Embolización de aneurismas intracraneales múltiples en sesión única

Objetivo: Determinar los resultados clínicos y angiográficos en pacientes con aneurismas intracraneales múltiples tratados endovascularmente en una única sesión. Materiales y Métodos: Se incluyó a todos los pacientes mayores de 18 años con aneurismas múltiples (≥2), rotos o no rotos, tratados con terapia endovascular en una única sesión entre 2019 y 2021. Se recolectaron los datos clínicos y angiográficos. Se determinó la tasa de oclusión inmediata y del seguimiento. La escala de Rankin modificado se usó para valorar el resultado clínico. Resultados: Se trataron 25 pacientes, de los cuales 14 se presentaron con hemorragia subaracnoidea. Se diagnosticaron un total de 78 aneurismas, de los cuales 59 aneurismas fueron tratados. La localización más frecuente fue el segmento oftálmico. La altura máxima promedio fue de 5.2mm, lo cual tuvo diferencia estadística significativa con el estado de ruptura (p ≤ 0.02). El principal tipo de tratamiento endovascular fue la técnica de remodeling en el 39 % de casos. El Raymond Roy inmediato fue I en el 60 % y IIIa en el 35 % de casos. La tasa de complicaciones fue del 24 % y de mortalidad fue del 8 %. Conclusiones: El tratamiento endovascular en una única sesión es una opción efectiva y segura en casos de aneurismas intracraneales múltiples en nuestra institución con tasa de oclusión y complicaciones aceptable.

Objective: To determine clinical and angiographical outcomes in patients with multiple intracranial aneurysms who underwent endovascular therapy in a single session. Materials and Methods: Patients older than 18 years with multiple (≥2) ruptured or non-ruptured aneurysms were included, and all of them underwent endovascular therapy in a single session between 2019 and 2021. Clinical and angiographic data was collected. Immediate occlusion and follow-up data were collected. Rankin modified scale was used for assessing clinical outcomes. Results: Twenty-five patients were treated, and fourteen had subarachnoid hemorrhage. Seventy-eight aneurysms were diagnosed, and 59 of them were treated. The most frequent location was at the ophthalmic segment. Maximum average height was 5.2- mm, which showed significant statistical difference with a ruptured condition (p≤0.02). The main modality for endovascular therapy was the remodeling technique, which was used in 39% of all cases. Immediate Raymond Roy staging was I in 60% of all cases, and IIIa in 35% of all cases. Complication rate was 24%, and mortality rate was 8%. Conclusions: Single session endovascular therapy is an effective and safe option for cases of multiple intracranial aneurysms in our institution. Occlusion and complication rates were acceptable.

Transvenous embolization of a ruptured thalamic arteriovenous malformation supplied by the tuberothalamic artery.

Background: Basal ganglia and thalamic arteriovenous malformations (AVM) represent 10% of all AVM. They are associated with a high rate of morbidity and mortality due to their high hemorrhagic presentation and eloquence. Radiosurgery has been the first line treatment, whereas surgical removal and endovascular therapy are possible in selected cases. Deep AVM with small niduses and a single draining vein can achieve cure with embolization. Case Description: A 10-year-old boy with sudden headache and vomiting underwent a brain computed tomography scan that showed a right thalamic hematoma. Cerebral angiography revealed a small ruptured right anteromedial thalamic AVM with a single feeder arising from the tuberothalamic artery and a single drainage to the superior thalamic vein. Transvenous approach using precipitating hydrophobic injectable liquid 25%® achieved a complete obliteration of the lesion in a single-session. He was discharged home without neurological sequelae and maintained clinically intact at follow-up. Conclusion: Transvenous embolization of deep-located AVM as a primary treatment is curative in selected cases, with complication rates comparable to other therapeutic strategies.

Experiencia en patología cervical alta en el Hospital Guillermo Almenara Irigoyen 2016 - 2021

Introducción : El complejo C0-C1-C2 es responsable de la transición de la carga axial, con función biomecánica única, siendo afectada por múltiples patologías, que por lo general la literatura no las considera como un solo ítem, sino que lo desarrolla según su etiología, pero en nuestro estudio se ha considerado en 5 grupos: traumática, congénita, inflamatoria reumática, neoplásica y degenerativa. Objetivo : Determinar las características epidemiológicas, clínicas y del tratamiento en la patología cervical alta. Materiales y métodos : Se incluyeron a todos los pacientes con diagnóstico clínico radiológico de alguna patología cervical alta que hayan sido sometidos a tratamiento quirúrgico entre 2016 y 2021 en el Hospital Almenara. Se usó el test "t" de student y de chi cuadrado. Se dividió a los pacientes en alguno de los 5 grupos antes mencionados. Resultados : Se consideraron 31 pacientes, con una edad media de 51.16 años. La patología cervical alta más frecuente fue la traumática con el 35.48%. El déficit motor se presentó en el 51.61% y el déficit sensitivo se presentó en el 54.84%. La cirugía más frecuente fue la fijación cervical alta con el 43.89%. La tasa de complicaciones fue del 16.13% con una mortalidad del 0%. Conclusiones : La patología cervical alta es rara, siendo la del tipo traumática la más frecuente, pero un manejo oportuno y adecuado permite un mejor pronóstico funcional del paciente.

Introduction : The C0-C1-C2 complex is responsible of axial load transition, and its biomechanical function is unique, it is affected by multiple pathological conditions; and generally speaking, the literature does not consider these conditions as a single item, it describes them according to etiology. For our study we considered five groups: trauma-related, congenital, rheumatic-inflammatory, neoplastic, and degenerative. Objective : To determine epidemiological, clinical, and therapy-related characteristics in upper cervical pathological conditions. Materials and methods : All patients with a clinical-radiological diagnosis of any upper cervical pathological condition that had undergone surgery between 2016 and 2021 in Guillermo Almenara Hospital were included. Student's t test and chi square methods were used. patients were divided into one of the five aforementioned groups. Results : Thirty-one patients were included in the study; their mean age was 51.16 years. The most frequent upper cervical pathological condition was trauma-related, with 35.48%. Motor deficit occurred in 51.61% of all patients, and sensitive deficit occurred in 54.84%. The most frequently surgical procedure performed was upper cervical fixation, in 43.89% of all patients. Complication rate was 16.13%, and mortality was 0%. Conclusions : Upper cervical pathological conditions are rare, trauma-related conditions are most frequent, but timely and adequate management allow us to achieve better functional prognosis for these patients.

Pandemic impact on aneurysmal subarachnoid hemorrhage in Peru's high COVID-19 lethality setting: A public institutional experience.

Background: The COVID-19 pandemic in 2020 profoundly impacted healthcare worldwide, and Peru was particularly affected, experiencing the highest COVID-19 case fatality rate globally. Methods: We conducted a retrospective comparative study of patients presenting with aneurysmal subarachnoid hemorrhage (SAH) at a public Peruvian national referral center specializing in cerebrovascular diseases. Two study periods were considered, one during the first wave of the COVID-19 pandemic and a second identical period in 2019. Variables included patient demographics, comorbidities, COVID-19 infection status, clinical presentation, treatment approaches, and hospital outcomes. Results: We analyzed 114 patients with aneurysmal SAH, 65 (57.0%) treated in 2019 and 49 (43.0%) in 2020. The mean time from emergency admission to the day of definitive treatment during 2019 and 2020 was 2.72 and 1.93 days, respectively. Likewise, the mean time from symptom onset to the date of definitive treatment was 6.71 and 7.70 days, respectively. We identified significant associations between complications such as sepsis, respiratory failure, acute kidney failure, and hospital mortality. The proportion of fatalities was significantly higher in 2020 compared to 2019 (36.7% vs. 15.4%, respectively). Interestingly, there was no statistically significant association between COVID-19 infection status and mortality during the 2020 period. Conclusion: Patients with aneurysmal SAH treated during the pandemic had a higher proportion of sepsis, respiratory failure, acute kidney failure, and mortality compared to the pre-pandemic period. Reallocating healthcare resources to prioritize COVID-19 patients may have inadvertently neglected or delayed care for patients with other emergency conditions, such as aneurysmal SAH. This highlights the importance of maintaining adequate care for non-infectious emergencies during a pandemic.

Neuralgia del glosofaríngeo izquierdo: una patología poco frecuente. Un reporte de caso

La neuralgia del glosofaríngeo es una patología rara donde hay dolor agudo y punzante en la fosa amigdalina, ángulo de la mandíbula y base de la lengua. Su principal causa es la compresión neurovascular la cual se puede diagnosticar con una resonancia cerebral. Su manejo es médico, principalmente; con fármacos, especialmente, carbamazepina y oxcarbazepina; y si no hay respuesta, va a cirugía mediante descompresión microvascular e interposición de material blando (politetrafluoroetileno), con o sin transección del IX par craneal. Se presenta el caso de una mujer de 64 años, hipertensa controlada, con dolor característico, que con 5 fármacos antineuropáticos y 1 derivado de opioides no cedía el dolor. La resonancia cerebral con secuencia FIESTA muestra una compresión neurovascular del IX PC con la PICA izquierda. Se le realiza descompresión microvascular del IX PC, con resolución de la sintomatología y sin recurrencia, saliendo de alta pronto. Se concluye que el manejo quirúrgico de esta patología en casos refractarios al tratamiento médico es una opción con buenas tasas de éxito y baja morbilidad.

Glossopharyngeal neuralgia is a rare pathology, with a sharp and stabbing pain in the tonsillar fossa, angle of the jaw and base of the tongue. Its main etiology is neurovascular compression, which can be diagnosed with a brain MRI. Its management is mainly medical with drug, especially carbamazepine and oxcarbazepine, and if there is no response, surgery is performed through microvascular decompression and interposition of soft material (polytetrafluoroethylene) with or without transection of IX cranial nerve. We present the case of a 64-year-old woman, with controlled hypertension, with classic pain, who did not relieve pain with 5 antineuropathic drugs and 1 opioid derivative. Brain MRI with FIESTA sequence shows a neurovascular compression of the glossopharyngeal nerve with the left PICA. Microvascular decompression of the glossopharyngeal nerve was performed, with resolution of the symptoms and without recurrence, and she was discharged soon. We concluded that the surgical management of this pathology in refractory cases to medical treatment is an option with good success rates and low morbidity.

Aneurisma tipo blister roto con manejo satifactorio con la técnica de remodelado - Reporte de un caso

Introducción : Los aneurismas tipo blíster son aneurismas pequeños, complejos, menores de 3mm, con alta tasa de morbilidad y mortalidad, así como de resangrado y recurrencia. Son difíciles de tratar y se han propuesto técnicas microquirúrgicas y endovasculares, siendo estas últimas las de menor tasa de complicaciones. Caso Clínico : Mujer de 74 años, ingresa con 6 horas de evolución de trastorno de sensorio brusco. La tomografía muestra hemorragia subaracnoidea difusa a predominio izquierdo. Se le realiza una angiografía cerebral que evidencia un aneurisma blíster de la trifurcación de la arteria cerebral media izquierda. Se emboliza con técnica de remodeling y coils, logrando obliterar la totalidad del aneurisma. Conclusión : Los aneurismas tipo blíster son aneurismas complejos y raros, siendo la terapia endovascular una alternativa segura y eficaz con menor tasa de complicaciones.

Introduction : Blister-like aneurysms are small, complex, smaller than 3mm, with high rate of morbidity and mortality, as well as rebleeding and recurrence. They are difficult to treat and microsurgical and endovascular techniques are current treatment modalities. Endovascular technique has the lowest rate of complications. Clinical case : 74-year-old woman, admitted with 6 hours of sudden sensory disorder. The CT scan shows diffuse subarachnoid hemorrhage predominantly on the left side. A cerebral angiography showed a blister-like aneurysm of the left middle cerebral artery trifurcation. The patient was treated with coiling and remodeling technique, achieving a complete occlusion. Conclusion : Blister-like aneurysms are complex and rare, whereas endovascular therapy is a safe and effective alternative with low complication rate.

Predictores de mortalidad intrahospitalaria y de mal pronóstico funcional en pacientes sometidos a evacuación quirúrgica de hemorragia intracerebral / Predictors of in-hospital mortality and poor functional outcomes in patients who underwent surgical evacuation of intracerebral hemorrhage

RESUMEN Objetivo : Determinar predictores de mortalidad intrahospitalaria y mal pronóstico funcional en pacientes sometidos a cirugía por hemorragia intracerebral. Materiales y métodos : Se analizaron las historias clínicas, reportes operatorios y tomografías cerebrales de pacientes con hemorragia intracerebral desde marzo 2018 hasta marzo de 2020. Se realizó un análisis de regresión logística univariado y multivariado para determinar predictores independientes de mortalidad intrahospitalaria y mal pronóstico funcional al alta. Resultados : La mortalidad intrahospitalaria fue de 33,7 % (n = 31 pacientes). Predictores independientes de mortalidad fueron el sexo femenino (OR = 3.01; p = 0.031) y un Glasgow < 8 puntos al ingreso (OR = 3.19; p = 0.031). Un mal pronóstico funcional luego de la intervención se encontró en 77 pacientes (83,7 %). Predictores independientes de mal pronóstico funcional fueron una Escala de Rankin modificada > 3 (OR = 15.5; p = 0.01) y déficit motor pre-operatorio (OR = 8.95; p = 0.042). Conclusiones : En pacientes con diagnóstico de hemorragia intracerebral tratados con cirugía se encontró una alta mortalidad y morbilidad. El sexo femenino y factores clínicos como el estado de conciencia y el estado funcional al ingreso fueron predictores independientes de mortalidad intrahospitalaria y mal pronóstico funcional.

ABSTRACT Objective : To determine predictors of in-hospital mortality and poor functional prognosis in patients undergoing surgery for intracerebral hemorrhage. Materials and Methods : Clinical records, operative reports, and cerebral CT scans of patients with intracerebral hemorrhage from March 2018 to March 2020 were analyzed. Univariate and multivariate logistic regression analyses were performed for determining independent predictors of in-hospital mortality and poor functional prognosis at discharge. Results : In-hospital mortality was 33.7% (n= 31 patients). Independent predictors for mortality were female sex (OR= 3.01, p= 0.031) and Glasgow score <8 on admission (OR= 3.19, p= 0.031). A poor functional prognosis after the intervention was found in 77 patients (83.7%). Independent risk factors for a poor functional prognosis were score >3 in the modified Rankin scale (OR= 15.5; p= 0.01), and preoperative motor deficit (OR= 8.95; p= 0.042). Conclusions : In patients with intracerebral hemorrhage who were surgically treated, high morbidity and mortality rates were found. Female sex and clinical factors, such as consciousness condition and functional status on admission were independent predictors for in-hospital mortality and poor functional prognosis.

Abordaje transradial para angiografía cerebral diagnóstica: primera experiencia en un hospital de la seguridad social / Transradial approach for diagnostic cerebral angiography: first experience in a social security hospital

RESUMEN El abordaje transradial está ganando territorio en el campo neuroendovascular para procedimientos diagnósticos y terapéuticos. Menos complicaciones, menor tiempo hospitalario y mayor confort del paciente son características de este abordaje. Sin embargo, la transición del abordaje femoral clásico al abordaje radial es difícil de lograr en instituciones con protocolos establecidos. Presentamos nuestra experiencia inicial utilizando el abordaje transradial para angiografía cerebral diagnóstica realizados exitosamente logrando la cateterización de todos los vasos supra-aórticos.

ABSTRACT The transradial approach for diagnostic cerebral angiography is aiming to become the standard technique in the neuroendovascular field for both diagnostic and therapeutic procedures. Some characteristics for this approach include less complications, shorter hospital stay and more comfort for patients. However, transitioning from the classical femoral approach to the radial approach is difficult to achieve in facilities with well-established protocols. We report our initial experience using the transradial approach for diagnostic cerebral angiography, where all supraaortic blood vessels were successfully catheterized.

Uso de la embolización de la arteria meníngea media en recidiva de hematoma subdural crónico / Use of embolization of the middle meningeal artery in chronic subdural hematoma recurrence

RESUMEN El hematoma subdural crónico (HSDC) es una patología neuroquirúrgica frecuente, con una recurrencia de hasta el 30% de los casos. La embolización de la arteria meníngea media (AMM) es una estrategia de manejo adyuvante para disminuir la recidiva, especialmente en pacientes con factores de riesgo para recurrencia, y tiene una baja tasa de complicaciones. Presentamos el caso de un varón de 83 años con antecedente de anticoagulación, que es admitido en centro sanitario por presentar hemiparesia derecha, disartria y alteración de la marcha, con un tiempo de enfermedad de una semana. Se realizó trepanación y evacuación del HSDC sin complicaciones. Un mes después retornó por recidiva del HSDC, por lo que se realizó trepanación y evacuación adecuada del HSDC, seguida de embolización de la AMM ipsilateral. El control a los dos meses mostró ausencia de recidiva, con mejoría neurológica del paciente. Concluimos que la embolización de la AMM fue un tratamiento adyuvante eficaz para disminuir la recidiva del HSDC y podría estar indicada en pacientes con factores de riesgo asociados a la recurrencia.

ABSTRACT Chronic subdural hematoma (CSDH) is a frequent neurosurgical condition, which may develop recurrence in up to 30% of all cases. Embolization of the middle meningeal artery (MMA) is an adjuvant management strategy for reducing recurrence, especially in patients with risk factors, and it has a low complication rate. We present the case of an 83-year old male with history of anticoagulation, who was admitted in a healthcare facility because of right hemiparesis, dysarthria and gait impairment, and he had been sick for one week. A trepanation and CSDH evacuation were uneventfully performed. One month later, the patient was brought back because of CSDH recurrence, so another trepanation and adequate CSDH evacuation were performed, followed by embolization of the ipsilateral MMA. A control assessment after two months revealed absence of recurrence and neurological improvement. We conclude that MMA embolization was an efficacious adjuvant therapy aiming to reduce CSDH recurrence, and this procedure may be indicated in patients with risk factors for recurrence.