G. Bravo

Cavernomas of the central nervous system: Clinical syndromes, CT scan diagnosis, and prognosis after surgical treatment in 25 cases

SummaryWe present our clinical experience and the results of surgical management with 25 cavernomas of the CNS, treated in our hospital in the last 10 years. The location of the lesion assessed by clinical and CT scan examinations, proved to be the most significative factor determining the prognosis of cavernomas of the CNS, after surgical removal.The symptoms started in most of the cases in the third decade of life. 19 cases were located in the cerebral hemispheres and produced three well defined clinical syndromes:1)Irritative syndrome (seizures) present in 70% of the cases.2)Space-occupying lesion syndrome (20%) and3)haemorrhagic syndrome (10%). The remaining six cases were located within the basal ganglia, brainstem, pineal region, cerebellum and spinal cord, showing a progressive course.CT scan studies were performed on 24 cases. The characteristic image of a cavernoma is represented by a moderately hyperdense nodule with discreet contrast uptake. Calcification was observed in and around the lesions in 33% of the cases. Perilesional hypodensities suggestive of brain tissue atrophy were noted in 22% of the CT scans. On the other hand, 12% of cerebral hemisphere cavernomas showed atypical CT scan images that suggested an erroneous diagnosis of cystic gliomas.Radical surgical removal was performed in all cases. The postoperative results varied according to the location of the lesions. Complete recovery was obtained with cerebral hemisphere cavernomas presenting with a progressive history suggesting tumour or a haemorrhagic syndrome. 85% of the cases presenting with seizures, were symptom-free and taking no anticonvulsants 1 year after surgery. In deeply placed cavernomas (basal ganglia and brainstem) the surgical results were poor. In the latter cases surgery has to be carefully evaluated when a mode of treatment is to be considered in patients whose CT scan data strongly suggest a diagnosis of cavernoma.

Neurosurgical experience with tumours of the pineal region at Clinica Puerta de Hierro

SummaryThe clinicopathological experience with 50 cases of pineal region tumours at Clinica Puerta de Hierro is presented. In this series, 88% of the patients were evaluated by CT-scan. Pineal region tumours make up approximately 0.7% of the intracranial expansive processes in the Spanish population. The largest group of lesions appearing in this localization is that of the germinomas (38%), followed by nontumoural lesions (20%) and tumours generally considered to be of the vicinity, such as meningiomas, gliomas and metastases (18%), tumours of the pineal parenchyma (14%), and non-germinoma germinal tumours (10%).In our series, in addition to an intracranial hypertension syndrome, an ophthalmological and, to a minor degree, an endocrinological syndrome predominate in germ-cell tumours, with a cerebellar syndrome appearing in gliomas of the pineal region.All the patients in the series diagnosed as having a germinoma and treated by irradiation are alive, and free of disease, after follow-up ranging from 2 to 20 years (mean: 8 years). The experience obtained with the present series supports the opinion that, in radiosensitive tumours, surgical resection adds no therapeutic benefit to treatment with radiotherapy alone.We suggest that when dealing with a tumour of the pineal region, CT-scan and clinical assessment now permit an initial selection of patients susceptible to surgery as a first therapeutic option, indicating those patients who, because they are considered to have either a “probable germinoma” or a “tumour of uncertain diagnosis”, should undergo stereotaxic biopsy or trial radiotherapy and, only when this has proved a failure, should be subjected to open surgery.

Simultaneous posterior and middle cranial fossa neurinomas

SummaryA case of unilateral association of a neurinoma of the VIII nerve and a neurinoma of the temporal fossa in a 33-year-old woman without von Recklinghausen disease stigmata is presented.This uncommon association can mimic the picture of a trigeminal neurinoma with a dumb-bell extension into the posterior fossa.

Dissemination of pituitary adenomas

SummaryThe authors present a case of a histologically benign adenoma that seeded in the subarachnoid space with several independent nodules. A review is made of the pertinent literature, and the authors stress the possibility that a benign pituitary adenoma may spread, following operation, through the leptomeningeal spaces.

Meningioma of the anterior part of the third ventricle

SummaryThe authors report the clinical features, radiological findings, and surgical management in a case of meningioma of the anterior part of the third ventricle in a 59-year-old woman. The unusual fact in our patient compared with the other reported cases is that she never developed symptoms or signs of increased intracranial pressure. A review of the literature is presented. Ours is the second case in which CT scan has been used in the diagnosis.

Fibrous xanthomas of the brain. Report of two cases.

Summary Two patients are presented with respectively a fibrous xanthoma and a xanthosarcoma of the brain. Four cases with these rare neoplasms of the brain were described before by Kepes and coworkers in 1973. The histological characteristics and differential diagnosis are discussed.

Evolution of Intracranial Pressure and Cerebral Blood Flow in Cryogenic Cerebral Edema

An experimental model of focal vasogenic cerebral edema has been developed in order to achieve, in the unanesthetized animal, a double goal: 1) to avoid the effect that general anesthesia has directly upon the parameters under study; 2) to compare variables between left and right hemispheres.

Brainstem haematomas: Early and late prognosis

SummaryThe purpose of the present retrospective study is to analyse 14 patients harbouring brainstem haematomas and to discuss the early and late prognosis.The patients were divided into two groups: group A (survivors), 8 patients with follow-up duration ranging between 8 months and 12 years; and group B (nonsurvivors), 6 patients.At the time of onset or hospital admission, the former were under 50 years of age and had no important clinical history. Their degree of consciousness was altered only slightly or moderately and their brainstem haemorrhages were focal or only slightly diffuse. Three patients in this group underwent surgical treatment. The members of group B, who died within days of their admission to the hospital, were over 60 years of age, had a number of clinical antecedents and severe alterations of consciousness, while 83% of them presented diffuse brainstem haemorrhages. None of the patients of this group were treated surgically.It was concluded that:1)the indications for surgery for these lesions were progressive hydrocephalus, increase in the mass effect with progressive symptomatology and suspected “cryptic vascular malfomation” with risk of later rebleeding or brain tumour;2)surgical treatment was necessary to improve the symptomatology in 3 patients in group A, although there were no significant differences between surgically treated and nonsurgically treated patients in the same group with respect to prognosis;3)age, clinical history, degree of alteration of consciousness and type of haemorrhage are the major factors affecting the early and late prognosis of brainstem haemorrhages.

Subjective postoperative results in cervical spondylotic myelopathy

SummaryA retrospective study of operative results after a minimum follow-up period of five years was carried out in a series of 34 patients operated upon for cervical spondylotic myelopathy (CSM).In all the cases, myelography showed involvement of two or more intervertebral spaces. Constitutional spinal canal narrowing was not present, and only one operation was performed in each patient. Of the 34 patients, 16 also had symptoms of cervical spondylotic radiculopathy (CSR).Seventy-four percent of the patients thought that operation resulted in overall improvement of the preoperative clinical picture. This subjective improvement was similar whether the operative procedure consisted of anterior intersomatic fusion or of laminectomy.Amelioration of CSM symptoms occurred in only 8 of the 20 patients subjected to anterior fusion (40%), in contrast to 10 of the 14 patients subjected to laminectomy (71%). In the 16 patients with CSR symptoms associated with CSM, amelioration of CSR symptoms occurred in 6 of the 11 patients subjected to anterior fusion (55%), and in 4 of the 5 patients subjected to laminectomy (80%).It is suggested that laminectomy offers the best results for CSM, associated or not with CSR, when two or more intervertebral spaces are affected.

Relationship Between the Location and Delimitation of the Epileptogenic Zone and Surgical Results. A Report of 24 Patients Operated on Using the Technique Described by J. Talairach et al.

The authors present the surgical results of the first 20 out of 24 medically uncontrollable epileptic patients operated on using the technique described by Talairach et al. The minimum postoperative follow-up period was 6 months and the mean 19.6 months. 12 patients became seizure free. Three patients have had a significant decrease in the number of seizures and 5 have had the frequency of attacks reduced to 20-50% of the preoperative level. In 11 of the 20 patients, the epileptogenic zone lay in the frontal lobe.