S. Castro

Spinal Metastatic Disease: Analysis of Factors Determining Functional Prognosis and the Choice of Treatment

The authors surveyed 31 surgical and radiotherapy series comprising over 2300 patients with spinal metastases to determine the influence of factors such as tumor biology and topography, pretreatment neurological status, the presence of a myelographic block, the progression rate of symptoms, and the general medical condition of the patient on both the functional prognosis and the choice of treatment. Both life expectancy and the functional results after therapy are mainly dependent on tumor biology, which in turn determines radiosensitivity. The remaining factors seem to have only complementary predictive power. Because radiotherapy has been found to be as effective as operation plus radiotherapy in the management of the majority of patients with spinal metastases, it is very important to improve the selection of surgical candidates (less than 42% of the total cases) to prevent unnecessary surgery-related morbidity and mortality. Factors considered important in the selection of therapy are the location of the tumor within the spinal canal, the neurological status at the time of treatment, and the systemic condition of the patient.

Symptomatic Subependymoma: Report of Four New Cases Studied with Computed Tomography and Review of the Literature

The authors describe four cases of subependymoma studied with computed tomography (CT) and review 18 previously reported cases in an attempt to define the most characteristic CT presentation of this rare, benign tumor. Subependymoma usually appears as an isodense, or even hypodense, intraventricular tumor on plain CT scan and shows minimal or no enhancement in postcontrast studies. Differential diagnosis between subependymoma and the more malignant true ependymoma is difficult, particularly when the tumor occurs in the posterior fossa. Recognition of subependymoma should prompt the surgeon to attempt radical tumor removal because it can be achieved without sacrificing contiguous tissue and carries a good prognosis.

Giant intrasacral schwannomas: Report of six cases

SummaryOnly 4 of the 30 previously reported cases of giant sacral schwannomas have been studied with Magnetic Resonance Imaging (MRI). We are reporting 6 more cases, 5 of which had MRI studies. There were 5 women and 1 man (average age 45 years) with long lasting symptoms consisting of lumbosacral and radicular pain accompanied by urinary disturbances and dysaesthetic sensations in the lower limbs. CT clearly defined sacral bone involvement but poorly demonstrated intraspinal tumour extension which was more evident in MRI studies. MRI also clearly showed the intrapelvic extension of the tumour, its relationship with the neighbouring structures and the dumbell growth pattern due to tumour extension through sacral foramina which are important data for making a properative diagnosis and surgical planning. Surgical treatment consisted of piecemeal tumour resection through a posterior approach in four cases. Two patients underwent operation through an abdominal transperitoneal approach followed by a sacral laminectomy. Total intracapsular resection was apparently achieved in 5 cases. Through an average follow-up period of 9.2 years and despite a rather conservative approach, the recurrence rate has been very low in our series and only one patient had to be re-operated on for tumour recurrence.

Subarachnoid haemorrhage of unknown aetiology.

SummaryThe authors review the literature on subarachnoid haemorrhage of unknown aetiology (SAHUE) and analyze a personal series of 212 patients diagnosed as SAHUE. These patients represent 30% of all cases of primary SAH admitted over a 14.5 year period.The age, sex, antecedents and initial clinical presentation of patients with SAHUE were indistinguishable from those of patients with subarachnoid haemorrhage due to ruptured aneurysm (SAHRA). However, the present series of SAHUE compare favourably with both a personal and a previously reported series of SAHRA insofar as clinical grade on admission (94% of patients in grades I–II of Botterell), presence of blood on CT (51%), vasospasm (5%), ischaemic deficits (3.3%), persistent hydrocephalus (3.5%), rebleeding (6%) and fatal result (3.9%) are concerned.The amount of blood on CT scan in our patients with SAHUE was associated with a significantly higher incidence of brain ischaemia and hydrocephalus but did not correlate with the Botterell grade on admission or final outcome, which were good in the majority of cases regardless of the presence or not of visible cisternal haemorrhage. The results of the present series confirm that the final prognosis of patients with primary SAH showing normal four-vessel cerebral angiography is essentially favourable.

Asociaciones tumorales en el sistema nervioso central. Estudio de ocho casos con verificación quirúrgica

Resumen La presencia de formaciones tumorales multiples de la misma histogenesis en el interior de la cavidad craneal (TMI) es una situacion bien conocida desde los puntos de vista neurorradiologico, neuroquirurgico y neuropatologico. Mucho menos frecuentes son las asociaciones tumorales intracraneales (ATI), es decir, los cuadros constituidos por dos o mas tumores de distinta histogenesis en la cavidad craneal; aproximadamente, el 50% de las ATI consisten en la asociacion sincronica o diacronica de un meningioma y un glioblastoma multiforme. Una forma especial de ATI es la que se ha denominado en la literatura tumor en colision (ATI-C), consistente en la presencia de dos tumores de distinta histogenesis topograficamente yuxtapuestos. Se presentan ocho enfermos, con ATI y ATI-C, estudiados en el Servicio de Neurocirugia del Hospital Universitario “12 de Octubre”; admitidos entre 1976 y 1998. Se destacan las dificultades diagnosticas en los primeros casos antes de la introduccion de los nuevos metodos de neuroimagen. Asimismo, se considera que las discrepancias entre distintas exploraciones radiologicas, quirurgicas y quirurgico-evolutivas deben hacer pensar en la posibilidad de ATI. En ultima instancia, se revisa la literatura medica pertinente a las ATI y las ATI-C.

Aneurismas del complejo arteria vertebral-arteria cerebelosa posteroinferior

Resumen Se revisan 11 pacientes con hemorragia subaracnoidea producida por la rotura de un aneurisma del complejo arteria vertebral (AV) - arteria cerebelosa posteroinferior (ACPI). Esta cifra supone el 2,3% del total de aneurismas vistos en nuestro Servicio entre 1974 y 1993. Se analiza la clinica de presentacion, localizacion, presencia de vasoespasmo angiografico, sintomas isquemicos y evolucion final. Se practico tomografia computarizada en 9 casos, discutiendose la localizacion de sangre y los hallazgos patologicos en la TC inicial. Esta serie tiene la particularidad de tener tres casos de malformacion arteriovenosa en la arteria cerebelosa posteroinferior asociada al aneurisma. Se discute la frecuencia de dicha asociacion y su significado patologico.

Quistes epidermoides y dermoides intracraneales intradurales: tratamiento quirúrgico y seguimiento de 32 casos

Resumen Se presentan 27 casos de quistes epidermoides y 5 casos de quistes dermoides intracraneales intradurales que fueron intervenidos quirurgicamente en nuestro Servicio durante un periodo de 18 anos. Los pacientes fueron estudiados radiologicamente mediante neumoencefalografia en 5 casos, angiografia cerebral en 16, tomografia computadorizada (T.C.) en 24 casos y resonancia magnetica (R.M.) en 13 (9 preoperatoriamente y 4 postoperatoriamente). Se realizo un seguimiento posquirurgico en 30 pacientes durante un periodo medio de 4 anos. En ambos tipos de quiste la localizacion predominante fue supratentorial (un 59,2 % de los epidermoides y 60 % de los dermoides). Como localizaciones poco frecuentes de quiste epidermoide se presentan 2 intraventriculares (IV ventriculo y region atrial), 2 intradiencefalicas, una paratrigeminal y otra interhemisferica supracallosa. En la mayoria de los quistes la exeresis se practico mediante tecnica microquirurgica. Se considero total en 16 pacientes (50 % de los casos), casi total en 7 (21,8 %) y parcial en 9 (28,1 %). Se consiguio mejoria clinica en 14 pacientes (46,6 %), estabilizacion sintomatica en 11 (36,6 %) y empeoramiento en 5 (16,6 %). Cinco pacientes presentaron recidiva tras un intervalo posquirurgico medio de 7 anos. Cuatro de ellos empeoraron clinicamente y fueron reintervenidos. En nuestra experiencia observamos que la R.M. ofrece mayor informacion diagnostica que la T.C. en la recidiva, especialmente en la secuencia potenciada en densidad protonica. Asimismo hemos comprobado que varios pacientes con imagen radiologica posquirurgica de restos quisticos o recidiva pueden permanecer largo tiempo asintomaticos y nuestra actitud terapeutica en estos casos ha sido expectante.