Transoral robotic surgery of the central skull base: preclinical investigations.

In this study we explored possible applications of the da Vinci system in approaching the skull base at optic chiasm level on two cryopreserved cadavers, using an entirely transoral robotic technique (TORS). We used a standard 12 mm endoscopy and 8 mm terminals. Bone drilling was performed manually. The da Vinci system is equipped with very good illumination and 3D viewing, thus providing excellent vision and great maneuverability even in the less accessible areas of the skull. Our experience demonstrates that an entirely transoral skull base robotic approach to this complex anatomical region has many advantages as compared to traditional techniques.

[Ectopic relapse of an operated craniopharyngioma. Case report and review of the literature]. / Recidiva a distancia de craneofaringioma intervenido. Caso clínico y revisión de laliteratura.

INTRODUCTION. Craniopharyngioma is an embrionary tumor of the sellar and/suprasellar region derived from fusiform cells of Rathke´s cleft. Although locoregional relapse is the way classically proposed for relapse after treatment, it has been described, in a few cases, the possibility of ectopic relapse out of the sellar-suprasellar region, by direct seeding of cells during surgery on the surgical field, or by cell dissemination in the cerebrospinal fluid (CSF). It is proposed to report the case of a patient with relapse of a craniopharyngioma in the frontal lobe, who was previously operated ten years after, as well as to review the similar cases reported in the literature to the date. RESULTS. A systematic review of the literature has allowed to find 21 cases previously reported. Direct cellular seeding was the most frequent implantation mechanism. In all cases, the preferred treatment was radical surgical removal when this was possible. The time of latency between first surgery and relapse differed from 1 to 21 years. CONCLUSIONS. It is interesting, in the differential diagnosis, to bear in mind the possibility of ectopic relapse of craniopharyngioma in patients who have been operated because of this type of tumor and who present a new mass in nervous central system (CNS). In view of the long time of latency that can pass between the resection of a craniopharyngioma and his relapse, there becomes necessary a long follow-up of these patients by periodic imaging tests.

[Bilateral acute subdural haematoma without subarachnoid haemorrhage secondary to rupture of an anterior communicating aneurysm. A case report and review of the literature]. / Hematoma subdural agudo bilateral sin hemorragia subaracnoidea secundario a ruptura de aneurisma comunicante anterior. Presentacion de un caso y revision de la bibliografia.

INTRODUCTION: Pure acute subdural haematomas caused by aneurysmal rupture are a highly infrequent event, with only 51 cases published in the literature to date, with only six cases due to the rupture of anterior communicating artery aneurysm. AIM: To describe a case of an acute subdural haematoma not associated with subarachnoid haemorrhage due to ruptured of an anterior communicating cerebral artery aneurysm. CASE REPORT: A 55-year-old woman without a traumatic history, who is found at home with a level of consciousness of 4 points on the Glasgow Coma Scale and a bilateral arreactive mydriasis, which are reversed with medical measures. Cranial CT shows an acute bi-hemispherical convexity and interhemispheric subdural haematoma with no evidence of associated subarachnoid haemorrhage. The angio-CT reveals an anterior communicating artery aneurysm. We proceed to urgent embolization of the aneurysm. The patient was admitted to the Intensive Care Unit, where intracranial pressure is monitored and controlled initially with medical treatment. Patient outcome was unfavorable, confirming in the control CT scan coincident with an increase of uncontrolled medically intracranial hypertension, established ischemic infarctions areas, which made any surgical treatment non-viable. CONCLUSION: In the case of an acute subdural haematoma without subarachnoid haemorrhage nor traumatic brain injury or its external stigmas, we must consider the rupture of a cerebral aneurysm as a possible cause. Likewise, the initial management of the acute subdural haematoma in patients with poor neurological condition should be priority and surgical.

TITLE: Hematoma subdural agudo bilateral sin hemorragia subaracnoidea secundario a ruptura de aneurisma comunicante anterior. Presentacion de un caso y revision de la bibliografia.Introduccion. Los hematomas subdurales agudos de causa aneurismatica son muy infrecuentes, con solo 51 casos publicados en la bibliografia hasta la fecha, y unicamente seis de ellos por un aneurisma de la arteria comunicante anterior. Objetivo. Describir un caso de hematoma subdural agudo no asociado a hemorragia subaracnoidea, debido a la rotura de un aneurisma de la arteria comunicante anterior. Caso clinico. Mujer de 55 años sin antecedente traumatico, con un nivel de conciencia de 4 puntos en la escala de coma de Glasgow y midriasis bilateral arreactiva, que posteriormente revierte con medidas medicas. La tomografia computarizada craneal evidencia hematoma subdural agudo, de convexidad bihemisferica e interhemisferico izquierdo, sin hemorragia subaracnoidea asociada. En la angiotomografia se observa un aneurisma de la arteria comunicante anterior. De forma urgente, se procede a su embolizacion. En la unidad de cuidados intensivos se instauran medidas medicas para el control y la monitorizacion de la presion intracraneal. La evolucion de la paciente no es favorable, y en la tomografia computarizada de control, ante un episodio de aumento de la presion intracraneal refractario al tratamiento medico, se constatan areas de infartos isquemicos establecidos en multiples localizaciones. Ante estos hallazgos se desestima el tratamiento quirurgico y la paciente fallece en los siguientes dias. Conclusion. Ante un hematoma subdural agudo sin hemorragia subaracnoidea, en ausencia de traumatismo craneoencefalico o de sus estigmas externos, debemos considerar la rotura de un aneurisma cerebral como posible causa. El tratamiento inicial del hematoma subdural agudo en pacientes con deterioro neurologico ha de ser quirurgico y prioritario.

[Quality of life in intracranial aneurysm: surgery versus endovascular treatment]. / Calidad de vida en pacientes con aneurismas intracraneales: cirugía versus tratamiento endovascular.

BACKGROUND: Based on earlier studies, we aimed to determine the quality of life of patients with intracranial aneurysm after their treatment by surgery or embolization and to compare the quality of life of these two groups. METHODS: The SF-36 health questionnaire was retrospectively applied to 93 patients with intracranial aneurysm treated with surgery (n=56) or embolization (n=37). RESULTS: The quality of life of some patients was impaired but 50% of patients treated with surgery and 40.5% of patients treated with embolization showed no impairment in any SF-36 domain. The quality of life in the Physical Functioning domain was higher in embolization-treated than in surgery-treated patients. CONCLUSIONS: Some patients with intracranial aneurysms treated with surgery or endovascular embolization have an impaired quality of life. Endovascular treatment may cause less limitation in physical function. The quality of life of these patients is affected by numerous factors, in addition to the type of treatment.

[Neuropsychological impairment in patients with intracranial aneurysms: surgical versus endovascular treatment]. / Alteraciones neuropsicológicas en pacientes con aneurismas cerebrales: tratamiento quirúrgico versus tratamiento endovascular.

OBJECTIVES: To describe the neuropsychological status of patients with intracranial aneurysms and to compare the cognitive status of patients with intracranial aneurysm treated by surgical or endovascular methods. MATERIAL AND METHODS: Ninety-three cases with intracranial aneurysms treated with surgery (n = 56) or embolization (n = 37) were included. A neuropsychological assessment was applied to both groups retrospectively, at least one year after treatment. RESULTS: Neuropsychological impairment was found in both groups. 35.7% of the patients treated with surgery and 43.2%, of those treated with embolization did not show any cognitive impairment. Visual Memory and Cued Recall of verbal information are better in patients treated by embolization. CONCLUSIONS: Our results show that a large proportion of patients with intracranial aneurysms have cognitive impairment after treatment. Endovascular management may cause less impairment in visual and verbal memory. However, bleeding may be the most important factor to explain these cognitive impairments.

Isolated primary Langerhans' cell histiocytosis of central nervous system.

Solitary eosinophilic granuloma that involves the CNS is an uncommon lesion and most frequently affects the hypothalamus. We report a new and rare case of solitary eosinophilic granuloma of the left temporal lobe in a patient without systemic disease. The diagnosis was confirmed by electron microscopy and immuohistochemical techniques. The treatment of choice is surgical resection. There is a better prognosis in comparison with cases accompanied by systemic disease.

[Melanocytic schwannoma. A case report and review of the literature]. / Schwannoma melanocítico. A propósito de un caso y revisión de la literatura.

INTRODUCTION AND CLINICAL CASE: We report a new unusual case of a patient without known familiar history of melanocytic schwannoma or Carney complex with multiple melanocytic schwannoma in the spinal canal. Histologically, the tumor was composed of irregular interlacing spindle-shaped cells with pigments. The diagnosis is made by immunohistochemical techniques and electron microscopy findings. CONCLUSION: We review the literature, and the different theories on the origin of these tumors are discussed.

[Central neurocytoma: analysis of three cases and review of the literature]. / Neurocitoma central: a propósito de tres casos y revisión de la literatura.

INTRODUCTION AND CLINICAL CASES: Three cases of central neurocytoma, confirmed by immunohistochemical study are reported. The central neurocytoma has recently been added to the differential diagnosis of intraventricular tumors. It is more frequent than previously thought, with high incidence in young patients. The positivity for synaptophysin and neuron specific enolase, the negativity for neurofilament protein and glial fibrillary acid protein, and the finding of elements of neuronal differentiation on electron microscopy, are the main pathological features of these tumors. CONCLUSION: The surgical treatment is the election, and radiotherapy is reserved for malignant cases or recurrence.

[Multiple calcified cerebral lesions, probably due to metastasis]. / Multiples lesiones cerebrales calcificadas de probable origen metastásico.

INTRODUCTION: Metastases are an infrequent (though possible) cause of cerebral calcifications due to the speed with which they grow. We report the case of a patient in whom some metastatic looking calcified cerebral lesions led to the discovery that she was suffering from lung cancer. CASE REPORT: Woman, aged 60, with no antecedents of interest except hyperlipaemia who came to clinic after suffering from alterations of her higher functions for three weeks. Nothing abnormal was found during the general exploration. Neurologically, she was found to have sensory aphasia together with impaired gnosia and praxis. A brain CAT scan revealed several calcified cerebral lesions throughout both hemispheres, associated with perilesional edema and mass effect with contrast enhancement. Cerebral MRI confirmed these findings. X ray of the thorax was normal but the thoracic CAT scan revealed a spiculated lesion that suggested a malign primary lung neoplasia. CONCLUSION: The presence of cerebral calcifications with perilesional edema and contrast enhancement forces us to rule out a metastatic origin. Although no respiratory clinical features are present, a study of the lungs should be performed as they are the most probable source of the aetiology.

Different patterns of medication change after subthalamic or pallidal stimulation for Parkinson's disease: target related effect or selection bias?

BACKGROUND: Bilateral subthalamic nucleus (STN) deep brain stimulation (DBS) is favoured over bilateral globus pallidus internus (Gpi) DBS for symptomatic treatment of advanced Parkinson's disease (PD) due to the possibility of reducing medication, despite lack of definitive comparative evidence. OBJECTIVE: To analyse outcomes after one year of bilateral Gpi or STN DBS, with consideration of influence of selection bias on the pattern of postsurgical medication change. METHODS: The first patients to undergo bilateral Gpi (n = 10) or STN (n = 10) DBS at our centre were studied. They were assessed presurgically and one year after surgery (CAPIT protocol). RESULTS: Before surgery the Gpi DBS group had more dyskinesias and received lower doses of medication. At one year, mean reduction in UPDRS off medication score was 35% and 39% in the Gpi and STN groups, respectively (non-significant difference). Dyskinesias reduced in proportion to presurgical severity. The levodopa equivalent dose was significantly reduced only in the STN group (24%). This study high-lights the absence of significant differences between the groups in clinical scales and medication dose at one year. In the multivariate analysis of predictive factors for off-state motor improvement, the presurgical levodopa equivalent dose showed a direct relation in the STN and an inverse relation in the Gpi group. CONCLUSION: Differences in the patterns of medication change after Gpi and STN DBS may be partly due to a patient selection bias. Both procedures may be equally useful for different subgroups of patients with advanced PD, Gpi DBS especially for patients with lower threshold for dyskinesia.