Nuevos enfoques en el abordaje a la base de cráneo / NEW REGARDS RELATED TO THE APPROACH TO THE SKULL BASE

Los abordajes tradicionales a la base de cráneo incluyen incisiones transcraneales con grandes resecciones óseas, retracción y manipulación del cerebro generando altos índices de morbimortalidad. Los abordajes endoscópicos cambian el enfoque de la base de cráneo permitiendo crear corredores más directos, disminuyendo las complicaciones. Esto comprende un verdadero trabajo en equipo entre Neurocirujanos y Otorrinolaringólogos experimentados. El objetivo de este artículo fue analizar y describir algunos de los abordajes endoscópicos ampliados de base de cráneo.

Traditional approaches to the skull base include transcranial incisions with large bone resections, brain retraction and manipulation, generating high rates of morbidity and mortality. Endoscopic approaches shift the focus of the skull base allowing to create more direct corridors, reducing complications.True teamwork is necessary between experienced Neurosurgeons and Otolaryngologists. The aim of this paper was to analyze and describe some of the extended endoscopic skull base approaches.

Uso del drenaje lumbar preoperatorio en la cirugía de base de cráneo / Use of preoperative lumbar drainage in skull base surgery

La inserción de un Drenaje Lumbar, es una estrategia cada día más aceptada para mitigar no sólo la fístula de líquido cefalorraquídeo, que puede seguir en el postoperatorio a una cirugía de base de cráneo, sino para disminuir el edema cerebral transoperatorio. Se realiza un estudio retrospectivo de 461 casos, intervenidos quirúrgicamente con lesiones tumorales de la base del cráneo y aneurismas intracraneales, con diferentes diagnósticos; Meningioma de fosa anterior (n = 46), meningioma de fosa media (n = 103), Meningioma de fosa posterior (n = 42), aneurismas intracraneales (n = 203), tumores malignos de fosa posterior (n = 38), Síndrome Chiari I-Siringomielia (n = 24). La mayoría fueron abordados por vía intracraneal, sólo en algunos casos utilizamos el abordaje combinado; Abordaje pterional (n = 283), abordaje fronto-orbito-cigomático FOC (n = 23), bifrontal (n = 22), frontal unilateral (n = 18), pre y retrosigmoideo (n = 14), retrosigmoideo (n = 17), craniectomía bilateral de fosa posterior (n = 49), craniectomía mínima de fosa posterior (n = 24), Combinado FOC-transeptoesfenoidal (n = 5), transoral (n = 4), transfacial (n = 2). Del total de pacientes intervenidos en 22 pacientes se desarrolló una fistula de LCR (22/461 = 4,7 por ciento), entre ellos, 3 casos necesitaron reparación directa. Edema cerebral, meningitis postquirúrgica y neumoencéfalo fueron las complicaciones más frecuentemente encontradas con un 4,1 por ciento, 2,6 por ciento y 3,03 por ciento respectivamente. El uso rutinario del Drenaje Lumbar preoperatorio, se acompaña de un bajo índice de complicaciones tales como fístulas de LCR, neumoencéfalo y sepsis del SNC, además de ser un proceder bien tolerado por los pacientes.

The Lumbar Drainage insert is a strategy every day more accepted, not only to mitigate the cerebrospinal fluid leaks that can be continued in the postoperative of skull base surgery, also to decrease brain edema during surgery. We carried out a retrospective study of 461 cases, operated with tumoral lesions of skull base and intracranial aneurysm, with different diagnoses; anterior fossa meningioma (n = 46), middle fossa meningioma (n = 103), posterior fossa meningioma (n = 42), intracranial aneurysm (n = 203), malignant tumors of posterior fossa (n = 38), Chiari I-Siringomielia Syndrome (n = 24). Most was approached for intracranial route, only in some cases we use the combined approached; Pterional Approach (n = 283), Frontal orbito-zygomatic FOZ (n = 23), Bifrontal Approach (n = 22), unilateral Frontal Approach (n = 18), Pre and retrosigmoid Approach (n = 14), Retrosigmoid Approach (n = 17), bilateral Craniectomy of posterior fossa (n = 49), minimal Craniectomy of posterior fossa (n = 24), Combined FOZ-transeptosphenoidal Approach (n = 5), Transoral Approach (n = 4), Transfacial Approach (n = 2). The total of patients operated, in 22 patients a CSF leak it was developed (22/461 = 4,7 percent), among them, 3 cases needed direct surgical repair, brain edema, post-surgical meningitis and pneumocephalus were the most frequently complications with 4,1 percent, 2,6 percent and 3,03 percent respectively. The routine use of preoperative Lumbar Drainage is follow to a low incidence of complications as CSF leaks, pneumocephalus and CNS infection, besides being well tolerated by the patients.

Analysing the effect of early acetazolamide administration on patients with a high risk of permanent cerebrospinal fluid leakage

In this study, we examined the role of early acetazolamide administration in reducing the risk of cerebrospinal fluid [CSF] leakage in patients with a high risk of permanent CSF leakage. In a randomised clinical trial, 57 patients with a high risk of permanent CSF leakage [rhinorrhea, otorrhea, pneumatocele or imaging-based evidence of severe skull-base fracture] were analysed. In the experimental group, acetazolamide, at 25 mg/kg/day, was started in the first 48 hours after admission. In the control group, acetazolamide was administered after the first 48 hours at the same dose administered to the patients in the experimental group. The following factors were compared between the two groups: duration of CSF leakage, duration of hospital stay, incidence of meningitis, need for surgical intervention and need for lumbar puncture [LP] and lumbar drainage [LD]. All of the patients in the experimental group stopped having CSF leakage less than 14 days after the first day of admission, but 6 out of 21 patients [22%] in the control group continued having CSF leakage after 14 days of admission, which was a significant difference [P=0.01]. This study showed that early acetazolamide administration can prevent CSF leakage in patients with a high risk of permanent CSF leak

Severe complication of posterior nasal packing: Case Report

Introduction: Severe Epistaxis is common in patients with head trauma, especially when associated with multiple fractures of the face and skull base. Several methods of controlling bleeding that can be imposed. The anterior nasal tapenade associated with posterior Foley catheter is one of the most widespread, and the universal availability of necessary materials or their apparent ease of execution. Methods: Case report on control of severe epistaxis after severe TBI, with posterior nasal packing by Foley catheter and control tomography showing multiple fractures of the skull base and penetration of the probe into the brain parenchyma. Conclusion: This is a rare but possible complication in the treatment of severe nose bleeds associated with fracture of the skull base. This brief report highlights risks related to the method and suggests some care to prevent complications related through a brief literature review...

Dental broken needle migration to the skull base: a case of dental broken needle migration to the skull base: anatomical considerations and prevention

Introduction: the needle fracture during the inferior alveolar nerve block is not a common accident, but whenit occurs can cause great inconvenience to the professional and patient, because the surgical removal shouldonly be performed without risk of sequelae to the patient. Aim: relate a case of broken dental needle duringinferior alveolar nerve block and the needle fragment dislocation to the skull base becoming impossible itssurgical removal. Described preventive procedures to avoid that complication with anatomical considerationsrelated to the inferior alveolar nerve block. Case report: a young female, 18 years old required care afterfracture of the dental needle during inferior alveolar nerve anesthesia. She was submitted to CT scan thatdetermined the impossibility of surgical removal of the fragment because it has migrated to the skull basebecoming close to vital anatomic structures because its could produce irreparable sequelae such loss of tonguesensation and movement of the lip. A conservative treatment was offered. Conclusions: surgical removal ofits instrument should be correctly evaluated to avoided irreparable sequelae to the patient. The knowledgeof anatomical structures in the pterigomandibular region may reduce the risk of injury to nerves and anotherstructures and prevent further complications.

Angiofibroma juvenil: a propósito de un caso / Juvenile angiofibroma: a purpose of a case

El angiofibroma Juvenil es descrito como una rara y benigna enfermedad, que es principalmente diagnosticado en adolescentes masculinos. Es altamente vascularizado y un tumor de crecimiento lento, pero localmente invasivo y destructivo. Originándose en el margen del agujero esfenopalatino, este se extiende hacia la fosa pterigopalatina, senos paranasales y cavidad nasal, ocasionando síntomas como el dolor, obstrucción nasal unilateral y epistaxis. El objetivo principal es reportar un caso de un masculino de 14 años de edad con un angiofibroma. El presentó una evolución clínica de 4 meses con aumento de volumen de la media cara derecha, movimiento tónico clónico generalizado, anosmia y sangrado nasal. El fue operado realizando exéresis tumoral por una incisión transfrontal extendida y procedimientos de base de cráneo.

Abordaje tipo keyhole transciliar supraorbitario. Criterio de seleccion de pacientes / Transciliar supraorbitary keyhole approach. Case selection guidelines

Objective: to describe our initial experience with the supraorbital transciliar keyhole approach with emphasis on patients selection criteria. Methods: between july 2003 to june 2004, 7 patients were operated through this approach. Diagnosis included 1 pituitary macroadenoma, 1 craniopharyngioma, 1 clinoidal meningioma, 1 olfactory tract meningioma, 2 ApCom aneurysms and 1 carotid-ophthalmic aneurysm. In all patients the surgical techniqued was similar. Results: many factors demonstrate the advantage of this technique: minimal brain exposure, and cerebral retraction, shortened surgical time and early hospital discharge. There were no approach-related complications. All the lesions were of less than 35mm of diameter and under the medial third of the third ventricle. Conclusion: the supraorbital transciliar keyhole approach, endoscope assisted, is a safe way to reach sellar and parasellar lesions when the lesion is of less than 30mm, without extension to posterior fossa

Base de craneo: anatomia y patologia tumoral. revision conceptual / Skull base: anatomy and pathology tumoral conceptual review

Objective. Skull Base Tumors (SBT) span a spectrum from congenitallesions to malignant neoplasms The purpose of this study was to summarize the most relevant anatomical landmarks and to display and organize in a simple manner the SBT and perineural tumoral spread (PTS). Materials and methods. The study displays a selection of cases selected based on teaching value gathered by the author in the 1997-2002 period. Results. SBT can be classified in three main groups: 1-Intrinsic SBT: includes Chordoma, Chondrosarcoma, Meningioma, Neural Sheath Tumors and Metastasic Lesions. 2- SBT spreading from below: Includes Nasopharyngeal Carcinoma, Nasopharyngeal Juvenile Angiofibroma and Paranasal Sinus Tumors. 3-SBT from above: It is refers mainly to Pituitary gland macroadenoma. PTS occurs most commonly associated with adenoid cystic and squamous cell carcinomas originated at the Head and Neck region. Most commonly involves nV and nVII. The most important pathway of PTS through the Skull Base is the maxillary division of the trigeminal nerve (nV2). Conclusion. An adequate knowledge of the anatomy, pathology and spread patterns is an important tool for therapy planning and follow-up care.

Objetivo. Revisar la anatomía de la base de cráneo, sistematizar los tumores (TBC) que la afectan y analizar la diseminación perineural (DPN). Material y método. Revisión del archivo recolectado por los autores entre los años 1997-2002 y de casos publicados Resultados. Los TBC se pueden clasificar en: 1) Lesiones intrínsecas como el cordoma, condrosarcoma, meningioma, tumores de la vaina neural y metástasis. 2) TBC que parten desde abajo en los cuales se incluyen el carcinoma nasofaríngeo, el angiofibroma juvenil nasofaríngeo y tumores de los senos paranasales. 3) TBC que la comprometen desde sitios por sobre ella y que se refiere principalmente al macroadenoma hipofisiario. La DPN se observa asociada a tumores adenoideos quisticos y carcinomas de células escamosas originados en la región de cabeza y cuello. Compromete comúnmente nV y nVII. Las vías mas importantes de DPN es la división maxilar del nervio trigémino (nV2). Conclusión. Un adecuado conocimiento de la anatomía, patología y vías de diseminación es una importante herramienta en la planificación de la terapia y seguimiento de los TBC.

Traumatic facial paralysis

The cosmetic deformity caused by facial nerve paralysis is very annoying both for the patient and the surgeon. Traumatic injury of the facial nerve, together with Bell's palsy, remain as the two major causes of facial nerve paralysis. Traumatic facial nerve injury may be operative, post-operative or in a casuality, as it may be involved in fracture base of the skull. With the progress of ear surgery, more cases of operative and post-operative facial nerve paralysis are met with. It is the variations in opinion concerning the management of such cases that make the difference in the prognosis. Fisch and Schwartzenberg [4] stated that, under conservative treatment, 90% of late and 75% of early facial paralysis recover satisfactorily. The problem is still with the remaining 10-25% of cases