Parálisis facial: guía de práctica clínica de la Sociedad Española de ORL / Facial paralysis: Clinical practice guideline of the Spanish Society of Otolaryngology

La parálisis de Bell es la forma más común de paresia o parálisis facial. Sin embargo, no todos los pacientes con parálisis facial tienen una parálisis de Bell. Otras causas frecuentes incluyen las secuelas del tratamiento del neurinoma del VIII par, el cáncer de cabeza y cuello, la iatrogenia, el zóster ótico y los traumatismos. El abordaje de cada una de estas situaciones es totalmente diferente. El objetivo de esta guía es servir de consejo para el tratamiento y el seguimiento de los pacientes con parálisis facial. Nuestra idea es que la guía sea práctica, haciendo hincapié en recomendaciones efectivas y útiles en el manejo diario de los pacientes. Esta guía ha sido promovida por la Sociedad Española de ORL y escrita por médicos con experiencia en la enfermedad del nervio facial, incluyendo al menos un especialista de cada comunidad autónoma. Redactada en un formato de preguntas y respuestas, incluye 56 cuestiones relevantes relacionadas con el nervio facial

Bell's palsy is the most common diagnosis associated with facial nerve weakness or paralysis. However, not all patients with facial paresis/paralysis have Bell's palsy. Other common causes include treatment of vestibular schwannoma, head and neck tumours, iatrogenic injuries, Herpes zoster, or trauma. The approach to each of these conditions varies widely. The purpose of this guideline is to provide clinicians with guidance on the treatment and monitoring of patients with different causes of facial paralysis. We intend to draft a practical guideline, focusing on operationalised recommendations deemed to be useful in the daily management of patients. This guideline was promoted by the Spanish Society of Otolaryngology and developed by a group of physicians with an interest in facial nerve disorders, including at least one physician from each Autonomous Community. In a question and answer format, it includes 56 relevant topics related to the facial nerve

Facial paralysis: Clinical practice guideline of the Spanish Society of Otolaryngology. / Parálisis facial: guía de práctica clínica de la Sociedad Española de ORL.

Bell's palsy is the most common diagnosis associated with facial nerve weakness or paralysis. However, not all patients with facial paresis/paralysis have Bell's palsy. Other common causes include treatment of vestibular schwannoma, head and neck tumours, iatrogenic injuries, Herpes zoster, or trauma. The approach to each of these conditions varies widely. The purpose of this guideline is to provide clinicians with guidance on the treatment and monitoring of patients with different causes of facial paralysis. We intend to draft a practical guideline, focusing on operationalised recommendations deemed to be useful in the daily management of patients. This guideline was promoted by the Spanish Society of Otolaryngology and developed by a group of physicians with an interest in facial nerve disorders, including at least one physician from each Autonomous Community. In a question and answer format, it includes 56 relevant topics related to the facial nerve.

The Experience of a Facial Nerve Unit in the Treatment of Patients With Facial Paralysis Following Skull Base Surgery.

: The management of facial paralysis following skull base surgery is complex and requires multidisciplinary intervention. This review shows the experience of a facial nerve (FN) unit in a tertiary university referral center. A multidisciplinary approach has led to the breaking of some old treatment paradigms. An overview of five FN scenarios is presented. For each setting a contemporary approach is proposed in contrast to the established approach. 1) For patients with an anatomically preserved FN with no electrical response at the end of surgery for vestibular schwannoma, watchful waiting is usually advocated. In these cases, reinforcement with an interposed nerve graft is recommended. 2) In cases of epineural FN repair, with or without grafting, and a poor expected prognosis, an additional masseter-to-facial transfer is recommended. 3) FN transfer, mainly hypoglossal-to-facial and masseter-to facial, are usually chosen based on the surgeons' preference. The choice should be based on clinical factors. A combination of techniques improves the outcome in selected patients. 4) FN reconstruction following malignant tumors requires a combination of parotid and temporal bone surgery, involving different specialists. This collaboration is not always consistent. Exposure of the mastoid FN is recommended for lesions involving the stylomastoid foramen, as well as intraoperative FN reconstruction. 5) In patients with incomplete facial paralysis and a skull base tumor requiring additional surgery, consider an alternative reinnervation procedure, "take the FN out of the equation" before tumor resection. In summary, to achieve the best results in complex cases of facial paralysis, a multidisciplinary approach is recommended.

Facial nerve repair: the impact of technical variations on the final outcome.

OBJECTIVES: To analyze the outcome of facial nerve (FN) reconstruction, the impact of technical variations in different conditions and locations, and the importance of additional techniques in case of suboptimal results. STUDY DESIGN: Retrospective study. SETTING: University-based tertiary referral center. PATIENTS: Between 2001 and 2017, reconstruction of the FN was performed on 36 patients with varying underlying diseases. INTERVENTIONS: FN repair was performed by direct coaptation (n = 3) or graft interposition (n = 33). Microsurgical sutures were used in 17 patients (47%) and fibrin glue was used in all cases. Additional reinnervation techniques (hypoglossal-facial or masseter-facial transfers) were performed in five patients with poor results after initial reconstruction. MAIN OUTCOME MEASURES: FN function was evaluated using the House-Brackmann (HB) and the electronic clinician-graded facial function (eFACE) grading systems. Minimum follow-up was 12 months. RESULTS: FN reconstruction yielded improvement in 83% of patients, 21 patients (58.3%) achieving a HB grade III. The eFACE median composite, static, dynamic and synkinesis scores were 69.1, 78, 53.2, and 88.2 respectively. A tendency towards better outcome with the use of sutures was found, the difference not being significant. All patients undergoing an additional reinnervation procedure achieved a HB grade III, eFACE score being 74.8. CONCLUSIONS: FN reconstruction offers acceptable functional results in most cases. No significant differences are expected with technical variations, different locations or conditions. In patients with poor initial results, additional reinnervation techniques should be always considered. The eFACE adds substantial information to the most used HB scale.

Evolution of Patients With Immediate Complete Facial Paralysis Secondary to Acoustic Neuroma Surgery.

OBJECTIVE: To study the evolution of patients with immediate complete facial paralysis after acoustic neuroma surgery in different scenarios and assess different facial reanimations techniques. METHODS: This study included 50 patients with complete facial paralysis immediately after acoustic neuroma surgery. Data were analyzed into 4 groups according to the need and type of reconstruction of the facial nerve, either none, immediate, or on a deferred basis. All patients had intraoperative facial nerve monitoring, and facial nerve function was evaluated according the House-Brackmann (HB) scale. RESULTS: Of all patients with immediate total paralysis, no patients achieved totally normal facial function (grade I), and only 5 (10%) recovered to a grade II. For all groups included, the majority of patients (82%) achieved an acceptable final facial function (grade III HB). In this series, only 2 patients remained with a grade VI facial function. CONCLUSIONS: The possibility of recovering near normal facial function after a grade VI facial paralysis is very low. Procedures like the immediate repair of the facial nerve with an interposed donor graft may provide better facial function in patients with partially injured facial nerve. Even in cases of total section, there are other procedures that can improve the results.

Guía de actuación clínica en la hemorragia subaracnoidea. Sistemática diagnóstica y tratamiento / Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment

OBJETIVO: Actualización de la guía para el diagnóstico y tratamiento de la hemorragia subaracnoidea de la Sociedad Española de Neurología. MATERIAL Y MÉTODOS: Revisión y análisis de la bibliografía existente. Se establecen recomendaciones en función del nivel de evidencia que ofrecen los estudios revisados. RESULTADOS: La causa más frecuente de hemorragia subaracnoidea espontánea (HSA) es la rotura de un aneurisma cerebral. Su incidencia se sitúa en torno 9 casos por 100.000 habitantes/año y supone un 5% de todos los ictus. La hipertensión arterial y el tabaquismo son sus principales factores de riesgo. Se ha de realizar el tratamiento en centros especializados. Se debe considerar el ingreso en unidades de ictus de aquellos pacientes con HSA y buena situación clínica inicial (grados I y II en la escala de Hunt y Hess). Se recomienda la exclusión precoz de la circulación del aneurisma. El estudio diagnóstico de elección es la tomografía computarizada (TC) craneal sin contraste. Si esta es negativa y persiste la sospecha clínica se aconseja realizar una punción lumbar. Los estudios de elección para identificar la fuente de sangrado son la resonancia magnética (RM) y la angiografía. Los estudios ultrasonográficos son útiles para el diagnóstico y seguimiento del vasoespasmo. Se recomienda el nimodipino para la prevención de la isquemia cerebral diferida. La terapia hipertensiva y el intervencionismo neurovascular pueden plantearse para tratar el vasoespasmo establecido. CONCLUSIONES: La HSA es una enfermedad grave y compleja que debe ser atendida en centros especializados, con suficiente experiencia para abordar el proceso diagnóstico y terapéutico

OBJECTIVE: To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment. MATERIAL AND METHODS: A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed. RESULTS: The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm. CONCLUSIONS: SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes

NF2 genetic alterations in sporadic vestibular schwannomas: clinical implications.

HYPOTHESIS: NF2 gene alterations may have a clinical impact in non-NF2 vestibular schwannomas (VSs). BACKGROUND: It has been suggested that NF2 mutations might correlate with clinical expression of VS in NF2 patients. The aim of this study was to analyze the impact of genetic alterations in the NF2 gene on epidemiologic, clinical, and radiologic features of patients with sporadic VS. The association between cigarette consumption and the molecular genetic findings was also studied. METHODS: The study group consisted of 51 patients who underwent surgery for removal of vestibular schwannoma in our institution between January 2006 and December 2010. Five highly polymorphic microsatellite DNA markers were used to observe the frequency of loss of heterozygosity (LOH) in chromosome 22. The NF2 gene mutations were detected using polymerase chain reaction amplification and denaturing high-performance liquid chromatography analysis (PCR/dHPLC), and direct sequencing of NF2. Multiplex ligation-dependent probe amplification (MLPA) of the NF2 gene was also performed. RESULTS: An NF2 mutation was identified in 49%, 22q LOH in 57%, and MLPA alterations in 13.7% of the cases. One mutational hit was present in 27%, and 2 hits were present in 45% of the tumors. No association was found between the type of NF2 mutation and relevant clinical parameters. The presence of NF2 mutations detected by PCR/dHPLC was associated with no complaint of hearing loss at the time of diagnosis (p = 0.023), with subjective aural fullness (p = 0.022) and with an absence of tumor involvement of the internal auditory canal (p = 0.029). Patients with NF2 mutations had lower mean corrected PTA thresholds compared with those with no NF2 mutation (p = 0.037). Inactivation of the NF2 gene by mutation, MLPA, or LOH was more frequent in smokers when compared with never smokers (p = 0.048). CONCLUSION: NF2 mutations may play a role in the pathophysiology of hearing loss as well as in the pattern of growth of VS. Cigarette smoking in patients with VS seems to play a role in both the risk of developing the tumor and also in its genetic profile. More studies are needed to corroborate these results and, more broadly, to establish links between molecular and clinical data.

Novel multitarget ligand ITH33/IQM9.21 provides neuroprotection in in vitro and in vivo models related to brain ischemia.

ITH33/IQM9.21 is a novel compound belonging to a family of glutamic acid derivatives, synthesized under the hypothesis implying that multitarget ligands may provide more efficient neuroprotection than single-targeted compounds. In rat hippocampal slices, oxygen plus glucose deprivation followed by re-oxygenation (OGD/Reox) elicited 42% cell death. At 1 µM, ITH33/IQM9.21 mitigated this damage by 26% and by 55% at 3 µM. OGD/Reox also elicited mitochondrial depolarization, overproduction of reactive oxygen species (ROS), enhanced expression of nitric oxide synthase (iNOS) and reduction of GSH levels. These changes were almost fully prevented when 3 µM ITH33/IQM9.21 was present during slice treatment with OGD/Reox. In isolated hippocampal neurons, ITH33/IQM9.21 reduced [Ca(2+)](c) transients induced by a high K(+) depolarizing solution or glutamate. In a photothrombotic model of stroke in mice, intraperitoneal injection of ITH33/IQM9.21 at 1.25 mg/kg, 2.5 mg/kg or 5 mg/kg given before and during 2 days after stroke induction, reduced infarct volume by over 45%. Furthermore, when the compound was administered 1 h post-stroke, a similar effect was observed. In conclusion, these in vitro and in vivo results suggest that ITH33/IQM9.21 exhibits neuroprotective effects to protect the vulnerable neurons at the ischemic penumbra by an effective and multifaceted mechanism, mediated by reduction of Ca(2+) overload, providing mitochondrial protection and antioxidant actions.

CDP-choline at high doses is as effective as i.v. thrombolysis in experimental animal stroke.

Use of thrombolysis in acute ischaemic stroke may be limited by a narrow benefit/risk ratio. Pharmacological inhibition of the ischaemic cascade may constitute an effective and safer approach to stroke treatment. This study compared the effects of high doses of cytidine diphosphate-choline (CDP-choline; 1000 mg/kg) with recombinant tissue plasminogen activator (rt-PA; 5 mg/kg) in an experimental animal model of embolic stroke. Fifteen rats were embolized in the right internal carotid artery with an autologous clot and were divided into three groups: (1) infarct; (2) intravenous rt-PA 5 mg/kg 30 minutes post-embolization; and (3) CDP-choline 1000 mg/kg, intraperitoneal, three doses, 30 minutes, 24 hours, and 48 hours post-embolization. Functional evaluation scores were evaluated using Rogers test, lesion volume by haematoxylin and eosin staining, cell death with transferase-mediated dUTP nick-end labelling, and plasma levels of interleukin-6 (IL-6) and tumor necrosis factor-alpha with enzyme-linked immunosorbent assay. In this study, CDP-choline and rt-PA produced a significant reduction in brain damage considering infarct volume, cell death, and inflammatory cytokines (tumour necrosis factor-alpha and IL-6) compared with the infarct group. Additionally, CDP-choline significantly decreased infarct volume, cell death, and IL-6 levels with respect to the rt-PA group. From these results, we conclude that high-dose CDP-choline may be an effective treatment for acute ischaemic stroke even in absence of thrombolysis.

Reversible posterior leukoencephalopathy syndrome after lateral skull base surgery.

OBJECTIVE: To describe the clinical course, diagnostic features and management of a case of reversible posterior leukoencephalopathy syndrome after a lateral cranial base removal. PATIENT: A 58-year-old male patient with an inconspicuous clinical history presented with a lethargic state without localized neurologic deficit in the postoperative period of a subtotal petrosectomy for an adenoid cystic carcinoma of the temporal bone. INTERVENTIONS: Cranial T2-weighted magnetic resonance imaging showed increased signal intensity in the occipital and cerebellar regions, centered at the cortical and subcortical white matter. Antihypertensive drugs, anticonvulsants, and antibiotics were administered. A complete resolution of the symptoms and radiologic findings were achieved within 1 to 2 weeks. RESULTS: The clinical presentation, radiologic findings, and resolution of the clinical setting are consistent with a diagnosis of reversible posterior leukoencephalopathy syndrome. CONCLUSION: To our knowledge, this is the first report of reversible posterior leukoencephalopathy syndrome after a lateral cranial base surgery.

Human cadaver brain infusion skull model for neurosurgical training.

BACKGROUND: Microsurgical technique and anatomical knowledge require extensive laboratory training. Human cadaver models are especially valuable as they supply a good microsurgical training environment simultaneously providing authentic brain anatomy. We developed the "skull infusion model" as an extension of our previous "brain infusion model" taking it a step further maintaining simplicity but enhancing realism. METHODS: Four human cadaveric brains donated for educational purposes were explanted at autopsy. The specimens were prepared cannulating carotid and vertebral arteries with plastic tubings, flushed with abundant water and fixed for 1 month in formaldehyde. They were then enclosed with white silk clothing (emulating the dura mater) and inserted into human skulls cut previously into two pieces. Tap water at a flow rate of 10 L/h was infused through the arterial tubings. RESULTS: Diverse microsurgical procedures were performed by two trainees, including craniotomies with microsurgical approaches and techniques such as sylvian fissure exposure, extra-intracranial and intra-intracranial bypass, approaches to the ventricles and choroidal fissure opening. The water infusion fills the arterial system, leaking into the interstitial and cisternal space and finally moistening the whole specimen. This makes vascular microsurgical techniques become extremely realistic, increasing its compliance making manipulations easier and more authentic. CONCLUSIONS: Standard microsurgical laboratories frequently have difficulties to work with decapitated human cadaver heads but could have human brains readily available. Using the infusion model and inserting it in a human skull makes the environment much more realistic. Its simplicity and inexpensiveness make it a good alternative for developing microsurgical techniques.

Cyclin D1 expression and facial function outcome after vestibular schwannoma surgery.

HYPOTHESIS: The proto-oncogen cyclin D1 has been implicated in the development and behavior of vestibular schwannoma. This study evaluates the association between cyclin D1 expression and other known prognostic factors in facial function outcome 1 year after vestibular schwannoma surgery. METHODS: Sixty-four patients undergoing surgery for vestibular schwannoma were studied. Immunohistochemistry analysis was performed with anticyclin D1 in all cases. Cyclin D1 expression, as well as other demographic, clinical, radiologic, and intraoperative data, was correlated with 1-year postoperative facial function. RESULTS: Good 1-year facial function (Grades 1-2) was achieved in 73% of cases. Cyclin D1 expression was found in 67% of the tumors. Positive cyclin D1 staining was more frequent in patients with Grades 1 to 2 (75%) than in those with Grades 3 to 6 (25%). Other significant variables were tumor volume and facial nerve stimulation after tumor resection. The area under the receiver operating characteristics curve increased when adding cyclin D1 expression to the multivariate model. CONCLUSION: Cyclin D1 expression is associated to facial outcome after vestibular schwannoma surgery. The prognostic value of cyclin D1 expression is independent of tumor size and facial nerve stimulation at the end of surgery.

[CSF fistulae following surgery for cerebellopontine angle tumours and their relationship with the body mass index]. / Fístulas de LCR tras la cirugía de tumores del ángulo pontocerebeloso y su relación con el índice de masa corporal.

INTRODUCTION: The most frequent complication after vestibular schwannoma surgery is cerebrospinal fluid (CSF) fistula. MATERIAL AND METHODS: Retrospective study of 170 patients who had vestibular schwannoma (163) or other tumours in the cerebello pontine angle (CPA) (7). Resection was carried out using different approaches: retrosigmoid (66%), translabyrinthine (24%), middle cranial fossa (5%) and others (5%). We studied the day of onset, location and treatment of the CSF leaks, and the influence of demographic, radiological and clinical variables, including Body Mass Index. RESULTS: 27 patients developed a CSF fistula (15.9%): 15 were incisional (8.8%), 8 patients developed CSF rhinorrhea (4.7%), 1 CSF otorrhea (0.6%) and 3 a combination of the above (1.8%). We controlled 11 CSF fistulae with bed rest and compressive dressings (6.5%), 7 required lumbar drainage (4.1%), 2 lumbar drainage and wound closure with local anaesthesia (1.2%) and 7 patients required returning to the operating room under general anaesthesia (4.1%). There was not a significant relationship between the apparition of CSF and tumour size, type of approach, age or body mass index (BMI). CONCLUSIONS: Despite the great development and new surgical techniques, CSF fistulae are still a frequent complication after VS surgery. There might be other aetiological factors such as intracranial pressure. There was no significant relationship between CSF fistula and BMI. Adequate management and early conservative measures led to reduced reintervention rates of less than 5% in all patients.

Fístulas de LCR tras la cirugía de tumores del ángulo pontocerebeloso y su relación con el índice de masa corporal / CSF fistulae following surgery for cerebellopontine angle tumours and their relationship with the body mass index

Introducción: La complicación más frecuente tras la cirugía del schwannoma vestibular (SV) es la fístula de líquido cefalorraquídeo. Métodos: Estudio retrospectivo de 170 pacientes intervenidos por SV (163) y otros tumores del ángulo pontocerebeloso (7). La resección se realiza por las vías retrosigmoidea (66%), translaberíntica (24%), fosa media (5%) y otras (5%). Se estudiaron día de aparición, localización, tratamiento e influencia de variables demográficas, clínicas (incluido el índice de masa corporal [IMC]) y radiológicas. Resultados: Se desarrolló fístula de líquido cefalorraquídeo (LCR) en 27 pacientes (15,9%), de las cuales 15 fueron incisionales (8,8%), 8 fueron rinolicuorreas (4,7%), 1 fue otolicuorrea (0,6%) y 3 fueron una combinación de éstas (1,8%). Se controlaron 11 fístulas con medidas conservadoras (6,5%), 7 pacientes mediante colocación de drenaje lumbar (4,1%), 2 pacientes precisaron drenaje lumbar y cierre con anestesia local (1,2%) y 7 pacientes requirieron reintervención bajo anestesia general (el 4,1% del total). No se demuestra relación significativa entre la aparición de las fístulas de LCR y la vía de abordaje, el tamaño tumoral, la edad ni el IMC. Conclusiones: A pesar de los avances técnicos, la fístula de LCR continúa siendo una complicación frecuente tras la cirugía del SV, no habiéndose desarrollado una técnica que garantice su desaparición. Podría haber otros factores implicados en su etiología, como la presión intracraneal. No se ha demostrado una relación entre las fístulas de LCR y el IMC. El empleo precoz de medidas conservadoras nos ha permitido reducir la tasa de reintervenciones bajo anestesia general a cifras inferiores al 5% de todos los pacientes intervenidos (AU)

Introduction: The most frequent complication after vestibular schwannoma surgery is cerebrospinal fluid (CSF) fistula. Material and methods: Retrospective study of 170 patients who had vestibular schwannoma (163) or other tumours in the cerebello pontine angle (CPA) (7). Resection was carried out using different approaches: retrosigmoid (66%), translabyrinthine (24%), middle cranial fossa (5%) and others (5%). We studied the day of onset, location and treatment of the CSF leaks, and the influence of demographic, radiological and clinical variables, including Body Mass Index. Results: 27 patients developed a CSF fistula (15.9%): 15 were incisional (8.8%), 8 patients developed CSF rhinorrhea (4.7%), 1 CSF otorrhea (0.6%) and 3 a combination of the above (1.8%). We controlled 11 CSF fistulae with bed rest and compressive dressings (6.5%), 7 required lumbar drainage (4.1%), 2 lumbar drainage and wound closure with local anaesthesia (1.2%) and 7 patients required returning to the operating room under general anaesthesia (4.1%). There was not a significant relationship between the apparition of CSF and tumour size, type of approach, age or body mass index (BMI). Conclusions: Despite the great development and new surgical techniques, CSF fistulae are still a frequent complication after VS surgery. There might be other aetiological factors such as intracranial pressure. There was no significant relationship between CSF fistula and BMI. Adequate management and early conservative measures led to reduced reintervention rates of less than 5% in all patients (AU)

Assessment of 31P-NMR analysis of phospholipid profiles for potential differential diagnosis of human cerebral tumors.

We describe a novel protocol for the non-histological diagnosis of human brain tumors in vitro combining high-resolution (31)P magnetic resonance spectroscopy ((31)P-MRS) of their phospholipid profile and statistical multivariate analysis. Chloroform/methanol extracts from 40 biopsies of human intracranial tumors obtained during neurosurgical procedures were prepared and analyzed by high-resolution (31)P-MRS. The samples were grouped in the following seven major classes: normal brain (n = 3), low-grade astrocytomas (n = 4), high-grade astrocytomas (n = 7), meningiomas (n = 9), schwannomas (n = 3), pituitary adenomas (n = 4), and metastatic tumors (n = 4). The phospholipid profile of every biopsy was determined by (31)P-NMR analysis of its chloroform/methanol extract and characterized by 19 variables including 10 individual phospholipid contributions and 9 phospholipid ratios. Most tumors depicted a decrease in phosphatidylethanolamine (PtdEtn) and phosphatidylserine (PtdSer), the former mainly in neuroepithelial neoplasms and the latter in metastases. An increase in phosphatidylcholine (PtdCho) and phosphatidylinositol (PtdIns) appeared predominantly in primary non-neuroepithelial tumors. Linear discriminant analysis (LDA) revealed the optimal combination of variables that could classify each biopsy between every pair of classes. The resultant discriminant functions were used to calculate the probability of correct classifications for each individual biopsy within the seven classes considered. Multilateral analysis classified correctly 100% of the normal brain samples, 89% of the meningiomas, 75% of the metastases, and 57% of the high-grade astrocytomas. The use of phospholipid profiles may complement appropriately previously proposed methods of intelligent diagnosis of human cerebral tumors.

[Hemi-hypoglossal-facial intratemporal side to side anastomosis]. / Anastomosis hipoglosofacial intratemporal hemiterminoterminal.

Conventional hypoglossal-facial anastomosis and the interposition jump graft variation are the most popular techniques for facial nerve reconstruction resulting from proximal facial nerve injury. We present a modification of this technique, the hemi-hypoglossal facial intratemporal side to side anastomosis, which overcomes many of the failings of previous techniques. The method involves mobilization of the intratemporal facial nerve, which is anastomosed to a partially incised hypoglossal nerve. It is especially indicated in patients with multiple cranial nerve palsies.

Anastomosis hipoglosofacial intratemporal hemiterminoterminal / Hemi-hypoglossal-facial intratemporal side to side anastomosis

La anastomosis hipoglosofacial directa y la anastomosis con interposición de nervio auricular mayor son las técnicas de reconstrucción facial más utilizadas cuando el extremo proximal del nervio facial no es accesible. Presentamos una modificación de la técnica, la anastomosis hipoglosofacial intratemporal hemiterminoterminal, que soluciona muchos inconvenientes de las técnicas previas. La porción intratemporal del nervio facial se libera y anastomosa al nervio hipogloso, seccionado parcialmente. La técnica está especialmente indicada en pacientes con múltiples déficit de pares craneales

Conventional hypoglossal-facial anastomosis and the interposition jump graft variation are the most popular techniques for facial nerve reconstruction resulting from proximal facial nerve injury. We present a modification of this technique, the hemi-hypoglossal facial intratemporal side to side anastomosis, which overcomes many of the failings of previous techniques. The method involves mobilization of the intratemporal facial nerve, which is anastomosed to a partially incised hypoglossal nerve. It is especially indicated in patients with multiple cranial nerve palsies

Cyclin D1 expression and histopathologic features in vestibular schwannomas.

OBJECTIVE: To evaluate cyclin D1 expression in vestibular schwannoma and its relationship with histologic, clinical, and radiologic features. PATIENTS: Twenty-one patients with histologically confirmed vestibular schwannoma. INTERVENTION: Immunohistochemistry analysis was performed with anticyclin D1. Histopathologic features studied included Antoni pattern and nuclear and stromal degenerative changes. Clinical charts, audiometric data, and magnetic resonance imaging characteristics were reviewed. MAIN OUTCOME MEASURES: Cyclin D1 expression and its association with histologic, clinical, and radiologic findings. RESULTS: Cyclin D1 expression was found in 52% of cases. Cyclin D1 expression was more frequent in right-sided tumors (p = 0.02) and in tumors with nuclear degenerative changes (p < 0.0001). Patients with negative cyclin D1 expression had longer duration of deafness (p = 0.02) and higher 2,000-Hz hearing thresholds (p = 0.04) than cyclin D1+ patients. CONCLUSION: Cyclin D1 expression, present in nearly half of the cases, may play a role in the development of these tumors. Further studies are needed to fully understand the contributions of histopathologic and immunohistochemical factors to vestibular schwannoma biological activity.

Impact of facial dysfunction on quality of life after vestibular schwannoma surgery.

OBJECTIVES: This study was performed to evaluate the impact of facial dysfunction on quality of life in patients who underwent surgery for vestibular schwannoma. Other factors with a possible impact on quality of life were also assessed. METHODS: We performed a retrospective review of 95 patients who underwent removal of a unilateral vestibular schwannoma. The Glasgow Benefit Inventory, an open-ended questionnaire, and a pain scale were sent to each patient. The questions were answered by 70 respondents (74%). After a minimum 1-year follow-up, the overall House-Brackmann postoperative facial function was grade I-II in 61% of patients, grade III-IV in 36%, and grade V-VI in 3%. RESULTS: The open-ended questionnaire showed that 33% of patients stated a complaint related to facial dysfunction; it was the main complaint for 13% of patients. No significant difference was found in terms of Glasgow Benefit Inventory scores between patients with and without facial dysfunction, nor between those with different House-Brackmann grades. The most frequent complaint after surgery was hearing loss (46%). Postoperative pain was significantly associated with a worse postoperative quality of life. CONCLUSIONS: An overestimation of the effect of facial paralysis after vestibular schwannoma resection may exist on the surgeon's part. Detailed information about the possibility of hearing loss, vestibular problems, and pain must be given to all patients.

DNA methylation of multiple genes in vestibular schwannoma: Relationship with clinical and radiological findings.

HYPOTHESIS: The purpose of this study was to examine the DNA methylation profile of several genes in a series of vestibular schwannomas, and to analyze its relationship with clinical and radiological features. BACKGROUND: Aberrant methylation of promoter regions is a major mechanism for silencing of tumor suppressor genes in several tumors. There is limited information about methylation status in vestibular schwannoma, with no clinical or radiological implications described to date. METHODS: The methylation status of 16 tumor-related genes including RASSF1A, RAR-B, VHL, PTEN, HMLH1, RB1, TP16, CASP8, ER, TIMP3, MGMT, DAPK, TP73, GSTP1, TP14, and THBS1 was examined in a series of 22 vestibular schwannomas.The bisulfite modification of genomic DNA was performed. Clinical and radiological features were compared with the methylation results. RESULTS: Methylation values from 9% to 27% were found in 12 of 16 genes tested, including RASSF1A, VHL, PTEN, TP16, CASP8, TIMP3, MGMT, DAPK, THBS1, HMLH1, TP73, and GSTP1. A significant association was found between CASP8 and RASSF1A methylation. Methylation of CASP8 was associated with the patient's age and the tumor size. Methylation of TP73 was associated with hearing loss. RASSF1A methylation was inversely correlated with the clinical growth index. CONCLUSION: Aberrant methylation of tumor-related genes may play a role in the development of vestibular schwannomas. Our results may provide useful clues to the development of prognostic assays for these tumors.