Ventriculitis por Listeria monocytogenes / Ventriculitis secondary to Listeria monocytogenes

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[Endoscopy-assisted surgery of the sellar region]. / Cirugía de la región selar asistida por endoscopia.

OBJECTIVE: To evaluate the usefulness of endoscopic assisted surgery of pituitary adenomas in transesphenoidal surgery, and in surgery of craneopharyngiomas using either minimally invasive approaches to the cranial base or transventricular approaches. MATERIAL AND METHODS: We present our preliminary experience in eleven patients operated of sellar region tumor by endoscopic assisted resection: 6 pituitary adenoma via transesphenoidal approach, 4 craneopharyngiomas 3 through supraciliar approach and 1 by transcortical transventricular approach, and 1 suprasellar cyst. RESULTS: By using the 30 degrees optic the use of endoscope allowed complete resection, confirmed by postoperative MRI, of all six pituitary macroadenomas providing control of resection of supraselar remnants. Complete resection was achieved in three out of four craneopharyngiomas, 2 of them being recurrences. Three were operated by using a supraciliar approach to the cranial base and in one case transcortical transventricular resection of a recurrent intraventricular craneopharyngioma was performed. In the case with partial resection remnant were let in place due to the close adherence to peritumoral structures. In the three craneopharyngiomas operated via supraciliar approach endoscope allowed better control of inferior aspect of ipsilateral optic nerve and internal carotid artery. In the case of intraventricular craneopharyngioma, the use of 30 degrees endoscope provide control of resection of the anterior part of third ventricle through the foramen of Monro with no additional opening. The suprasellar cyst was fenestrated. CONCLUSIONS: No matter which approach is going to be used in the resection of sellar tumors, endoscopy can play a crucial role in achieve complete resection with minimal morbidity by using minimally invasive procedures.

Cirugía de la región selar asistida por endoscopia / Endoscopy-assisted surgery of the sellar region

Objetivos: El estudio pretende evaluar la utilidad del uso del endoscopio en la cirugía de la región selar a través del abordaje transesfenoidal transnasal en los adenomas hipofisarios y a través de abordajes mínimamente invasivos a la base de cráneo o el sistema ventricular en el caso de craneofaringiomas. Material y métodos: Presentamos la experiencia preliminar en once casos intervenidos mediante cirugía asistida con endoscopia. Seis pacientes presentaban macroadenomas hipofisarios y fueron intervenidos por vía transesfenoidal transnasal. Cuatro pacientes presentaban craneofaringiomas, 2 de ellos recidivantes, que fueron abordados, 3 a través de un acceso supraciliar y uno mediante un abordaje transcortical transventricular, abordaje utilizado en un quiste supraselar intraventricular. Resultados : Se consiguió la exéresis completa confirmada por RM de los adenomas hipofisarios en los que el uso del endoscopio con óptica de 30° fue de utilidad en el control de la exéresis de los tumores con expansión supraselar. En el caso de los craneofaringiomas se alcanzó la exéresis completa en 3 de ellos uno de los cuales era recidivante, 2 por vía supraciliar y otro transcortical transventricular. En el caso restante, un craneofaringioma recidivante, la exéresis fue parcial por la íntima adherencia de la cápsula tumoral a las estructuras circundantes. En los 3 casos de acceso supraciliar, el endoscopio fue útil para el control de la exéresis del tumor localizado inferior al nervio óptico y la carótida interna ipsilaterales. En el acceso intraventricular el craneofaringioma que ocupaba el tercio anterior y medio del tercer ventrículo pudo resecarse a través del foramen de Monro, mediante una óptica de 30° que permitió controlar y resecar el resto tumoral del tercio anterior. El quiste fue fenestrado. Conclusiones: En cualquiera de las posibles vías de abordaje a la región selar, el uso de la cirugía asistida por endoscopia favorece una mayor radicalidad en la resección mediante el uso de abordajes mínimamente invasivos (AU)

Objective: To evaluate the usefulness of endoscopic assisted surgery of pituitary adenomas in transesphenoidal surgery, and in surgery of craneopharyngiomas using either minimally invasive approaches to the cranial base or transventricular approaches. Material and methods:We present our preliminary experience in eleven patients operated of sellar region umor by endoscopic assisted resection: 6 pituitary adenoma via transesphenoidal approach, 4 craneopharyngiomas 3 throung supraciliar approach and 1 by transcortical transventricular approach, and 1 suprasellar cyst. Results: By using the 30 degrees optic the use of endoscope allowed complete resection, confirmed by postoperative MRI, of all six pituitary macroadenomas providing control of resection of supraselar remnants. Complete resection was achieved in three out of four craneopharyngiomas, 2 of them being recurrences. Three were operated by using a supraciliar approach to the cranial base and in one case transcortical transventricular resection of a recurrent intraventricular craneopharyngioma was performed. In the case with partial resection remnant were let in place due to the close adherence to peritumoral structures. In the three craneopharyngiomas operated via supraciliar approach endoscope allowed better control of inferior aspect of ipsilateral optic nerve and internal carotid artery. In the case of intraventricular craneopharyngioma, the use of 30 degrees endoscope provide control of resection of the anterior part of third ventricle through the foramen of Monro with no additional opening. The suprasellar cyst was fenestrated. Conclusions: No matter which approach is going to be used in the resection of sellar tumors, endoscopy can play a crucial role in achieve complete resection with minimal morbidity by using minimally invasive procedures (AU)

[Intrathecal baclofen and Botulinum toxin in infantile cerebral palsy]. / Baclofén intratecal y toxina botulínica en la parálisis cerebral infantil.

INTRODUCTION: Infantile cerebral palsy is considered to be a motor disorder affecting both posture and movement. It is the manifestation of a cerebral lesion that took place during the maturing process of the brain. Spastic cerebral palsy is the most frequent variety. The spasticity presented by these patients strongly influences their functioning and gives rise to several complications that affect their quality of life. AIMS AND DEVELOPMENT: The main aim of this study is to determine a set of suitable and effective therapeutic steps that can be used to improve patients' spasticity and to prevent the complications that stem from them, such as contractures, deformities, surgery, etc. Multiple treatments were used, including physiotherapy, rehabilitation and oral pharmacotherapy, with few satisfactory results. At present there are two very promising therapeutic alternatives for patients with infantile cerebral palsy: Botulinum toxin, which we already have a great deal of experience with, and intrathecal treatment with baclofen. We report on a series of 10 patients aged between 8 and 15 years who had had an intrathecal baclofen infusion pump implanted. To date (maximum follow-up: 12 months), their clinical course has been satisfactory in most cases, with no severe complications related to the surgical technique, except in one individual who presented a fistula that resolved spontaneously. CONCLUSIONS: Intrathecal baclofen seems to be a very useful alternative in the treatment of spasticity to improve the quality of life of these patients and those around them.

[Association between cerebral infarction and malignant glioma]. / Asociación de infarto cerebral y glioma maligno.

INTRODUCTION: It is very rare for cerebral infarction to be the first symptom of an intracranial tumour. Only three cases have been reported in which cerebral infarction is thought to have been caused by the arterial compromise triggered by incipient high grade gliomas that are not yet visible in radiological tests. CASE REPORT: A 46-year-old male with no relevant medical history or cardiovascular risk factors who presented with acute hemiplegia on the right-hand side of the body and a significantly impaired level of consciousness. Computerised axial tomography of the brain showed a left frontal malignant ischemic infarct that exerted an important mass effect. The patient was submitted to a left-side frontoparietal decompressive craniectomy. Post-operative progress was good and the patient even recovered his normal level of consciousness, although he was left with right hemiparesis and conduction dysphasia. Seven months after the craniectomy the patient experienced a progressive deterioration with symptoms of endocranial hypertension. Magnetic resonance imaging of the brain revealed the presence of a highly malignant tumour in the previously infarcted territory. A histological study of the excised lesion showed it to be a glioblastoma multiforme. CONCLUSIONS: The proximity in time, as well as the identical location of the two lesions, led us to think that the glioblastoma, although not yet visible in radiological explorations, affected a branch of the middle cerebral artery and gave rise to the infarct. Therefore, in the presence of a cerebral infarct in patients with no risk factors for suffering a brain vascular pathology, it is advisable to carry out a radiological follow-up so as to be able to diagnose a possible lesion due to a tumour.

Asociación de infarto cerebral y glioma maligno / Association between cerebral infarction and malignant glioma

Introducción. La primera manifestación de un tumor intracraneal raramente es la aparición de un infarto cerebral. Tan sólo se han documentado tres casos en los que se considera como causa de un infarto cerebral la afectación arterial provocada por gliomas incipientes de alto grado aún no visibles radiológicamente. Caso clínico. Se trata de un varón de 46 años sin antecedentes médicos de interés ni factores de riesgo cardiovasculares que presentó de manera aguda una manifiesta hemiplejía derecha y deterioro importante del nivel de conciencia. En la tomografía axial computarizada craneal se demostró un infarto isquémico maligno frontal izquierdo que ejercía un gran efecto de masa. Se practicó una craniectomía descompresiva frontoparietal izquierda. El posoperatorio fue favorable y el paciente recuperó hasta la normalidad su nivel de conciencia, aunque quedó con una hemiparesia derecha y disfasia de conducción. Siete meses después de la craniectomía, experimentó un deterioro progresivo con clínica de hipertensión endocraneal. La resonancia magnética cerebral demostró la presencia de un tumor de alto grado de malignidad sobre el territorio previamente infartado. El estudio histológico de la lesión resecada determinó que se trataba de un glioblastoma multiforme. Conclusión. La cercanía en el tiempo, así como la idéntica localización de ambas lesiones, hace pensar que el glioblastoma, no siendo aún visible radiológicamente, comprimió o invadió una rama de la arteria cerebral media y originó el infarto. Por tanto, ante la presencia de un infarto cerebral en un paciente sin factores de riesgo para sufrir patología vascular cerebral, sería recomendable realizar un seguimiento radiológico posterior con el fin de diagnosticar una posible lesión tumoral

Introduction. It is very rare for cerebral infarction to be the first symptom of an intracranial tumour. Only three cases have been reported in which cerebral infarction is thought to have been caused by the arterial compromise triggered by incipient high grade gliomas that are not yet visible in radiological tests. Case report. A 46-year-old male with no relevant medical history or cardiovascular risk factors who presented with acute hemiplegia on the right-hand side of the body and a significantly impaired level of consciousness. Computerised axial tomography of the brain showed a left frontal malignant ischemic infarct that exerted an important mass effect. The patient was submitted to a left-side frontoparietal decompressive craniectomy. Post-operative progress was good and the patient even recovered his normal level of consciousness, although he was left with right hemiparesis and conduction dysphasia. Seven months after the craniectomy the patient experienced a progressive deterioration with symptoms of endocranial hypertension. Magnetic resonance imaging of the brain revealed the presence of a highly malignant tumour in the previously infarcted territory. A histological study of the excised lesion showed it to be a glioblastoma multiforme. Conclusions. The proximity in time, as well as the identical location of the two lesions, led us to think that the glioblastoma, although not yet visible in radiological explorations, affected a branch of the middle cerebral artery and gave rise to the infarct. Therefore, in the presence of a cerebral infarct in patients with no risk factors for suffering a brain vascular pathology, it is advisable to carry out a radiological follow-up so as to be able to diagnose a possible lesion due to a tumour

Sagittal synostosis: results of surgical treatment in 210 patients.

From 1977 to 1996, 210 patients suffering from scaphocephaly, have been operated on in our institutions. The surgical technique depended on the patients age. Single wide sagittal synostectomy was performed in 155 babies aged less than 3 months, obtaining good cosmetic results. Patients older than 3 months needed more complex and aggressive procedures to achieve similar results. The conclusions is that sagittal suturectomy is the proper treatment in younger patients under 3 months of age, and that a greater effort must be made to diagnose and treat these patients early.

[Spontaneous resolution of a congenital depressed skull fracture]. / Fractura hundimiento craneal congénita con resolución espontánea.

Congenital depressed skull fracture is rare and in most cases its etiology remains unclear. We present a female newborn infant with a congenital depressed skull fracture and no evidence of antepartum or intrapartum traumatism. The baby had normal neurological status and the depressed fracture healed spontaneously in a few weeks. Based on our experience of this case and a literature review, we conclude that congenital depressed skull fractures should be managed conservatively if the skull depression is less than 2cm, there is no previous trauma, no local edema or hematoma, and if the neonate shows normal neurological status.

Fractura-hundimiento craneal congénita con resolución espontánea / Spontaneous resolution of a congenital depressed skull fracture

Las fracturas craneales congénitas son un proceso poco frecuente cuya etiología queda en la mayoría de casos sin aclarar. Se presenta el caso de una recién nacida con fractura hundimiento craneal congénita, sin antecedente de traumatismo anteparto o intraparto, que evolucionó sin presentar ninguna sintomatología que, manteniendo una actitud expectante, presentó resolución espontánea de la fractura dentro de las primeras semanas de vida. Basándose en la experiencia de este caso y tras revisar la bibliografía sobre el tema la conclusión es que si no existe traumatismo previo, el recién nacido permanece neurológicamente asintomático, no hay signos locales de edema o hematoma y el hundimiento es menor de 2 cm, lo más recomendable consiste en una actitud expectante sin proceder a la reducción quirúrgica inmediata, ya que en estos casos la resolución espontánea es el resultado más probable (AU)

Pediatric brain tumors: loss of heterozygosity at 17p and TP53 gene mutations.

Cytogenetic and molecular analyses of primitive neuroectodermal tumors (PNETs) of the central nervous system (CNS) have demonstrated material losses of 17p, the region that contains the TP53 gene, as the most frequent abnormality. Mutations in the TP53 gene are, however, very rare in these tumors. These findings strongly suggest that another, as yet unidentified, gene on 17p may be involved. We performed a search for loss of heterozygosity (LOH) on 17p by microsatellite markers on 26 childhood CNS tumors as well as TP53 gene mutations (exons 5-8) by single-strand conformational polymorphism analysis on 41 pediatric brain tumor samples of distinct histologic types. LOH was detected in 10 cases: 7 PNET, 2 astrocytomas, and 1 glioblastoma multiforme. In 4 of the PNETs the losses were limited to more distal markers. On the other hand, TP53 mutations were detected in 6 of 41 samples studied. Our results not only confirm the low penetrance of the TP53 gene on pediatric CNS tumors, but also provide further evidence of a putative tumor suppressor gene distal to TP53, between markers (D17S938, D17S926) and 17pter, specifically taking part in the development of PNET.

Craniopharyngioma in children. Surgical treatment by a transbasal anterior approach.

The authors present two cases of giant, ossified, craniopharyngioma in paediatric patients; one was subtotally (more than 90%) and the other, totally resected, both by a transfrontal-nasal approach. The results have been excellent, with total clinical recovery, olfactory function preserved and no cosmetic sequelae.

[Lumbosacral dermal sinus as entry point of purulent meningitis. Report of 3 cases]. / Seno dérmico lumbo-sacro como puerta de entrada de meningitis purulenta. Presentación de tres casos.

Defects of neural tube closure, although minimal, can provide access for infections of the central nervous system. All skin alterations in rear middle line of the body, however, minimal, must be carefully investigated as they could give access to bacterial meningitis. We present three new cases of dermal lumbosacral sinus which went unnoticed in the neonatal period later becoming the access point for bacterial meningitis.

Successful surgical treatment of an odontogenic ossified craniopharyngioma. Case report.

A large, highly ossified craniopharyngioma was diagnosed and surgically treated in a 2-year-old girl. About 20 teeth were macroscopically identified in the operative specimen, some of them totally developed, complete with crown and root. Pathological study established the diagnosis of craniopharyngioma with formation of teeth. Only five cases have been reported previously, and only one patient survived the operation. The patient is alive 3 years after surgical treatment. Radiotherapy was not used.

Subdural hematomas in neonates. Surgical treatment.

7 cases of acute subdural hematomas diagnosed and surgically treated during the first week of life are presented. 5 of them are alive and well at 6 and 7 months and 3, 4 and 6 years of follow-up. Free interval, raised intracranial pressure, lateralizing signs, fall of hematocrit and presence of blood in CSF were constant. Subdural puncture was negative in 6 cases, including a hemophilic patient (hemophilia B). Clinical diagnosis was ratified by means of neuroradiological procedures. The authors conclude that craniectomy is the treatment of choice and subdural tapping a useless procedure.

Giant arteriovenous fistula of the vein of Galen in early infancy treated successfully with surgery. Case report.

A giant arteriovenous fistula in a newborn infant was treated by surgical occlusion of the feeding vessels at 20 days of life. Congestive heart failure responded favorably to operative treatment. Because of persistent hydrocephalus, a shunt was inserted at 2 months of age. At 9 months of age, the child remained without signs of cardiac failure. Cerebral damage was manifested by a mild left hemiparesis. Successful surgical treatment of this unusual lesion in a neonate is exceptional.

Preoperative treatment of ruptured intracranial aneurysms with tranexamic acid and monitoring of fibrinolytic activity.

The fibrinolytic activity in cerebrospinal fluid has been monitored by determination of levels of fibrin split products (FSP) in 23 patients with ruptured intracranial aneurysms. In 20 of these 23, FSP was found in the cerebrospinal fluid (CSF), with levels ranging from 10 to 80 micrograms/ml. Eleven of the 23 patients were treated with 2 gm tranexamic acid daily. In these patients FSP was found in only two cases during the 2nd week, while in 12 untreated patients it was found in 10 cases. These results suggest that there exists a localized fibrinolytic activity, and monitoring the FSP levels in the CSF may be a simple and accurate method for controlling the efficiency of antifibrinolytic therapy. Thus, treatment could be begun with a lower dose, which could be increased later as deemed necessary from the results of careful monitoring.