[Holospinal epidural haematoma following heart surgery]. / Hematoma epidural holomedular poscirugía cardíaca.

INTRODUCTION: Spinal epidural haematomas are rare entities associated to spinal traumatic injuries and vascular lesions or which can appear spontaneously. There are no direct reports linking them to heart surgery. CASE REPORT: We report the case of a female aged 43 years who underwent surgery to change a mitral valve because of a rheumatic heart disease, and who, from the immediate post operative period onwards, presented paraplegia with a sensory and motor level that reached C3, breathing troubles and quadriplegia. Diagnosis was performed in five days because it was thought that she was suffering from an ischemic spinal cord infarction. Spiral computerised tomography scans revealed an epidural haematoma of the whole spinal cord from C2 to T12, with acute spinal cord compression. Ingurgitation of the epidural venous plexus and venous hypertension were also observed. CONCLUSION: The study of a growing motor and sensory deficit in a patient with immediate heart surgery must include early imaging in order to rule out a space occupying pathology, such as a spinal epidural haematoma. This case is singular because of the extension involved and the fact that it is directly linked with heart surgery procedure.

Hematoma epidural holomedular poscirugía cardíaca / Holospinal epidural haematoma following heart surgery

Introducción. Los hematomas epidurales medulares son entidades raras asociadas a traumatismos, lesiones vasculares o presentes de forma espontánea. No hay informes directos asociados a cirugías cardíacas. Caso clínico. Mujer de 43 años intervenida quirúrgicamente para un recambio de válvula mitral por cardiopatía reumática, que presenta desde el postoperatorio inmediato una paraplejía con nivel sensitivo y motor ascendente hasta C3, dificultad ventilatoria y cuadriplejía. El diagnóstico se realiza en cinco días, por pensarse en un infarto medular isquémico. La tomografía helicoidal muestra un hematoma epidural holomedular desde C2 hasta T12, con una compresión medular aguda. Se corrobora una ingurgitación del plexo venoso epidural e hipertensión venosa. Conclusión.El estudio de un déficit motor y sensitivo ascendente en un paciente con cirugía cardíaca inmediata debe incluir estudios de imagen tempranos para descartar cualquier patología ocupativa, como un hematoma epidural medular. El presente caso es único por su extensión y por asociarse directamente al procedimiento quirúrgico cardíaco (AU)

Introduction. Spinal epidural haematomas are rare entities associated to spinal traumatic injuries and vascular lesions or which can appear spontaneously. There are no direct reports linking them to heart surgery. Case report. We report the case of a female aged 43 years who underwent surgery to change a mitral valve because of a rheumatic heart disease, and who, from the immediate post-operative period onwards, presented paraplegia with a sensory and motor level that reached C3, breathing troubles and quadriplegia. Diagnosis was performed in five days because it was thought that she was suffering from an ischemic spinal cord infarction. Spiral computerised tomography scans revealed an epidural haematoma of the whole spinal cord from C2 to T12, with acute spinal cord compression. Ingurgitation of the epidural venous plexus and venous hypertension were also observed. Conclusion. The study of a growing motor and sensory deficit in a patient with immediate heart surgery must include early imaging in order to rule out a space-occupying pathology, such as a spinal epidural haematoma. This case is singular because of the extension involved and the fact that it is directly linked with heart surgery procedure (AU)

Is it healthy to be chaotic?

The concept of Chaos has proven to be one of the greatest scientific advances that have led to radical philosophical implications. It deals with dynamic systems whose determining factors are completely unknown to us. Sometimes it seems that these dynamic systems exhibit a stochastic behavior while others portray simpler or better known behaviors where determinism is obvious. When the physician faces chaotic, dynamic systems, he or she wonders if it is healthy for these biologic systems to be chaotic. When analyzing the variation in brain and heart rates mathematically, the conclusion is that these rates are chaotic, complicated and unpredictable. Because each organ regulates its own performance, the mathematical variations seem to be the result of the organ's determinism rather than fluctuation. This healthy variability is neither a random nor an uncontrolled fluctuation. It is a certain, well-harmonized chaos, that 'provides the body with the flexibility to respond to different stimuli'.

[Chronic hydrocephaly in adults. A diagnostic and therapeutic challenge]. / Hidrocefalia crónica del adulto. Reto diagnóstico y terapéutico.

OBJECTIVE: To describe the main clinical features of the different conditions which present as chronic hydrocephaly, emphasising the diagnosis and treatment. DEVELOPMENT: In the study of any dementia syndrome, normotensive hydrocephaly (HN) is of particular interest since this condition may be treated and cured. However, prediction of which cases will benefit from surgery is one of the most important aspects of diagnosis. The development of paraclinical investigations of the dynamics of cerebrospinal fluid (CSF) has led to great advances in the management of these chronic forms of hydrocephaly, since they are the best parameters for prognosis when deciding whether to insert a by pass. The treatment of post traumatic hydrocephaly has also benefited from these studies, since the cases of simple atrophy may now be distinguished from those which follow a clinical course similar to HN. Recently, two types of hydrocephaly have been identified as being very different from the typical forms. These are external hydrocephaly, in which CSF accumulates in the convexity of the cerebral hemispheres, and long term ventriculomegaly, in which severe ventricular dilation is accompanied by cognitive alterations and features of acute hydrocephaly. CONCLUSIONS: Treatment of each of these conditions is a challenge. Therefore careful analysis of the clinical features, imaging studies and CSF dynamics is essential when deciding whether or not to use by pass treatment.

Simultaneous treatment of a pituitary adenoma and an internal carotid artery aneurysm through a supraorbital keyhole approach.

We describe a case in which an incidental left carotid aneurysm was found during the preoperative evaluation of a pituitary adenoma. After magnetic resonance imaging (MRI) and angiography delineated their characteristics, we chose to treat both lesions simultaneously through a left supraorbital keyhole approach. The aneurysm clipping was followed by intracapsular resection of the tumor that was identified later as a non-secretory adenoma. The postoperative course was uneventful. This case shows that in carefully selected patients it is possible to treat successfully concurrent conditions through a minimally invasive approach, with the well known advantages of low morbidity and a short hospital stay.

Hidrocefalia crónica del adulto. Reto diagnóstico y terapéutico / Chronic hydrocephaly in adults. A diagnostic and therapeutic challenge

Objetivo. Presentar las principales características clínicas de las diferentes entidades que se manifiestan como hidrocefalia crónica, con énfasis en su diagnóstico y tratamiento. Desarrollo. En el estudio de cualquier síndrome demencial, la hidrocefalia normotensa (HN) tiene un interés particular por la potencial mejoría y curación del cuadro, pero la capacidad para predecir los casos en que será benéfica la cirugía es uno de los puntos más importantes en el diagnóstico. El advenimiento de estudios paraclínicos sobre la dinámica del líquido cefalorraquídeo (LCR) ha revolucionado el manejo de estas formas crónicas de hidrocefalia, ya que constituyen el mejor parámetro pronóstico para decidir colocar un sistema de derivación (SD). El tratamiento de la hidrocefalia postraumática también se ha beneficiado con estos estudios, ya que es posible determinar los casos de atrofia simple de los que cursan con evolución similar a la HN. Recientemente se han identificado dos variedades de hidrocefalia muy diferentes a las formas típicas: la hidrocefalia externa, en la que el LCR se acumula en la convexidad de los hemisferios cerebrales, y la ventriculomegalia de larga evolución, en la que una dilatación ventricular extrema se acompaña de alteraciones cognitivas y datos de hidrocefalia aguda. Conclusiones. Cada una de estas entidades ofrece un reto para su tratamiento, por lo que un análisis cuidadoso de las manifestaciones clínicas, de los estudios de imagen y de la dinámica del LCR es esencial para ofrecer o no un tratamiento en base a SD (AU)

[Minimally invasive surgery in intracranial aneurysms]. / Cirugía de mínima invasión en aneurismas intracraneales.

INTRODUCTION: The use of minimally invasive procedures in neurosurgery permits a significant reduction in peri-operative morbidity and duration of hospital stay. The fronto-latero-basal (FLB) approach gives good exposure of the structures of the anterior and middle fossas with access to most aneurysms of the anterior circulation, thus avoiding extensive craniotomies and the use of brain retractors. OBJECTIVE: We present an analysis of 27 patients operated on to clip 29 aneurysms of the anterior circulation using the FLB approach. PATIENTS AND METHODS: The study included 27 patients, 18 women and 9 men with an average age of 47.53 years. On clinical staging, using the Hunt and Hess scale, 12 patients were between 0 and 1, 8 at stage II, 6 at stage III and 1 at stage IV. RESULTS: The aneurysms were mainly on the internal carotid artery (16), middle cerebral artery (5), anterior communicating artery (5) and bifurcation of the carotid and middle cerebral arteries (3). The surgical operation lasted an average of 166.15 minutes; it was possible to clip the artery in 28 cases (96.5%). Two patients died (of renal failure and of disseminated intravascular coagulation). Most patients were discharged with a score of 5 points on the Glasgow prognosis scale 7.6 days after operation. CONCLUSIONS: Use of minimally invasive procedures such as FLB gives optimal functional and aesthetic results, with the advantage of being possible using the basic instruments available in any neurosurgical department, without depending on advanced technology.

Cirugía de mínima invasión en aneurismas intracraneales / Minimally invasive surgery of intracranial aneurysms

Introducción. El uso de procedimientos de mínima invasión en neurocirugía permite disminuir de manera significativa la morbilidad transoperatoria y el tiempo de estancia hospitalaria. El abordaje frontolaterobasal (FLB) ofrece una buena exposición de estructuras del piso anterior y medio con acceso a la mayor parte de los aneurismas de la circulación anterior, evitando las craneotomías extensas así como el uso de retractores cerebrales. Objetivo. Presentar un análisis de 27 pacientes intervenidos para pinzadura de 29 aneurismas de la circulación anterior por medio del abordaje FLB. Pacientes y métodos. Se incluyeron 27 pacientes, 18 mujeres y 9 varones con una edad media de 47,53 años. El estadio clínico de acuerdo con la escala de Hunt y Hess ubicó a 12 pacientes en 0 o I, 8 en el II, 6 en el III y 1 en el estadio IV. Resultados. Los aneurismas se localizaron preferentemente en la carótida interna (16), cerebral media (5), comunicante anterior (5) y bifurcación de carótida con cerebral media (3). El tiempo quirúrgico promedio fue de 166,15 minutos, lográndose la pinzadura en 28 casos (96,5 por ciento) con dos fallecimientos (por insuficiencia renal y coagulopatía diseminada). La mayor parte de los pacientes se egresaron con 5 puntos en la escala pronóstica de Glasgow a los 7,6 días de realizado el procedimiento. Conclusiones. El uso de procedimientos de mínima invasión como el FLB ofrece resultados óptimos tanto funcionales como estéticos, con la ventaja de que puede realizarse con el instrumental básico de cualquier servicio de neurocirugía sin dependencia tecnológica (AU)

[Attention deficit syndrome. Basic aspects of its diagnosis and treatment]. / Síndrome de atención deficitaria. Aspectos básicos del diagnóstico y tratamiento.

INTRODUCTION: The attention deficit syndrome is one of the commonest behavior disorders of infancy, although it is considerably underestimated. DEVELOPMENT: The aetiology of attention deficit syndrome is multifactorial since genetic, environmental, nutritional and psychosocial factors have been found to be associated with its development. Diagnosis depends mainly on the identification of behavior changes especially of inattention, impulsiveness and hyperactivity: it should be made at home and at school and based on the exclusion of severe organic and neurological disorders which also present initially with similar characteristics. Electrophysiological studies may be useful since multiple electroencephalographic changes have been reported, as have prolonged latency of III and V waves of brain stem evoked potentials, The best management requires educational therapy combined with controlled medical treatment. Use of stimulants should be carefully considered and the tricyclic drugs are preferably the first pharmacological option. CONCLUSIONS: Current findings regarding the repercussions of attention deficit syndrome in adults shows the need for early diagnosis and treatment of the condition so as to avoid severe personality disorders including antisocial and criminal behavior. It is essential that the parents and the child himself understand the condition in order to achieve satisfactory results of long term treatment.

Síndrome de atención deficitaria.Aspectos básicos del diagnóstico y tratamiento / Attention deficit syndrome. Basic aspects of diagnosis and treatment

Introducción. El síndrome de atención deficitaria (SAD) es uno de los trastornos conductuales más comunes de la infancia, a pesar de lo cual es altamente subestimado. Desarrollo. La etiología del SAD es multifactorial pues se identifica con factores genéticos, ambientales, nutricionales y psicosociales en su desarrollo. El diagnóstico se basa primordialmente en la identificación de alteraciones conductuales en las que predominan la desatención, impulsividad e hiperactividad; debe realizarse en casa y en la escuela, y basarse en la exclusión de trastornos orgánicos y neurológicos severos que cursan también en períodos iniciales con manifestaciones semejantes. Los estudios de electrofisiología pueden ser útiles puesto que se han comunicado alteraciones electroencefalográficas múltiples, así como prolongaciones en las latencias de las ondas III y V de los potenciales evocados de tallo. El empleo de una terapia educativa combinada con un tratamiento médico controlado es la medida que ofrece mejores resultados en el manejo; asimismo, debe valorarse de forma muy cuidadosa la administración de estimulantes, con preferencia del uso de tricíclicos como primera medida farmacológica. Conclusiones. Los hallazgos actuales sobre la repercusión del SAD en la vida adulta ponen de manifiesto la necesidad de realizar un diagnóstico y tratamiento temprano de la entidad, para evitar graves trastornos de personalidad e incluso conductas antisociales y criminales. La comprensión del cuadro por parte de los padres y del niño afectado es también de vital importancia para lograr un tratamiento a largo plazo con resultados satisfactorios (AU)

Conceptos actuales sobre cerebelo y cognición / Current concepts regarding the cerebellum and cognition

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[Current concepts regarding the cerebellum and cognition]. / Conceptos actuales sobre cerebelo y cognición.

OBJECTIVE: To review the main cognitive processes regulated by the cerebellum and the anatomical circuits involved in their clinical correlation. DEVELOPMENT: The cerebellum is generally regarded as a regulator of motor function with a key role in movement coordination. Clinical evidence of the relation of the cerebellum to neural functions typically considered as cortical, is supplied by several neuropsychological alterations detected in both degenerative disorders and acute insult to the region such as vascular event and surgery. More anatomical circuits between the cerebellum and several cortical areas and limbic system, with the ventral pons region as main afference and efference relay of all these pathways. Cerebellar structures that are phylogenetically older such as the floculonodullar lobe, vermix, fastigial nuclei and globus nuclei have a tight relationship to emotional control and autonomic manifestations. More complex circuits are founded in the regulation of learning, motor planning and language. Functional imaging studies have helped to confirm the relationship between the cerebellum and memory processes, finding a selective activation of lateral regions during to cerebellar damage, such a frontal like syndromes, memory deficits and aphasia and even though dysmetria with incoordination between mental process velocity and its motor execution. CONCLUSIONS: All the data from clinical and functional studies indicate that the cerebellum has a central co-ordinating function not only of movement but also regulating thought. The cerebellum should, therefore, be reconsidered as a complex neurone system at much the same level as the more advanced cortical structures.

Juvenile familial amyotrophic lateral sclerosis: four cases with long survival.

Four cases are reported of juvenile familial amyotrophic lateral sclerosis (JFALS) with exceptionally long survival (mean=27 years), and consequent development of dementia. Subjects' mean age at onset was 15.7 years. Their clinical features and electrophysiological findings support the diagnosis. One subject's MRI scan showed severe atrophy to the cortex and brain stem; wallerian degeneration in the pyramidal pathway, as reported in other studies, could not be found. JFALS is characterized by the involvement of other neuronal systems not present in the adult form and by long survival after disease onset.

Optic neuritis progressing to multiple sclerosis.

We report a partially retrospective and longitudinal study of patients with optic neuritis (ON) that developed multiple sclerosis (MS). We assessed clinical features or factors that might differentiate these patients from those with ON that did not develop MS. Of the cases followed, 110 (67%) were found to have an idiopathic origin of the disease; whereas 55 (33%) were found to develop it secondary to another disease. Of the 110 idiopathic cases, 13 (12%), developed MS over an average of 2 years. The results of these patients in the laboratory analyses of blood and CSF as well as the results of the MRI and evoked potential studies, were significantly different from the ON patients without MS. We conclude that the percentage of patients with ON in our sample that developed MS is similar to that found in Japan and is relatively low in comparison to other reports.

Frequency of motor neuron diseases in a Mexico City referral center.

OBJECTIVE: To analyze the incidence and clinical characteristics of MND (Motor Neuron Diseases) in a Mexican institution. MATERIAL AND METHODS: It was a retrospective study, of 274 definitive MND patients seen in a neurological reference hospital of Mexico City during the period of 1965-1995 (248 as Amyotrophic Lateral Sclerosis, 15 as Progressive Bulbar Palsy, 8 as Primary Lateral Sclerosis and 3 as Progressive Spinal Atrophy). RESULTS: The frequency of MND increased gradually in our institution in the 31 years revised. The mean age of onset in our series was approximately 48 years in contrast to a higher age found in other series. The clinical features are similar to those found elsewhere. CONCLUSIONS: Our study showed that the frequency of MND is increasing in Mexico in a similar fashion to that observed in the rest of the world. This makes conceivable that the incidence of MND in Mexico may also resemble the figures reported worldwide. Prospective population studies are required to establish the incidence of MND in Mexico.