Mario N. Carvi y Nievas

Early combined cranioplasty and programmable shunt in patients with skull bone defects and CSF-circulation disorders.

Abstract Objective: This study assesses the clinical outcome after early combined cranioplasty (own frozen bone) and shunt implantation (Codman-Medos programmable VP shunt) in patients with skull bone defects and cerebrospinal fluid (CSF) circulation disorders. Method: Medical records were reviewed retrospectively for the last 100 patients with CSF disorders after trauma or subarachnoid hemorrhage (SAH), who previously underwent decompressive craniotomy owing to therapy-resistant brain swelling. Patients treated with early (5 to 7 weeks after injury) combined cranioplasty and shunt implantation were analysed and a follow-up for the survivors was obtained. Results: In 60 patients with a daily CSF external drainage over 150 ml and dilated ventricles in CT scan, a programmable VP shunt was implanted simultaneously with the cranioplasty within 5.1 weeks after decompression. The neurological condition 6 months later was good (independent patients) in 39 cases (65%); 12 patients (20%) survived with a severe disability; three patients (5%) remained in a persistent vegetative state and only six patients (10%) died. There were few complications: bone or shunt infection (three cases), post-operative intracranial bleeding (one case), transitory neurological impairment after bone reimplantation (two cases), bone resorption (two cases) and shunt dysfunction (three cases). Conclusion: The early reimplantation of the patients own skull bone combined to the employment of a programmable shunt system allowed us a dynamic adjustment of the intracranial pressure (ICP) changes. The combined treatment reduced the number of required surgical procedures, complications and unsatisfactory patient outcomes.

Unusual sequestered disc fragments simulating spinal tumors and other space-occupying lesions. Clinical article.

OBJECT In this study the authors evaluated disease incidence, treatment, and outcome in patients with unusual sequestered disc fragments simulating spinal tumors or another space-occupying lesion on preoperative MR imaging. METHODS The authors retrospectively reviewed data from the last 3000 patients with a histological diagnosis of disc herniation. Patients with preoperative MR imaging findings that simulated a spinal tumor or other space-occupying lesion were individually analyzed. RESULTS In 11 patients (0.4%), MR imaging findings of unusual sequestered disc fragments were mistaken for another spinal space-occupying lesion. In 8 cases, the fragments had migrated to the posterior spinal space; in 3 cases, into the dural sac. In 3 patients, the fragments were distant from the original disc space. A heterogeneous mass was revealed with low-intensity or isointense signal on T1-weighted MR images as well as low signal (4 cases) or high signal (7 cases) intensity on T2-weighted images, relative to the spinal structures. A slight diffuse or peripheral Gd enhancement rim was observed in 7 patients. Disc fragments were located in the cervical (1 patient), thoracic (2 patients), and lumbar (8 patients) spine. All lesions were completely removed. Discectomy was required in 4 patients. A complete recovery occurred in 8 patients and a minor neurological deficit remained in 3. CONCLUSIONS Atypically located disc herniations should be considered in the differential diagnosis in patients with MR imaging data indicating spinal space-occupying disorders. All of these lesions, even those intradurally located, can be completely removed.

Complementary use of computed tomographic angiography in treatment planning for posterior fossa subarachnoid hemorrhage.

OBJECTIVE The goal of this study was to determine whether the complementary use of computed tomographic angiographic (CTA) assessments would provide additional benefits in the evaluation and treatment of ruptured vertebrobasilar artery aneurysms. METHODS In the past 4.5 years, 35 patients with an infratentorial dominant pattern of subarachnoid hemorrhage were complementarily examined with CTA scanning, after undergoing one or more three-dimensional rotational projection digital subtraction angiographic (DSA) studies. The results of these studies were interpreted by the treating neurosurgeon and an interventional radiologist, to examine the usefulness of the findings for the detection of aneurysms and to determine the grade of parent artery vascular filling and the optical definition of the aneurysm. This information provided additional benefits for case management. RESULTS Thirty-three aneurysms were detected. For 10 patients, no aneurysm was identified in repeated examinations with the two methods. We detected only 16 of the 25 ruptured aneurysms (64%) on the first DSA scans and, even with repeated examinations, 6 aneurysms were not clearly identified with this technique. CTA scanning revealed the ruptured aneurysms in 25 cases and demonstrated increased vascular filling and improved optical definition of the aneurysms, compared with DSA scanning, in 12 cases (48%). The information obtained from the CTA scans allowed the selection of five patients for endovascular treatment and facilitated the surgical procedures in five cases. CONCLUSION Complementary CTA examination of the vertebrobasilar complex provides a higher rate of aneurysm detection and improves the optical definition and anatomic projection of these aneurysms, compared with DSA scanning alone. This facilitates therapeutic decision-making (surgical versus endovascular procedures) and allows neurosurgeons to use more restricted surgical exposures.

Reliability of neuronavigation-assisted trans-sphenoidal tumor resections

Abstract Objective: To analyse the surgical reliability of neuronavigation-assisted trans-sphenoidal tumor resections. Method: In the past 7 years, all patients, who underwent neuronavigation-assisted trans-sphenoidal tumor resection in our department, were additionally intraoperatively controlled with a radioscopic device. Tumor removal was repeatedly checked up with the navigator and the tip of the pointer was correlated with the lateral intraoperative skull radiologic examination to confirm the real pointer deepness, spatial location and trajectory. The reliability of these assessments was analysed by simple images comparison and searching for tumor-related differences, and controlled with post-operative magnetic resonance studies. Results: During the analysed period, a total of 36 patients were treated in our department. Diagnosis included 14 non-secreting adenomas, 18 secreting adenomas and four non-pituitary tumors. Tumors diameter ranged from 1.4 to 4.5 cm. A mean accuracy of 0.8 mm could be achieved for all patients. In all cases, the real deepness, position and trajectory of the navigator were identical to those observed with X-ray examinations. At least nine from ten pointer determinations were identical in all cases. Particularly, all pituitary tumors with suprasellar extension could be safely controlled, even during advanced stages of resection and before the tumor capsule detached from suprasellar neighbor structures. Intrasellar, clival and suprasellar tumors were adequately removed as confirmed with MRI. Conclusions: Radioscopic controlled neuronavigation shows high reliability and allows surgeons to be more confident during the trans-sphenoidal resection of skull base tumors. This offers the advantage to reduce the patients X-ray exposure and the possibility of simultaneous multiplanar images evaluation.

Severe intracranial bleedings during endovascular procedures: outcome of surgically treated patients

Abstract Objective: Severe intracranial bleedings (SIBs) during endovascular procedures (EPs) are accompanied by acute intracranial hypertension and brain herniation signs. The purpose of this study was to determine the effectiveness of urgent surgical management and its related patient outcome in cases with such a fatal complication. Method: Medical records were reviewed retrospectively for the last 750 patients treated in our department in the past 12 years with acute non-traumatic intracranial bleeding, who underwent a diagnostic or therapeutic EP. Patients with a severe intra-procedural bleeding episode undergoing urgent surgical management (within 30 minutes after bleeding) were analysed. Results: Fourteen of 750 patients with ruptured vascular malformations presented a new SIB during EP. In nine patients, this occurred during initial angiography, two during aneurysm coiling, two during balloon angioplasty and one during arteriovenous malformation (AVM) embolization. The neurological condition 6 months later was good (independents patients) in seven cases with only a mild disability in two of them. Two patients showed a severe disability. Four patients died without recovering their consciousness. One patient presented a satisfactorily course but died weeks later owing to a pulmonary embolism. Conclusion: Despite the fatal spontaneous prognosis of severe intracranial bleeding occurring during endovascular diagnostic or therapeutic procedures, a favorable outcome can be expected if an appropriated treatment was set within 30 minutes of the bleeding.

Benefits of adapting minimal invasive techniques to selected patients with spontaneous supratentorial intracerebral hematomas.

Abstract Objectives: This study assesses the benefits of adapting minimal invasive techniques (MIT) to selected patients with spontaneous supratentorial intracerebral hematomas (SSICHs). Methods: The study compares the post-operative residual clot volume and clinical outcome of 89 selected, MIT evacuated SSICH-patients to those of 138 unselected cases operated in our department. Selection criteria includes patient age, early admission and MIT treatment. MIT treatment included: 28 patients with deep SSICHs smaller than 30 cm3 associated with intraventricular bleeding who underwent neuronavigation-guided stereotactic catheter lysis, 37 patients with deep hematomas larger than 30 cm3 and 24 patients with a lobar hemorrhage compressing eloquent regions who underwent microsurgical (endoscopic or neuronavigation assisted) clot aspiration. Results: In eight (9%) of the patients in the MIT group, the CT scan control showed a residual clot smaller than 30% of the initial hemorrhage. The neurological condition 3 months later revealed 24 (26.9%) of these patients having a severe disability and 46 (51.6%) patients independent or slightly disabled. Nineteen patients (21.9%) died or remained vegetative. In the control group, 48 (34.7%) cases showed residual clots (<30%). Sixty-two (44.9%) patients of this group were severely disabled and only 40 (28.9%) were independent. Thirty-six (26%) patients died or were vegetative. There was a p<0.001 significant difference in volume of residual clots as well as p<0.01 for the outcome between the two groups. Conclusions: Adapting minimally invasive techniques to case selection improves the effectiveness of clot removal and the outcome of the patients with SSICHs.

Cerebral vein thrombosis associated with aneurysmal subarachnoid bleeding: implications for treatment

BACKGROUND Cerebral vein thrombosis associated with aneurysmal subarachnoid bleeding is an uncommon event rarely described in the literature. We report here a case and summarize the problems in the management of this patient. CASE DESCRIPTION A 48-year-old female suffered from two episodes of severe headache and vomiting 7 days before and on the day of admission. She was deeply somnolent with mild paresis of her right leg. Computed tomography (CT) scans revealed diffuse basal subarachnoid bleeding and a left parietal subcortical hemorrhagic area. A cerebral angiogram demonstrated an anterior communicating artery aneurysm. The angiographic late venous phase showed nonopacification of the cortical veins on the hemorrhagic area compatible with cerebral vein thrombosis. She underwent successful aneurysm clipping combined with moderate systemic anticoagulation. After 7 days of gradual clinical improvement she presented acute bilateral cerebral herniation signs and died 48 hours later. CT scan showed a generalized brain swelling. Postmortem examination confirmed the correct occlusion of the ruptured aneurysm sac and the presence of a postthrombotic subcortical left parietal hemorrhage as well as a complete obstruction of the superior sagittal sinus extended into both transverse sinus. CONCLUSIONS The fatal outcome with the documented extended thrombosis, despite careful anticoagulation therapy, indicates the necessity of closely meshed follow-up studies examining the sinus patency in such complicated cases with associated pathology.

The influence of configuration and location of ruptured distal cerebral anterior artery aneurysms on their treatment modality and results: analysis of our casuistry and literature review.

AbstractObjective: To assess the influence of configuration and location of ruptured distal cerebral anterior artery aneurysms on their treatment modality and results.Method: The influence of the aneurysm configuration (basic or complex configuration) and location (infracallosal or supracallosal) on the treatment-related radiological results (partial or complete aneurysm occlusion) and clinical outcome (favorable or unfavorable) was retrospectively analysed in all admitted patients with ruptured pericallosal aneurysms within the last 10 years. The expected benefit from each form of treatment was individually discussed.Results: During this period, 21 patients with ruptured pericallosal aneurysms (three previously coiled in other departments) had been admitted to our department. Within the endovascular group (ten patients), five infracallosal basic aneurysms presented a complete occlusion and favorable patient outcome. Three patients with infracallosal complex aneurysms presented a favorable outcome (two an...Abstract Objective: To assess the influence of configuration and location of ruptured distal cerebral anterior artery aneurysms on their treatment modality and results. Method: The influence of the aneurysm configuration (basic or complex configuration) and location (infracallosal or supracallosal) on the treatment-related radiological results (partial or complete aneurysm occlusion) and clinical outcome (favorable or unfavorable) was retrospectively analysed in all admitted patients with ruptured pericallosal aneurysms within the last 10 years. The expected benefit from each form of treatment was individually discussed. Results: During this period, 21 patients with ruptured pericallosal aneurysms (three previously coiled in other departments) had been admitted to our department. Within the endovascular group (ten patients), five infracallosal basic aneurysms presented a complete occlusion and favorable patient outcome. Three patients with infracallosal complex aneurysms presented a favorable outcome (two aneurysms were partially occluded and a frustrated procedure was replaced by clipping). Two supracallosal basic aneurysms showed a complete occlusion with one unfavorable outcome and one frustrated procedure followed by clipping and favorable outcome. In the surgical group (11 patients), five infracallosal complex aneurysms presented a complete occlusion with four favorable and one unfavorable outcomes. One patient with a supracallosal basic aneurysm presented a complete occlusion with a favorable outcome, and five patients with supracallosal complex aneurysms presented a complete occlusion in four cases and favorable outcome in all of them. Conclusion: The results of this study suggest that patients with infracallosal basic configured aneurysms are expected to benefit from endovascular procedures, whereas better radiological and clinical results can be obtained in surgically treated patients harboring supra- or infracallosal aneurysms of complex configuration.

Delayed outcome from surgically treated patients with benign nerve associated tumors of the extremities larger than 5 cm

Abstract Background: The purpose of this work was to analyse the surgical procedure used and the outcome from patients with solitary nerve associated benign tumors of the extremities (SNABTE) >5 cm. Methods: A 15 year review was performed for all patients with SNABTE treated in our department. The surgical procedures used (complete or incomplete tumor removal, with or without nerve preservation), the needs for grafting techniques as well as the outcome were analysed. Results: Nine (9·5%) of 94 patients with SNABTE met the study requirements. The histological diagnosis revealed a schwannoma in four cases, a neurofibroma in three cases, one lipoma and one lipofibroma. Seven lesions could be completely excised. Preservation of the nerve bundles with complete neurological recovery was possible in five cases. The resection of a 22 cm neurofibroma without preservation of the nerve did not add measurable residual neurological deficits. One patient with a peroneal neurofibroma required a grafting procedure. Intentional incomplete tumor excisions were performed in two patients with well preserved nerve functions where a median nerve lipofibroma and a radial nerve neurofibroma were diagnosed. All patients showed different degrees of improved outcome. Conclusions: We conclude that the complete resection of large SNABTE, excepting lipofibromas and some neurofibromas, is always possible and associated with an improved outcome. The nerve preservation should be attempted in all cases, particularly in those with conserved functionality of a major nerve trunk.

Cerebral vasospasm: a review of current developments in drug therapy and research

Abstract In this manuscript a comprehensive coverage of recent developments in the drug therapy of vasospasm while providing the background information that neuroscientists need to understand its rationale. The range of new agents