Global neurosurgery: Reflections on myelomeningocele in the Zanzibar archipelago (Tanzania).

Objective: Our main goal was to describe the general characteristics and demographic data of myelomeningocele (MMC) patients at Mnazi Mmoja Surgical NED Institute (MMSNI) in Zanzibar and to assess the clinical characteristics and medium-term result-impact of the implemented health care measures. Methods: This is a retrospective study on 41 MMC patients treated at the MMSNI in Zanzibar (Tanzania) from September 2016 to September 2018. Patient demographics, prenatal care, clinical and radiographic characteristics, surgical management and nursing care, and clinical outcomes were abstracted. Results: The mean age of the patients was 6.1 ± 4.6 days, and 53.7% were males. A total of 51.2% came from Zanzibar, 39% to Pemba, and 9.8% from mainland Tanzania. Maternal ultrasound checkups revealed hydrocephalus in 18.7% of the cases. 85.4% of the newborns were operated on. Surgical wound infection was the most frequent complication (28.6%). A significantly higher risk of complications was observed in children from Pemba Island (p = 0.046) and those born by vaginal delivery (p = 0.694), particularly infections. During follow-up, 48.57% of the patients presented with infantile hydrocephalus and in the majority of them, a ventriculoperitoneal shunt was inserted. Conclusions: Proper prenatal care with early diagnosis, together with the neurosurgical and nursing standard of care in a specialized institution, are all essential to increase the chances of successful treatment of newborns harboring MMC and is one of the main goals pursued in the MMSNI, as the only referral public health center with locally trained health personnel in Zanzibar archipelago.

The NED foundation experience: A model of global neurosurgery.

Introduction: The Neurosurgery Education and Development (NED) Foundation (NEDF) started the development of local neurosurgical practice in Zanzibar (Tanzania) in 2008. More than a decade later, multiple actions with humanitarian purposes have significantly improved neurosurgical practice and education for physicians and nurses. Research question: To what extent could comprehensive interventions (beyond treating patients) be effective in developing global neurosurgery from the outset in low and middle-income countries? Material and method: A retrospective review of a 14- year period (2008-2022) of NEDF activities highlighting landmarks, projects, and evolving collaborations in Zanzibar was carried out. We propose a particular model, the NEDF model, with interventions in the field of health cooperation that have simultaneously aimed to equip, treat, and educate in a stepwise manner. Results: 138 neurosurgical missions with 248 NED volunteers have been reported. In the NED Institute, between Nov 2014-Nov 2022, 29635 patients were seen in the outpatient clinics and 1985 surgical procedures were performed. During the course of NEDF's projects, we have identified three different levels of complexity (1, 2 and 3) that include the areas of equipment ("equip"), healthcare ("treat") and training ("educate"), facilitating an increase of autonomy throughout the process. Discussion and Conclusion: In the NEDF's model, the interventions required in each action area (ETE) are coherent for each level of development (1, 2 and 3). When applied simultaneously, they have a greater impact. We believe the model can be equally useful for the development of other medical and/or surgical specialties in other low-resource healthcare settings.

A pure extradural hemangioblastoma mimicking a dumbbell nerve sheath tumor in cervical spine: illustrative case.

BACKGROUND: Spinal extradural hemangioblastomas (HBs) are quite uncommon, with most reported cases involving the thoracic and lumbar areas. Therefore, the presence of a dumbbell-shaped pure extradural cervical HB is exceptional, making preoperative diagnosis particularly challenging. OBSERVATIONS: The authors report a case of a 27-year-old woman who presented to their outpatient clinic with progressive cervicobrachialgia and numbness in the left arm. Magnetic resonance imaging showed a C5-6 intradural extramedullary lesion, and, despite some atypical features, the diagnosis of a possible neurogenic tumor was made. A multidetector computed tomography scan and angiography confirmed the expansion and remodeling of the left neural foramen as well as the highly vascularized nature of the mass. Preoperative embolization of the lesion was performed. Complete tumor resection was accomplished, followed by a C5-6 posterior fusion. Histopathology and immunohistochemistry revealed an HB. LESSONS: HBs should be considered among the differential diagnosis of cervical extradural tumors. Exhaustive preoperative workup and surgical planning are decisive in order to attain gross-total resection with favorable outcomes.

Cervical intramedullary solitary fibrous tumor: Case report and review of the literature.

BACKGROUND: Solitary fibrous tumors (SFTs) are benign tumors derived from mesenchymal tissues that predominantly occur in the pleura. Establishing the diagnosis of these very rare intramedullary spinal lesions, with no clear-cut pathognomonic radiographic characteristics, is particularly challenging. CASE DESCRIPTION: Two males, 30 and 41 years of age, presented with progressive cervical myelopathies attributed to a cervical intramedullary exophytic tumor with associated spinal cord edema. One patient showed that the lesion was highly vascularized. Both patients underwent surgical excision of firm, solid, focal, and, particularly in one of them, very vascular/hemorrhagic tumors; at surgery, there was some adherence between the tumors and the cord tissue, but gross-total resections were achieved in both cases, demonstrated on postoperative MR scans. Histological and immunohistochemical findings confirmed the diagnosis of SFT (WHO Grade I). After a 6-month postoperative period, both patients neurologically improved and had no MR evidence of tumor recurrence. CONCLUSION: Intramedullary cervical exophytic SFTs are extremely rare. Although these solid tumors may present with hemorrhagic features and at surgery demonstrate significant adherence to the pial/cord surface, complete surgical resections are feasible resulting in good outcomes.

Anatomía microquirúrgica en 3D del tracto corticoespinal y de la vía del lemnisco basada en microdisección de fibras y demostración a través de tractografía / 3D microsurgical anatomy of the cortico-spinal tract and lemniscal pathway based on fiber microdissection and demonstration with tractography

Objetivo: Realizar un estudio anatómico de microdisección de fibras y radiológico mediante tractografía basada en tensor de difusión (DTT) para demostrar tridimensionalmente el tracto corticoespinal y el lemnisco medial. Material y métodos: Bajo visión microscópica y con el uso de instrumental microquirúrgico se disecaron y estudiaron 10 hemisferios cerebrales y 15 troncoencéfalos humanos a través de la técnica de microdisección de fibras. Se obtuvieron imágenes de resonancia magnética cerebrales de 15 sujetos sanos, empleando secuencias potenciadas en difusión para el trazado y reproducción mediante DTT del tracto corticoespinal y la vía del lemnisco. Resultados: Se demostraron y describieron anatómicamente el tracto corticoespinal y lemnisco medial en gran parte de sus trayectorias, identificando las relaciones entre sí y con otros haces de sustancia blanca y núcleos de sustancia gris cercanos, especialmente en el troncoencéfalo, con la correspondiente representación mediante DTT. Conclusiones: Mediante la técnica de microdisección se apreció la disposición, arquitectura y organización topográfica general del tracto corticoespinal y lemnisco medial. Este conocimiento ha aportado una perspectiva anatómica única y profunda que ha favorecido la representación y la correcta interpretación de las imágenes de DTT. Esta información debe ser trasladada a la práctica clínica para favorecer el análisis crítico y exhaustivo por parte del cirujano ante posibles lesiones localizadas en el interior del troncoencéfalo y, en consecuencia, mejorar la indicación y planificación quirúrgica, incluyendo la selección preoperatoria de estrategias óptimas y posibles zonas de abordajes a su interior, alcanzando una técnica microquirúrgica más segura y precisa

Objective: To demonstrate tridimensionally the anatomy of the cortico-spinal tract and the medial lemniscus, based on fiber microdissection and diffusion tensor tractography (DTT). Material and methods: Ten brain hemispheres and brain-stem human specimens were dissected and studied under the operating microscope with microsurgical instruments by applying the fiber microdissection technique. Brain magnetic resonance imaging was obtained from 15 healthy subjects using diffusion-weighted images, in order to reproduce the cortico-spinal tract and the lemniscal pathway on DTT images. Results: The main bundles of the cortico-spinal tract and medial lemniscus were demonstrated and delineated throughout most of their trajectories, noticing their gross anatomical relation to one another and with other white matter tracts and gray matter nuclei the surround them, specially in the brain-stem; together with their corresponding representation on DTT images. Conclusions: Using the fiber microdissection technique we were able to distinguish the disposition, architecture and general topography of the cortico-spinal tract and medial lemniscus. This knowledge has provided a unique and profound anatomical perspective, supporting the correct representation and interpretation of DTT images. This information should be incorporated in the clinical scenario in order to assist surgeons in the detailed and critic analysis of lesions located inside the brain-stem, and therefore, improve the surgical indications and planning, including the preoperative selection of optimal surgical strategies and possible corridors to enter the brainstem, to achieve safer and more precise microsurgical technique

3D microsurgical anatomy of the cortico-spinal tract and lemniscal pathway based on fiber microdissection and demonstration with tractography. / Anatomía microquirúrgica en 3D del tracto corticoespinal y de la vía del lemnisco basada en microdisección de fibras y demostración a través de tractografía.

OBJECTIVE: To demonstrate tridimensionally the anatomy of the cortico-spinal tract and the medial lemniscus, based on fiber microdissection and diffusion tensor tractography (DTT). MATERIAL AND METHODS: Ten brain hemispheres and brain-stem human specimens were dissected and studied under the operating microscope with microsurgical instruments by applying the fiber microdissection technique. Brain magnetic resonance imaging was obtained from 15 healthy subjects using diffusion-weighted images, in order to reproduce the cortico-spinal tract and the lemniscal pathway on DTT images. RESULTS: The main bundles of the cortico-spinal tract and medial lemniscus were demonstrated and delineated throughout most of their trajectories, noticing their gross anatomical relation to one another and with other white matter tracts and gray matter nuclei the surround them, specially in the brain-stem; together with their corresponding representation on DTT images. CONCLUSIONS: Using the fiber microdissection technique we were able to distinguish the disposition, architecture and general topography of the cortico-spinal tract and medial lemniscus. This knowledge has provided a unique and profound anatomical perspective, supporting the correct representation and interpretation of DTT images. This information should be incorporated in the clinical scenario in order to assist surgeons in the detailed and critic analysis of lesions located inside the brain-stem, and therefore, improve the surgical indications and planning, including the preoperative selection of optimal surgical strategies and possible corridors to enter the brainstem, to achieve safer and more precise microsurgical technique.

Anatomía de los pedúnculos cerebelosos en 3D basada en microdisección de fibras y demostración a través de tractografía / 3D anatomy of cerebellar peduncles based on fibre microdissection and a demonstration with tractography

Objetivo: Realizar un estudio anatómico de microdisección de fibras y radiológico mediante tractografía basada en tensor de difusión (DTT) para demostrar tridimensionalmente los pedúnculos cerebelosos superiores, medios e inferiores. Material y métodos: Bajo visión microscópica y con el uso de instrumental microquirúrgico en el laboratorio, se disecaron 15 troncoencéfalos, 15 hemisferios cerebelosos y 5 hemisferios cerebrales humanos, entre julio de 2014 y julio de 2015. Se obtuvieron imágenes de resonancia magnética cerebrales realizas a 15 sujetos sanos entre julio y diciembre de 2015, empleando secuencias potenciadas en difusión para el trazado de los pedúnculos cerebelosos y su reproducción mediante DTT. Resultados: Se demostraron y describieron anatómicamente las principales fibras de los pedúnculos cerebelosos a lo largo de gran parte de su trayectoria en el cerebelo y troncoencéfalo, identificando las relaciones entre sí y con otros haces de sustancia blanca y núcleos de sustancia gris que los rodean, con la correspondiente representación mediante DTT. Conclusiones: Mediante la técnica de microdisección se apreció la disposición, arquitectura y organización topográfica general de los pedúnculos cerebelosos. Este conocimiento ha aportado una perspectiva anatómica única y profunda que ha favorecido la representación y correcta interpretación de las imágenes de DTT. Esta información debe ser trasladada a la práctica clínica para favorecer el análisis crítico y exhaustivo por parte del cirujano ante la presencia de lesiones que puedan localizarse cercanas a este grupo de haces en el cerebelo y/o troncoencéfalo, y, en consecuencia, mejorar la planificación quirúrgica y alcanzar una técnica microquirúrgica más segura y precisa

Objective: To perform an anatomical and radiological study, using fibre microdissection and diffusion tensor tractography (DTT), to demonstrate the three-dimensionality of the superior, middle and inferior cerebellar peduncles. Material and methods: A total of 15 brain-stem, 15 cerebellar hemispheres, and 5 brain hemispheres were dissected in the laboratory under the operating microscope with microsurgical instruments between July 2014 and July 2015. Brain magnetic resonance imaging was obtained from 15 healthy subjects between July and December of 2015, using diffusion-weighted images, in order to reproduce the cerebellar peduncles on DTT. Results: The main bundles of the cerebellar peduncles were demonstrated and delineated along most of their trajectory in the cerebellum and brain-stem, noticing their overall anatomical relationship to one another and with other white matter tracts and the grey matter nuclei the surround them, with their corresponding representations on DTT. Conclusions: The arrangement, architecture, and general topography of the cerebellar peduncles were able to be distinguished using the fibre microdissection technique. This knowledge has given a unique and profound anatomical perspective, supporting the correct representation and interpretation of DTT images. This information should be incorporated in the clinical scenario in order to assist surgeons in the detailed and critical analysis of lesions that may be located near these main bundles in the cerebellum and/or brain-stem, and therefore, improve the surgical planning and achieve a safer and more precise microsurgical technique

[3D anatomy of cerebellar peduncles based on fibre microdissection and a demonstration with tractography]. / Anatomía de los pedúnculos cerebelosos en 3D basada en microdisección de fibras y demostración a través de tractografía.

OBJECTIVE: To perform an anatomical and radiological study, using fibre microdissection and diffusion tensor tractography (DTT), to demonstrate the three-dimensionality of the superior, middle and inferior cerebellar peduncles. MATERIAL AND METHODS: A total of 15 brain-stem, 15 cerebellar hemispheres, and 5 brain hemispheres were dissected in the laboratory under the operating microscope with microsurgical instruments between July 2014 and July 2015. Brain magnetic resonance imaging was obtained from 15 healthy subjects between July and December of 2015, using diffusion-weighted images, in order to reproduce the cerebellar peduncles on DTT. RESULTS: The main bundles of the cerebellar peduncles were demonstrated and delineated along most of their trajectory in the cerebellum and brain-stem, noticing their overall anatomical relationship to one another and with other white matter tracts and the grey matter nuclei the surround them, with their corresponding representations on DTT. CONCLUSIONS: The arrangement, architecture, and general topography of the cerebellar peduncles were able to be distinguished using the fibre microdissection technique. This knowledge has given a unique and profound anatomical perspective, supporting the correct representation and interpretation of DTT images. This information should be incorporated in the clinical scenario in order to assist surgeons in the detailed and critical analysis of lesions that may be located near these main bundles in the cerebellum and/or brain-stem, and therefore, improve the surgical planning and achieve a safer and more precise microsurgical technique.

The Medial and Lateral Lemnisci: Anatomically Adjoined But Functionally Distinct Fiber Tracts.

OBJECTIVE: The dense and complex distribution of neural structures in the brainstem makes it challenging to understand their real configuration. We used the fiber microdissection technique to show the course of the medial and lateral lemnisci within the brainstem. Although these structures seem anatomically alike, they are functionally distinct. METHODS: Fifteen human brainstems and 8 brain hemispheres (formalin-fixed and previously frozen) were dissected and studied under the operating microscope by applying the fiber microdissection technique. RESULTS: We delineated and described the medial and lateral lemnisci, noting their gross elaborate arrangement. These structures are intimately compact and closely related to one another in their common trajectory through the tegmenta of the pons and midbrain. However, we were not able to identify the exact origin and termination of their fibers or the accurate delimitation between the medial lemniscus, spinothalamic tract, and lateral lemniscus along their course in the brainstem. CONCLUSIONS: Using the fiber microdissection technique, we were able to define a general perspective of the topography and architecture of the medial and lateral lemnisci in the brainstem. This perspective should be incorporated into interpretations of magnetic resonance imaging techniques, recognizing both their benefits and limitations. It should also be applied to surgical planning and strategies to achieve a safer and more precise microsurgical procedure.

Bilateral ophthalmic segment aneurysm clipping with one craniotomy: operative technique and results.

AIM: Surgical indications for ophthalmic segment aneurysms are getting narrower due in part to success of endovascular techniques like flow diverters. Wide necks, large size, intraluminal thrombus, optic nerve compression or recurrence after endovascular therapy make the case for surgical treatment. Bilateral aneurysms are less established but worth considering surgical indication. Our objective is to review a series of bilateral ophthalmic segment aneurysms managed through a single craniotomy, describe the surgical technique and evaluate the results. MATERIAL AND METHODS: Between 1997 and 2012, 11 patients with bilateral ophthalmic segment aneurysms were treated through a single craniotomy at UCSF Medical Center. An intradural clinoidectomy was performed to expose and clip the ipsilateral aneurysm. Medially and superiorly projecting contralateral aneurysm could be clipped through the interoptic triangle without clinoidectomy. Indocyanin green videoangiography was performed routinely. RESULTS: Eleven patients harboring 22 ophthalmic segment aneurysms were treated with a single craniotomy. Complete neck occlusion was achieved in 96 % of aneurysms. One patient presenting with subarachnoid hemorrhage Hunt-Hess grade 5 died from vasospasm complications. The remaining 10 patients had good outcomes (mRS ≤ 2) after a mean 2.2 years follow up. There were no recurrences after surgical treatment. CONCLUSION: Decompressing the optic nerve, completely occluding the aneurysm neck, providing a durable repair and avoiding antiplatelet agents are the well established advantages of microsurgical management. This experience demonstrates safety and feasibility of contralateral clipping of carefully selected ophthalmic segment aneurysms, thus pointing another advantage of surgical clipping when bilateral aneurysms are diagnosed.

Historia de la neurocirugía española. La escuela de Valencia: J.J. Barcia Goyanes / The History of Spanish Neurosurgery: The Valencian School: J.J. Barcia Goyanes

El Prof. Juan José Barcia-Goyanes inició la neurocirugía desde la anatomía y la neuropsiquiatría como respuesta a una necesidad de un servicio denominado: «Enfermedades nerviosas» en 1931 en el Hospital General de Valencia. Desde la primera intervención, con los métodos e instrumentos que ya se usaban en Europa y EE.UU., la actividad neuroquirúrgica fue el motor del servicio, donde nacieron las especialidades auxiliares: neurorradiología, neurofisiología, neuropatología y técnicas nuevas como la estereotaxia, la neurocirugía funcional y la palencefalografía. El servicio cumple este año su 80 aniversario. La producción bibliográfica del Prof. Barcia abarcó tanto las materias de neurología, neurocirugía y psiquiatría, como de antropología, pensamiento médico, historia de la medicina, morfología e historia del lenguaje anatómico en su obra de madurez: «Onomatologia anatomica nova», así como una interesante obra poética. Fue miembro fundador de la Sociedad Luso-española de Neurocirugía y de la Sociedad de Neurocirugía de Levante (AU)

Professor Juan José Barcia-Goyanes started neurosurgical practice from anatomy and neuropsychiatry in response to a vacancy at a department known as “Nervous diseases”, in 1931at Hospital General in Valencia, Spain. Since the first intervention, based on the methods and surgical instruments already used in Europe and the U.S.A., the neurosurgical practice became the mainstay of the department, from which other auxiliary specialties emerged, such as neuroradiology, neurophysiology, neuropathology and also new techniques such as stereotactic surgery, functional neurosurgery and palence phalography. This year, the department celebrates its 80th anniversary. The broad spectrum of Prof. Barcia’s scientific work included fields like neurology, neurosurgery and psychiatry, as well as anthropology, medical thought, history of medicine, morphology and history of anatomical language in his work “Onomatologica anatomica nova”, in addition to an interesting poetic work. He was a founding member of the Luso-Spanish Neurosurgical Society and the Neurosurgical Societyof Levante (AU)

Distal aneurysms of intracranial arteries: application of numerical nomenclature, predilection for cerebellar arteries, and results of surgical management.

BACKGROUND: Distal intracranial aneurysms are rare, have unclear origins, and are frequently nonsaccular. Published clinical experience with these aneurysms is limited. OBJECTIVE: To examine differences between distal aneurysms of cerebral and cerebellar arteries and to examine results associated with surgical therapy in 140 patients. METHODS: Distal aneurysms in the cerebral arteries were defined as outside the circle of Willis, on or beyond the A2 anterior cerebral artery, M2 middle cerebral artery, or P2 posterior cerebral segments. Distal aneurysms in the cerebellar arteries were on or beyond the s2 superior cerebellar artery, a2 anterior inferior cerebellar artery, or p2 posterior inferior cerebellar artery segments. Clinical data, microsurgical technique, and patient outcomes were reviewed. RESULTS: The incidence of distal cerebellar artery aneurysms was 4.3 times greater than distal cerebral artery aneurysms (6.5% vs. 28.6%; P< 0.01). The A3 anterior cerebral artery segment and the p2 and p3 posterior inferior cerebellar artery segments were the most common sites. Presentation with aneurysm rupture was more frequent with cerebellar aneurysms (65% vs. 40%; P< 0.05). Distal cerebellar artery aneurysms were less likely than distal cerebral artery aneurysms to be clipable (40% vs. 72%; P< 0.01), with 42% treated with trapping alone. Overall, 14% required a bypass. CONCLUSIONS: Distal intracranial aneurysms have a predilection for cerebellar arteries and are not as rare as the literature suggests. Application of standardized nomenclature for segmental anatomy to these lesions will increase the precision of anatomic description and clarity of clinical discourse. Although technically difficult, good clinical results can be expected with surgical management.

[The history of Spanish neurosurgery: the Valencian school: J.J. Barcia Goyanes]. / Historia de la neurocirugía española. La escuela de Valencia: J.J. Barcia Goyanes.

Professor Juan José Barcia-Goyanes started neurosurgical practice from anatomy and neuropsychiatry in response to a vacancy at a department known as "Nervous diseases", in 1931 at Hospital General in Valencia, Spain. Since the first intervention, based on the methods and surgical instruments already used in Europe and the U.S.A., the neurosurgical practice became the mainstay of the department, from which other auxiliary specialties emerged, such as neuroradiology, neurophysiology, neuropathology and also new techniques such as stereotactic surgery, functional neurosurgery and palencephalography. This year, the department celebrates its 80th anniversary. The broad spectrum of Prof. Barcia's scientific work included fields like neurology, neurosurgery and psychiatry, as well as anthropology, medical thought, history of medicine, morphology and history of anatomical language in his work "Onomatologica anatomica nova", in addition to an interesting poetic work. He was a founding member of the Luso-Spanish Neurosurgical Society and the Neurosurgical Society of Levante.

Xantoastrocitoma pleomórfico con extensión intraventricular y transformación anaplásica en paciente adulto: caso clínico / No disponible

El xantoastrocitoma pleomórfico (XAP) es un tumor astrocitario raro, de localización más frecuente superficial en hemisferios cerebrales de niños y adultos jóvenes. Se trata de un tumor de bajo grado que tiene un pronóstico relativamente favorable; sin embargo, se han descrito pacientes con progresión maligna. Presentamos así un caso inusual de un varón de 54 años con una tumoración multiquística parietooccipital derecha con extensión intraventricular. Tras la exéresis quirúrgica el estudio histológico mostró una lesión con células pleomórficas, cúmulos de lípidos en su citoplasma, cuerpos granulares intensamente eosinófilos, núcleos únicos bien delimitados y positividad inmunohistoquímica frente a sinaptofisina, proteína gliofibrilar ácida (GFAP), proteína S-100, vimentina y CD56 de forma focal. Tras descartar otras entidades, como metástasis por carcinoma de células grandes y una lesión primaria tipo astrocitoma subependimario de células grandes, se diagosticó de XAP. A los 9 meses de seguimiento el paciente presentó una extensa recidiva tumoral local considerada irresecable, con deterioro neurológico progresivo y signos radiológicos de progresión maligna, confirmados histológicamente mediante la realización de una biopsia cerebral que demostró cambios respecto a la lesión inicial que incluían focos de necrosis, mayor actividad mitótica (5×10 campos de gran aumento) e índice de proliferación celular medido con la tinción nuclear de Ki67 del 10%. El presente caso ilustra la extensión intraventricular, así como un comportamiento agresivo no característico de estas lesiones (similar a un astrocitoma anaplásico o glioblastoma primario), exigiendo un tratamiento quirúrgico óptimo inicial con seguimiento estrecho clínico-radiológico, considerando el potencial de transformación maligna del XAP (AU)

[Pleomorphic xanthoastrocytoma with intraventricular extension and anaplastic transformation in an adult patient: Case report]. / Xantoastrocitoma pleomórfico con extensión intraventricular y transformación anaplásica en paciente adulto: caso clínico.

Pleomorphic xanthoastrocytoma (PXA) is a rare, low-grade astrocytic tumour that usually occurs in the superficial cerebral hemispheres of children and young adults. Although it has a relatively favourable prognosis, malignant progression of these tumours has been described. Therefore, we present an unusual case of a 54-year-old male with a right, multicystic, parietooccipital tumour extending through the ipsilateral ventricle. After surgical resection, histological examination revealed a lesion with pleomorphic cells, cytoplasmic lipidisation, intensely eosinophilic granular bodies, well-delimitated unique nuclei and focal, positive immunoreactivity for synaptophysin, glial fibrillary acidic protein (GFAP), S-100 protein, vimentin and CD56. Once other tumours, such as giant cell metastatic carcinoma or primary lesion like subependymal giant cell astrocytoma, were ruled out, a final diagnosis of XAP was established. After a follow-up period of 9 months, the patient suffered an extensive and local tumour relapse considered inoperable, with progressive neurological deterioration and radiological findings of malignant progression. The brain biopsy procedure revealed anaplastic changes, including necrosis foci, higher mitotic activity (5×10 high-power fields) and a 10% proliferation index measured by Ki67 labelling. The present case showed intraventricular extension and a more aggressive behaviour, both uncommon in these tumours (similar to anaplastic astrocytoma or glioblastoma multiforme), thus demanding an initial, optimal surgical treatment with close clinical and radiological follow-up, due to the high potential for malignant transformation of XAPs.

Radiocirugía con acelerador lineal en el tratamiento del schwannoma vestibular / Linear accelerator radiosurgery for the treatment of vestibular schwannoma

Introducción y objetivo. Entre las opciones terapéuticas para pacientes con schwannoma vestibular se encuentra la radiocirugía. Presentamos así nuestra experiencia en el tratamiento de esta patología con esta técnica. Pacientes y métodos. Estudio retrospectivo de 20 pacientes (11 mujeres y 9 varones; edad media: 55,15 años) con diagnóstico de schwannoma vestibular, que recibieron tratamiento con radiocirugía con acelerador lineal desde abril del 2005 hasta diciembre del 2008. El tiempo de seguimiento fue de 12-42 meses, tanto clínico, con valoración de los pares craneales VII (escala de House-Brackmann) y VIII (escala de Gardner-Robertson), como radiológico (con medición del volumen tumoral). Se emplearon el test exacto de Fisher y la prueba de regresión logística para el análisis estadístico. Resultados. El 25% presentó algún empeoramiento de la audición. Cinco pacientes presentaron tumores grandes en el momento del tratamiento (iguales o mayores que 3,5 cm3), de los cuales cuatro empeoraron de cefalea, inestabilidad, mareos/vértigo, parestesias faciales y acúfenos, con una asociación estadísticamente significativa (p < 0,05) en las pruebas aplicadas. A partir del primer año del tratamiento, se observó una tendencia a la disminución del volumen tumoral, sin observarse ningún crecimiento de la lesión a medio-largo plazo, con control local del 100%. Conclusiones. La radiocirugía se ofrece como una alternativa de tratamiento para pacientes con schwannoma vestibular de tamaño adecuado, con alta seguridad terapéutica, que emplea dosis relativamente bajas de radiación, índice bajo de complicaciones y buen control del crecimiento tumoral a medio plazo (AU)

Introduction and aim. Radiosurgery is among the treatment options for patients with vestibular schwannoma. We present the experience in our institution in the treatment of this disease with this technique. Patients and methods. A retrospective study was made including 20 patients (11 women and 9 men; median age: 55.15 years-old) with vestibular schwannoma who received linear accelerator radiosurgery treatment since April 2005 until December 2008. Follow-up period was between 12 and 42 months, considering clinical examination of cranial nerves VII (House-Brackmann scale) and VIII (Gardner-Robertson scale) as well as radiological findings (considering tumor volume). For statistical analysis, the Fisher’s exact test and logistic regression test were used. Results. Certain worsening of hearing function was present in 25% of the patients. Five patients had large tumors at the moment of the treatment (equal or larger than 3.5 cm3), from which four deteriorated from headache, unsteady gait, dizziness/vertigo, facial numbness and tinnitus, with statistical significance (p < 0.05). From the first year of treatment on, there was a tumor volume decrease tendency, with no tumor growth in the medium/long term follow-up, achieving a local control rate of 100%. Conclusions. Radiosurgery has become an alternative in the treatment of patients with vestibular schwannoma of appropriate size, with high safety level, using low radiation doses, low rate of complications and good tumor control rate in the medium term follow-up (AU)