Miguel Ángel Arráez

Endoscopic transchoroidal and transforaminal approaches for resection of third ventricular colloid cysts

To review our experience over 10 years in endoscopic resection of third ventricular colloid cysts, describing the details of the transventricular–transchoroidal approach used in selected patients. This series included 24 patients with colloid cysts of the third ventricle treated in our department between October 2001 and January 2013 using an endoscopic approach. Clinical presentation, preoperative radiological findings, endoscopic technique employed, and complications were assessed in all patients. The mean length of patient follow-up was 5.16 years. The most common symptom was headache (75 %). The average size of the resected colloid cysts was 16.25 mm, the maximum diameter measured in cranial magnetic resonance imaging. Resection was transforaminal in 16 cases (66.7 %), transchoroidal in 7 (29.17 %), and transseptal in 1; macroscopically complete resection was achieved in 23 of 24 procedures (95.8 %). Complications included three intraventricular hemorrhages, four memory deficits (two of them transient), one case of temporary potomania, two soft tissue infections, and one meningitis. There were no statistically significant differences between the route of resection and number of complications. The Glasgow Outcome Scale at 1 year after surgery was 5 in 82.6 % of the patients. A transventricular endoscopic approach allows macroscopically complete resection of third ventricle colloid cysts in most cases. The option of opening the choroidal fissure (transventricular–transchoroidal approach) during the procedure can address third ventricle colloid cysts that do not emerge sufficiently through the foramen of Monro without increasing procedure-related morbidity.

Success criteria in pediatric neuroendoscopic procedures. Proposal for classification of results after 67 operations

PurposeControversial issues exist concerning criteria for patient selection and long-term success in pediatric neuroendoscopic procedures. We designed a classification of success grades applicable to high-pressure and chronic hydrocephalus and also to those cases in which different endoscopic maneuvers are performed during the same procedure. We then evaluated the success rate and complications in our series.MethodsA total of 59 patients underwent 67 neuroendoscopic procedures between January 2003 and January 2011. A retrospective study was made of the preoperative history, operative reports, and postoperative imaging findings and medical records. A 5-grade scale was developed to assess the type of success depending on clinical and radiological data. Complications related to the surgical procedure were also recorded.ResultsTwo patients were excluded from the success analysis due to insufficient follow-up time. The final results for the first procedures in 57 patients were complete and permanent success (grade I) in 49.1%, complete but transitory success (grade II) in 10.5%, partial success (grade III) in 12.3%, doubtful success (grade IV) in 5.3%, and failure (grade V) in 22.8%. In eight cases a second procedure followed the failure of the first: grade I success was achieved in seven cases (87.5%) and grade V in one case (12.5%). The highest success rates were achieved in cases of hydrocephalus caused by tumors or arachnoid cysts and the lowest in slit ventricle syndrome.ConclusionsA common classification of degrees of success, such as that proposed here, would aid the development of comparative and cooperative studies.

Multicentric glioblastoma multiforme. Report of 3 cases, clinical and pathological study and literature review.

Multicentric gliomas are uncommon lesions of the central nervous system. Their management remains controversial, but histopathologic diagnosis after complete or partial resection must be performed to differentiate these tumors from other multiple cerebral lesions. Three cases of multicentric glioma are presented, one of which had supra- and infratentorial lesions. Histological specimens were obtained from removal of at least one of the lesions. Neuropathological examinations confirmed the diagnosis of grade IV malignant glioma (glioblastoma). All 3 patients died soon after symptom onset. However, one patient, with metachronous glioblastomas, had a comparatively long survival. We discuss the pathogenetic hypotheses and the diagnostic problems, especially the differential diagnosis from other multifocal diseases of the central nervous system.

Recomendaciones sobre el uso de ácido 5-aminolevulínico en la cirugía de los gliomas malignos. Documento de consenso

Among the prognostic factors when it comes to patients with high-grade gliomas, we find the radicality of the surgery performed. The limitations of this factor are caused by either the extension of the tumour or its location in an eloquent area. To achieve this goal, in the last few years we have developed several methods that allow us to maximise tumour resection, while always trying to cause the least possible co-morbidity. One of these methods includes the use of 5-amino-levulinic acid (5-ALA) and the development of fluorescence guided surgery. However, optimal performance requires knowledge of the product employed, the mode of administration and precautions to consider. Members of the neuro-oncology work group of the Spanish Neurosurgical Society (SENEC) have prepared this guideline or consensus document for anyone who wishes to become familiar with the use of 5-ALA fluorescence-guided surgery in the management of high-grade gliomas. For those who already utilise this technique, this document can be useful for consultation purposes.

Gangliocitoma selar asociado a adenoma hipofisario productor de hormona de crecimiento. Caso clínico

INTRODUCTION Intrasellar gangliocytomas are uncommon entities which, unusually, may be found in association with hormone-releasing pituitary adenomas. CASE REPORT The patient was a 49-year-old female who presented a sellar lesion with associated acromegaly. A trans-sphenoidal tumour was removed, with no medical improvement. Histopathological analysis revealed a gangliocytoma with an associated somatotroph adenoma. DISCUSSION We found 85 cases of intrasellar gangliocytomas with associated hormone-releasing pituitary adenomas reported in the literature, with the following distribution: 50 growth hormone-releasing (GH) cases (59%), 15 mixed (GH and prolactin-releasing) cases (17%), 11 prolactin-releasing cases (13%), 7 adrenocorticotropic hormone-releasing (ACTH) cases (8%) and 2 corticotropin hormone-releasing (CRH) cases (2%). CONCLUSIONS Mixed gangliocytomas-adenomas are uncommon entities. Association with growth hormone-releasing cases is more frequent and the most common presentation is among middle-aged females. Diagnosis is histopathological. Identification of this entity is important because it may lead to a limitation in therapeutic response in incomplete resections.

Shunt overdrainage syndrome: review of the literature

Shunt overdrainage in patients with hydrocephalus still represents a challenge for neurosurgeons, in part due to the lack of agreement or uniformity concerning the entity. Important problems exist relating to the real incidence of the entity, its definition, classification, and the pathophysiological theories behind the various treatment strategies proposed. Recent reports have suggested that the evidence about overdrainage and its consequences is not so robust as presumed. Consequently, the topic requires more detailed examination. In this review, we comment on all the main facets related with shunt overdrainage.

Surgery of Superior Cerebellar Artery Aneurysm (SCA)

In a 57-year-old male, a persistent headache was evaluated by neurologists. MRI was done, and incidental superior cerebellar artery (SCA) aneurysm was discovered after assessment of abnormal image at the lateral aspect of the mesencephalon. CT-angio and angiography (Fig. 18.1) showed an aneurysm with saccular form at proximal portion of right SCA. Endovascular treatment was precluded by neuroradiologist due to the morphological characteristics of the aneurysm’s neck [1–3].

Factores relacionados con el pronóstico de la ventriculostomía premamilar endoscópica en pacientes pediátricos

Endoscopic third ventriculostomy (ETV) for paediatric patients has different success rates between the published series, making its recommendation controversial. Different definitions of ETV success, hydrocephalus aetiology or patient age at diagnosis may influence the outcome of the ETV procedure. The aim of this work was to analyse our clinical series and to examine the influence of different factors on ETV outcome. This was a retrospective study of 45 patients who had undergone ETV at our Paediatric Hospital between 2003 and 2009. Successful outcome was defined as a combination of features including clinical improvement or stability, with at least 1 positive radiological parameter. The influence of age, hydrocephalus aetiology, existence or not of previous shunt and the type of endoscopic procedure were analysed in relation to ETV outcome. Up to 29% of patients were younger than 1 year. The most frequent causes of hydrocephalus were: brain tumour, aqueductal stenosis and myelomeningocele. The overall success rate was 69%, with a mean follow-up period of 26 months and mean ETV survival of 14 months. We obtained statistically significant differences in ETV success between patients aged over and under 6 moths. Our ETV success rate can be considered safe and effective for the treatment of paediatric hydrocephalus. To our knowledge, ETV is most effective in patients aged 6 months and over.

6. Linfoma del nervio ciático

Introduccion Los linfomas del SNC son cuadros relativamente infrecuentes. Se estima que vienen a constituir menos del 1% de todos los linfomas, y casi esa misma cifra de los tumores intracraneales. Su presentacion en el sistema nervioso periferico es un hecho mucho mas infrecuente. Cuando lo hacen suele ser por extension secundaria desde un nodulo linfomatoso o en el contexto de una diseminacion sistemica. Material y metodos Se presenta el caso de un paciente de 64 anos, remitido a nuestro centro con un cuadro de siete meses de evolucion de perdida de fuerza progresiva y dolor en miembro inferior derecho, y diagnosticado mediante RMN de tumoracion de nervio ciatico. Fue intervenido y el diagnostico anatomopatologico fue de linfoma de alto grado. El estudio sistemico descarto la presencia de linfoma a otros niveles, aunque el paciente desarrollo durante su ingreso un cuadro severo y rapidamente de polineuropatia sensitivo-motora mixta, confirmada electromiograficamente. Discusion y conclusiones La aparicion de un linfoma solitario en un nervio periferico es un hecho de extraordinaria rareza, de la que solo hay descritos seis casos en la literatura. La posterior afectacion a otros niveles del SNP sin constancia de localizacion extraneural del linfoma constituye otro hecho de excepcional interes en este cuadro, del que no hay referencias previas. La etiologia de la afectacion polineuropatica que se presenta en algunos linfomas es objeto de controversia y se han postulado diversas hipotesis en torno a ella. En el presente trabajo se describe este singular caso, asi como se revisan los aspectos clinicos, diagnosticos, etiopatogenicos y terapeuticos descritos en toda la literatura publicada al respecto.

2. Aneurismas distales de la circulación posterior

Introduccion Los aneurismas de la circulacion posterior constituyen tan solo del 5–15% de todos los aneurismas intracraneales. De ellos, alrededor de las dos terceras partes se localizan en la arteria basilar, generalmente en la region de la salida de sus ramas, y el resto en la PICA. La aparicion de aneurismas en regiones distales de arterias de la circulacion posterior es excepcional y su tratamiento quirurgico constituye un reto. Material y metodos Se presentan dos casos de HSA secundarios a aneurismas distales en arterias de la circulacion posterior: uno situado en la arteria cerebelosa superior, y el otro en el segmento velomedular de la PICA. Ambos fueron intervenidos quirurgicamente pudiendose clipar la malformacion con exito: el primero a traves de un abordaje supracerebeloso infratentorial y el segundo por un abordaje subtonsilar transcerebelomedular. La evolucion postoperatoria de ambos pacientes fue satisfactoria. Discusion y conclusiones Los aneurismas situados en regiones distales de arterias de la circulacion posterior son muy infrecuentes, habiendose publicado pocos casos en la literatura. El abordaje endovascular de los mismos no suele ser factible por la dificultad de cateterizacion de estos segmentos, por lo que el tratamiento quirurgico suele ser el tratamiento indicado. Se trata de intervenciones que entranan una enorme dificultad no solo en la eleccion de la via de abordaje, sino tambien desde el punto de vista tecnico. En el presente trabajo se describen los casos y se revisa la literatura publicada al respecto, haciendo hincapie en las diversas vias de abordaje descritas.