Efecto de la amigdalotomía e hipotalamotomía unilateral en pacientes con agresividad refractaria / Effect of tonsillotomy and unilateral hypothalamotomy in patients with refractory aggressiveness

Resumen Antecedentes: El tratamiento neuroquirúrgico, aunque polémico, se considera un recurso útil en el tratamiento de enfermedades psiquiátricas crónicas como la agresividad refractaria. Objetivo: Evaluar los resultados clínicos y los efectos colaterales de la hipotalamotomía posteromedial (HPM) asociada a amigdalotomía en pacientes con agresividad refractaria. Método: Se realizó un ensayo clínico en pacientes con agresividad crónica y refractaria a tratamiento farmacológico. Se les realizó amigdalotomía central asociada a HPM mediante termocoagulación por radiofrecuencia. El grado de agresividad se cuantificó mediante la escala global de agresividad de Yudofsky. Los cambios postoperatorios en la conducta agresiva continuaron siendo evaluados cada 6 meses durante al menos 36 meses. Resultados: Se observó un cambio estadísticamente significativo de la conducta agresiva, a lo largo de 36 meses de seguimiento. Se describen los efectos colaterales de la asociación de ambos procedimientos, siendo el de mayor frecuencia la somnolencia y algunos casos de reducción en la conducta sexual. Conclusión: Las lesiones unilaterales simétricas y simultáneas del núcleo central de la amígdala y del hipotálamo posteromedial contralaterales a la dominancia motora dan el mismo efecto clínico en la reducción de la agresividad patológica que las lesiones bilaterales.

Abstract Background: Neurosurgical treatment, although controversial, is considered a useful resource in the treatment of chronic psychiatric diseases such as refractory aggressiveness. Objective: To evaluate the clinical results and side effects of posteromedial hypothalamotomy associated with amygdalotomy in patients with refractory aggressiveness. Method: A clinical trial was conducted in patients with chronic aggressiveness and refractory to pharmacological treatment. A central amygdalotomy associated with posteromedial hypothalamotomy was performed using thermo-coagulation by radiofrequency. The degree of aggressiveness was quantified by the Yudofsky's global scale of aggression. Postoperative changes in aggressive behavior continued to be evaluated every 6 months for at least 36 months. Results: A statistically significant change in aggressive behavior was observed during 36 months of follow-up. The collateral effects of the association of both procedures are described, the most frequent being drowsiness and some cases of reduction in sexual behavior. Conclusion: Symmetric and simultaneous unilateral lesions of the central nucleus of the amygdala and the posteromedial hypothalamus contralateral to motor dominance give the same clinical effect in the reduction of the pathological aggression that the bilateral lesions.

Transtemporal amygdalohippocampectomy: a novel minimally-invasive technique with optimal clinical results and low cost / Amigdalo-hipocampectomia transtemporal: técnica minimamente invasiva com ótimos resultados clínicos e baixo custo

ABSTRACT Mesial temporal sclerosis creates a focal epileptic syndrome that usually requires surgical resection of mesial temporal structures. Objective: To describe a novel operative technique for treatment of temporal lobe epilepsy and its clinical results. Methods: Prospective case-series at a single institution, performed by a single surgeon, from 2006 to 2012. A total of 120 patients were submitted to minimally-invasive keyhole transtemporal amygdalohippocampectomy. Results: Of the patients, 55% were male, and 85% had a right-sided disease. The first 70 surgeries had a mean surgical time of 2.51 hours, and the last 50 surgeries had a mean surgical time of 1.62 hours. There was 3.3% morbidity, and 5% mild temporal muscle atrophy. There was no visual field impairment. On the Engel Outcome Scale at the two-year follow-up, 71% of the patients were Class I, 21% were Class II, and 6% were Class III. Conclusion: This novel technique is feasible and reproducible, with optimal clinical results.

RESUMO A esclerose mesial temporal é uma síndrome epiléptica focal que requer ablação de estruturas mesiais temporais. Objetivo: Descrever e padronizar a técnica operatória e resultados clínicos. Métodos: Série prospectiva de casos de uma única instituição, realizadas por um único cirurgião, de 2006 a 2012. 120 doentes foram submetidos a amigdalo-hipocampectomia transtemporal por acesso mínimo (keyhole). Resultados: 55% eram do sexo masculino, 85% apresentavam doença do lado direito. As primeiras 70 cirurgias tiveram um tempo cirúrgico médio de 2,51 horas, e as últimas 50 cirurgias tiveram um tempo cirúrgico médio de 1,62 horas. Houve morbidade de 3,3%. 5% dos doentes apresentaram atrofia leve de músculo temporal. O controle das convulsões foi avaliado com a Escala de Engel no segundo ano de pós operatorio, 71% eram Classe I, 21% Classe II, 6% Classe III. Conclusão: Esta nova técnica é viável, reprodutível e com resultados clínicos adequados.

Anterior temporal lobectomy versus selective amygdalohippocampectomy in patients with mesial temporal lobe epilepsy / Lobectomia temporal anterior versus amigdalohipocampectomia seletiva para epilepsia de lobo temporal mesial

ABSTRACT Objective To contribute our experience with surgical treatment of patients with mesial temporal lobe epilepsy (mTLE) undergoing anterior temporal lobectomy (ATL) or selective amygdalohippocampectomy (SelAH). Method This is a retrospective observational study. The sample included patients with medically refractory mTLE due to unilateral mesial temporal sclerosis who underwent either ATL or SelAH, at Hospital de Clinicas – UFPR, from 2005 to 2012. We report seizure outcomes, using Engel classification, cognitive outcomes, using measurements of verbal and visuospatial memories, as well as operative complications. Result Sixty-seven patients (33 ATL, 34 SelAH) were studied; median follow-up was 64 months. There was no statistically significant difference in seizure or neuropsychological outcomes, although verbal memory was more negatively affected in ATL operations on patients’ dominant hemispheres. Higher number of major complications was observed in the ATL group (p = 0.004). Conclusion Seizure and neuropsychological outcomes did not differ. ATL appeared to be associated with higher risk of complications.

RESUMO Objetivo Contribuir com nossa experiência para o tratamento cirúrgico de pacientes com epilepsia do lobo temporal mesial submetidos a lobectomia temporal anterior (LTA) ou amigdalohipocampectomia seletiva (AHS). Método Estudo retrospectivo observacional. Foram incluídos pacientes com epilepsia refratária devido a esclerose mesial temporal unilateral, submetidos a LTA ou AHS no Hospital de Clínicas – UFPR, entre 2005-2012. Foram comparados os resultados cognitivos (análises de memórias verbal e visuoespacial), controle de crises (Engel) e complicações cirúrgicas. Resultados Sessenta e sete pacientes (33 LTA, 34 AHS) foram estudados; o período de acompanhamento médio foi de 64 meses. Não houve diferença no controle das crises ou resultado neuropsicológico, mas a memória verbal foi mais negativamente afetada nos pacientes submetidos à LTA no hemisfério dominante. Maior número de complicações graves ocorreu no grupo de LTA (p = 0.004). Conclusão Controle de crises e resultados neuropsicológicos não diferiram. LTA pareceu estar associada a um maior risco cirúrgico.

Trans-cortical sub-pial amygdalo-hippocampectomy: technical aspects

To highlight the technical details involved and their impact on seizure control and accordingly the quality of life in patients with complex partial seizures caused by various pathologies during surgical resection of the amygdala and the hippocampus using a simple transcortical transventricular sub-pial approach to the region. Eleven patients presenting with complex partial seizures not responding to medical treatment caused by various pathologies including mesial temporal lobe sclerosis, benign and malignant temporal lobe tumors were operated upon by trans-cortical sub-pial amygdalo-hippocampectomy either alone or combined with other approaches in the period between January 2005 to November 2007. Pre-operatively all patients' symptoms and signs along with medications used for seizure control were documented. Patients were not taken into surgery unless an adequate level of anti-epileptics was documented in serum. An MRI with and without contrast was performed in all patients before surgery. All patients were operated through a standard trans-cortical approach to the temporal horn of the lateral ventricle. Following identification of hippocampus and choroidal fissure and plexus a subpial disconnection of the hippocampus was done from anterior to posterior followed by a subpial amygdalectomy and then the surgical specimen was removed either alone or combined with the tumor. No cortical mapping was used. An awake craniotomy was used in 3 patients with dominant hemisphere lesions. Post operatively all patients were clinically assessed; all neurological deficits were noted and documented. The need for anti-epileptic therapy as well as seizure control was documented. A follow-up MRI was performed 2 months after surgery in all patients to document the extent of resection of amygdala and hippocampus. Functional and radiological outcome were then correlated with surgical technique by analyzing the operative details for each individual case. Patients were followed-up for periods ranging from 6 months to 2 years. Seizure control was classified into four classes according to Engel. Class I were patients no longer having seizures whether or not on treatment. Class II were patients who experienced only one or several seizures, class III patients who were still having seizures but with a less frequency than before and class IV were patients who showed no seizure control following surgery. 11 patients with complex partial seizures caused by various pathologies have been operated using a standard trans-cortical trans-ventricular completely sub-pial approach to the amygdala and the hippocampus for various pathological lesions of the temporal lobe. There were no mortalities or major neurological deficits. One patient developed meningitis, one developed ventriculitis, one developed a temporary partial third nerve palsy. Two patients exhibited a short term memory deficit. Eight patients showed an Engel class I seizure control, two patients showed an Engel class II seizure control and one patient showed an Engel class III seizure control. The trans-cortical trans-ventricular completely sub-pial approach to the amygdala and the hippocampus offers a simple and reliable as well as safe technique for the surgical resection of the amygdala and the hippocampus with results comparable to those of other reported series using more complex approaches to the region

Impacted cisterna magna without syringomyelia associated with lancinating headache, throbbed nuchal pain and paraparesis treated byposterior fossa decompression

A 29-year-old woman with acute lancinating headache, throbbed nuchal pain and subacute paraparesis underwent brain MRI in supine position that depicted: the absence of the cisterna magna, filled by non herniated cerebellar tonsils and compression of the brain stem and cisternae of the posterior fossa, which are aspects of the impacted cisterna magna without syringomyelia and without hydrocephalus. During eight days, pain was constant and resistant to drug treatment. Osteodural-neural decompression of the posterior fossa, performed with the patient in sitting position, revealed: compression of the brainstem, fourth ventricle and foramen of Magendie by herniated cerebellar tonsils, which were aspirated. Immediately after surgery, the headache and nuchal pain remmited. MRI depicted the large created cisterna magna and also that the cerebellar tonsils did not compress the fourth ventricle, the foramen of Magendie and the brainstem, besides the enlargement of posterior fossa cisternae. Four months after surgery, headache, nuchal pain and paraparesis had disappeared but hyperactive patellar and Achilles reflexes remained.

Uma paciente de 29 anos de idade com quadro agudo de cefaléia lancinante, dor terebrante na nuca e paraparesia subaguda foi submetida a RM do encéfalo, em posição supina, que revelou: ausência da cisterna magna, preenchida por tonsilas cerebelares não herniadas e compressão do tronco encefálico e das cisternas da fossa posterior, compatíveis com o diagnóstico de cisterna magna impactada sem siringomielia e sem hidrocefalia. Por oito dias a dor foi constante e resistente aos analgésicos. Com a paciente em posição sentada, foi realizada descompressão osteodural-neural da fossa posterior associada a aspiração das tonsilas cerebelares. Os achados perioperatórios foram caracterizados por herniação das tonsilas cerebelares que comprimiam o tronco cerebral, o quarto ventrículo e o forame de Magendie. No pós-operatório imediato houve remissão da cefaléia e da dor na nuca. A RM evidenciou a cisterna magna recém-criada, alargamento do quarto ventrículo e das cisternas do tronco encefálico. Quatro meses depois, a paciente continuava sem cefaléia, sem dor na nuca e sem paraparesia. Entretanto, permaneceu a hiperatividade dos reflexos patelares e aquileus.

Anatomia microcirúrgica do hipocampo na Amígdalo-hipocampectomia seletiva sob a perspectiva da técnica de Niemeyer e método pré-operatório para maximizar a corticotomia / Hippocampal microsurgical anatomy regarding the selective amygdalohippocampectomy in the Niemeyer’s technique perspective and preoperative method to maximize the corticotomy

O conhecimento da anatomia microcirúrgica do hipocampo tem importância fundamental na cirurgia da epilepsia do lobo temporal. Uma das técnicas mais utilizadas na cirurgia da epilepsia é a técnica de Niemeyer. OBJETIVO: Descrever em detalhes a anatomia do hipocampo e mostrar uma técnica na qual pontos de referências anatômicos pré-operatórios visualizados na RNM são usados para guiar a corticotomia. MÉTODO: Foram utilizados 20 hemisférios cerebrais e 8 cadáveres para dissecções anatômicas microcirúrgicas do lobo temporal e hipocampo para identificação e descrição das principais estruturas do hipocampo. Foram estudados prospectivamente 32 pacientes com epilepsia do lobo temporal refratários ao tratamento clínico submetidos a amígdalo-hipocampectomia seletiva pela técnica de Niemeyer três parâmetros anatômicos foram mensurados na RNM pré operatória e transferidos para o ato cirúrgico. RESULTADOS: O hipocampo foi dividido em cabeça, corpo e cauda e sua anatomia microcirúrgica descrita em detalhes. As medidas adquiridas são apresentadas e discutidas. CONCLUSÃO: A complexa anatomia do hipocampo pode ser entendida de uma forma tridimensional durante dissecções microcirúrgicas. As medidas pré-operatórias mostraram-se guias anatômicos úteis para corticotomia na técnica de Niemeyer.

The deep knowledge of hippocampal microsurgical anatomy is paramount in epilepsy surgery. One of the most used techniques is those proposed by Niemeyer. PURPOSE: To describe the hippocampal anatomy in details and to present a technique which preoperative anatomical points in MRI are identified to guide the corticotomy. METHOD: Microsurgical dissections were performed in twenty brain hemispheres and eight cadaveric heads to identify temporal lobe and hippocampus structures. Thirty two patients with drug-resistent temporal lobe epilepsy underwent a selective amygdalohippocampectomy with Niemeyer’s technique being measured three preoperative MRI preoperative distances to guide the corticotomy. RESULTS: The hippocampus was divided in head, body and tail and its microsurgical anatomy described in details. The MRI measurements are presented and discussed. CONCLUSION: The knowledge of the complex anatomy of the hippocampus can be achieved in a three-dimensional way during microsurgical dissections not. The preoperative MRI measurement is a reasonable guide to perform temporal corticotomy in Niemeyer’s techinique.

Amigdalopexia cerebelosa en el manejo de la malformación de chiari de tipo I / Cerebellar amygdalopexy in the management of Chiari I malformation

Antecedentes. El tratamiento de la malformación de Chiari de tipo I asociada a siringomielia es controvertido. En este trabajo se presenta un análisis clínico, quirúrgico y radiológico de los pacientes con esta afección que fueron manejados durante un periodo de doce años. Material y métodos. Se incluyeron 48 pacientes, donde se encontró un discreto predominio en el sexo femenino. El cuadro clínico estuvo dominado por cefalea, dolor cervical, signos y síntomas cerebelosos, afección de nervios craneales bajos y lesión de la vía piramidal. Resultados. Tanto el grado de descenso amigdalino como el tamaño de la siringomielia fueron muy variables, sin encontrar correlación entre ambos. La cirugía consistió en una craniectomía occipital, laminectomía de C1, ascenso de amígdalas cerebelosas mediante coagulación bipolar y plastía de duramadre. Los mejores resultados clínicos se obtuvieron en el dolor y los síntomas cerebelosos, mientras que los peores fueron en la afección de los nervios craneales bajos y de la vía piramidal, sin embargo, en la gran mayoría de los pacientes se logró detener la progresión de los síntomas. No se presentaron complicaciones serias en el presente estudio. Conclusión. El procedimiento propuesto ofrece una alternativa segura, efectiva y comparable con otros métodos más riesgosos para el manejo de esta malformación.

BACKGROUND: The treatment of Chiari I malformation associated with syringomyelia is controversial. OBJECTIVE: We describe a series of patients with this disease treated during a twelve-year period. We also present clinical, surgical and radiological findings. MATERIAL AND METHODS: Forty eight patients were included; a non significant female predominance was found. Clinical course was characterized by headache, cerebellar signs and symptoms, neck pain and involvement of lower cranial nerves and pyramidal tract. The degree of tonsillar descent and syringomyelia size varied and a correlation between them was not found. Surgery consisted in an occipital craniectomy, C1 laminectomy and tonsillar elevation through bipolar coagulation and duraplasty. RESULTS: The best results were observed in pain and cerebellar symptoms, while a deficit of lower cranial nerves and pyramidal tract were observed. However, in most patients we were able to slow symptom progression. No adverse effects were documented. CONCLUSIONS: The surgicalprocedureproposed herein is an effective and safe treatment alternative for this malformation, and its results are comparable to other riskier procedures.

Selective amygdalohippocampectomy for temporal lobe epilepsy management

Epilepsy surgery has a proven treatment effect on patients with medical intractable partial seizures, presumably through its resection of epileptogenic zone. This prospective and nonrandomized controlled study examines whether minimal invasive microneurosurgical interventional through frontolateral trans-sylvian approach for a high selective amygdalohippocampectomy would reduce the frequency of epilepsy and antiepileptic drugs [AEDS], for patients who have had long history of poor response on pharmacotherapy, via measuring over one year the clinical, activity of daily living and EEG outcomes. Our inclusion/ exclusion criteria for selected cases and according to the definition of ILAE are, intractable temporal lobe epilepsy [TLE] either right or left side origin, all patients had a history of treatment for more than 13 years by AEDS polytherapy and according to our inclusion criteria they should have at least 4 seizures a month. Selective amygdalohippocampectomy was done for 17 patients and all of them were followed up for one year. The study confirmed that selective amygdalohippo-campectomy reduces the seizures frequency and drugs doses in patients with mesial temporal lobe epilepsy [MTS]. However, amygdalohippocampectomy did not signify cessation of all AEDS, but all patients showed satisfactory seizure free outcome under monotherapy. There is also significant difference in epilepsy frequency postoperatively especially psychomotor component. The findings are important for the understanding of selective amygdalohippocampectomy role in the treatment of intractable TLE [MTS] with or without secondary generalization

Microanatomia cirúrgica relevante na amigdalohipocampectomia seletiva: um estudo estereoscópico / Relevant anatomy regarding the selective amygdalohipocampectomy-campectomy printing study

O lobo temporal é o mais heterogêneo do cérebro humano, tendo em sua composição alocórtex e estruturas do sistema límbico. Crises convulsivas parciais complexas com origem no lobo temporal correspondem a 70 dos pacientes refratários ao tratamento clínico que são encaminhados a centros de cirurgia de epilepsia. Os procedimentos cirúrgicos utilizados no tratamento da epilepsia do lobo temporal tiveram forte impacto na qualidade de vida dos pacientes. O conhecimento anatômico profundo é fundamental para ressecções cirúrgicas seguras das estruturas do lobo temporal. Ao serem estudados diferentes ângulos de visão, não somente a anatomia convencional, mas também a anatomia microcirúrgica e técnicas não-convencionais de dissecção, como a dissecção de fibras brancas cerebrais a segurança do procedimento é aumentada à medida que aumenta a chamada “visão de raios X” do cirurgião. O objetivo deste estudo é apresentar a anatomia relevante na amigdalohipocampectomiaseletiva com técnicas de dissecção convencionais e não-convencionais, bem como documentar com fotografias convencionais e estereoscopia. Métodos: Vinte cérebros fixados em formalina e seis cadáveres fixados em Carolina’s perfect solution® (Carolina Biological Supply company, Burlington, NC) foram dissecados com microscópio cirúrgico com aumentos de três a 40 vezes. Cada crânio foi colocado no fixador tipo Mayfield e a cabeça estendida e rodada para simular a posição cirúrgica. Craniotomia pterional e amigdalohipocampectomia seletiva transilviana foram realizadas a seguir. As dissecções anatômicas foram documentadas com estereoscopia. Resultados: A amigdalohipocampectomia seletiva transilviana é documentadapor etapas e a dissecção de fibras brancas utilizada para ilustrar esta anatomia. Conclusão: A complexa anatomia do lobo temporal relacionada à amigdalohipocampectomia seletiva e suas variantes podem ser totalmente entendidas mediante diferentes perspectivas anatômicas.

Amigdalectomía como factor de riesgo para desarrollar el síndrome de inmunodeficiencia adquirida / Tonsillectomy as a risk factor for developing acquired immuno-deficiency syndrome

Se realizó un estudio retrospectivo en 321 pacientes de la consulta externa de Infectología del Hospital Central Militar de la Cd. de México, D.F. y del Centro Médico ®La Raza¼, IMSS en los cuales se tenía el diagnóstico de SIDA. La edad de los pacientes fue de 18 a 69 años con un promedio de 24. Predominó el sexo masculino con 83 por ciento de los casos. Se investigó la relación existente con amigdalectomía encontrándose que 29.7 por ciento de los pacientes presentaban este antecedente. Comparado con el grupo control (paciente sin SIDA con el antecedente de amigdalectomía fue menos frecuente (9 por ciento) que en el grupo de estudio (29.7 por ciento). Se encuentra una relación estadística significativa entre el antecedente de amigdalectomía y la presentación de SIDA posteriormente. Clínicamente se necesitan más estudios para confirmar esto

Tonsilolito gigante / Giant tonsilolite

Se ha indicado que los tonsilolitos se forman de caseum retenido en las criptas amigdalinas en asociación confilamentos de Leptothrix buccalis, un saprofito oral comun, que forma el nido para las concreciones compuestas de sales de calcio. Se presenta el caso de un paciente de 54 años de edad, sexo femenino, quien consulto por halitosis, sensación de cuerpo extrano y dolor en lado izquierdo de la garganta, con otalgia de evolución cronica. Al examen se encontro amigdala izquierda voluminosa, con hiperemia difusa, conteniendo masa de color blanco-amarillento, dura, con dolor a la palpación de la region. Una radiografia de cuello mostro imagen radiopaca, redondeada, de contornos definidos a nivel de orofaringe. Bajo anestesia general, se extrajo una concreción ovoide, petrea, con un tamano de 26 X 23 mm