Revisión de intoxicación por monóxido de carbono / Revision of carbon monoxide intoxication

El monóxido de carbono es un gas muy peligroso que pasa desapercibido en el ambiente. Puede producir cefalea, náuseas, taquicardia, debilidad, convulsines, coma y muerte. El diagnóstico se basa en una historia compatible y el examen físico, en conjunción con el laboratorio. La intervención más importante en el manejo de la intoxicación por el monóxido de carbono es alejar al paciente de la fuente de monóxido de carbono y la terapia con oxígeno, para salvar la vida y prevenir las secuelas

Carbon monoxide is a very dangerous gas that pass unaware in the environment. It can produce headache, nausea, tachycardia, malaise, seizures, coma and death. The diagnosis is based upon a compatible history and physical examination in conjunction with the laboratory. The most important interventions in the management of carbon monoxide poisoning are removal from the source of carbon monoxide and oxygen therapy, to save the life and to prevent secuelae

Malformación del desarrollo cortical: nuestra experiencia acerca de 150 casos / Cortical development malformations (CDM): our experience on 150 cases

Objetivo Realizar una evaluación retrospectiva de 150 pacientes de una serie de 570 (26.3%), operados por epilepsia refractaria con diagnóstico de algún tipo de malformación del desarrollo cortical (MDC), desde 1988 a noviembre de 2009. Material y método. 118 niños y 32 adultos; 69 localización temporal (42 niños, 27 adultos) y 81 extratemporal (76 niños y 5 adultos). La evaluación prequirúrgica incluye: características clínico-semiológicas de las crisis epilépticas, EEG de superficie, video EEG, TC y/o RM y evaluación neuropsicológica. Población: varones: 86; mujeres 64; edad, media de 6.7 años (rango: 6 m – 18.9 a) en los niños y media de 31.3 años (rango: 19-59 a) en los adultos. Evolución de epilepsia: media de 4.9 años para los niños (rango: 1 mes a 17 años) y media de 13.8 (rango: 2 meses a 50 años). Aspectos clínicos: tipos de crisis: pudiendo un mismo paciente presentar más de una de ellas, vinculadas a la localización, CPS, ausencias, crisis tónicas, automatismos, crisis versivas, CPC, anopsia transitoria, “drop attacks”, “Startle epilepsia”, escotoma, automatismos masticatorios, crisis clónicas, fotopsia, desviación ocular, “head attacks”. Imágenes: la TC fue normal en 5, y se realizó IRM en todos a partir de 1996

Objective: To evaluate the surgical results in a group of patients with epilepsy associated with cortical development malformations (CDM). Method: A retrospective study in 150 patients of a series of 570 patients (26.3%) who have undergone surgery for intractable epilepsy with a diagnosis of CDM, since 1988. Clinical features,scalp EEG, video EEG, CT scan, MRI and neuropsychological evaluation were assessed. Population: males: 86 patients, females: 64; mean age, children: 6.7 years (range: 0,5-18.9) and adults: 31.3 years (range: 19-59); mean evolution of epilepsy, children: 4.9 years (range: 1mo-17 yr.), adults: 13.8 years (range: 2mo-50 yr.). Clinical manifestations: CPS, absences,tonic crises, automatisms and versive crises, CPS, transitory anopsia, drop attacks and Startle epilepsy, scotoma, masticatory automatisms, clonic crises, photopsia, eye deviation and head attacks. Imaging: CT scan was normal in 5, and MRI was performed since 1996. Twenty of 150 (13.3%) required chronic intracranial electrodes implantation. Surgical procedures: resectives: lesionectomies 63 (wide lesionectomy, 17 and + MST, 5), standard anterior temporal lobectomies (SATL) 37, anteromesial resections (Spencer) 9, corticectomies 11(+MST, 1),amigdalo- hippocampectomies 3, anatomic hemispherectomy 1, lobectomy1 and polectomies 4; disconnecting procedures: functional hemispherectomies (FH) 10, hemispherotomy 4, hemi-hemispherectomy 1, multiple subpial transection (MST) 1 and 2 callosotomies...

Esclerosis temporal mesial: paradigma de la epilepsia de resolución quirúrgica: 2da. parte / Temporary mesial sclerosis: Surgical resolution epilepsy paradigm 2nd. Part*

Objective. To describe the Mesial Temporal Lobe Sclerosis (MTS), in relation to its anatomical, clinical, iconographic, neurophysiologic, neuro psychologic, and surgical aspects, in reference to the epilepsy cases that needed a surgical resolution. Additionally, it’s realized a statistical analysis of our series and its results.Material and methods. From the series of 469 patients (115 adults and 354 children) operated on between 1989 and 2007, at National Pediatrics . Dr. Juan Garrahan, FLENI, Dr. Cosme Argerich, and Prof. Dr. R. Rossi Hospitals; who harbored RefractoryEpilepsy ; were analyzed 91 cases (19,4%) with the diagnosis of MTS; 38 patients belong to the pediatric group and 53 were adults. Results. The results were evaluated by the Engel score. Applying this classification, our population of patients showed thenext pattern of distribution: 69 (75,8%) are in Engel’s class IA, from this group, 36 (52,2%) are children, and 33 (47,8%), adults; 4 adults patients;( 4,4%) are in Engel’s class IB, 3 patients (3,3%) in Engel’s class IC; 1 (in Engel’s class ID(1,1%); 4 adults in Engel’s class IIA (4,4%); 5 in Engel’s class IIB (5;5%) and 3 (3,3%) in Engel’s class IVA; from then, one patient was a child, and underwent the implantation of VNS, the rest were adults. One adult patient committed suicide, one year after surgery (was in Engel’s class IA). One patient is on his first post operative year,and then couldn’t been included in statistical analysis, because follow up wasn’t enough. Conclusion. The MTS is the paradigm of Refractory Epilepsy inthe adult population, and in the pediatric subgroup involved a significant percentage: the presurgical evaluation must be exhaustive for adequate selection of cases. The extent of resection should be done with high degree of selectivity. The early diagnosis and treatment can obtain a high index of good results without ictal phenomena and the absence of necessity of antiepileptic drugs.

Epilepsia refractaria del lobulo temporal secundaria a patología dual: Nuestra experiencia acerca de 32 casos / Refractory temporal lobe epilepsy secondary to dual pathology: Review of 32 cases

Classical dual pathology is the coexistence of temporal mesial sclerosis (TMS) and an ipsilateral extra-hippocampal lesion. The aim of this presentation is to increase the awareness of the existence of this pathology as well as variants as a cause of refractory temporal lobe epilepsy and its difficult pre-op diagnosis. Of the 32 cases here presented, 19 were adults and 13 children. Adults: 17 had TMS + cortical dysplasia (CD) and of the remaining patients, 1 had TMS + oligodendroglioma and 1 TMS+ ganglioglioma. Children: pathology findings were: A) TMS + malformation of cortical development 6; B) TMS + CD + ganglioglioma 2; TMS + ganglioglioma + post-infectious sequelae 1 (“triple pathology”) and C) CD associated with low-grade glioma 1 and with MAV 1.Surgical techniques: LATS and the Spencer variant were the most commonly used techniques. Results: Patients in both groups are in Engel Class I and II. Conclusion: The good results in this series can be attributed to the complete resection of these entities.

Hemisferectomías y hemi-hemisferectomías: nuestra experiencia acerca de 49 casos / Hemispherectomy and hemi-hemispherectomy: Review of 49 cases

Objective. To review the results of hemispherectomy in the treatment of refractive epilepsy. Methodology. Analytic retrospective cohort study including every patient presenting refractive epilepsy to pharmacologic therapy, operated with hemispherectomy techniques from 1988 to 2008 (n=49). Of 507 patients, operated for refractive epilepsy in the last 20 years, in 49 cases we used any kind of hemispherectomy techniques (9,7%). The male/female relationship was 1.13-1, with 53% males and 47% females. The mean age was 8±5 years old, minimum 4 months and maximum 19 years old. The epilepsy time evolution was 3±2 years. The age of initial presentation was 3±1 years old. The more frequent pathologies were: Rasmussen encephalopathy (30,6%) and secuelar lesions (34,7%). Results. The results were evaluated with the Engel score. Using this classification, our patients were distributed in this manner: 40 patients (81,6%) were in class I of Engel; 4 patients (8,2%) in class II of Engel and 5 patients (10,2%) en Engel III and IV. 88% (43 cases) without complications, 4% (2 cases) present hematomas and the same occur with hydrocephalus and postoperative meningitis. One patient died a few days posterior to surgery because of hematologic complications. Conclusion. The hemispherectomy for the management of refractive epilepsy is a safe procedure with high positive results and small morbimortality in selective pathologies.

Resultados de la cirugía de epilepsia en esclerosis tuberosa / Results of surgical treatment of epilepsy in tuberous sclerosis patients

Objective. We review our experience with surgical treatment in tuberous sclerosis and refractory epilepsy. Method. Between june 1995 and june 2008 , surgery was performed in 12 patients with tuberous sclerosis and refractory epilepsy. Median age: 6 years (r=6 months-19 years). 6 males and 6 females. Epilepsy began during the first year of life. They have been studied with RMI and video-EEG. Two patients were studied with intracranial electrodes. Electrocorticography was performed in 7, somatosensory evoked potentials in 2 and cortical stimulation in 1. Epileptogenic region was frontal in 4, temporal in 3, parietal in 2, occipital in 1 and bilateral in 2. Surgical procedures were resection of the epileptogenic regions and associated tuber(s) in 6, temporal lobectomy in 1, callosotomy in 1, parietal lobectomy in 1, frontal polectomy and vagus nerve stimulation in 1. A second surgery was performed in 1 case. Results. The outcome of seizures was classified with Engel’s outcome classification: 7 patients were in class I , 2 in class II and III . Callosotomy and vagus nerve stimulation were performed in 2 patients who had multifocal abnormality , seizure freedom was achieved in more than 60%.

Esclerosis temporal mesial: paradigma de la epilepsia de resolución quirúrgica / Mesial temporal sclerosis: paradigm of surgically treatable epilepsy

Objetivo. Describir la esclerosis temporal mesial (ETM) es sus aspectos anatómicos, fisiopatológico, clínico, imagenológico, neurofisiológico, neuropsicológico y quirúrgico; y su relación con la epilepsia de resolución quirúrgica. Luego analizar estadísticamente nuestra casuística y resultados. Materiales y métodos. De los 469 (115 adultos y 354 niños) pacientes intervenidos quirúrgicamente por presentar epilepsia entre los años 1989-2007 en el Hospital Dr. Juan P. Garraham, FLENI, Hospital Dr. Cosme Argerich y Hospital Prof. Dr. Rodolfo Rossi, se analizar 91 pacientes (19.4%) con el diagnóstico de ETM; 38 de los cuales (41.75%) son niños y 53 (58.25%) adultos. Resultados. Los resultados son evaluados mediante el score de Engel. Aplicando esta clasificación, nuestra población tiene la siguiente distribución; 69 pacientes (75.8%) se encuentran en clase IA de Engel, de ellos 36 son niños (52.2%) y 33 adultos (47.8%); 4 pacientes adultos se encuentran en Engel IB (4.4%), 3 en Engel IC (3.3%), 1 adulto en Engel ID (1.1%), 4 adultos en Engel IIA (4.4%), 5 adultos en Engel IIB (5.5%) y 3 pacientes en Engel IVA (3.3%) de ellos 1 niño a quien posteriormente se le implantó un estimulador del nervio vago y los 2 restantes adultos. Un paciente adulto se suicidó luego de un año de la cirugía (en clase IA de Engel). Un paciente se encuentra durante su primer año postoperatorio por lo cual no puede ser incluido aún en la estadística de resultados. Conclusión. La ETM es el paradigma de la epilepsia refractaria en al población adulta y la causa de un porcentaje significativo de pacientes pediátricos sometidos a cirugía. La evolución prequirúrgica debe ser exhaustiva para lograr la selección del paciente. La resección quirúrgica debe ser realizada con la mayor selectividad posible. El diagnóstico y tratamiento precoz permite lograr un alto índice de curación.

Esclerosis temporomesial en adultos: revisión del síndrome y evalución de resultados / Mesial temporal sclerosis in adults: Revision of the syndrome and assessment of results

Objective: To describe the presentation and the management of the Mesial Temporal Sclerosis (ETM) in adult patients and to evaluate the results of the presented series. Description: the authors selectioned 3 cases among 53 adults who underwent surgical treatment with ETM diagnosis. Case 1: female patient, 32 years old. Antecedents of complex partial crisis since 6 years old, some of the crisis related to febrile episodes. Aura related like unpleasent gastroesophageal sensation, break of contact, right hand dystonia, cephalic turn to right and oroalimentary and manual automatism. RMI and EEG-video: injury compatible with left ETM. Case 2: male patient, 24 years old. Antecedents of complex partial crisis since 13 years old. Breack of contact, verbal automatisms (repeats unintelligible sounds) and sensation of postictal sikness. RMI: increase of signal (FLAIR) in both hippocampus, impressing right atrophy. EEG-video with profund electrodes implanted: start of the crisis on a right mesial temporal level. Case 3: female patient, 21 years old. Antecedents of complex partial crisis since 12 years old. Complex partial crisis with bimanual and oroalimentary automatisms with an episode of generalization. RMI and EEG-video: injury compatible with right ETM. Intervention: case 1 and 2 were resolved by the realization of an anteromesial resection of Spencer. In case 3 a selective amygdalo hippocampectomy was practiced. Conclusion: ETM is the paradigm of the refractory epilepsy in an adult population. Precocious diagnosys and treatment allow to obtain a high index of cure with small amount of significant sequels.

Técnicas de resonancia magnética como herrramientas esenciales para el abrodaje de tumores del SNC / Magnetic resonance imaging techniques as essential tools for the approach to CNS tumors

Objetivo. Mostrar la capacidad de las técnicas especiales de RMI (espectroscopía, difusión, perfusión, ADC, tractografía y RMI funcional (RMf) para: 1. Valorar las características intrínsecas (bioquímicas, grado de malignidad e infiltración) y extrínsecas (relación con las estructuras cerebrales normales) de las procesos expansivos del sistema nervioso central. 2. Decidir con la RMf la táctica quirúrgica más apropiada para cada caso. Material y método. Se presentan dos pacientes del sexo masculino de 35 y 40 años respectivamente, con lesiones turmorales en áreas elocuentes motoras del hemisferio cerebral derecho a los cuales se le efectuó cirugía, planificación y resección quirúrgica en base a los estudios de RMf (philips 1.5 T Intera Achieva). Resultados. La localización de las áreas elocuentes mediante RMF y los hallazgos basados en las técnicas imagenológicas descriptas permitieron determinar la estrategia y planificación del abordaje quirúrgico obteniéndose una excelente correlación entre los hallazgos imagenológicos e intraoperatorios. Conclusión. En tumores cerebrales localizados en áreas elocuentes los estudios de RMI con técnicas especiales pueden contribuir sustancialmente a : 1. El diagnóstico presuntivo del tipo de tumor, grado de malignidad e infiltración del mismo. 2. La planificación de la estrategia quirúrgica para minimizar las secuelas neurológicas post operatorias.

Síndrome de Guillain-Barré. Presentación de 2 casos con diplejía facial / Guillain-Barré Syndrome: unusual presentation with facial paralysis

Se presentan dos pacients con síndrome de Guillain-Barré. Ingresan al hospital con parálisis facial, una forma no común de presentación. El diagnóstico se confirmó con estudio electrofisiológico. El tratamiento administrado fue plasmaféresis e inmunoglobulinas intravenosas y los dos pacientes tuvieron mejoría significativa