J.F. Alén

Intracranial Hemangiopericytoma: Study of 12 Cases

Summary Most hemangiopericytomas (HPCs) are located in the musculoskeletal system and the skin, while the intracranial location is rare. They represent 2 to 4% in large series of meningeal tumours, thus accounting for less than 1% of all intracranial tumours. Many authors have argued about the true origin of this tumour. The current World Health Organization classification of Central Nervous System tumours distinguishes HPC as an entity of its own, and classified it into the group of “mesenchymal, non-meningothelial tumours”. Radical surgery is the treatment of choice, but must be completed with postoperative radiotherapy, which has proved to be the therapy most strongly related to the final prognosis. HPCs have a relentless tendency for local recurrence and metastases outside the central nervous system which can appear even many years after diagnosis and adequate treatment of the primary tumour. Twelve patients with intracranial HPC were treated at our Unit between 1978 and 1999. There were 10 women and 2 men. Ten tumours were supratentorial and most located at frontoparietal parasagittal level. The most common manner of presentation was a focal motor deficit. All tumours were hyperdense in the basal Computed Tomography scans and most enhanced homogeneously following intravenous contrast injection. In 50% of cases, tumour margins were irregular or lobulated. Seven tumours were studied with Magnetic Resonance Imaging, being six of them iso-intense with the cortical gray matter on T1-weighted and T2-weighted images. Twenty operations were performed in the 12 patients. In 10 cases radical excision could be achieved with no operative mortality. Total recurrence rate was 33.3%. Eight patients were treated with external radiotherapy at some time through the course of their disease. Eight out of the 12 patients in this series are disease-free (Glasgow Outcome Scale categories 1 and 2) after a mean follow up of 52 months.

Prognostic Factors on Hospital Admission after Spontaneous Subarachnoid Haemorrhage

Summary Background and Objective. Factors related to prognosis after subarachnoid haemorrhage (SAH) have been mainly extracted from surgical series, and only few authors have considered these factors in total management or population series. Though the level of consciousness is a major determinant of outcome after subarachnoid haemorrhage, there is not a consensus about which classification should be used to define it. The objective of this study was twofold. Firstly to find which factors recorded on hospital admission relate to outcome determining their relative importance in a non-selected series of patients suffering from aneurysmal SAH admitted to our centre, and secondly to assess the validity of the WFNS clinical scale for predicting the final result. Methods. A series of 294 patients consecutively admitted to Hospital 12 de Octubre Madrid between January 1990 and June 2000 with the diagnosis of aneurysmal SAH were retrospectively reviewed. All factors possibly related to prognosis were recorded on hospital admission. Outcome was measured by means of the Glasgow Outcome Scale measured one month after hospital discharge. Relationship between factors and outcome was evaluated by univariate and logistic regression multivariate analysis. Results. Although several factors appeared related to prognosis in the univariate analysis, only the age, the level of consciousness defined by the WFNS scale and the presence of global brain hypodensity on the initial CT scan had a significant prognostic influence in the logistic regression model. Global brain hypodensity was strongly related to mortality. Since a number of factors associated with poor outcome in the univariate analysis are related to age, their influence could be explained by the difficulty of recovery of the ageing brain. The WFNS grading scale failed to predict significant differences in outcome between some of its grades. Conclusions. Age and clinical grade on admission are the most important factors influencing the final outcome of patients suffering aneurysmal SAH. A reappraisal of the WFNS grading scale should be considered as no significant differences in outcome were found between some of its grades.

The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury.

BACKGROUND Since 1999, the Italian guidelines have been used at our department for the management of patients with mild head injury (MHI). According to these guidelines, a computed tomography (CT) scan should be obtained in all patients with coagulopathy and these should routinely undergo strict observation during the first 24 hours after injury; in addition they should have a control CT scan before discharge. With the increased use of anticoagulant therapy in the elderly population, admitting patients in such treatment with a MHI to the emergency rooms has become very common. The aim of our study was to evaluate the need of performing a control CT scan in patients on anticoagulation treatment who showed neither intracranial pathology on the first CT-scan nor neurologic worsening during the observation period. METHODS We prospectively analyzed the course of all patients on anticoagulation treatment consecutively admitted to our unit between October 2005 and December 2006 who suffered from a MHI and showed a normal initial CT scan. All patients underwent strict observation during the first 24 hours after admission and had a control CT scan performed before discharge. RESULTS One hundred thirty-seven patients were included in this study. Only two patients (1.4%) showed hemorrhagic changes. However, neither of them developed concomitant neurologic worsening nor needed admitting or surgery. CONCLUSION According with our data, patients on anticoagulation treatment suffering from MHI could be managed with strict neurologic observation without routinely performing a control CT scan that can be reserved for the rare patients showing new clinical symptoms.

A comparison of different grading scales for predicting outcome after subarachnoid haemorrhage.

SummaryBackground. Most scales used to assess prognosis after subarachnoid haemorrhage (SAH) are based on the level of consciousness of the patient. Based on information from a logistic regression model, Ogilvy et al. developed a new grading scheme (Massachussetts General Hospital (MGH) Scale) which applied a simple scoring method to each prognostic factor considered relevant such as level of consciousness, age, quantity of blood in the first CT scan and size of the aneurysm. The purpose of this study is to introduce a modified version of the MGH scale, built up using factors applicable to every patient suffering SAH, and compare this new scale to the World Federation of Neurological Surgeons scale (WFNS), the Glasgow Coma Scale (GCS) scale for SAH and the MGH scale.Method. A series of 442 patients consecutively admitted to Hospital 12 de Octubre between January 1990 and September 2001 with the diagnosis of spontaneous SAH were retrospectively reviewed. Outcome was assessed by means of the Glasgow Outcome Scale measured six months after hospital discharge. Differences between grades of the WFNS, the GCS scale for SAH, the MGH scale and the new scale were computed by χ2 statistics. ROC curves were plotted for the different scales and their areas compared.Findings. Both WFNS and GCS scales fail to present significant differences between most of their grades, while the proposed scale shows a constant inter-grade significant difference in predicting outcome. The proposed scale presents a significantly higher prognostic efficacy in the whole series of patients suffering spontaneous SAH, patients with idiopathic subarachnoid haemorrhage (ISAH) and patients with confirmed aneurysmal SAH. The MGH scale is not applicable to some groups of patients suffering SAH.Interpretation. Grading scales including additional factors to the level of consciousness show higher prognostic efficacy. The proposed modification of the MGH scale makes it applicable to every patient suffering SAH without losing its prediction capability.

Cerebral aneurysm rupture after r-TPA thrombolysis for acute myocardial infarction.

BACKGROUND Intracranial hemorrhage is the most dreaded risk of thrombolytic therapy for acute myocardial infarction because of the high mortality and disability rates associated with this complication. Brain structural lesions may predispose a patient to bleeding. To date, aneurysm rupture has not been described as a complication of such therapy. CASE DESCRIPTION A 66-year-old hypertensive woman was admitted because of chest pain. Myocardial infarction was diagnosed and fibrinolytic therapy with recombinant tissue plasminogen activator (r-TPA) was initiated. Eight hours after admission she became unconscious. Brain computed tomography scan showed subarachnoid hemorrhage, and a cerebral arteriography showed an anterior communicating artery aneurysm. Because of her poor clinical condition treatment was postponed. Death occurred 7 days later because of multiorgan failure. CONCLUSIONS Cerebral aneurysms should be considered as a possible contributing factor to intracranial bleeding after thrombolytic therapy.

Utilidad de la TAC secuencial y la monitorización de la presión intracraneal para detectar nuevo efecto masa intracraneal en pacientes con traumatismo craneal grave y lesión inicial Tipo I-II

Utilidad de la TAC secuencial y la monitorizacion de la presion intracraneal para detectar nuevo efecto masa intracraneal en pacientes con traumatismo craneal grave y lesion inicial Tipo I-II

Intratumoural bleomycin as a treatment for recurrent cystic craniopharyngioma. Case report and review of the literature

INTRODUCTION The majority of craniopharyngioma (CF) have a cystic component and only 10% are completely solid. In tumors with a large cystic component, stereotactic drainage or instillation of radioctive and/or chemotherapeutic agents have been used. Only several authors have reported the use of bleomycin for the treatment of cystic CF. CASE REPORT The authors present the case of a nineteen years old patient with a recurrent cystic CF who was treated with intratumoral injections of bleomycin. The patient had been operated on three times before because of regrowth of the tumor. This last time he had a severe disturbance of his visual acuity and a huge regrowth of the cystic CF. An intracystic catheter stereotactically placed was connected to an Ommaya reservoir and, after assuring the impermeability of the cyst, bleomycin was administered through the reservoir up to a total dose of 45mg distributed in six doses. No complications were detected during and after the procedure. A MR performed 4 months after treatment showed a clear reduction in the size of the cyst but 10 months later a new regrowth of the cyst was detected by MR with no new signs or symptoms. A total dose of 30 mg divided in six doses was administered. No complications occurred. The MR 18 months after the first treatment showed the reduction in size of the tumor. The ophtalmological study showed almost normal visual acuity in both eyes. DISCUSSION Although there is not an stablished protocol for the indication and the form of application of intracystic bleomycin, results with this treatment for cystic CF seem good in the literature. However, the risk of local complications after the administration of intratumoural bleomycin in these patients is around 10%, and some fatal toxic reactions have been recently reported. CONCLUSION Intracystic administration of bleomycin is a valid option as adjuvant therapy for CF in patients with recurrences that are not surgical candidates because of the high risk of complications. The role of bleomycin as a primary treatment for CF and treatment protocols remain to be stablished with additional studies.

Idiopathic subarachnoid hemorrhage and venous drainage: are they related?

OBJECTIVE In the past, several possible explanations for idiopathic subarachnoid hemorrhage (ISAH) have been proposed; however, neuroimaging studies have never provided conclusive data about the structural cause of the bleeding. The aim of this study is to determine whether there are anatomic differences in the deep cerebral venous drainage in patients with ISAH compared with those with aneurysmal subarachnoid hemorrhage (ASAH) and those without intracranial hemorrhage. METHODS We reviewed the venous phase of carotid digital angiograms of 100 consecutive patients who had a final diagnosis of ISAH. We also analyzed the angiograms of a control group of 112 patients with ASAH and the angiograms of a nonhemorrhagic group of 25 patients having incidental aneurysms. The anatomic variants of the basal vein of Rosenthal (BVR) on both sides were classified into the following types: Type A (normal continuous), in which the BVR is continuous with the deep middle cerebral veins and drains mainly into the vein of Galen; Type B (normal discontinuous), in which there is discontinuous venous drainage, anterior to the uncal vein and posterior to the vein of Galen; and Type C (primitive), which drains mainly to veins other than the vein of Galen. We calculated the proportions to analyze the differences in the type of venous drainage between patients with ISAH, patients with ASAH, and patients without hemorrhage. χ2 statistics were used to search for differences. RESULTS Types A and C venous drainage were present in 23.8 and 32.3%, respectively, of patients with ISAH compared with 58.7 and 15.4%, respectively, in the ASAH group and 57.5 and 5%, respectively, in the nonhemorrhagic group (P < 0.001). A primitive variant was present in at least 1 hemisphere in 38 patients with ISAH (41.8% of the cases) compared with 24 patients with ASAH (21.4%) and 2 patients (8%) in the nonhemorrhagic group (P < 0.001). CONCLUSION In patients with ISAH, deep cerebral venous drainage more commonly drains directly into dural sinuses instead of via the vein of Galen compared with patients with ASAH and patients without intracranial hemorrhage. The way in which this venous configuration might influence bleeding remains unknown.

Meningiomas of the basal posterior fossa. Surgical experience in 80 cases

INTRODUCTION Despite recent improvements in microsurgical and radiotherapy techniques, treatment of basal posterior fossa meningiomas still carries an elevated risk of morbidity. We present our results in a series of patients with this type of tumor and review the recent literature looking for the results obtained with different approaches and the new tendencies and algorithms proposed for managing these challenging lesions. MATERIAL AND METHODS We analyzed retrospectively the clinical presentation and outcome of 80 patients consecutively operated between 1979 and 2003 for basal posterior fossa meningioma (foramen magnum tumors excluded). All patients had preoperative CT scans and the majority MRI studies. A total of 114 operations were performed including two-stage operations, reoperation for recurrence, CSF diversion, and XII-VII anastomosis. The most commonly used approaches were lateral suboccipital retrosigmoid, subtemporal-transtentorial, frontotemporal pterional and supra-infratentorial presigmoid. Thirteen patients received postoperative radiotherapy. RESULTS There were 59 (73.7%) women and 21 men (mean age = 51.5 years; range = 18-78 yrs). Most common presenting symptoms were cranial nerve dysfunction, gait disturbances and intracranial hypertension. The mean duration of symptoms was 2.9 years. 70% of the tumors were over 3 cm in size. Fifty patients (62.5%) had a complete resection, 22 (27.5%) subtotal resection (> 90% tumor volume removed), and 8 (10%) only partial resection. Postoperative complications included hematoma, CSF leak, and infection. Fifty four (67.5%) patients developed new or increased cranial nerve deficits and 12.5% somatomotor, somatosensory or cerebellar deficits immediately after surgery with subsequent improvement in most cases. Following initial surgery 67 patients made a good recovery, 10 developed variable degrees of disability and 3 died. Eleven patients died later in the course for tumor recurrence with or without reoperation, malignant meningioma or unrelated causes. There were 9 recurrences in the subgroup of patients having complete resection initially (mean follow-up = 8.6 years). The majority of patients having initial subtotal or partial resections have been managed without reoperation during a mean follow-up period of 6.5 years (radiosurgery and/or observation). DISCUSSION AND CONCLUSION Current microsurgical and radiotherapy techniques allow either a cure or an acceptable control of basal posterior fossa meningiomas. In patients with tumor invasion of the cavernous sinus, extracranial extension, violation of the arachnoidal membranes in front of the brainstem, or encasement and infiltration of major arteries, a subtotal excision seems preferable followed by observation and/ or radiosurgical treatment. Apart from the patients age and the clinical presentation (symptomatic or not), the size and secondary extensions of the tumor must be taken into account for planning treatment in the individual patient.

Acute perfusion changes after spontaneous SAH: a perfusion CT study.

BackgroundPerfusion computed tomography (CT) is a rapid technique that allows the measurement of acute disturbances in local and global cerebral blood flow in patients suffering stroke and spontaneous subarachnoid haemorrhage (SAH). The purpose of this study was to establish the relationship between different measures of brain perfusion made on dynamic-contrast CT reconstructions performed as soon as SAH has been diagnosed and the severity of the bleeding determined by the clinical grade, the extent of the bleeding and the outcome of the patients.MethodsAfter the diagnosis of SAH by conventional CT, a perfusion CT was performed before CT angiography. All imaging studies were performed on a six-slice spiral CT scanner. All images were analysed using perfusion software developed by Philips, which produces perfusion CT quantitative data based on temporal changes in signal intensity during the first pass of a bolus of an iodinated contrast agent. Measurements of mean transient time (MTT), time to peak (TTP), cerebral blood volume (CBV) and cerebral blood flow (CBF) in volumes of interest corresponding to territories perfused by the major cerebral arteries were performed. Different data regarding severity of the bleeding—such as level of consciousness, amount of bleeding in conventional CT—were collected. All poor-grade patients received a ventriculostomy catheter so that ICP recordings were obtained. Also, the occurrence of delayed cerebral ischaemia (DCI) was recorded. Outcome was assessed by the Glasgow Outcome Scale 6 months after the bleeding. For statistical analysis, non-parametric correlations between variables were performed.FindingsThirty-nine patients have been included in the study since January 2007. In SAH patients there are increasing perfusion abnormalities as the severity of the bleeding increases. The most affected perfusion parameters are TTP and MTT, as they significantly increase with the clinical severity of the bleeding and the total volume of bleeding (P < 0.01, Spearman’s Rho). When average MTT time is increased over 5.9 s there is a 20-fold (95% CI = 2.1-182) risk of poor outcome. All patients presenting this MTT time suffered from DCI. This value has a positive predictive value of 100% for DCI and 90% for a poor outcome.ConclusionsSAH causes cerebral blood flow abnormalities even in the acute phase of the illness, consisting mainly of an increase in circulation times (TTP and MTT), which are correlated with the severity of the bleeding.