Gregorio Rodríguez-Boto

Treatment of a carotid cavernous fistula via direct transovale cavernous sinus puncture.

Endovascular treatment is the treatment of choice for indirect carotid cavernous fistulas (CCFs). Direct surgical obliteration of CCFs is recommended in highly symptomatic patients or in those with an aggressive pattern of venous drainage. However, this is a technically challenging approach associated with significant procedural morbidity. The authors present a case in which they decided to attempt a novel access to the cavernous sinus through the foramen ovale before recommending surgery for an otherwise untreatable dural CCF. This 52-year-old man with an indirect CCF and neurological deficit had undergone several attempts to embolize the shunt by means of the standard approaches. Ultimately direct cavernous sinus access was obtained through the foramen ovale, resulting in complete obliteration of the shunt. The occlusion was radiographically stable at the 6-month follow-up evaluation, and the patient has remained asymptomatic. Percutaneous transovale puncture of a CCF is a feasible alternative to accessing the cavernous sinus when traditional transvenous catheterization or direct superior ophthalmic vein approach is not possible.

Conceptos básicos sobre la fisiopatología cerebral y la monitorización de la presión intracraneal

INTRODUCTION Many brain processes that cause death are mediated by intracranial hypertension (ICH). The natural course of this condition inevitably leads to brain death. The objective of this study is to carry out a systematic review of cerebral pathophysiology and intracranial pressure (ICP) monitoring. DEVELOPMENT Studying, monitoring, and recording ICP waves provide data about the presence of different processes that develop with ICH. CONCLUSIONS Correct monitoring of ICP is fundamental for diagnosing ICH, and even more importantly, providing appropriate treatment in a timely manner.

Multiple spinal arteriovenous fistulas: A case-based review

The occurrence of multiple spinal dural arteriovenous fistulas (AVFs) is rare. The majority of cases reported are synchronous and the lesions are mainly found at different spinal levels. Metachronous AVFs have been defined as lesions that manifest in a temporal sequence after treatment of a first AVF. In this report, we present two distinct cases of multiple spinal AVFs. Also, we review the main features of the cases previously reported, with emphasis on the proposed theories for the origin of multiple AVFs. In patients with failure to improve after treatment of a spinal DAVF, a whole-spine angiographic examination is mandatory, not only to ascertain the complete closure of the treated fistula, but also to look for a possible second lesion at a different spinal level.

Combined staged therapy of complex arteriovenous malformations: initial experience

Definitive treatment of complex supratentorial arteriovenous malformations (AVMs) has been classically assigned to ruptured or progressively symptomatic cases. The aim of this study is to report our initial experience in the treatment of complex AVMs by means of staged embolization with Onyx followed by microsurgery.

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.

Cell therapy with autologous mesenchymal stromal cells in post-traumatic syringomyelia

BACKGROUND AIMS Recently, clinical studies show that cell therapy with mesenchymal stromal cells (MSCs) improves the sequelae chronically established in paraplegic patients, being necessary to know which of them can obtain better benefit. METHODS We present here a phase 2 clinical trial that includes six paraplegic patients with post-traumatic syringomyelia who received 300 million MSCs inside the syrinx and who were followed up for 6 months. Clinical scales, urodynamic, neurophysiological, magnetic resonance (MR) and studies of ano-rectal manometry were performed to assess possible improvements. RESULTS In all the cases, MR at the end of the study showed a clear reduction of the syrinx, and, at this time, signs of improvement in the urodynamic studies were found. Moreover, four patients improved in ano-rectal manometry. Four patients improved in neurophysiological studies, with signs of improvement in evoked potentials in three patients. In the American Spinal Injury Association (ASIA) assessment, only two patients improved in sensitivity, but clinical improvement in neurogenic bowel dysfunction was observed in four patients and three patients described improvement in bladder dysfunction. Spasms reduced in two of the five patients who had them previous to cell therapy, and spasticity was improved in the other two patients. Three patients had neuropathic pain before treatment, and it was reduced or disappeared completely during the study. Only two adverse events ocurred, without relation to the cell therapy. CONCLUSIONS Cell therapy can be considered as a new alternative to the treatment of post-traumatic syringomyelia, achieving reduction of syrinx and clinical improvements in individual patients.

Intrathecal administration of autologous mesenchymal stromal cells for spinal cord injury: Safety and efficacy of the 100/3 guideline

BACKGROUND AIMS Cell therapy with autologous mesenchymal stromal cells (MSCs) in patients with spinal cord injury (SCI) is beginning, and the search for its better clinical application is an urgent need. METHODS We present a phase 2 clinical trial in patients with chronic SCI who received three intrathecal administrations of 100 x 106 MSCs and were followed for 10 months from the first administration. Efficacy analysis was performed on nine patients, and safety analysis was performed on 11 patients. Clinical scales, urodynamic, neurophysiological and neuroimaging studies were performed previous to treatment and at the end of the follow-up. RESULTS The treatment was well-tolerated, without any adverse event related to MSC administration. Patients showed variable clinical improvement in sensitivity, motor power, spasms, spasticity, neuropathic pain, sexual function or sphincter dysfunction, regardless of the level or degree of injury, age or time elapsed from the SCI. In the course of follow-up three patients, initially classified as ASIA A, B and C, changed to ASIA B, C and D, respectively. In urodynamic studies, at the end of follow-up, 66.6% of the patients showed decrease in postmicturition residue and improvement in bladder compliance. At this time, neurophysiological studies showed that 55.5% of patients improved in somatosensory or motor-evoked potentials, and that 44.4% of patients improved in voluntary muscle contraction together with infralesional active muscle reinnervation. CONCLUSIONS The present guideline for cell therapy is safe and shows efficacy in patients with SCI, mainly in recovery of sphincter dysfunction, neuropathic pain and sensitivity.

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.

Response to: Pathophysiology of normal perfusion pressure breakthrough: more than just abnormal arteries …

We appreciate the comments on the article ‘ Normal perfusion pressure breakthrough phenomenon: what still remains unknown ’ 1 that TA Mattei kindly made in this letter. 2 As the author states, two main theories have been postulated so far in order to explain the development of oedema and/or multifocal haemorrhage after the obliteration of intracranial arteriovenous malformations (AVMs). On one hand, ‘ normal perfusion pressure breakthrough (NPPB) phenomenon ’ is based on the loss of cerebral vessel autoregulation due to the chronic vasodilation of perinidal microcirculation, which is a consequence of a vascular ‘ steal phenomenon ’ caused by the malformation. 3 Th us, when a high-fl ow shunt, such as the AVM, is obliterated, the redistribution of the cerebral blood fl ow (CBF) from the AVM to the adjacent cerebral vessels might cause oedema and haemorrhage. On the other hand, a diff erent but complementary concept is the ‘ occlusive hyperaemia ’, which deals with thrombotic and venous obstruction phenomena that may also generate such manifestations. 4