Long-term outcomes of deep brain stimulation for treatment-resistant schizophrenia: Exploring potential targets.

BACKGROUND: Schizophrenia is a complex and disabling disorder. Around 30% of patients have treatment-resistant schizophrenia (TRS). OBJECTIVE: This study summarizes the outcomes after three years follow-up of the first series of patients with TRS treated with deep brain stimulation (DBS) and discuss surgical, clinical and imaging analysis. METHODS: Eight patients with TRS treated with DBS in the nucleus accumbens (NAcc) or the subgenual cingulate gyrus (SCG) were included. Symptoms were rated with the PANSS scale and normalized using the illness density index (IDI). A reduction in IDI-PANSS of ≥25% compared to baseline was the criterion of good response. The volume of activated tissue was calculated to perform a connectomic analysis for each patient. An estimation of the tracts and cortical areas modulated was generated. RESULTS: Five women and three men were analyzed. After 3 years' follow-up, positive symptoms improved in 50% of the SCG group and 75% of the NAcc group (p = 0.06), and general symptoms improved in 25% and 50% respectively (p = 0.06). The SCG group showed activation of the cingulate bundle and modulation of orbitofrontal and frontomesial regions; in contrast, the NAcc group showed activation of the ventral tegmental area projections pathway and modulation of regions associated with the "default mode network" (precuneus) and Brodmann areas 19 and 20. CONCLUSIONS: These results showed a trend toward improvement for positive and general symptoms in patients with TRS treated with DBS. The connectomic analysis will help us understand the interaction of this treatment with the disease to pursue future trial designs.

Long-Term Results of Deep Brain Stimulation for Treatment-Resistant Depression: Outcome Analysis and Correlation With Lead Position and Electrical Parameters.

BACKGROUND: Long-term efficacy and mechanisms of action of deep brain stimulation (DBS) for treatment-resistant depression (TRD) are under investigation. OBJECTIVE: To compare long-term outcomes with active electrode's coordinates and its electrical parameters in patients with TRD treated with DBS in the subgenual cingulate gyrus (SCG-DBS). METHODS: Seventeen patients with TRD underwent SCG-DBS. Demographic and baseline characteristics were recorded. The 17-item Hamilton Depression Rating Scale was used to measure the response to the therapy. The anterior commissure-posterior commissure coordinates of the active contacts and the total electrical energy delivered were calculated and correlated with clinical outcomes. Patient-specific tractographic analysis was performed to identify the modulated pathways in responders. RESULTS: Twelve women (70.6%) and 5 men (29.4%) with a median age of 48 yr (34-70 years) were included. Along the 5-year follow-up, 3 main clinical trajectories were observed according to symptom's improvement: great responders (≥80%), medium responders (≥50%-79%), and poor responders (<50%). Active contacts' coordinates and total electrical energy delivered showed no correlation with clinical outcomes. Brodmann area 10 medial was the most frequently stimulated area and the forceps minor, the most frequently modulated tract. CONCLUSION: SCG-DBS for TRD is clearly effective in some patients. Active contacts' coordinates were highly variable within the region and, like electrical parameters, did not seem to correlate with clinical outcomes. In the current series, Brodmann area 10 medial and the forceps minor were the most frequently targeted area and modulated pathway, respectively.

Occipital nerve stimulation and deep brain stimulation for refractory cluster headache: a prospective analysis of efficacy over time.

OBJECTIVE: Occipital nerve stimulation (ONS) and deep brain stimulation (DBS) are widely used surgical treatments for chronic refractory cluster headache (CH). However, there is little literature regarding long-term follow-up of these treatments. METHODS: The authors describe two prospective cohorts of patients with refractory CH treated with ONS and DBS and compare preoperative to postoperative status at 6 and 12 months after the surgery and at final follow-up. Efficacy analysis using objective and subjective variables is reported, as well as medication reduction and complications. RESULTS: The ONS group consisted of 13 men and 4 women, with a median age of 44 years (range 31-61 years). The median number of attacks per week (NAw) before surgery was 28 (range 7-70), and the median follow-up duration was 48 months. The DBS group comprised 5 men and 2 women, with a median age of 50 years (range 29-64 years). The median NAw before surgery was 56 (range 14-140), and the median follow-up was 36 months. The NAw and visual analog scale score were significantly reduced for the ONS and DBS groups after surgery. However, while all the patients from the DBS group were considered responders at final follow-up, with more than 85% being satisfied with the treatment, approximately 29% of initial responders to ONS became resistant by the final follow-up (p = 0.0253). CONCLUSIONS: ONS is initially effective as a treatment for refractory CH, although a trend toward loss of efficacy was observed. No clear predictors of good clinical response were found in the present study. Conversely, DBS appears to be effective and provide a more stable clinical response over time with an acceptable rate of surgical complications.

Efficacy of Sphenopalatine Ganglion Radiofrequency in Refractory Chronic Cluster Headache.

BACKGROUND: In the literature, there are only short series of radiofrequency of the sphenopalatine ganglion (SPG) to treat chronic refractory cluster headache (CCHr) with variable results. Furthermore, there is no consensus on which methodology to use: radiofrequency ablation (RFA) or pulsed radiofrequency (PRF). METHODS: We conducted a prospective analysis of 37 patients with CCHr who underwent RFA or PRF of the SPG in our center between 2004 and 2015. RESULTS: The mean age of the patients was 40 years (range, 26-59 years). PRF was performed in 24 patients, and RFA was performed in 13 patients. A total of 5 patients (13.5%) experienced complete clinical relief of both pain and parasympathetic symptoms, 21 patients (56.8%) had partial and transient relief, and 11 patients (29.7%) did not improve. There was no evidence of significant superiority of one radiofrequency modality over the other (P = 0.48). There were no complications associated with the technique. The passage of time tended to decrease the efficacy of both techniques (P < 0.001). The mean follow-up was 68.1 months (range, 15-148 months). To our knowledge, this is the series with the largest number of patients and the longest follow-up period published in the literature. CONCLUSIONS: Radiofrequency of the SPG is a safe, fast, and partially effective method for the treatment of CCHr. Given its low rate of complications and its low economic cost, we think it should be one of the first invasive treatment options, prior to techniques with greater morbidity and mortality, such as neuromodulation.

Clinoidectomía anterior extradural en el manejo de meningiomas paraselares: análisis de 13 años de experiencia y revisión de la literatura / Extradural anterior clinoidectomy in the management of parasellar meningiomas: Analysis of 13 years of experience and literature review

Antecedentes y objetivo: La clinoidectomía anterior extradural (CaE) es una técnica microquirúrgica clave que facilita la resección de tumores localizados en la región paraselar. Actualmente, no existe consenso de la ejecución vía extradural o intradural, o evidencia científica que apoye su uso de manera rutinaria. El propósito de este artículo es exponer nuestra experiencia en la realización de la CaE como parte del manejo de los meningiomas paraselares. Materiales y métodos: Se realizó un análisis retrospectivo de las CaE empleadas en las resecciones de meningiomas paraselares realizadas en nuestro centro entre los años 2003 y 2015. Se registraron un total de 53 pacientes. Realizamos un análisis de nuestra serie de casos, enfocándonos en los resultados visuales, las tasas de resección y las complicaciones postoperatorias. A través de una revisión bibliográfica, se discuten las ventajas e inconvenientes de la CaE, consideraciones técnicas, comparación con la clinoidectomía anterior intradural e impacto visual. Resultados: El tipo de tumor más frecuente fueron los meningiomas de clinoides anterior (33,9%). Los síntomas iniciales más frecuentes fueron la disminución de la agudeza visual (45,3%) y la cefalea (22,6%). La resección tumoral total se consiguió en el 67,9% de los casos, siendo subtotal en el restante 32,1%. Con respecto a los déficits visuales, el 67,9% de los pacientes presentaron estabilidad clínica, el 22,6% mejoraron y el 9,4% experimentaron empeoramiento. El grado de resección tumoral no influyó de manera significativa en los resultados visuales posquirúrgicos, ni en la agudeza visual (p=0,71) ni en los déficits campimétricos (p=0,53). El 24,5% de los pacientes experimentaron paresia del iiipar transitoria y el 1,9%, permanente. La tasa de fístula de líquido cefalorraquídeo postoperatoria fue del 3,8%. La mortalidad fue del 0%. El periodo medio de seguimiento fue de 82,3 meses. Conclusiones: En nuestra experiencia, la CaE es una técnica segura que facilita la resección de los meningiomas localizados en la región paraselar, favorece la desvascularización temprana del tumor, reduce la necesidad de retracción del parénquima cerebral y podría ejercer un papel positivo en la preservación de la función visual y en la aparición de recidivas tumorales en la apófisis clinoides anterior (ACa)

Background and aim: The extradural anterior clinoidectomy (EAC) is a key microsurgical technique that facilitates the resection of tumors located in the parasellar region. There is currently no consensus regarding the execution of the procedure via extradural or intradural nor scientific evidence that supports its routine use. The purpose of this article is to expose our experience in performing EAC as part of the management of the parasellar meningiomas. Materials and methods: A retrospective analysis of the EAC for parasellar meningioma resection performed in our center between 2003 and 2015 was done. A total of 53 patients were recorded. We analized our series focusing on visual outcomes, resection rates and complications. Through an extensive bibliographic research, we discussed the advantages and disadvantages of the EAC, technical considerations, comparison with the intradural clinoidectomy and its visual impact. Results: The most frequent tumors were anterior clinoidal meningiomas (33.9%). The most common initial symptoms were decreased visual acuity (45.3%) and headache (22.6%). A gross total resection was achieved in 67.9%, being subtotal in the remaining 32.1%. Regarding the visual deficits 67.9% of the patients presented clinical stability, 22.6% improvement and 9.4% worsening. The degree of tumor resection did not significantly influence post-surgical visual outcomes, either visual acuity (P=.71) or campimetric alterations (P=.53). 24.5% of the patients experienced iiinerve transient paresis and 1.9% permanent. The postoperative cerebrospinal fluid leak rate was 3.8%. Mortality rate was 0%. The mean follow-up was 82.3 months. Conclusions: In our experience, EAC is a safe technique that facilitates the resection of the meningiomas located in the parasellar area, helps to achieve early tumor devascularization, reduces the need for retraction of the cerebral parenchyma and could play a positive role in the preservation of visual function and the appearance of tumor recurrences in the anterior clinoid process (ACP)

Ausencia de conflicto neurovascular durante la microdescompresión vascular en el manejo de la neuralgia trigeminal esencial: ¿qué hacer? Revisión sistemática de la literatura / Absence of neurovascular conflict during microvascular decompression while treating essential trigeminal neuralgia. How to proceed? Systematic review of literature

Introducción: La presencia de conflicto neurovascular es la hipótesis aceptada en el desarrollo de la neuralgia trigeminal y la microdescompresión vascular, la técnica quirúrgica más empleada en su tratamiento. Sin embargo, pese a los avances diagnósticos, en ocasiones dicho conflicto es indetectable intraoperatoriamente. El objetivo de este trabajo es revisar sistemáticamente las opciones de manejo ante dicha situación. Resultados: Existen diversas técnicas descritas que se pueden emplear ante la ausencia de conflicto neurovascular durante una microdescompresión vascular. Describimos dichas técnicas, sus tasas de éxito, la recurrencia del dolor y de complicaciones, y damos nuestras recomendaciones sobre la materia. Conclusiones: No existe un consenso terapéutico, pero se dispone de diversas opciones quirúrgicas ante la ausencia de conflicto neurovascular. Creemos que las técnicas destructivas como la RPS deben relegarse a última línea terapéutica

Introduction: Neurovascular conflict is the most accepted hypothesis for the cause for trigeminal neuralgia. Microvascular decompression of the trigeminal nerve is the most common surgical treatment for these patients. However, despite advances in diagnostic techniques, neurovascular conflict is sometimes not detected during surgery. The aim of this paper is to systematically review all the options available to best manage this scenario. Results: Several techniques that could be used during microvascular decompression for trigeminal neuralgia in the absence of neurovascular conflict have been described. The success rates of these techniques, pain recurrence rates and rates of complications are also reported. Finally, we provide suggestions based on our experience. Conclusions: There is no gold standard, but several techniques could be successfully used in the absence of neurovascular conflict. The use of destructive techniques, such as PSR, should be held as treatments of last resort

Extradural anterior clinoidectomy in the management of parasellar meningiomas: Analysis of 13 years of experience and literature review. / Clinoidectomía anterior extradural en el manejo de meningiomas paraselares: análisis de 13 años de experiencia y revisión de la literatura.

BACKGROUND AND AIM: The extradural anterior clinoidectomy (EAC) is a key microsurgical technique that facilitates the resection of tumors located in the parasellar region. There is currently no consensus regarding the execution of the procedure via extradural or intradural nor scientific evidence that supports its routine use. The purpose of this article is to expose our experience in performing EAC as part of the management of the parasellar meningiomas. MATERIALS AND METHODS: A retrospective analysis of the EAC for parasellar meningioma resection performed in our center between 2003 and 2015 was done. A total of 53 patients were recorded. We analized our series focusing on visual outcomes, resection rates and complications. Through an extensive bibliographic research, we discussed the advantages and disadvantages of the EAC, technical considerations, comparison with the intradural clinoidectomy and its visual impact. RESULTS: The most frequent tumors were anterior clinoidal meningiomas (33.9%). The most common initial symptoms were decreased visual acuity (45.3%) and headache (22.6%). A gross total resection was achieved in 67.9%, being subtotal in the remaining 32.1%. Regarding the visual deficits 67.9% of the patients presented clinical stability, 22.6% improvement and 9.4% worsening. The degree of tumor resection did not significantly influence post-surgical visual outcomes, either visual acuity (P=.71) or campimetric alterations (P=.53). 24.5% of the patients experienced iiinerve transient paresis and 1.9% permanent. The postoperative cerebrospinal fluid leak rate was 3.8%. Mortality rate was 0%. The mean follow-up was 82.3 months. CONCLUSIONS: In our experience, EAC is a safe technique that facilitates the resection of the meningiomas located in the parasellar area, helps to achieve early tumor devascularization, reduces the need for retraction of the cerebral parenchyma and could play a positive role in the preservation of visual function and the appearance of tumor recurrences in the anterior clinoid process (ACP).

Hemorragia subaracnoidea no aneurismática secundaria a panarteritis nodosa en edad pediátrica: caso clínico / Non-aneurysmal subarachnoid haemorrhage secondary to panarteritis nodosa at paediatric age: a case report

Introducción. La panarteritis nodosa es una vasculitis necrotizante que afecta de manera predominante a arterias de pequeño y mediano calibre de la piel y los órganos internos. La afectación neurológica sucede en un 25% de casos: los ictus isquémicos son relativamente frecuentes, pero las lesiones hemorrágicas resultan extremadamente raras. La hemorragia subaracnoidea es una expresión poco común de la enfermedad, asociada la inmensa mayoría de las veces a patología aneurismática. En nuestro conocimiento, sólo existe otro caso descrito de panarteritis nodosa con hemorragia subaracnoidea en la edad pediátrica sin patología aneurismática subyacente. Caso clínico. Niña de 7 años que presentó una hemorragia subaracnoidea no aneurismática con extensión intraparenquimatosa a los ganglios basales izquierdos. Previamente se había diagnosticado panarteritis nodosa y enfermedad protrombótica, en tratamiento con fármacos inmunodepresores y antiagregantes en ese momento. Conclusiones. Las características clínicas de la panarteritis nodosa, junto con el tratamiento antiagregante para prevenir la enfermedad tromboembólica en nuestra paciente, podrían haber predispuesto al evento hemorrágico en el proceso de la vasculitis cerebral. El manejo estándar de la hemorragia subaracnoidea es necesario en estos casos debido a que los aneurismas cerebrales son la causa más común de hemorragia subaracnoidea en un contexto de panarteritis nodosa

Introduction. Polyarteritis nodosa is a necrotizing vasculitis that mainly affects small and medium-sized arteries in skin and internal organs. Neurological involvement is reported in around 25% of cases: ischemic stroke is relatively common, but haemorrhagic lesions are extremely rare. Subarachnoid haemorrhage in polyarteritis nodosa is an uncommon expression of this disease, mostly associated with aneurism rupture. To the best of the authors’ knowledge, there is just one published case in pediatric age with polyarteritis nodosa and subarachnoid haemorrhage with no underlying aneurismal disease. Case report. A 7-year-old girl, who presented a non-aneurismal subarachnoid haemorrhage with intraparenchymal extension in the left basal ganglia. She was previously diagnosed with polyarteritis nodosa and prothrombotic condition, being under immunosuppressive and anti-platelet treatment at that moment. Conclusions. The clinical features of polyarteritis nodosa together with continued anti-platelet therapy to prevent thromboembolic disease in this patient could have predisposed to the haemorrhagic event in the process of cerebral vasculitis. Standard subarachnoid haemorrhage management is initially required in such cases as cerebral aneurysms are the most common cause of haemorrhage in the context of polyarteritis nodosa disease

Absence of neurovascular conflict during microvascular decompression while treating essential trigeminal neuralgia. How to proceed? Systematic review of literature. / Ausencia de conflicto neurovascular durante la microdescompresión vascular en el manejo de la neuralgia trigeminal esencial: ¿qué hacer? Revisión sistemática de la literatura.

INTRODUCTION: Neurovascular conflict is the most accepted hypothesis for the cause for trigeminal neuralgia. Microvascular decompression of the trigeminal nerve is the most common surgical treatment for these patients. However, despite advances in diagnostic techniques, neurovascular conflict is sometimes not detected during surgery. The aim of this paper is to systematically review all the options available to best manage this scenario. RESULTS: Several techniques that could be used during microvascular decompression for trigeminal neuralgia in the absence of neurovascular conflict have been described. The success rates of these techniques, pain recurrence rates and rates of complications are also reported. Finally, we provide suggestions based on our experience. CONCLUSIONS: There is no gold standard, but several techniques could be successfully used in the absence of neurovascular conflict. The use of destructive techniques, such as PSR, should be held as treatments of last resort.

Importancia de la mutación de la isocitrato deshidrogenasa tipo I como factor pronóstico en pacientes con glioblastomas y revisión de la literatura / Isocitrate dehydrogenase type I mutation as a prognostic factor in glioblastoma and a literature review

Objetivo: La respuesta al tratamiento y el pronóstico de los glioblastomas multiformes (GBM) puede ser distinta entre diferentes individuos. Este hecho está haciendo que cada vez estén cobrando más importancia los biomarcadores genéticos para intentar diferenciar distintos subtipos de GBM. Uno de los que está adquiriendo más importancia es la isocitrato deshidrogenasa (IDH1). El objetivo del trabajo es analizar la diferencias tanto clínicas como pronósticas de los GBM con y sin mutación de la IDH1. Materiales y método: Estudio retrospectivo de pacientes con GBM intervenidos entre los años 2007 y 2012. Los criterios de inclusión fueron: pacientes entre 18-85 años, sometidos por primera vez a cirugía, resección macroscópicamente completa, tratamiento coadyuvante con quimioterapia y radioterapia y Karnofsky status > 70. Resultados: N = 61 pacientes (36 varones/25 mujeres). Edad media de 62,3 años. En 14 pacientes (23%) se encontró la IDH1 mutada. La supervivencia media de los pacientes con mutación de la IDH1 (IDH1-m) fue de 23,6 meses respecto a los 11,9 meses que presentaban los de la IDH1 en estado natural (IDH1-wt) (p = 0,028). Existió una tendencia en los pacientes con IDH1-m a presentar la enfermedad en edades más tempranas 58,7 vs. 63,4 años, pero estas diferencias no fueron significativas. Conclusiones: Se deberían considerar los GBM con IDH1-m como una entidad distinta a los IDH1-wt. Se trata de dos subtipos de GBM con una historia natural y un pronóstico totalmente distinto por lo que se deberían clasificar en un futuro en función de la presencia de la mutación de la IDH1

Objective: Treatment response and prognosis in glioblastoma (GBM) tumours can differ among patients, highlighting the growing relevance of genetic biomarkers to differentiate glioblastoma sub-types. The biomarker isocitrate dehydrogenase (IDH1) is currently receiving considerable attention. The objective of this work was to analyse the clinical and prognostic differences between glioblastomas with and without the IDH1 mutation. Methods: A retrospective study was performed on patients with GBM who underwent surgery between 2007 and 2012. The inclusion criteria were: patient age between 18-85 years who underwent surgery for the first time with complete macroscopic resection, complete adjuvant treatment with chemotherapy and radiotherapy, and a Karnofsky performance score > 70. Results: A total of 61 patients (36 males/25 famales) were included and with a mean age of 62.3 years. An IDH1mutation was found in 14 patients (23%). Median survival in patients with the IDH1 mutation (IDH1-m)was 23.6 months compared with 11.9 months in those with the wild type IDH1 (IDH1-wt) (P = .028). Disease onset in IDH1-m patients tended to be at a younger age, 58.7 vs. 63.4 years, but this difference was not statistically significant. Conclusion: Glioblastomas with IDH1-m should be considered a different entity from the IDH1-wt, as their natural history and prognosis differ. In the near future we should be classified glioblastomas based on the presence of the IDH1 mutation

[Isocitrate dehydrogenase type I mutation as a prognostic factor in glioblastoma and a literature review]. / Importancia de la mutación de la isocitrato deshidrogenasa tipo I como factor pronóstico en pacientes con glioblastomas y revisión de la literatura.

OBJECTIVE: Treatment response and prognosis in glioblastoma (GBM) tumours can differ among patients, highlighting the growing relevance of genetic biomarkers to differentiate glioblastoma sub-types. The biomarker isocitrate dehydrogenase (IDH1) is currently receiving considerable attention. The objective of this work was to analyse the clinical and prognostic differences between glioblastomas with and without the IDH1 mutation. METHODS: A retrospective study was performed on patients with GBM who underwent surgery between 2007 and 2012. The inclusion criteria were: patient age between 18-85 years who underwent surgery for the first time with complete macroscopic resection, complete adjuvant treatment with chemotherapy and radiotherapy, and a Karnofsky performance score>70. RESULTS: A total of 61 patients (36 males/25 famales) were included and with a mean age of 62.3 years. An IDH1mutation was found in 14 patients (23%). Median survival in patients with the IDH1 mutation (IDH1-m) was 23.6 months compared with 11.9 months in those with the wild type IDH1 (IDH1-wt) (P=.028). Disease onset in IDH1-m patients tended to be at a younger age, 58.7 vs. 63.4 years, but this difference was not statistically significant. CONCLUSION: Glioblastomas with IDH1-m should be considered a different entity from the IDH1-wt, as their natural history and prognosis differ. In the near future we should be classified glioblastomas based on the presence of the IDH1 mutation.

Tumor miofibroblástico inflamatorio cerebral / Inflammatory myofibroblastic tumor in the brain

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[Complications related with implanted devices in patients with Parkinson's disease treated with deep brain stimulation. A study of a series of 124 patients over a period of 16 years]. / Complicaciones relacionadas con dispositivos implantados en pacientes con enfermedad de Parkinson tratados con estimulacion cerebral profunda. Estudio de una serie de 124 pacientes durante 16 años.

INTRODUCTION: Establishing protocols of the best candidates for deep brain stimulation in patients with Parkinson's disease and a greater knowledge of the technique have increased its safety profile. Yet, the complications related with implanted devices still occur with a far-from-negligible frequency and have both an economic and clinical impact. AIM: From a broad series of patients undergoing deep brain stimulation included consecutively for the treatment of their Parkinson's disease, data concerning the complications related with implanted devices were gathered and compared with those in the literature. PATIENTS AND METHODS: Altogether 124 patients with a total of 242 implanted electrodes and 252 generator replacements were included in the study. Mean follow-up time was 8.4 years (range: 3-16 years). Data on all the complications related with implanted devices were collected retrospectively. RESULTS: Findings showed that 23 implanted device-related complications occurred (17.7% of the patients): 12 (9.6%) had culture-positive ulcers, five (4%) had culture-negative ulcers, four (3.2%) were left with infections following generator replacement, one (0.8%) had a generator malfunction, and electrode migration took place in one (0.8%). Significant differences were observed as regards the effectiveness of the treatment involving surgical revision of the ulcers, which suggests that the culture-negative ulcers responded to the surgical revision better than the culture-positive ulcers (80% healing versus 16.6%; p = 0.028). CONCLUSIONS: The results observed in the series were comparable to those in the existing literature. The presence of culture-positivity in the ulcers is a factor forecasting surgical revision.

TITLE: Complicaciones relacionadas con dispositivos implantados en pacientes con enfermedad de Parkinson tratados con estimulacion cerebral profunda. Estudio de una serie de 124 pacientes durante 16 años.Introduccion. La protocolizacion de los mejores candidatos para la estimulacion cerebral profunda en pacientes con enfermedad de Parkinson y el mayor conocimiento de la tecnica han aumentado su perfil de seguridad. Sin embargo, las complicaciones relacionadas con los dispositivos implantados siguen teniendo una frecuencia no menospreciable y presentan un impacto tanto clinico como economico. Objetivo. En una serie amplia de pacientes con estimulacion cerebral profunda incluidos consecutivamente para el tratamiento de su enfermedad de Parkinson, se recogieron las complicaciones relacionas con los dispositivos implantados y se compararon con la bibliografia. Pacientes y metodos. Se incluyeron en el estudio 124 pacientes con un total de 242 electrodos implantados y 252 recambios de generador. Seguimiento medio de 8,4 años (rango: 3-16 años). Se recogieron de forma retrospectiva todas las complicaciones relacionadas con los dispositivos implantados. Resultados. Se produjeron 23 complicaciones relacionadas con los dispositivos implantados (el 17,7% de los pacientes): 12 (9,6%) ulceras con cultivo positivo, cinco (4%) ulceras con cultivo negativo, cuatro (3,2%) infecciones tras recambio de generador, una (0,8%) malfuncion de generador y una (0,8%) migracion del electrodo. Se observaron diferencias significativas respecto a la efectividad del tratamiento de la revision quirurgica de las ulceras, lo que indica que las ulceras con cultivo negativo respondieron mejor que las ulceras con cultivo positivo a la revision quirurgica (80% frente a 16,6% de curacion; p = 0,028). Conclusiones. Se observan en la serie unos resultados comparables a la bibliografia existente. La presencia de positividad en el cultivo de las ulceras constituye un factor pronostico a la revision quirurgica.

Complicaciones relacionadas con dispositivos implantados en pacientes con enfermedad de Parkinson tratados con estimulación cerebral profunda. Estudio de una serie de 124 pacientes durante 16 años / Complications related with implanted devices in patients with Parkinson’s disease treated with deep brain stimulation. A study of a series of 124 patients over a period of 16 years

Introducción. La protocolización de los mejores candidatos para la estimulación cerebral profunda en pacientes con enfermedad de Parkinson y el mayor conocimiento de la técnica han aumentado su perfil de seguridad. Sin embargo, las complicaciones relacionadas con los dispositivos implantados siguen teniendo una frecuencia no menospreciable y presentan un impacto tanto clínico como económico. Objetivo. En una serie amplia de pacientes con estimulación cerebral profunda incluidos consecutivamente para el tratamiento de su enfermedad de Parkinson, se recogieron las complicaciones relacionas con los dispositivos implantados y se compararon con la bibliografía. Pacientes y métodos. Se incluyeron en el estudio 124 pacientes con un total de 242 electrodos implantados y 252 recambios de generador. Seguimiento medio de 8,4 años (rango: 3-16 años). Se recogieron de forma retrospectiva todas las complicaciones relacionadas con los dispositivos implantados. Resultados. Se produjeron 23 complicaciones relacionadas con los dispositivos implantados (el 17,7% de los pacientes): 12 (9,6%) úlceras con cultivo positivo, cinco (4%) úlceras con cultivo negativo, cuatro (3,2%) infecciones tras recambio de generador, una (0,8%) malfunción de generador y una (0,8%) migración del electrodo. Se observaron diferencias significativas respecto a la efectividad del tratamiento de la revisión quirúrgica de las úlceras, lo que indica que las úlceras con cultivo negativo respondieron mejor que las úlceras con cultivo positivo a la revisión quirúrgica (80% frente a 16,6% de curación; p = 0,028). Conclusiones. Se observan en la serie unos resultados comparables a la bibliografía existente. La presencia de positividad en el cultivo de las úlceras constituye un factor pronóstico a la revisión quirúrgica (AU)

Introduction. Establishing protocols of the best candidates for deep brain stimulation in patients with Parkinson’s disease and a greater knowledge of the technique have increased its safety profile. Yet, the complications related with implanted evices still occur with a far-from-negligible frequency and have both an economic and clinical impact. Aim. From a broad series of patients undergoing deep brain stimulation included consecutively for the treatment of their Parkinson’s disease, data concerning the complications related with implanted devices were gathered and compared with those in the literature. Patients and methods. Altogether 124 patients with a total of 242 implanted electrodes and 252 generator replacements were included in the study. Mean follow-up time was 8.4 years (range: 3-16 years). Data on all the complications related with implanted devices were collected retrospectively. Results. Findings showed that 23 implanted device-related complications occurred (17.7% of the patients): 12 (9.6%) had culture-positive ulcers, five (4%) had culture-negative ulcers, four (3.2%) were left with infections following generator replacement, one (0.8%) had a generator malfunction, and electrode migration took place in one (0.8%). Significant differences were observed as regards the effectiveness of the treatment involving surgical revision of the ulcers, which suggests that the culture-negative ulcers responded to the surgical revision better than the culture-positive ulcers (80% healing versus 16.6%; p = 0.028). Conclusions. The results observed in the series were comparable to those in the existing literature. The presence of culturepositivity in the ulcers is a factor forecasting surgical revision (AU)

Metástasis medulares de gliosarcoma. Presentación de un caso y revisión de la literatura / Spinal cord metastasis from gliosarcoma. Case report and review of the literature

INTRODUCCIÓN: El gliosarcoma es un tumor cerebral primario infrecuente similar al glioblastoma multiforme. En contrapartida al glioblastoma multiforme, debido a su componente sarcomatoso, los gliosarcomas tienen mayor tendencia a realizar metástasis extracraneales (11% de los casos). A pesar de ello, las metástasis medulares del gliosarcoma cerebral primario son extremadamente infrecuentes. CASO CLÍNICO: Se presenta el caso de una paciente intervenida de gliosarcoma cerebral que en el curso evolutivo de su enfermedad presenta una paraparesia, diagnosticándose e interviniéndose de metástasis medular de gliosarcoma. Realizamos una revisión sistemática de la literatura sobre los casos descritos de metástasis intramedular, sus características, el tratamiento realizado y el pronóstico. CONCLUSIONES: Únicamente se han descrito 4 casos de metástasis intramedular de gliosarcoma en la literatura. Se trata de una entidad infrecuente pero en la que debemos pensar ante la aparición de clínica medular en el curso evolutivo de un paciente con gliosarcoma cerebral

INTRODUCTION: Gliosarcoma is a rare neoplasm of the central nervous system, similar to glioblastoma multiforme. In contrast to glioblastoma, it is characterised by its propensity for extracranial metastasis (11% of the cases) due to its sarcomatous component. Intramedullary metastasis from primary gliosarcoma is extremely rare. CASE REPORT: A patient who had surgery for primary cerebral gliosarcoma developed paraparsis during the course of the disease. A magnetic resonance image showed an intramedullaryspinal cord metastasis requiring surgical treatment. This article reviews the literature on intramedullary spinal cord metastasis from gliosarcoma, and highlights the characteristics, treatment and overall survival. CONCLUSIONS: Only 4 cases of intramedullary gliosarcoma metastasis are described in the literature. This extremely rare entity should be suspected with the onset of spinal cord symptoms during the course of primary cerebral gliosarcoma

[Spinal cord metastasis from gliosarcoma. Case report and review of the literature]. / Metástasis medulares de gliosarcoma. Presentación de un caso y revisión de la literatura.

INTRODUCTION: Gliosarcoma is a rare neoplasm of the central nervous system, similar to glioblastoma multiforme. In contrast to glioblastoma, it is characterised by its propensity for extracranial metastasis (11% of the cases) due to its sarcomatous component. Intramedullary metastasis from primary gliosarcoma is extremely rare. CASE REPORT: A patient who had surgery for primary cerebral gliosarcoma developed paraparesis during the course of the disease. A magnetic resonance image showed an intramedullary spinal cord metastasis requiring surgical treatment. This article reviews the literature on intramedullary spinal cord metastasis from gliosarcoma, and highlights the characteristics, treatment and overall survival. CONCLUSIONS: Only 4 cases of intramedullary gliosarcoma metastasis are described in the literature. This extremely rare entity should be suspected with the onset of spinal cord symptoms during the course of primary cerebral gliosarcoma.

Fibrosarcoma epitelioide esclerosante a nivel paraespinal. Caso clínico y revisión de la literatura / Sclerosing epithelioid fibrosarcoma of the paravertebral column. Case report and literature review

El fibrosarcoma epitelioide esclerosante (SEF) es una variante poco frecuente de fibrosarcoma de bajo grado con características histológicas e inmunohistoquímicas bien definidas, caracterizado por su mal pronóstico. Presentamos un caso de SEF a nivel paraespinal en un paciente varón de 49 años con un tumor que se extiende hacia el foramen L4-L5 e invade la raíz L5. La histología de la pieza quirúrgica y el estudio inmunohistoquímico fueron compatibles con SEF. Este caso es particularmente inusual por su origen a nivel paraespinal e ilustra, a pesar de su bajo grado, el potencial de malignidad del SEF (AU)

Sclerosing epithelioid fibrosarcoma (SEF) is a rare variant of low-grade fibrosarcoma, with specific histological and immunohistochemical features and a poor prognosis. We report a case of SEF of the paravertebral column in a 49-year old male who presented a paraspinal mass with extension into the L4-L5 neural foramen and invasion of the L5 nerve root. Histology of the tumourectomy specimen and its immunohistochemical study led to the diagnosis of SEF. This case was particularly unusual due to its paravertebral column location and, despite its low grade, illustrates the malignant potential of SEF (AU)

Integración de la cirugía endoscópica en una unidad de base de cráneo: experiencia en los primeros 72 casos / Endoscopic surgery in the skull base unit: Experience in the first 72 cases

Introducción: La formación de un equipo multidisciplinar es imprescindible para desarrollar y ampliar las indicaciones en la cirugía endonasal endoscópica de la base de cráneo. El objetivo de este trabajo es presentar nuestra experiencia en el grupo de pacientes con afectación de la base de cráneo intervenidos con un abordaje endonasal endoscópico. Métodos: De enero de 2008 a enero de 2012, 72 pacientes con afectación de la base de cráneo fueron diagnosticados y tratados en nuestro centro. Resultados: La edad media de los pacientes en el momento del diagnóstico fue de 53 años. Las diferentes patologías incluyeron 36 adenomas de hipófisis, 10 fístulas de líquido cefalorraquídeo y 5 papilomas invertidos como las más frecuentes. En 45 casos se llevó a cabo un abordaje transesfenoidal transellar, en 4 casos un abordaje transmaxilar transpterigoideo y en 6 casos un abordaje transnasal ampliado. En 12 pacientes se realizó un abordaje a través del etmoides y/o del seno esfenoidal y en 4 casos se utilizó un abordaje frontal tipo Draf IIb/III. En el 61% de los adenomas se consiguió una resección total, en el 22% subtotal y en el 17% parcial. El 86% de las fístulas de líquido cefalorraquídeo se repararon con éxito. No se evidenció ninguna recidiva en los papilomas invertidos intervenidos. En 21 pacientes (29%) ocurrió algún tipo de complicación, apareciendo 6 complicaciones de orden mayor. Conclusiones: Nuestro centro apuesta por la colaboración multidisciplinar en la cirugía endoscópica de la base de cráneo como línea de excelencia (AU)

Introduction: A multidisciplinary team is essential to develop and expand the indications in endonasal endoscopic skull base surgery. The aim of this study was to present our experience in a group of patients with skull base lesions treated using endonasal endoscopic approach. Methods: From January 2008 to January 2012, 72 patients with skull base involvement were diagnosed and treated in our centre. Results: The mean patient age was 53 years. The different pathologies included 36 pituitary adenomas, 10 cerebrospinal fluid leaks and 5 inverted papillomas as the most frequent pathologies. We performed a transsphenoidal transellar approach in 45 cases, a transmaxillary transpterygoid approach in 4 cases and a transnasal expanded approach in 6 cases. We performed an ethmoidal/sphenoidal approach in 12 patients and a Draf IIb/III procedure in four cases. Total resection was achieved in 61% of patients with pituitary adenomas, subtotal in 22% and partial in 17%. Successful repair was achieved in 86% of CSF leaks. No recurrences were observed in patients with inverted papilloma. Complications were observed in 21 patients (29%), 6 being major complications. Conclusions: Our centre stresses the importance of multidisciplinary collaboration in endoscopic endonasal skull base surgery (AU)

Endoscopic surgery in the skull base unit: experience in the first 72 cases.

INTRODUCTION: A multidisciplinary team is essential to develop and expand the indications in endonasal endoscopic skull base surgery. The aim of this study was to present our experience in a group of patients with skull base lesions treated using endonasal endoscopic approach. METHODS: From January 2008 to January 2012, 72 patients with skull base involvement were diagnosed and treated in our centre. RESULTS: The mean patient age was 53 years. The different pathologies included 36 pituitary adenomas, 10 cerebrospinal fluid leaks and 5 inverted papillomas as the most frequent pathologies. We performed a transsphenoidal transellar approach in 45 cases, a transmaxillary transpterygoid approach in 4 cases and a transnasal expanded approach in 6 cases. We performed an ethmoidal/sphenoidal approach in 12 patients and a Draf IIb/III procedure in four cases. Total resection was achieved in 61% of patients with pituitary adenomas, subtotal in 22% and partial in 17%. Successful repair was achieved in 86% of CSF leaks. No recurrences were observed in patients with inverted papilloma. Complications were observed in 21 patients (29%), 6 being major complications. CONCLUSIONS: Our centre stresses the importance of multidisciplinary collaboration in endoscopic endonasal skull base surgery.