[Tansitional vesical cell carcinoma metastatizing to the sphenoid sinus]. / Metástasis esfenoidal de un carcinoma de células trancisionales de la vejiga.

Secundary tumors of the paranasal sinus are very uncommon with only one hundred cases reported in the literature up to 2001. The commonest site of the primary tumor is the kidney. The maxillary sinus is most often involved. The Sphenoid sinus is the rarest site. We report a rare case of metastasis to the sphenoid sinces from a transitional cell bladder tumor in a 69-year-old man who died after treatment with chemotherapy and we also review the liteature.

[Morbimortality in carotid endarterectomy]. / Morbimortalidad en la endarterectomía carotídea.

OBJECTIVE: To assess perioperative and long-term morbidity in patients diagnosed of carotid stenosis submitted to our Department for surgical endarterectomy. PATIENTS AND METHODS: A retrospective study of 97 endarterectomies performed by six neurosurgeons in 90 patients treated between January 1995 and December 2003. Ten patients were women. Average mean age was 69 years-old (range 38-86). Seven patients were treated bilaterally. Eighty-four stenosis were greater than 70%. Annual number of interventions per surgeon was 3 (range 0-10). The median follow-up was 121 days, (range 8-2106). RESULTS: Four patients died perioperatively and other 4 ones developed new neurologic deficits. The combined morbidity-mortality rate was 8.9% of the patients and 8.2% of the surgeries. Four patients needed reintervention, because of immediate postoperative new deficit (one) and surgical hematoma (three). Transient peripheral nerve palsy occurred in 8 patients and 21 medical complications were registered. In the long term, 7 patients died (6 because of cancer and 1 because of cardiopathy) and 5 presented neurologic events (3 ipsilateral and 2 in other locations). Last postoperative image control, performed on average after 52 days (0-2832), revealed 7 stenosis of the treated artery. CONCLUSIONS: Carotid endarterectomy can be safely performed in low-volume centers with acceptable results and reasonable morbidity and mortality rates when simple techniques are used. We consider crucial to evaluate self complications and results in order to improve them.

Morbimortalidad en la endarterectomía carotídea / Morbimortality in carotid endarterectomy

Objetivo. Evaluar las complicaciones perioperatorias y a largo plazo en pacientes tratados mediante endarterectomía por estenosis carotídea en nuestro Servicio. Pacientes y métodos. Estudio retrospectivo de 97 endarterectomías realizadas por 6 neurocirujanos en 90 pacientes entre enero de 1995 y diciembre de 2003. Diez de los pacientes fueron mujeres. La mediana de edad fue 69 años (rango 38-86). Siete pacientes se intervinieron bilateralmente. Ochenta y cuatro estenosis fueron mayores del 70%. El número de cirugías anual por cirujano fue de 3 (rango 0-10). El seguimiento clínico fue de 121 días, (rango 8-2106). Resultados. Fallecieron 4 pacientes en el postoperatorio inmediato y otros 4 presentaron déficits neurológicos añadidos, con una morbimortalidad de 8'9% de los pacientes y 8'2% de las cirugías. Cuatro pacientes se reintervinieron, 1 por déficit neurológico inmediato y 3 por hematoma quirúrgico. Hubo afectación transitoria de nervio periférico en 8 pacientes y se registraron 21 complicaciones médicas asociadas. Posteriormente 7 pacientes fallecieron (6 por cáncer y 1 por cardiopatía) y 5 presentaron ictus (3 ipsilaterales y 2 de otra localización). En el último control postoperatorio por imagen, a los 52 (0-2832) días, se constataron 7 estenosis en la arteria operada. Conclusiones. La endarterectomía carotídea puede realizarse con razonable seguridad en centros con bajo volumen de pacientes, con métodos sencillos y con resultados aceptables. El conocimiento de los resultados reales obtenidos en cada centro es importante para mejorarlos

Objective. To assess perioperative and long-term morbidity in patients diagnosed of carotid stenosis submitted to our Department for surgical endarterectomy. Patients and methods. A retrospective study of 97 endarterectomies performed by six neurosurgeons in 90 patients treated between january 1995 and december 2003. Ten patients were women. Average mean age was 69 years-old (range 38-86). Seven patients were treated bilateraly. Eighty-four stenosis were greater than 70%. Annual number of interventions per surgeon was 3 (range 0-10). The median follow-up was 121 days, (range 8-2106). Results. Four patients died perioperatively and another 4 developed new neurologic deficits. The combined morbiditymortality rate was 8'9% of the patients and 8'2% of the surgeries. Four patients needed reintervention, because of immediate postoperative new deficit (one) and surgical hematoma (three). Transient peripheral nerve palsy occurred in 8 patients and 21 medical complications were registered. In the long term, 7 patients died (6 because of cancer and 1 because of cardiopathy) and 5 presented neurologic events (3 ipsilateral and 2 in other locations). Last postoperative image control, performed on average after 52 days (0-2832), revealed 7 estenosis of the treated artery. Conclusions. Carotid endarterectomy can be safely performed in low-volume centers with acceptable results and reasonable morbidity and mortality rates when simple techniques are used. We consider crucial to evaluate self complications and results in order to improve them

[Multifocal motor neuropathy with conduction blocks and prurigo nodularis. A paraneoplastic syndrome in a patient with non-Hodgkin B-cell lymphoma?]. / Neuropatía multifocal motora con bloqueos de conducción y prurigo nodular. ¿Un síndrome paraneoplásico en un paciente con un linfoma no Hodgkin de tipo B?

Multifocal motor neuropathy with conduction blocks (MMNCB) is a peripheral demyelinating neuropathy. The etiology of this disease is unknown, but an autoimmune origin is postulated. Prurigo nodularis (PN), a chronic dermatosis also having an unknown etiology and many peripheral neuropathies of different nature are associated to hematological tumors. We have found no cases in the literature in which MMNCB was presented as a paraneoplastic syndrome of a non-Hodgkin B-cell type lymphoma (NHL-B). We present the case of a 67 year old man who simultaneously developed PN and MMNCB in upper limbs and who was diagnosed of a NHL-B 19 months later. We raise the hypothesis that both prurigo and neuropathy are a paraneoplastic syndrome for lymphoma with a possible common autoimmune pathogenic mechanism.

[First steps in neuronavigation]. / Primeros pasos en neuronavegación.

INTRODUCTION: We try to evaluate the introduction of a neuronavigation system widely used in a neurosurgical department. MATERIAL AND METHODS: We analyze the surgical procedures performed since the introduction of a neuronavigator in our hospital, the advantages and the problems related with its use. RESULTS: From 21/12/00 to 31/12/01, 64 cranial and 5 spinal procedures were performed in our centre with the aid of the BrainLAB neuronavigation system. They were 19.37% of the elective surgeries: 45.7% of cranial and 2.8% of spinal procedures. The accuracy of registration was 1.6 mm; the number of trials for registration was 2.8 on average, although in 3 cases it was not possible; there were disarrangements during 9 surgical procedures (two of them after the lesions were reached). Magnetic resonance imaging (MRI) was used in 54 instances, computerized tomography (CT) in 5, fluoroscopy (Rx) in 1, CT plus MRI in 8, CT plus Rx in 1. Since Z-Touch localization system and software was available, it was used exclusively, disregarding the use of external fiducials. DISCUSSION AND CONCLUSIONS: In our experience, neuronavigation needs extra time, but it helps in the election of the best position for the surgical approach, reduces the time required for scalp incision and craniotomy planning, and is useful for the opening of the dura and the corticectomy. As the operation proceeds, we found it less truhstworthy and necessary. The Z-touch system frees the imaging from the surgery. Its use in spinal operation is scarce and with limited results in our practice. We found the neuronavigation useful, and we employ it on a regular basis in every cranial procedure whenever it is possible.

Primeros pasos en neuronavegación / First steps in neuronavigation

Introducción: Se pretende evaluar la introducción de un sistema de neuronavegación de uso ampliamente extendido en el funcionamiento de un Servicio de Neurocirugía. Material y método: Se analizan las intervenciones realizadas desde la introducción de la neuronavegación en nuestro hospital, las ventajas de su uso y los problemas aparecidos. Resultados: Entre el 21/12/00 y el 31/12/01 se han realizado en nuestro centro 64 intervenciones craneales y 5 de raquis con la ayuda del sistema de neuronavegación BrainLAB. Suponen el 19'38 por ciento de las cirugías programadas: 45'7 por ciento de las craneales y 2'8 por ciento de las de raquis. La precisión de registro fue 1'6 mm; el número medio de intentos para realizar el registro fue de 2'8 aunque en 3 casos éste no se pudo llevar a cabo; hubo desajustes durante el procedimiento en 9 cirugías, (dos de ellas tras alcanzar la lesión). Se emplearon: resonancia magnética (RM) en 54, tomografía computarizada (TC) en 5, fiuoroscopia (Rx) en 1, TC y RM en 8, TC y Rx en 1. Desde que se dispuso del sistema localizador Z-touch y su software se han empleado exclusivamente, prescindiendo de los fiduciales externos. Discusión y conclusiones: En nuestra experiencia, la neuronavegación requiere tiempo extra, pero facilita la elección de la posición idónea para el abordaje, acelera la planificación de la incisión y craniotomía, y es útil para la apertura dural y corticectomía. A medida que el procedimiento avanza, nos parece menos fiable y necesario. El sistema con Z-touch independiza la toma de la imagen de la cirugía. Su empleo en la columna en nuestros pacientes es más escasa y con resultados más limitados hasta ahora. Encontramos a la neuronavegación útil, empleándola de manera rutinaria en los procedimientos craneales de cualquier tipo siempre que esto es posible (AU)

[Giant aneurysm of fast development]. / Aneurisma gigante de rápido crecimiento.

The percentage of aneurysms measuring more than 2'5 cm in diameter ranges from 3 to 13%, and occur more commonly in females. They come to clinical attention later than nongiant aneurysms, but 20% of them appear in patients 20 years of age or younger. Its natural history is incompletely understood. We present the case of a 24-year-old female admitted following a generalized seizure with postictal dysphasia and right hemiparesis caused by a subarachnoid hemorrhage due to a ruptured giant aneurysm located in the left temporal fossa, who died few hours later because of rebleeding. This patient had been followed during the last seven years at our unit because of untreated frontal osteomas, without evidence of any intracranial lesion in the computerized axial tomography (CT). Some months before her death, she had suffered a left micotic otitis, and she was studied because of the reappearance of her left cephalalgia without neurological deficit. This case is another evidence of quick appearance of a giant aneurysm, "silent" until the fatal outcome.

[Surgical treatment of patients with spinal infection]. / Tratamiento quirúrgico de pacientes con infección raquídea.

INTRODUCTION: The surgical treatment of spinal infection, relegated because of the development of more effective antibiotherapy and the fear of associated morbidity, is springing up again with the increase of new patients with weakening pathology. MATERIAL AND METHODS: The clinical records of 27 patients submitted to surgery because of spinal infection between January 1990 and December 1999 at our service have been retrospectively studied. They were assessed with the Frankel and Karnofsky clinical scales, and the radiological angulation of the spine. RESULTS: Male (n = 17) and dorsal lesions (n = 14) predominate. Most of patients presented with pain, and 13 had neurological compromise. 29 operations were performed on the 27 patients. One of them was previously operated upon before the period considered, that procedure has been excluded. The total surgeries performed were 5 simple and 4 instrumented laminectomies, 6 simple corpectomies, 10 corpectomies with anterior instrumentation and 4 with posterior instrumentation. One patient died, there was not definitive morbidity and any patient deteriorated on clinical scales although radiology was not always improved. DISCUSSION AND CONCLUSIONS: The aggressive treatment of spinal infection is indicated when conservative means are insufficient. Surgery permits a better recovery of the neurological deficit, and prevents spinal deformity and pain produced by the disease.

[Intradural cervical lipoma without neurologic involvement; report of a case]. / Lipoma cervical intradural sin compromiso neurológico; a propósito de un caso.

Lipomas are masses composed of mature adipose tissue, usually affecting lumbosacral levels, often associated with neural tube defects. Spinal lipomas at more rostral levels are usually unassociated with congenital abnormalities, but may produce a more severe neural compromise. Rare reports of cervical lipoma without neurological deficit have been described. We present the case of a 10-years-old girl who complained of cervical pain and stiff neck related to a C7-T1 intradural lipoma, without neurological affectation. The lipoma was partially resected without postoperative deterioration.

Lipoma cervical intradural sin compromiso neurológico; a propósito de un caso / Intradural cervical lipoma without neurological compromise: case report

Los lipomas son masas de tejido adiposo maduro, que se localizan con más frecuencia en la zona lumbosacra, y se asocian frecuentemente a defectos del tubo neural. Los lipomas espinales a niveles más rostrales se asocian con menos frecuencia con malformaciones congénitas, pero pueden producir afectación neurológica más grave. Sólo se han descrito raros casos de lipomas a nivel cervical sin compromiso neurológico. Presentamos una paciente de 10 años de edad que se quejaba de dolor cervical y tortícolis leve en relación con un lipoma intradural a nivel C7-T1 y sin afectación neurológica. El lipoma fue intervenido y resecado subtotalmente sin deterioro postoperatorio (AU)

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Tratamiento quirúrgico de pacientes con infección raquídea / Surgical treatment of patients with spinal infection

Introducción. El tratamiento quirúrgico de la patología infecciosa del raquis, relegado en parte por el desarrollo de tratamientos antibióticos más eficaces y por temor a la morbilidad asociada, está resurgiendo de nuevo con el aumento de pacientes con patologías debilitantes. Material y métodos. Se estudian retrospectivamente las historias clínicas de 27 pacientes sometidos a cirugía por infección raquídea entre Enero de 1990 y Diciembre de 1999 en nuestro Servicio. Se evalúan la evolución clínica mediante las escalas Frankel y Karnofsky y la angulación radiológica del raquis. Resultados. Predominan los varones (n=17) y la localización dorsal (n=14). La mayoría de los pacientes presentaban dolor y en 13 de ellos hubo afectación neurológica. Se practicaron 29 intervenciones en estos 27 pacientes. Uno de ellos fue intervenido por la misma patología antes del período estudiado, cirugía que no ha sido considerada en la presente revisión. En total se realizaron 5 laminectomías simples y 4 instrumentadas, 6 corpectomías simples, 10 con instrumentación anterior y otras 4 con instrumentación posterior. Falleció un paciente, la morbilidad no fue definitiva en los demás, y ningún paciente empeoró en las escalas empleadas aunque no siempre mejoró la imagen radiológica. Discusión y conclusiones. El tratamiento agresivo de las infecciones vertebrales está indicado en los casos que no se resuelven de manera conservadora. La cirugía permite una mejor recuperación de la afectación neurológica, deformidades y dolor producidos por la enfermedad (AU)

Aneurisma gigante de rápido crecimiento / Giant aneurysm of fast development

Los aneurismas de más de 2'5 cm de diámetro suponen el 3-13 por ciento de los aneurismas intracraneales, son más frecuentes en mujeres. Su edad de aparición suele ser más tardía que los de menor tamaño, aunque se encuentran en pacientes menores de 20 años de edad en el 20 por ciento de los casos. Su patogenia no está aún completamente clara. Se presenta el caso de una paciente de 24 años que ingresa tras sufrir una crisis convulsiva generalizada con disfasia y hemiparesia derecha residuales debidas a una hemorragia subaracnoidea por rotura de un aneurisma gigante de fosa temporal izquierda, y que fallece en las horas siguientes por resangrado. Esta paciente había sido estudiada en los últimos siete años en nuestra consulta por presentar osteomas frontales, que no precisaron tratamiento, sin evidencia en la tomografía axial computerizada (TAC) de alteraciones intracraneales. Unos meses antes de su muerte, había sufrido una otitis micótica izquierda y se hallaba en estudio por reaparecer tras su curación una cefalea hemicránea izquierda, sin localidad neurológica. Este caso aporta una nueva evidencia de la rápida aparición de un aneurisma de gran tamaño silente hasta poco antes del desenlace fatal (AU)

[Warthin's tumor in the neck]. / Tumor de Warthin de localización cervical.

Papillar lymphomatous cystoadenoma on the neck as first stage of development. Other lesions of this nature in atypical areas as larynx, minor salivary glands or oropharynx has been described, but is not frequent on heterotopic location so peculiar. In that case the real diagnostic problem was the differential with neck masses. Description of the case and review of the literature.

[Pharyngeal tuberculosis: a clinical case]. / Tuberculosis faríngea. Caso clínico.

A case of pharyngeal tuberculosis secondary to pulmonary tuberculosis is reported. The importance of biopsy for the histopathological and microbiological diagnosis is emphasized.

Diagnostic yield of stimulation and voluntary single-fiber electromyography in myasthenia gravis.

Voluntary and stimulation single-fiber electromyography were performed in the extensor digitorum communis muscle of 15 myasthenic patients. The increase in mean and individual mean consecutive difference as well as the proportion of blocking in the volitional activation were greater than in the stimulation method. These differences may be explained in part by the different degree of alteration in large as compared with small motor units in patients with myasthenia gravis.

[Berger's disease and acquired sensorineural hearing loss]. / Enfermedad de Berger e hipoacusia neurosensorial de origen adquirido.

A relation between kidney and inner ear disease, specifically neurosensorial hearing loss, has been established. Likewise, the role of tonsillitis in certain glomerulonephritides is well known. A case of post-streptococcal mesangial glomerulonephritis with IgA deposit (Berger's disease) and neurosensorial hearing loss is reported. The absence of any relevant family or personal history suggests an immunological origin for both disorders.

[Myoepithelial adenoma of palate minor salivary gland]. / Adenoma mioepitelial de glándula salival menor de paladar.

A case of myoepithelial adenoma of hard palate minor salivary glands is reported. This is a very rare tumor. Histological, clinical and therapeutical aspects are discussed and a literature review is carried out.

The carpal tunnel syndrome. Relationship between median distal motor latency and graded results of needle electromyography.

Needle Electromyography (NEMG) was performed in 228 patients who had been diagnosed by means of motor and sensory median nerve conductions of having Carpal Tunnel Syndrome (CTS). Evaluating abnormal spontaneous muscle activity (fibrillations, positive sharp waves, fasciculation potentials and myokymic discharges) and recruitment pattern, 51.7% of them showed abnormal NEMG. According to the amount of abnormality found, the studies were classified into: normal, grade 1, grade 2 and grade 3. Median Distal Motor Latency (DML) to APB was prolonged beyond the upper confidence limit in 155 (68%) hands, showing a mean value of 5.69 +/- 2.79 msec. Statistically significant difference (p < 0.001) of DML mean value among patients with a NEMG "normal", "grade 1" or "grade 2" have been found. We revise previous reports about NEMG on the CTS and discuss practical consequences of our findings.

Continuous muscle activity and distal spinal muscular atrophy.

A young man presented with myokymias, cramp-like difficulty in muscle relaxation and peroneal atrophy. EMG studies revealed continuous muscle activity (CMA) manifested as grouped potentials and high frequency discharges. Sensory nerve conduction studies and sural nerve biopsy gave normal results, and he was thought to suffer from distal spinal muscular atrophy with CMA. This association suggests that the lower motor neuron may have an important role in the generation of the continuous muscle activity.