Pablo Dominguez

Preoperative planning of DIEP and SGAP flaps: preliminary experience with magnetic resonance angiography using 3-tesla equipment and blood-pool contrast medium.

BACKGROUND Autologous breast reconstruction techniques can be used to create a breast, in particular the superior gluteal artery perforator (SGAP) and deep inferior epigastric artery perforator (DIEP) flaps. Preoperative imaging is an essential planning tool in mapping the location and size of perforator vessels. The aim of this report is to show the usefulness of angio-MR technique for preoperative planning of DIEP and SGAP flaps. Initial experience, surgical findings correlation and imaging findings will be described. METHODS From February 2007 to September 2007, ten consecutive women considered for breast reconstruction with DIEP (eight patients) and SGAP flaps (two patients) after previous mastectomy for breast cancer were studied. After written informed consent was obtained, a preoperative angio-MR using 3-Tesla equipment and blood-pool contrast medium was performed to localize and evaluate the main perforator vessels in each patient and procedure. RESULTS Angio-MR showed all the main perforator vessels later observed during the surgical procedure with a very good location concordance, but missed one main perforator vessels in each of two patients. In all patients undergoing SGAP flaps, an accurate identification of the main perforator vessels was achieved. Angio-MR clearly showed the intramuscular course of the perforator vessels for DIEP and SGAP flaps. Exact correlation between angio-MR and surgical findings was observed. CONCLUSIONS The use of angio-MR for preoperative perforator flaps evaluation yielded promising results and would allow not only to locate perforator vessels but also to globally assess presurgical planning of perforator flaps in a noninvasive, radiation and toxicity-free way.

Microvascular decompression may be effective for refractory SUNCT regardless of symptom duration.

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome is characterized by short-lived (5–240 s), strictly unilateral, periorbital, severe pain attacks, accompanied by ipsilateral conjunctival injection and lacrimation (1). SUNCT syndrome has been considered to be refractory to treatment, although recent small case series have suggested benefit from different antiepileptic drugs (2,3). In some cases surgical intervention may be advocated, particularly when the pain is medically intractable or the medications are not tolerated. We present a patient with chronic SUNCT syndrome who was successfully treated with posterior fossa vascular decompression 19 years after the onset of symptoms.

Spinal extradural arachnoid cysts in lymphedema-distichiasis syndrome

Purpose: Lymphedema-distichiasis syndrome is characterized by the presence of lower limb lymphedema and supernumerary eyelashes arising from the Meibomian glands. Spinal extradural arachnoid cysts have been observed in some families but their true frequency is unknown. The aim of this study is to determine the frequency of spinal extradural arachnoid cysts in lymphedema distichiasis syndrome.Methods: We collected clinical information from all 45 living members of a complete family of 48 members and performed molecular analysis of the FOXC2 gene in 30 individuals. We obtained spinal magnetic resonance imaging from all family members with a FOXC2 gene mutation.Results: Twelve family members carried a mutation in the FOXC2 gene and had clinical features of lymphedema-distichiasis syndrome. Of these, 58% (seven individuals) had extradural arachnoid cysts.Discussion: We suggest that a follow-up protocol for lymphedema-distichiasis syndrome families should include spinal magnetic resonance imaging for all affected members so that the timing of surgery for removal of these cysts can be optimized.

Atraumaticity study of 2 cochlear implant electrode arrays.

Hypothesis Evaluate, based on morphologic and histologic parameters, the atraumaticity of 2 electrode arrays implanted in 10 human temporal bones. Background Atraumatic surgery and electrode arrays are current topics in otologic surgery. The preservation of cochlear anatomy and its functions is a priority and morphologic evaluation of the surgical trauma is essential to continue improving in this field. Methods Ten preserved human temporal bones (TB) without anatomic alterations were used in this study. They were divided into 2 groups of 5, and atraumatic surgery was performed to insert HiFocus 1J (group A) and HiFocus Helix (group B) electrode arrays. Anatomic comparisons were performed using computed tomography and histologic analysis. Results Group A: the mean length for the cochlear longitudinal axis was 10.30 mm, and the cochlear transversal axis was 7.2 mm. Scala tympani insertion was achieved in 4/5 TB studied, with a mean depth and angle of insertion of 19.2 mm and 325.5°, respectively. Lateral location of the electrode array was achieved in all specimens. No significant correlation was observed between these dimensions and depth of insertion. Group B: the mean length for the cochlear longitudinal axis was 9.52 mm, and cochlear transversal axis was 6.38 mm. Scala tympani insertion was achieved in 4/5 TB studied, with a mean depth and angle of insertion of 17.5 mm and 352°, respectively. Modiolar location of the electrode array was achieved in all specimens. A positive correlation was established between the linear and angular insertion depths (p = 0.044). Conclusion In summary, it is safe to state that neither electrode array shows significant insertion trauma.

Stereotactic‐Guided Excisional Biopsy: A New Technique for Very Thin Breasts

Abstract:  Stereotactic biopsies are widely used for the diagnosis of breast lesions. Most biopsy devices require breast thickness of at least 25–30 mm with compression. We describe an alternative technique in order to perform excisional stereotactic‐guided biopsies for very thin breasts using the prone stereotactic table. In the outpatient setting and with local anesthesia, this procedure can be performed by a radiologist, a surgeon, and a nurse. After conventional stereotactic localization, a fine needle is placed at the site of the lesion. Once the point is marked with a skin marker, a 25G × 16 mm needle is introduced. Then, a couple of stereotactic views are taken to confirm the correct position of the needle. Later, the surgeon excises the lesion guided by the needle. Additional radiographs of the specimen and the remaining breast tissue are obtained to ensure the accuracy of the procedure.

Embolización arterial con microcoils en priapismo de alto flujo

High flow priapism occurs mainly as a result of a posttraumatic arteriocavernous fistula. Treatment aims to seal the fistula without damaging erectile function. Of all the available treatments, supraselective embolization of the lacerated artery achieves optimal sealing of the fistula with minimal damage to the surrounding tissues. There is no consensus regarding the best materials to be used. Although reabsorbable materials have traditionally been the most commonly used, it is also possible to achieve adequate resolution of the priapism with adequate conservation of erectile function using non-reabsorbable materials, especially microcoils. We describe two cases of patients with high flow priapism caused by bilateral arteriocavernous fistulas treated using microcoil embolization.

DNX-2401, an oncolytic virus, for the treatment of newly diagnosed diffuse intrinsic pontine gliomas: A case report

Diffuse intrinsic pontine gliomas (DIPGs) are aggressive glial brain tumors that primarily affect children, for which there is no curative treatment. Median overall survival is only one year. Currently, the scientific focus is on expanding the knowledge base of the molecular biology of DIPG, and identifying effective therapies. Oncolytic adenovirus DNX-2401 is a replication-competent, genetically modified virus capable of infecting and killing glioma cells, and stimulating an anti-tumor immune response. Clinical trials evaluating intratumoral DNX-2401 in adults with recurrent glioblastoma have demonstrated that the virus has a favorable safety profile and can prolong survival. Subsequently, these results have encouraged the transition of this biologically active therapy from adults into the pediatric population. To this aim, we have designed a clinical Phase I trial for newly diagnosed pediatric DIPG to investigate the feasibility, safety, and preliminary efficacy of delivering DNX-2401 into tumors within the pons following biopsy. This case report presents a pediatric patient enrolled in this ongoing Phase I trial for children and adolescents with newly diagnosed DIPG. The case involves an 8-year-old female patient with radiologically diagnosed DIPG who underwent stereotactic tumor biopsy immediately followed by intratumoral DNX-2401 in the same biopsy track. Because there were no safety concerns or new neurological deficits, the patient was discharged 3 days after the procedures. To our knowledge, this is the first report of intratumoral DNX-2401 for a patient with DIPG in a clinical trial. We plan to demonstrate that intratumoral delivery of an oncolytic virus following tumor biopsy for pediatric patients with DIPG is a novel and feasible approach and that DNX-2401 represents an innovative treatment for the disease.

Adenocarcinoma del saco endolinfático en la enfermedad de von Hippel-Lindau. A propósito de un caso

Tumors originating in the endolymphatic system are extremely rare, and very few articles have been published about this type of tumors. Up to 15% of cases are associated to von Hippel-Lindau disease. This article describes the case of a patient previously diagnosed with von Hippel-Landau disease that presented a sudden loss of hearing in the left ear. Specific imaging tests (computed tomography [CT] and magnetic resonance imaging [MRI]) showed the presence of a neoplasm originating in the left endolymphatic sac. Histological analysis of the surgical specimen determined it corresponded to an adenocarcinoma of the endolymphatic sac.

Fibroadenomas de mama con atipia o carcinoma en su interior: presentación de nuestra experiencia

La presencia de atipia o carcinoma en un fibroadenoma es un hallazgo infrecuente. Se ha realizado un estudio retrospectivo de los archivos de nuestro centro desde enero de 1995 hasta junio de 2003. Se encontraron un total de 881 fibroadenomas con confirmacion histologica, y siete de ellos con atipia o carcinoma asociados (dos carcinomas ductales in situ , dos carcinomas lobulillares in situ , y tres hiperplasias ductales con atipia). La edad media fue de 44 anos (rango: 36-67). Cuatro de los siete fibroadenomas se presentaron como lesiones palpables que habian experimentado crecimiento, que correspondieron a los cuatro casos de carcinoma. Hallazgos mamograficos (tres casos): dos agrupaciones de microcalcificaciones y un nodulo bien delimitado. Hallazgos ecograficos (seis casos): cuatro nodulos ovoideos bien definidos, un nodulo con calcificaciones y un nodulo ovoideo bien definido de ecoestructura heterogenea. El diagnostico inicial se realizo mediante biopsia escisional en 5 casos y mediante biopsia con aguja gruesa en otros dos casos. Los dos casos de biopsia con aguja gruesa tuvieron un primer resultado de fibroadenoma, pero la cirugia posterior demostro la presencia de carcinoma ductal in situ y un carcinoma lobulillar in situ . En conclusion se puede decir que los fibroadenomas con atipia o carcinoma pueden ser similares a los fibroadenomas habituales en mamografia y ecografia. Sin embargo, el crecimiento de un nodulo palpable, la presentacion mamografica como microcalcificaciones sospechosas o el hallazgo ecografico de un nodulo heterogeneo, obligan a la realizacion de una biopsia escisional para un diagnostico fiable.

Resonancia magnética intraoperatoria de 3 teslas: Nuestra experiencia en patología tumoral

OBJECTIVE To report our experience in the use of 3 tesla intraoperative magnetic resonance imaging (MRI) in neurosurgical procedures for tumors, and to evaluate the criteria for increasing the extension of resection. MATERIAL AND METHODS This retrospective study included all consecutive intraoperative MRI studies done for neuro-oncologic disease in the first 13 months after the implementation of the technique. We registered possible immediate complications, the presence of tumor remnants, and whether the results of the intraoperative MRI study changed the surgical management. We recorded the duration of surgery in all cases. RESULTS The most common tumor was recurrent glioblastoma, followed by primary glioblastoma and metastases. Complete resection was achieved in 28%, and tumor remnants remained in 72%. Intraoperative MRI enabled neurosurgeons to improve the extent of the resection in 85% of cases. The mean duration of surgery was 390±122minutes. CONCLUSION Intraoperative MRI using a strong magnetic field (3 teslas) is a valid new technique that enables precise study of the tumor resection to determine whether the resection can be extended without damaging eloquent zones. Although the use of MRI increases the duration of surgery, the time required decreases as the team becomes more familiar with the technique.