Long-term follow-up of patients with post-traumatic refractory high intracranial pressure treated with lumbar drainage.

Drainage of cerebrospinal fluid by means of external lumbar drainage (ELD) is controversial in the adult population with traumatic brain injury. We report our experience with ELD in the treatment of post-traumatic high intracranial pressure (ICP) and the results of the long-term follow-up in these patients. We undertook clinical evaluation of 30 patients with traumatic brain injury and high ICP treated with second-tier measures or with first-tier measures if second-tier measures were contraindicated. The study involved a retrospective review of collected data. Outcome at intensive care unit discharge and three to five years after injury were evaluated with the Glasgow Outcome Scale. The mean age of patients was 34.9 +/- 12.5 years and 25 (83%) were male. The median (interquartile range) Glasgow Coma score was 8 (7 to 10). ICP before and one hour after ELD placement was 33.7 +/- 9.0 and 12.5 +/- 4.8 mmHg respectively, a decrease in 21.2 +/- 8.3 mmHg (P < 0.0001). ELD was placed after a mean of 8.6 +/- 3.9 days. Cerebrospinal fluid drainage was maintained for a mean of 6.6 +/- 3.5 days. Four patients (13%) required ELD replacement and one patient developed a cerebrospinal fluid infection (3%). No pupillary changes were noted within 48 hours of ELD placement. Long-term outcome was favourable (good recovery or moderate disability) in 62% of the patients studied. The use of ELD resulted in a marked decrease in ICP These patients presented a good outcome in 62% of the cases in the long-term evaluation. Few complications related with ELD use were noted.

Correlation between brain interstitial and total serum cortisol levels in traumatic brain injury. A preliminary study.

INTRODUCTION: Brain cortisol availability has never been evaluated in patients with traumatic brain injury (TBI). Cerebral microdialysis is a well-established technique for monitoring brain metabolism in neurocritically ill patients, which may be used to measure interstitial cortisol. The objective of this preliminary study was to measure brain interstitial cortisol and its correlation with total serum cortisol in patients with TBI. METHODS: We prospectively studied 6 patients with severe TBI admitted to the Intensive Care Unit of our tertiary University Hospital in which multimodal neuromonitoring including cerebral microdialysis with a high cut-off of 100 k-Da and 20-mm long membrane was used. Serum and brain interstitial cortisol microdialysis samples were obtained every 8 h and analyzed afterwards. RESULTS: Linear regression analysis of total serum cortisol and brain interstitial cortisol in the whole population showed a moderate correlation (R2=0.538, p<0.001, no.=118). However, intra-individual correlation showed a great variability, with correlation coefficients ranging from a R2=0.091 to R2=0.680. CONCLUSION: Our prospective and preliminary study showed a moderate correlation of brain interstitial cortisol and total serum cortisol values in patients with diffuse TBI. However, intra-individual analysis showed a great variability. These results suggest that total serum cortisol may not reflect brain cortisol availability in half of TBI patients.

Intracranial retrograde dissemination in filum terminale myxopapillary ependymomas.

Myxopapillary ependymomas (ME) are considered benign tumours (WHO grade I) of the central nervous system with long term survival rates and a tendency to local recurrence. However an aggressive course has occasionally been described, leading to CSF dissemination and even systemic metastases. We describe the case of a 23-year-old man diagnosed with intracranial subarachnoid dissemination of a filum terminale ME three years after the initial diagnosis. We have performed a careful review of the literature on CSF dissemination in ME and finally propose treatment of these cases.

Papel del cirujano plástico en la obesidad mórbida: experiencia en dermolipectomía tras cirugía bariátrica / The role of the plastic surgeon in morbid obesity: our experience in dermolipectomies after bariatric surgery

La cirugía bariátrica ha demostrado ser en la actualidad el método más eficaz para conseguir grandes perdidas de peso estables. La mayor experiencia en este campo y el aumento del número de intervenciones realizadas, va creando una gran demanda de actuación por parte del cirujano plástico. Tras este tipo de cirugía se producen severas disminuciones de peso y del índice de masa corporal (IMC),lo que va a ocasionar grandes excedentes cutáneos Las dermolipectomías juegan un papel fundamental en la corrección de las deformidades estéticas, funcionales y psicológicas de estos pacientes, por lo que la Cirugía Plástica va a aportar una importante mejora en la calidad de vida y autoestima del paciente. En nuestra experiencia, se consiguen buenos resultados funcionales y estéticos, sin un elevado índice de complicaciones (AU)

Bariatric surgery has proven to be the most effective method for acquiring large and stable weight loss. A large amount of experience in this field, as well as an impressive number of interventions, has created a large demand for this specific surgery. After this type of surgery, massive weight loss, as well as BMI (Body Mass Index) decrease, can be observed. This, in turn, will lead to large amounts of loose redundant skin. Dermolipectomies play a fundamental role in the correction of aesthetic, functional and psychological deformities of these sickly individuals. It is therefore clear that Plastic Surgery will provide a serious improvement in the quality of life and self – esteem of the patient. In our experience, these procedures obtain good functional and aesthetic results, without and elevated number of complications (AU)

Estimulación cortical intraoperatoria en el tratamiento quirúrgico de los gliomas de bajo grado situados en áreas elocuentes / Intraoperative cortical mapping in the surgical resection of low-grade gliomas located in eloquent areas

Introducción. La selección de pacientes para cirugía en los gliomas de bajo grado, basada en criterios radiológicos, es, en ocasiones, insuficiente, dada la variabilidad individual en la localización de las áreas elocuentes y la preservación de función en el tejido cerebral infiltrado. Evaluamos la seguridad de la técnica de estimulación cortical intraoperatoria en un subgrupo de pacientes con tumores gliales de bajo grado, analizando en qué medida la aplicación de ésta modifica la posibilidad de resecciones completas y la aparición de déficits postquirúrgicos. Material y métodos. Veinticinco pacientes con gliomas de bajo grado (II/IV OMS) localizados en áreas cerebrales elocuentes fueron intervenidos para exéresis guiada con estimulación cortical intraoperatoria. La cirugía se efectuó bajo anestesia local y sedación o bajo anestesia general sin relajación muscular, en dependencia de la función a explorar. Todas las intervenciones se efectuaron desde una perspectiva oncológica, buscando la resección tumoral máxima, y deteniéndose al hallar tejido cerebral funcionante en la lesión o próximo a ella. Resultados. Se logró una exéresis completa o parcial máxima en 16 pacientes (64 por ciento); en cinco casos (20 por ciento) la resección fue parcial, y en el resto (16 por ciento), sólo pudo efectuarse biopsia. Los tumores de área motora suplementaria (AMS) y los de la región fronto-opercular, fueron los que con más frecuencia pudieron resecarse completamente. Trece pacientes (52 por ciento) presentaron un empeoramiento de su situación neurológica previa, pero en ocho de ellos se observó mejoría progresiva durante los días siguientes, con práctica resolución de la clínica a los 6 meses. Conclusiones. La estimulación cortical intraoperatoria permite optimizar el grado de resección minimizando las secuelas postoperatorias. La existencia de áreas funcionales y vías subcorticales en el seno de estos tumores es una realidad a tener en cuenta. La localización en región fronto-opercular izquierda y AMS permiten mayor grado de exéresis con menor morbilidad, mientras que las lesiones insulares continúan siendo un reto incluso con el apoyo de esta técnica (AU)

[Growing skull fracture in childhood. Presentation of 12 cases]. / Fractura evolutiva de cráneo en la infacia. Presentación de 12 casos.

Growing skull fractures (GSF) are rare complications of head injury (HI) in childhood. This entity consists of a skull fracture with an underlying dural tear that courses with a progressive enlargement of the fracture to produce a cranial defect. The pathophysiology and some aspects of its management are still controversial. In this review we present 12 patients diagnosedd and treated for a GSF at our institution between 1980 and 2002. 11 patients were under the age of 3 years and one patient was 5 years old at the moment of HI. The most common cause of injury was a fall from height. In the initial plain x-rayfilms, 11 patients showed a diastatic skull fracture and one patient only had a linear fracture. At this time, CT scan showed cortical contussion underlying the fracture in every case. The mean time between injury and presentation of GSF was 11.6 weeks. Diagnosis was made by palpation of the cranial defect and confirmed with skull x-rayfilms. The most frecuent location of GSF was in the parietal region. Associated lesions like hydrocephalus, encephalomalacia, lepto-menigeal cysts, brain tissue herniation and ipsilateral ventricular dilatation, were found in the preoperative CT or MRI. All patients underwent a dural repair with pericranium or fascia lata. The cranial defect was covered with local calvarial bone fragments in every case. Only one patient needed a cranioplasty with titanium mesh. Every child with a skull fracture must be followed until the fracture heals. Patients under the age of 3 years with a diastatic fracture and a dural tear, demostrated by TC or MRI, are more prone to develop GSF. In these cases, early repair must be adviced in order to prevent progressive brain damage.

Fractura evolutiva de cráneo en la infancia. Presentación de 12 casos / Growing skull fracture in childhood. Presentation of 12 cases

La fractura evolutiva de cráneo (FEC) es una complicación poco frecuente del traumatismo craneoencefálico (TCE) en la infancia. Consiste en una fractura con un desgarro dural subyacente, que se ensancha progresivamente hasta constituir un defecto craneal. Su fisiopatología, así como algunos aspectos del manejo terapéutico, son todavía controvertidos. Se presenta una revisión retrospectiva de 12 casos diagnosticados y tratados entre los años 1980 y 2002 en nuestra institución. Once pacientes eran menores de 3 años y uno tenía 5 años en el momento del traumatismo. La causa más frecuente de TCE fue la caída. En la radiografía inicial, 11 pacientes tenían fracturas con diastasis y solamente un paciente tenía fractura lineal. El hallazgo tomográfico común a todos los casos fue contusión cortical subyacente a la fractura. El intervalo promedio entre traumatismo y presentación de las FEC fue de 11,6 semanas. La localización preferente de las FEC fue en la región parietal. El diagnóstico se hizo por palpación de un defecto craneal y se confirmó con radiografía. Se encontraron lesiones asociadas en la TAC y RMN preoperatoria, como hidrocefalia, encefalomalacia, quistes leptomeníngeos, herniatión de tejido encefálico y dilatación ventricular ipsilateral. Todos los pacientes fueron sometidos a reparación plástica de la duramadre y el defecto craneal se cubrió con fragmentos óseos. Sólo un paciente precisó craneoplastia con malla de titanio. Todas las fracturas de cráneo en edad pediátrica deben controlarse hasta constatar su reparación. Los pacientes menores de 3 años con fracturas inicialmente diastasadas y con evidencia en la TAC o RMN de laceración dural, tienen mayor probabilidad de desarrollar una FEC. En estos casos se recomienda el tratamiento precoz para evitar un daño cerebral progresivo (AU)

[Intraoperative cortical mapping in the surgical resection of low-grade gliomas located in eloquent areas]. / Estimulación cortical intraoperatoria en el tratamiento quirúrgico de los gliomas de bajo grado situados en áreas elocuentes.

INTRODUCTION: Surgical selection of patients harboring low-grade gliomas based on radiological criteria may be insufficient due to individual variability in eloquent areas location and to the fact that function can be preserved within infiltrated brain tissue. Brain stimulation mapping safety for patients with low-grade gliomas is evaluated, analyzing whether this technique modifies the extent of resection and minimizes postoperative deficits. MATERIAL AND METHODS: Twenty-five patients with lowgrade gliomas (II/IV WHO) located in eloquent areas underwent tumor resection with the aid of intraoperative mapping. Patients underwent surgery under local or general anesthesia depending on the neurological function to be explored. All procedures were performed from an oncological point of view, trying to achieve a radical tumor resection but stopping removal whenever functional tissue was found within or near the lesion. RESULTS: Total or subtotal resection was achieved in 16 patients (64%); in five cases (20%) resection was partial, and in the remaining (16%) only a biopsy was obtained. Tumors located in the supplementary motor area (SMA) or in the operculum were those which could be more often totally resected. Thirteen patients (52%) experienced neurological worsening immediately after surgery but eight of them had almost completely recovered six months after the procedure. CONCLUSIONS: Intraoperative functional mapping can optimize extent of resection minimizing permanent morbidity. Functional tissue can be found within the infiltrated brain and this must be considered in the presurgical planning. SMA and opercular tumors allow radical resection with low morbidity whereas insular tumors remain a challenge even with the aid of this technique.

[Minor head injury management in Spain: a multicenter national survey]. / Manejo del traumatismo craneoencefálico leve en España: encuesta multicéntrica nacional.

INTRODUCTION AND OBJECTIVES: Despite of the high incidence of minor head injury, there is still controversy and disparity of criteria regarding its management. The lack of consensual protocols and clinical guidelines can lead to deficiencies in the attention to these patients and to inadequate use of resources. The objective of this study has been to describe the present situation of the management of this entity in the neurosurgical departments of the Spanish public hospitals, and to compare it with other European countries. MATERIAL AND METHODS: A 57-item questionnaire regarding different aspects of minor head injury was designed and distributed to the 66 neurosurgical departments of the Spanish National Health System between December 1999 and February 2000. RESULTS: A 83.3% of responses were obtained. More than 92,000 patients per year are assisted at the Spanish third-level hospitals (general hospitals) after suffering a minor head injury. In-hospital on duty neurosurgeons are not available in 49.1% of the Spanish neurosurgical departments. Only in 7.3% of the centres the neurosurgeon is the first physician that assists these patients. However, in 52.7% of the hospitals neurosurgical evaluation is required if the patient refers transient loss of consciousness. A GCS score of 13 is still included in the group of minor head injuries in 29.1% of the centres. Although 89.1% of the surveyed neurosurgical departments considered as satisfactory the attention they provide to these patients, 85.5% think that it would be convenient to elaborate clinical guidelines. Cranial x-ray is considered a useful diagnostic tool by only 38.2% of the centres, however, 89.1% of them still use it as a routine. CT-scan is systematically indicated in all patients after suffering a mild head trauma only in 5.5% of the centres, although it is completely available in 74.5% of them. The study of economical costs shows that choosing cranial CT as screening tool in these patients would mean a 40.6% reduction in costs compared to a management based on x-ray plus in-hospital observation. CONCLUSIONS: This study shows the inter-hospital variability of minor head injury management in Spain. Clinical guidelines are considered as positive and necessary. Although the Spanish situation is similar to that in other European countries, following the tendency toward a broader cranial CT utilisation, would improve diagnosis profitability and economical efficiency. The results of this study may contribute to the creation of consensual protocols and clinical guidelines in our country that help in daily practice decision-making optimising assistance quality.

Pott's puffy tumour: still not an eradicated entity.

Pott's puffy tumour is an infrequent entity characterised by one or more subperiosteal abscesses associated with frontal bone osteomyelitis. Although cases in patients of all ages have been reported, teenagers are the most frequently affected. Early diagnosis and aggressive treatment are essential because of the high risk of severe neurological complications, such as epidural abscess, subdural empyema, and secondary septic thrombosis of the dural sinuses. This paper describes the case of a patient with a subperiosteal abscess resulting from sinusitis, with orbital and intracranial extension, and subsequent neurological complications. Despite modern methods of diagnosis and treatment, 13 new cases have been published in the last 5 years; in at least 3 (23%) of these cases there were serious neurological complications. Upper respiratory infections and sinusitis are leading causes of visits to the emergency department in the paediatric age group; however, no risk factors for poor outcome have so far been identified in any of these patients.

Factors influencing surgical complications of intra-axial brain tumours.

OBJECT: Extensive surgical resection remains nowadays the best treatment available for most intra-axial brain tumours. However, postoperative sequelae can outweigh the potential benefits of surgery. The goal of this study has been to review the results of this treatment in our Department in order to quantify morbidity and mortality and determine predictive risk factors for each patient. METHOD: We report a retrospective study of 200 patients submitted to a craniotomy for intra-axial brain tumours including gliomas and metastases. Postoperative major complications are analysed and related to different variables. An exhaustive review of the literature concerning the main controversial points about primary and metastatic brain tumours surgery is done. FINDINGS: The overall major complication rate was 27.5%, with neurological complications being the most frequently encountered. We did not find a statistically significant relation between them and the grade of eloquence of the tumoural area. Infratentorial tumour location, previous radiotherapy and reoperations were factors strongly related to the incidence of regional complications. Age over 60 and severe concomitant disease were risk factors for systemic complications. INTERPRETATION: The results from published series concerning surgical complications after craniotomies for brain tumours are not comparable because of the lack of homogeneity between them. The knowledge of the complications rate in each particular neurosurgical department turns out essentially to provide the patient with tailored information about risks before surgery.

Brain metastases in endometrial carcinoma.

BACKGROUND: Brain metastases of endometrial carcinoma are rare. They tend to follow an unpredictable dissemination pattern, due to the different pathways that tumor cells can follow and to certain factors that influence their spread. When brain metastases occur, usually the disease is widely disseminated, but there are some exceptions such as the case presented here. METHODS: We report the case of a 76-year-old woman who presented a single occipital metastasis 18 months after a hysterectomy because of an endometrial carcinoma. No other metastases were found. DISCUSSION: We discuss the different dissemination pathways of endometrial carcinoma. Some hypotheses try to explain what determines the site of preference of distant metastases. The most accepted hypothesis suggests the presence of specific tumor cell receptors and endothelium receptors on the target organs, which would explain the preference of different cancers for different targets and for different areas inside the same target organ. CONCLUSION: Although brain metastases of endometrial carcinoma are rare and they usually occur in widely disseminated disease, they should be considered in patients with a single brain mass, even when the primary disease is unknown.