de hipotension-hipoxemia peritraumáticas y los trastornos de la coagulación no se correlacionaron con riesgo de deterioro. Por el contrario, la presencia de contusión inicial (p=0,01) y el cambio TAC (en forma de desarrollo de swelling cerebral generalizado, p=0,003) se correlacionaron con la aparición de deterioro; a su vez el deterioro multiplicó por 10 (OR = 9,8) el riesgo de muerte y 7 de los 8 pacientes que fallecieron desarrollaron hipertensión intracraneal intratable. Los 8 pacientes (14,2%) que necesitaron cirugía evacuadora o descompresiva presentaron simultáneamente cambio PIC y cambio TAC, si bien otros 13 en situación similar pudieron ser manejados sin cirugía. Mostraran o no deterioro PIC, los pacientes sin cambio TAC evolucionaron mejor que los que desarrollaron nuevas patologías, pero la diferencia no alcanzó diferencia significativa. Discusión y conclusiones. Más de la mitad de los pacientes con lesión inicial Tipo I-II desarrolla cambios patológicos secuenciales, y casi el 50% presenta hipertensión intracraneal. Dada la alta incidencia de cambios TAC y PIC, la escasez y debilidad de los factores predictores de dichos cambios, y la frecuente discordancia entre ambos tipos de cambio (30,3% de los casos), parece recomendable monitorizar la PIC desde el inicio y practicar TACs 2-4, 12, 24, 48 y 72 horas tras el impacto en todos los pacientes, y otros adicionales si la evolución clínica o de la PIC lo requiriera. Si bien parece indudable que el desarrollo de hipertensión intracraneal grave incrementó significativamente el riesgo de muerte, la escasez de la muestra en la serie no permite determinar la contribución del nuevo efecto masa y/o la elevación de la PIC al desarrollo de incapacidad moderada y grave en los pacientes que no fallecieron, causada principalmente por la lesión axonal difusa. Finalmente, demostrar que la practica de TAC secuencial y la monitorización de la PIC mejoran la evolución final de este tipo de pacientes requeriría un estudio prospectivo aleatorizado que no es practicable por diferentes razones, entre ellas las de tipo ético

Objective. To determine the incidence of pathological and intracranial pressure (ICP) changes during the acute posttraumatic period in severe head injury patients presenting with lesions Types I-II (TCDB classification) in the admission CT scan with the aim of defining the most appropriate strategy of sequential CT scanning and ICP monitoring for detecting new intracranial mass effect and improving the final outcome. Material and methods. 56 patients (ages 15-80 years) consecutively admitted during a 2 years period were included. All had the initial CT scan < 24 hours after injury (mean interval = 150 min), several CT controls within the first days of the course and ICP monitoring after admission. Different epidemiological, clinical and radiological variables were recorded and deterioration defined as the development of sustained ICP over 20 mmHg requiring aggressive medical and/or surgical treatment was considered the dependent variable. Uni and multivariate analyses were made for determining the correlation between different parameters and the occurrence of deterioration and the final outcome as assessed with the GOS. Results. The mean GCS score was 5 and 37% of the patients showed pupillary changes; 52.3% had peritraumatic hypotension-hypoxemia, 16.1% anemia and 12.3% coagulation changes. 50% of the patients showed petechial hemorrhages in the white matter or the brainstem, 66% SAH, 40% HIV, 39.3% brain contusion and 21.4% small extraxial hematomas. 57.1% of the patients showed CT changes through the acute post-traumatic period consisting of new contusion (26.8% of the cases), growing of previous contusion (68.2%) or previous extraaxial hematoma (10.7%), and generalized brain swelling (10.7%). 64.9% of the patients made a favourable and 35.7% an unfavourable outcome. Overall, 27 (48.9%) patients developed deterioration, 21 (37.5%) with concurrent CT changes and 6 (10,7%) without new pathology as seen by the CT control. The remaining 29 (51.7%) patients in this series did not develop deterioration in spite that 11(19.6%) showed CT changes. The age, the initial score, the occurrence of peritraumatic hypotension-hypoxemia and coagulation disorders did not correlate with the risk of deterioration. By contrast, the presence of contusion at the initial CT scan (p= 0.01) and the occurrence of CT change (only generalized brain swelling, p= 0.003) significantly correlated with the risk of deterioration; in his turn deterioration increased by a factor of 10 (OR = 9,8) the risk of death and 7 out of the 8 patients who died developed intractable intracranial hypertension. The 8 (14.2%) patients requiring surgery showed simultaneous ICP deterioration and CT changes, but another 11 patients in a similar condition could be managed without surgery. With or without ICP deterioration, patients showing CT changes had a worse outcome than those without new pathologies, but the difference did not reach statistical significance. Discussion and conclusions. Over 50% of the patients with initial Type I-II lesions developed new CT changes and nearly 50% showed intracranial hypertension during the acute posttraumatic period. Considering the high incidences of ICP and CT deterioration through the course, along with the absence of strong predictors and the discordances between CT and ICP changes (which were seen in 30.3% of the cases) we recommend ICP monitoring after admission in all patients and serial CT scanning at 2-4, 12, 24, 48 and 72 hours after injury with additional controls as indicated by clinical or ICP changes in all cases. Though it is clear that the presence of severe intracranial hypertension significantly increased the risk of death, the small size of the sample in this series prevented to assess to what extent the occurrence of new mass effect and/or raised ICP contributed to the development of moderate and severe disability in the survivors which were mainly due to the occurrence of diffuse axonal injury. Finally, demonstrating that sequential CT scanning and ICP monitoring improve the final outcome in this type of patients would require a prospective randomized trial which is impracticable for different reasons, among them the ethical ones