Microsurgical treatment of trigeminal neuralgia in patients older than 70 years: An efficacy and safety study. / Tratamiento microquirúrgico de la neuralgia trigeminal en mayores de 70 años, estudio de eficacia y seguridad.

INTRODUCTION: The increasing incidence of trigeminal neuralgia (TN) with age together with population ageing call for reexamination of surgical treatment options for refractory TN in elderly patients. METHODS: Retrospective review of a consecutive series of patients older than 70 who underwent microvascular decompression (MVD) for refractory TN between 1997 and 2015. Outcomes based on the Barrow Neurological Institute pain intensity score (BNI score) and surgical complications were compared to those of patients younger than 70 undergoing MVD in the same period. RESULTS: Forty patients older than 70 (mean = 74.8 years) underwent interventions. At a mean follow-up time of 34 months, 73% of the patients presented complete absence of pain without medication (BNI I) and 85% had good pain control with or without medication (BNI I-III). A comparison of these patients with the 85 patients younger than 70 treated surgically during the same period did not find a significant association between age and achievement of pain control (BNI I-II). However, there was a significant association between age older than 70 and complete pain relief (BNI I; P=.03). The mean hospital stay in patients over 70 was also significantly longer (P=.04), although the postsurgical complication rate was similar to that in younger patients. CONCLUSIONS: Elderly patients with refractory TN may benefit from treatment with MVD and the probability of success and surgical risk are comparable to those in younger patients.

Microvascular decompression for trigeminal neuralgia: A retrospective analysis of long-term outcomes and prognostic factors.

INTRODUCTION: Microvascular decompression is considered to be the most effective and only etiological surgical treatment for classical trigeminal neuralgia, relieving the neurovascular compression found in up to 95% of cases. This study aims to report the long-term outcomes and to identify prognostic factors in a series of patients with trigeminal neuralgia treated by microvascular decompression. METHODS: A retrospective observational study of 152 consecutive patients operated by microvascular decompression with at least six months of follow-up. The surgical results, including pain relief according to the Barrow Neurological Institute pain scale, complications and the medical treatment during the follow-up period were reviewed. Binary regression analysis was performed to identify factors associated with a good long-term outcome. RESULTS: A total of 152 patients with a mean age of 60 years and a mean follow-up of 43 months were included. At the final follow-up visit, 83% of the patients had achieved significant relief of the pain and 63% could reduce the absolute drug doses by 50% or more. The most frequent complications were wound infection (4.5%) and CSF fistula (7%). Being over 70 years of age and having paroxysmal pain were associated with a long-term pain relief. CONCLUSIONS: Our results support the notion that microvascular decompression is an effective and safe therapy in patients with trigeminal neuralgia. A multidisciplinary approach with an early referral to a neurosurgical unit many be beneficial in patients who are refractory to pharmacological treatment.

Treatment of neuropathic deafferentation pain using DREZ lesions; long-term results.

INTRODUCTION: Deafferentation pain secondary to spinal cord injury, brachial plexus avulsion and other peripheral nerve injuries is often refractory to conventional treatments. This study evaluates the long-term efficacy of spinal DREZ (Dorsal Root Entry Zone) lesions for the treatment of neuropathic pain syndromes caused by deafferentation. PATIENTS AND METHODS: A series of 18 patients with refractory deafferentation pain treated with radiofrequency DREZ lesions is presented. The immediate and long-term efficacy was measured with the Visual Analogue Scale (VAS) before and after treatment, the patient's subjective evaluation, the percentage of patients returning to work and the reduction in pain medication. RESULTS: Pain on the VAS significantly decreased from 8.6 preoperatively to 2.9 (p<.001) at discharge. Over the long-term, with a mean follow-up of 28 months (6-108) pain remained at 4.7 on the VAS (p<0.002). The percentage of patients with moderate to excellent pain relief was 77% at discharge and 68% at the last follow-up. Pain medication was reduced in 67% of the patients and 28% returned to work. The best results were obtained in patients with brachial plexus avulsion, with a significant long-term pain relief in all cases. CONCLUSIONS: Radiofrequency DREZ lesion is an effective and safe treatment for refractory neuropathic pain caused by deafferentation.

Microvascular decompression for trigeminal neuralgia: A retrospective analysis of long-term outcomes and prognostic factors.

INTRODUCTION: Microvascular decompression is considered to be the most effective and only etiological surgical treatment for classical trigeminal neuralgia, relieving the neurovascular compression found in up to 95% of cases. This study aims to report the long-term outcomes and to identify prognostic factors in a series of patients with trigeminal neuralgia treated by microvascular decompression. METHODS: A retrospective observational study of 152 consecutive patients operated by microvascular decompression with at least six months of follow-up. The surgical results, including pain relief according to the Barrow Neurological Institute pain scale, complications and the medical treatment during the follow-up period were reviewed. Binary regression analysis was performed to identify factors associated with a good long-term outcome. RESULTS: A total of 152 patients with a mean age of 60 years and a mean follow-up of 43 months were included. At the final follow-up visit, 83% of the patients had achieved significant relief of the pain and 63% could reduce the absolute drug doses by 50% or more. The most frequent complications were wound infection (4.5%) and CSF fistula (7%). Being over 70 years of age and having paroxysmal pain were associated with a long-term pain relief. CONCLUSIONS: Our results support the notion that microvascular decompression is an effective and safe therapy in patients with trigeminal neuralgia. A multidisciplinary approach with an early referral to a neurosurgical unit many be beneficial in patients who are refractory to pharmacological treatment.

[Supratentorial endodermal cyst. Case report]. / Quiste endodérmico supratentorial: caso clínico y revisión de la literatura.

Endodermal cysts (EC) of the central nervous system are very uncommon lesions predominantly located in the spinal canal. Although rare, intracranial EC have been mainly described in the posterior fossa, with the supratentorial location considered exceptional. Apart from the low frequency of these lesions, their pathoembriology still remais unknown. We report a patient with a huge frontal EC and review the literature. A 62-year-old man presented with abnormal behaviour, disorientation and decreased level of consciousness after moderate head injury. Initial cranial CT scan revealed a large cyst in the left frontal region with marked midline shift. Emergency puncture and decompression of the cyst demonstrated a milky fluid with high protein levels. Cranial MRI after patient improvement confirmed the existence of the cystic lesion with less mass effect. Delayed surgery was performed with craniotomy and total removal of the cyst. Pathological examination confirmed the presence of a typical EC. Patient made a complete recovery on follow-up with no recurrence on postoperative MRIs. Differential diagnosis of EC based on radiological data is quite difficult. As aggresive behaviour of this condition has been described following incomplete resections, the treatment of choice is a radical removal of the cyst in one or two stages depending on patient clinical condition.

Predictive value of magnetic resonance for identifying neurovascular compressions in trigeminal neuralgia. / Valor predictivo de la resonancia magnética para la identificación de compresiones neurovasculares en la neuralgia del trigémino.

INTRODUCTION: Microvascular decompression (MVD) is accepted as the only aetiological surgical treatment for refractory classic trigeminal neuralgia (TN). There is therefore increasing interest in establishing the diagnostic and prognostic value of identifying neurovascular compressions (NVC) using preoperative high-resolution three-dimensional magnetic resonance (MRI) in patients with classic TN who are candidates for surgery. METHODS: This observational study includes a series of 74 consecutive patients with classic TN treated with MVD. All patients underwent a preoperative three-dimensional high-resolution MRI with DRIVE sequences to diagnose presence of NVC, as well as the degree, cause, and location of compressions. MRI results were analysed by doctors blinded to surgical findings and subsequently compared to those findings. After a minimum follow-up time of six months, we assessed the surgical outcome and graded it on the Barrow Neurological Institute pain intensity score (BNI score). The prognostic value of the preoperative MRI was estimated using binary logistic regression. RESULTS: Preoperative DRIVE MRI sequences showed a sensitivity of 95% and a specificity of 87%, with a 98% positive predictive value and a 70% negative predictive value. Moreover, Cohen's kappa (CK) indicated a good level of agreement between radiological and surgical findings regarding presence of NVC (CK 0.75), type of compression (CK 0.74) and the site of compression (CK 0.72), with only moderate agreement as to the degree of compression (CK 0.48). After a mean follow-up of 29 months (range 6-100 months), 81% of the patients reported pain control with or without medication (BNI score i-iiiI). Patients with an excellent surgical outcome, i.e. without pain and off medication (BNI score i), made up 66% of the total at the end of follow-up. Univariate analysis using binary logistic regression showed that a diagnosis of NVC on the preoperative MRI was a favorable prognostic factor that significantly increased the odds of obtaining an excellent outcome (OR 0.17, 95% CI 0.04-0.72; P=.02) or an acceptable outcome (OR 0.16, 95% CI 0.04-0.68; P=.01) after MVD. CONCLUSIONS: DRIVE MRI shows high sensitivity and specificity for diagnosing NVC in patients with refractory classic TN and who are candidates for MVD. The finding of NVC on preoperative MRI is a good prognostic factor for long-term pain relief with MVD.

[Radiation-induced cranial tumors: clinical series and literature review]. / Tumores craneales radioinducidos: serie clínica y revisión de la literatura.

Radiation induced tumors are well-known but rare complications of radiotherapy. Meningiomas are the most common radiation-induced (RI) cranial tumors, followed by gliomas and sarcomas, while other tumors as haemangioblastomas remain extremely exceptional. We present 7 patients with RI brain tumors diagnosed and treated at our institution between 1990 and 2006. Retrospective review of their clinical charts is supplied. All patients were irradiated during childhood as a treatment for another disease, and fulfilled the criteria of RI neoplasia. Four patients developed meningiomas and three developed other tumors (one glioblastoma, one softtissue sarcoma and one hemangioblastoma). In all cases a complete surgical removal was achieved. Preoperative assessment based on MRI supplied the correct diagnosis in six patients. The most important risks factors described in the literature for developing RI tumors are the age at which radiotherapy was administered and the dose of radiation applied. Differential diagnosis of RI tumors includes any tumor appearing after radiotheraphy, especially recurrences of the primary disease, as RI neoplasias are a rare complication. Even in cases with complete surgical resection, prognosis of this clinical entity is basically related to the histology of the RI tumor.

[Intraventricular tension pneumocephalus after transsphenoidal surgery: a case report and literature review]. / Neumoencéfalo intraventricular a tensión secundario a cirugía transesfenoidal: presentación de un caso y revisión de la literatura.

Tension pneumocephalus is a rare complication of transsphenoidal approaches. The case of a 37 year old woman with a transsphenoidal resection of a pituitary adenoma who presented self-limited rhinoliquorrhea postoperatively is reported. Three days later the patient developed progressive decreased consciousness, amnesia and headache, showing an intraventricular tension pneumocephalus on CT scan. Urgent treatment with bilateral external ventricular drainage and anterior nasal tamponade was performed with good clinical outcome. Later transsphenoidal sealing of the dural defect was achieved without recurrence. Tension pneumocephalus following transsphenoidal surgery usually occurs after the presentation of a cerebrospinal fluid leak due to an incomplete sealing of the sphenoid sinus. The postoperative insertion of a lumbar drainage seems to be a predisposing condition for this complication. The combined approach of tension pneumocephalus with external ventricular drainage and repair of the sphenoid sinus offers optimal results solving the acute neurological deterioration and avoiding recurrence.

[Cerebral cavernomas. A review and update of aetiological, clinical and therapeutic features]. / Cavernomas cerebrales. Revisión y actualización etiológica, clínica y terapéutica.

INTRODUCTION: Cavernous angiomas are uncommon lesions, with a reported incidence of 0.4 to 0.8%, presenting a controversial management especially regarding their surgical treatment. AIM: To update cavernous angiomas characteristics and management through a deep review of the literature concerning their aetiology, epidemiology, history, signs and symptoms, diagnosis, and surgical and radiosurgical treatment. DEVELOPMENT AND CONCLUSIONS: Most important advances found in the recent literature include the identification of the genetic basis responsible for the familial form of cavernomatosis (CCM1, CCM2 and CCM3), the identification of the dynamic pattern of these lesions based on their pathology and imaging features, the deeper knowledge on their natural history depending on their supra/infratentorial location, and the main indications for surgical treatment and radiosurgical therapy suggested by the recent series.