Álvaro Pérez-Zamarrón

Penetrating brain injury by drill bit

Non-missile low velocity penetrating brain injuries are unusual among civilian population. They show specific characteristics different from missile wounds. In this paper we describe a rare case of self-inflicted penetrating head trauma by electric drill. We document neuroimaging studies and review the management concerning this pathology. To our knowledge, this is the first case of intracranial retained drill bit with such radiological findings reported in the literature. An 80-year-old male with no previous psychiatric disorder presented at our hospital after suffering an accident while working with an electric drill. Physical examination revealed right lower extremity plegia and three penetrating scalp wounds to the left parasagittal region. Skull X-ray and computed tomography demonstrated an intracranial metallic foreign body located in the left parietal lobe and an intraparenchymal hematoma with no mass effect close to the foreign body. The patient was taken to the operating room to remove the drill bit fragment. Antibiotic and antiseizure prophylaxis were administered. Postoperative computed tomography confirmed no residual metallic fragments and functional recovery was excellent. After psychiatric assessment, suicide attempt was confirmed and antidepressive therapy was then started. On follow-up, no complication was documented. It is essential to exclude penetrating brain trauma whenever a scalp wound is noticed in order to provide proper treatment and prevention care. The permanent neurological deficit in low velocity injuries is related to the degree and location of the primary injury. It also depends on an early diagnosis and treatment and the absence of delayed complications.

Efecto de los catéteres impregnados con antibiótico en la incidencia de infección tras procedimientos de derivación de líquido cefalorraquídeo

Fundamento y objetivo: La infeccion es una de las principales complicaciones asociadas a la colocacion de sistemas de derivacion de liquido cefalorraquideo (LCR). La utilizacion de cateteres impregnados con antibiotico (IA) parece disminuir la tasa de infeccion posquirurgica en la practica clinica. El objetivo de este trabajo ha sido determinar si el uso de sistemas IA reduce el riesgo de infeccion posquirurgica por Staphylococcus spp., principal agente de infeccion. Pacientes y metodo: Se identifico retrospectivamente a todos los pacientes a quienes se habian implantado cateteres impregnados con rifampicina y clindamicina en nuestro centro, incluidos cateteres externos (desde enero de 2006 hasta enero de 2007) y sistemas de derivacion interna (desde enero de 2004 hasta enero de 2007), y a aquellos a quienes se habian implantado cateteres externos y sistemas de derivacion interna sin IA durante los mismos periodos de tiempo. Mediante la prueba de la x2 se analizo y comparo el porcentaje de infeccion global, por Staphylococcus spp. y por bacilos gramnegativos en ambas cohortes. Resultados: Se registraron 65 procedimientos con cateteres IA y 66 procedimientos con cateteres no impregnados. Tanto el porcentaje de infeccion global como el porcentaje de infeccion por Staphylococcus spp. fueron significativamente menores en el grupo con cateteres IA (p = 0,046 y p = 0,029, respectivamente), sin que se observara un aumento significativo de las infecciones por bacilos gramnegativos. Conclusiones: El uso de sistemas de derivacion de LCR impregnados con rifampicina y clindamicina parece una herramienta util para reducir la aparicion de complicaciones infecciosas posquirurgicas por Staphylococcus spp. Deben llevarse a cabo estudios prospectivos, aleatorizados y doble ciego para confirmar estos resultados.

Retropharyngeal pseudomeningocele formation as a traumatic atlanto-occipital dislocation complication: case report and review

Retropharyngeal pseudomeningocele after atlanto-occipital dislocation is a rare complication, with only five cases described in the literature. It develops when a traumatic dural tear occurs allowing cerebrospinal fluid outflow, and it often appears associated with hydrocephalus. We present a case of a 29-year-old female who suffered a motor vehicle accident causing severe brain trauma and spinal cord injury. At hospital arrival the patient scored three points in the Glasgow Coma Scale. Admission computed tomography of the head and neck demonstrated subarachnoid hemorrhage and atlanto-occipital dislocation. Three weeks later, when impossibility to disconnect her from mechanical ventilation was noticed, a magnetic resonance imaging of the neck showed a large retropharyngeal pseudomeningocele. No radiological evidence of hydrocephalus was documented. Given the poor neurological status of the patient, with spastic quadriplegia and disability to breathe spontaneously due to bulbar-medullar injury, no invasive measure was performed to treat the pseudomeningocele. Retropharyngeal pseudomeningocele after atlanto-occipital dislocation should be managed by means of radiological brain study in order to assess for the presence of hydrocephalus, since these two pathologies often appear associated. If allowed by neurological condition of the patient, shunting procedures such as ventriculo-peritoneal or lumbo-peritoneal shunt placement may be helpful for the treatment of the pseudomeningocele, regardless of craniocervical junction management.

Spinal cord and brain glioblastoma multiforme without previous craniotomy

The frequency of symptomatic spinal cord metastases from brain glioblastoma multiforme (GBM) is between 1.3 and 8.8%. In almost all cases, there has been a history of surgical manipulation or radiation therapy that might have altered the blood‐brain barrier and introduced tumor cells through the cerebrospinal fluid pathways. The interval between the intracerebral GBM and its intramedullary metastasis is 12‐14 months and the mean survival time, under this condition, never exceeds 6 months.2‐4 However, in the absence of previous surgery or radiotherapy, it is difficult to distinguish between true metastasic from multicentric central nervous system GBM, as occurred in our case. 1‐4 A 52-year-old woman presented with a 2-month history of cervical pain and numbness in the left upper extremity; she was admitted with progressive paraparesis and acute urinary retention. Cervical magnetic resonance (MR) imaging demonstrated an intramedullary C4‐6 mass, which enhanced after Gd injection (Fig. 1). The tumor was resected after cervical laminectomy. Histopathological examination revealed that the lesion was a GBM. Considering this diagnosis, we performed brain MR imaging 1 week after the spinal cord surgery and discovered an enhancing mass, 2 cm in diameter, located in the right atrium (Fig. 2). Twenty days after the initial surgery, the intracerebral lesion was resected and its histopathological features were also consistent with a GBM.

Intraventricular haemorrhage caused by the rupture of a dural arteriovenous malformation of the middle cranial fossa

Dural arteriovenous malformations of the middle cranial fossa are very rare. Venous drainage flows either through superficial leptomeningeal veins or through the sphenoparietal, sphenopetrous and/or sphenobasilar sinuses. They often have an aggressive course and therefore poor outcome. It is essential to analyse and understand the angioarchitecture of the dural arteriovenous malformations in order to select and plan the correct treatments. We describe an exceptional case of intraventricular haemorrhage caused by the rupture of a dural arteriovenous malformation of the middle cranial fossa. To our knowledge, this is the first case report of such characteristics described in the literature.

Normal perfusion pressure breakthrough phenomenon: experimental models

One of the most life-threatening complications after the obliteration of intracranial arteriovenous malformations is the development of oedema and/or multifocal haemorrhage. Two main theories have been postulated so far in order to explain this situation. On one hand, “normal perfusion pressure breakthrough phenomenon” is based on the loss of cerebral vessel autoregulation due to the chronic vasodilation of perinidal microcirculation. On the other hand, the “occlusive hyperaemia” deals with thrombotic and venous obstruction phenomena that may also generate such manifestations. The aim of this study is to resume the main concepts of the “normal perfusion pressure breakthrough phenomenon” theory as well as the related animal models described up to date, their advantages and disadvantages, and the main conclusions obtained as a result of the experimental research.

Angiomas cavernosos epidurales espinales

the formation of vascular microcalcifications. Presence of the sign has been correlated to age and severity of kidney disease, but not to the appearance of ischaemic stroke.5 The case we present confirms that T1-weighted images of bilateral pulvinar hyperintensity secondary to calcification are not pathognomonic for Fabry disease. Researchers require further studies to evaluate the frequency of this sign, and its association with Fabry disease, in populations not previously diagnosed with Fabry disease. This will help us ascertain the diagnostic utility of this radiological sign in establishing ischaemic stroke aetiology.

Hemangiopericitoma de la fosa posterior: a propósito de un caso

Resumen El hemangiopericitoma es un tumor mesenquimal infrecuente originado de los pericitos de Zimmerman, que habitualmente asienta en tejidos blandos. Su variante meningea supone menos del 1% de todos los tumores intracraneales. Caracteristicamente presenta un comportamiento agresivo, con marcada tendencia a recurrir localmente y a lo largo del neuroeje, asi como a metastatizar en localizaciones extraneurales. Presentamos el caso de una paciente de 74 anos que debuto con clinica inespecifica, observandose durante la exploracion fisica una masa retroauricular no dolorosa a la palpacion, adherida a la piel. El estudio de neuroimagen demostro una lesion de gran tamano localizada en la fosa posterior que realzaba intensamente tras la administracion de contraste, asociada a llamativa osteolisis occipito-mastoidea y cuya vascularizacion provenia exclusivamente de ramas de la arteria carotida externa. La paciente se sometio a la reseccion quirurgica completa de la lesion, administrandose radioterapia inicial adyuvante una vez confirmado histologicamente el diagnostico de hemangiopericitoma. Dieciseis meses despues de la intervencion, la paciente se encuentra libre de enfermedad. El tratamiento de eleccion del hemangiopericitoma intracraneal es su reseccion quirurgica completa, siempre que sea tecnicamente posible, seguida de radioterapia adyuvante con dosis superiores a los 50 Gy. Esta combinacion ha demostrado aumentar el intervalo de tiempo libre de recurrencia. Un estrecho seguimiento a largo plazo de estos pacientes es esencial para detectar recurrencias o metastasis a distancia precozmente, pudiendo aparecer incluso decadas despues del adecuado tratamiento inicial.

Quiste óseo aneurismático del seno esfenoidal: a propósito de un caso

Resumen El quiste oseo aneurismatico es una patologia infrecuente que asienta generalmente en las metafisis de huesos largos y vertebras. La afectacion del seno esfenoidal es excepcional. Su origen se encuentra aun por definir, pero podemos considerarlos como un fenomeno vascular secundario a una lesion del hueso subyacente. Puede asociarse a otras enfermedades, presentes de forma metacronica o sincronica en distintas localizaciones de un mismo sujeto, como la displasia fibrosa poliostotica o los tumores de celulas gigantes. En este articulo se expone el caso de un paciente que presenta un quiste oseo aneurismatico en el seno esfenoidal y alteracion de la vision.

Genetic alterations of IDH1 and Vegf in brain tumors

This study evaluates the presence of R132H mutation in isocitrate dehydrogenase (IDH1) gene and the vascular endothelial growth factor (VEGF) +936 C/T polymorphism in brain tumors. The impact of these genetic alterations on overall survival (OS) and progression free survival (PFS) was evaluated.