Embolización preoperatoria con Onyx en tumores cuya irrigación principal proviene de la arteria cerebelosa superior. Reporte de dos casos y revisión de la literatura / Preoperative embolization with Onyx in tumors whose main supply comes from the superior cerebellar artery. Report of two cases and review of the literature

Introducción : Los hemangioblastomas y los meningiomas son neoplasias intracraneales frecuentes en las cuales la resección quirúrgica total es el tratamiento indicado. En algunas situaciones, son lesiones altamente vascularizadas, por lo cual es de utilidad la embolización preoperatoria. Descripción de los casos : Caso 1: paciente mujer de 42 años de edad, que consultó por cuadro de hipertensión endocraneana y ataxia de tipo cerebeloso. Se realizó resonancia magnética, la cual mostró un proceso expansivo en la parte superior del vermis cerebeloso. La angiografía cerebral demostró un tumor muy vascularizado, a expensas de la arteria cerebelosa superior. Previo a la cirugía se realizó una embolización con Onyx. Dos días después del procedimiento endovascular, se realizó la exéresis completa del tumor. La anatomía patológica informó hemangioblastoma. Caso 2: paciente mujer de 34 años de edad, que consultó por cuadro de cefalea intensa. La resonancia magnética mostró un tumor tentorial izquierdo, con crecimiento hacia arriba. Se realizó angiografía cerebral, la cual mostró que la irrigación principal del tumor provenía de la arteria cerebelosa superior. Se realizó una embolización preoperatoria del tumor con Onyx. Tres días después del tratamiento endovascular, se realizó la exéresis completa de la lesión. La anatomía patológica informó meningioma transicional. Discusión: La recomendación de embolización preoperatoria sería en pacientes con hemangioblastomas sólidos, de gran tamaño, irrigados por vasos que no puedan ser manipulados inmediatamente durante la resección. Algo similar sucede con los meningiomas. Sin embargo, es necesario evaluar caso por caso, ya que la embolización per se implica un riesgo para el paciente. Conclusión: Cuando es necesario, se puede realizar en forma segura y efectiva la embolización con Onyx a través de la arteria cerebelosa superior, de un tumor cuya irrigación principal está dada por dicha arteria y su acceso en una etapa temprana de la cirugía es difícil.

Introduction: Hemangioblastomas and meningiomas are frequent intracranial neoplasms in which gross total resection is the indicated treatment. In some situations, they are highly vascularized lesions, and preoperative embolization is useful. Description of the cases : Case 1: a 42-year-old female patient who consulted due to intracranial hypertension and cerebellar ataxia. Magnetic resonance imaging was performed, which showed an expansive process in the upper part of the cerebellar vermis. Cerebral angiography showed a highly vascularized tumor, at the expense of the superior cerebellar artery. Prior to surgery, Onyx embolization was performed. Two days after the endovascular procedure, gross total resection of the tumor was performed. The pathology reported hemangioblastoma. Case 2: a 34-year-old female patient who consulted due to severe headache. Magnetic resonance imaging showed a left tentorial tumor, with upward growth. Cerebral angiography was performed, which showed that the main irrigation of the tumor came from the superior cerebellar artery. A preoperative embolization of the tumor with Onyx was performed. Three days after endovascular treatment, gross total resection of the tumor was performed. The pathology reported transitional meningioma. Discussion : The recommendation of preoperative embolization would be in patients with solid hemangioblastomas, irrigated by vessels that cannot be manipulated immediately during resection. Something similar happens with meningiomas. However, it is necessary to evaluate case by case, since embolization per se implies a risk for the patient. Conclusion : When necessary, embolization with Onyx, through the superior cerebellar artery, of a tumor whose main irrigation is given by that artery and tis access at an early stage of surgery is difficult, can be performed safely and effectively.

Tratamiento combinado de MAVs intra craneales, embolización seguida de cirugía, por el mismo equipo de neurocirujanos. nuestra experiencia / Combined treatment of intracranial AVM, embolization followed by surgery, by the same team of neurosurgeons. our experience

Objetivo: Reportar nuestra experiencia en tratamiento combinado de MAVs intra craneales, embolización con Onyx y posterior resección micro quirúrgica. Material y Método: Se realizó un análisis retrospectivo descriptivo de los pacientes portadores de MAVs tratados por vía endovascular y luego operados por el mismo equipo. Entre agosto del 2009 y junio del 2014 tratamos 26 MAVs. Resultados: El 65% sexo masculino, el 35% femenino. La frecuencia de edades fue, 4% de 0 a 10 años, 31% de 11 a 20 años, 19% de 21 a 30 años, 19% de 31 a 40 años, 12% de 41 a 50 años, 15% de 51 a 60 años. La distribución de acuerdo a la escala de Spetzler-Martin fue; grado 2 29%, grado 3 50%, grado 4 21%. La forma de presentación más frecuente fue la hemorragia en 13 pacientes (50%), convulsiones 27%, cefalea 8%, robo circulatorio 15%. El porcentaje de lesión ocluida previa a la cirugía, el mínimo fue de 40%, el máximo 95% y el promedio 70,38% de oclusión. En el 50% de los casos la cirugía fue asistida con navegación. El promedio de pérdida hemática por paciente fue de 250 ml. De 43 sesiones de embolización, tuvimos 3 complicaciones (7%) relacionadas al procedimiento. La morbilidad relacionada a la cirugía fue del 11%. Conclusiones: El tratamiento endovascular con catéteres desprendibles y Onyx, es seguro, con baja morbilidad, permite altos grados de oclusión lo cual asegura una cirugía menos sangrante y con menor morbilidad.

Objective: To report our experience with the treatment of brain arteriovenous malformations (AVM) with surgical resection after embolization with Onyx liquid embolic agent. Methods: Between August 2009 and June 2014, 26 patients were treated by the same surgical-endovascular team. Results: The 65% were male, 35% female. 4% were 0 to 10 years, 31% 11-20 years, 19% 21-30 years, 19% 31-40 years, 12% 41-50 years, 15% 51-60 years. According Spetzler- Martin scale; grade 2 29%, grade 3 50%, grade 4 21%. The most frequent clinic presentation was hemorrhage 13 patients (50%). The average preoperative volumetric obliteration was 70,38%. The 50% of surgeries were navigation assisted. The average blood loss during resection was 250 ml. The morbidity related to the endovascular procedures were 7%. Surgery related morbidity were 11%. Conclusion: The preoperative embolization whit Onyx and detachable micro catheters is safe and effective with low morbidity, it allows high grades of intra nidal obliteration with less blood loss in surgery.

Obesity and pulmonary embolism: the mounting evidence of risk and the mortality paradox.

PURPOSE: To determine the prevalence of pulmonary embolism in obese patients according to age, gender and comorbid conditions and explore the relation of obesity to mortality. METHODS: The number of patients discharged from short-stay hospitals throughout the United States from 1998-2008 with pulmonary embolism who were obese or not obese, and in-hospital all-cause mortality were determined from the Nationwide Inpatient Sample. RESULTS: From 1998-2008, 203,500 of 17,979,200 (1.1%) obese patients were diagnosed with pulmonary embolism compared with 2,034,100 of 346,049,800 (0.6%) non-obese patients [relative risk (RR) =2.03]. Relative risk for pulmonary embolism was highest among obese patients aged 11-20 years (RR=5.80) and was higher in obese women (RR=2.08) than in obese men (RR=1.74). Mortality was 4.3% in obese patients with pulmonary embolism compared with 9.5% in non-obese patients (RR=0.45). Obesity had the greatest effect on mortality in older patients and little effect in teenagers and young adults. Among stable patients who did not receive thrombolytic therapy, mortality was 3.8% in obese patients and 8.4% in non-obese patients (RR=0.45). Among unstable patients, obesity had little effect on mortality. CONCLUSIONS: The prevalence of pulmonary embolism in hospitalized patients was higher in obese patients than in non-obese patients. Mortality in patients with pulmonary embolism was lower in obese patients than in non-obese patients, with the greatest effects in women, older patients and stable patients.

Obesity and thromboembolic disease.

Various abnormalities of hemostasis have been described in obesity, mainly concerning increased levels of plasminogen activator inhibitor-1, but other abnormalities of coagulation and platelet activation have been reported as well. Circulating microparticles have also been observed in obese patients. These suggest that obesity would be a risk factor for venous thromboembolism (VTE). Analysis of the database of the National Hospital Discharge Survey showed compelling evidence that obesity is, in fact, a risk factor for VTE. Obesity is also a risk factor for recurrent VTE. A synergistic effect of oral contraceptives with obesity has been shown.

Diabetes mellitus and risk of venous thromboembolism.

BACKGROUND: : To determine if diabetes mellitus is a risk factor for venous thromboembolism (VTE). RESEARCH DESIGN AND METHODS: : Data from the National Hospital Discharge Survey were analyzed from 1979 to 2005. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify diseases. RESULTS: : Among 92,240,000 patients with diabetes mellitus discharged between 1979 and 2005, 1,267,000 (1.4%) had VTE. The relative risk for VTE was elevated only in patients younger than 50 to 59 years and was highest in patients aged 20 to 29 years (relative risk = 1.73). Relative risks of VTE with uncomplicated type 1 diabetes mellitus and uncomplicated type 2 diabetes mellitus were similar and also age dependent. In patients with uncomplicated diabetes mellitus who did not have obesity, stroke, heart failure, or cancer, compared with those who did not have diabetes mellitus and did not have any of these comorbid conditions, the relative risk for VTE was 1.52 in patients aged 20 to 29 years and 1.19 in patients aged 30 to 39 years. In older patients, the relative risk of VTE in patients with diabetes mellitus was not increased. CONCLUSIONS: : Diabetes mellitus carries an increased risk for VTE, which is apparent only in younger patients in whom comorbid conditions that also increase the risk of VTE are unlikely to be present.

Apoplejía de adenomas hipofisarios: Reporte de cuatro casos / Pituitary apoplexy: Report of 4 cases

Objective. To describe four cases of patients with pituitary tumor apoplexyMaterial and method. We analyzed the information of four patients with pituitary tumor apoplexy. Results. One patient had acromegaly and the apoplexy happened during a treatment with lanreotido. The other three cases were patients with non functional pituitary tumors. All the cases were operated by endonasal transsphenoidal approach. Conclusion. Classic manifestations of pituitary tumor apoplexy include severe headache, visual field defects, and ophthalmoplegia. In the absence of contraindications, transsphenoidal decompression is recommended in most patients. pituitary tumor apoplexy include severe headache, visual field defects, and ophthalmoplegia. In the absence of contraindications, transsphenoidal decompression is recommended in most patients.

Olfactory groove meningiomas from neurosurgical and ear, nose, and throat perspectives: approaches, techniques, and outcomes.

OBJECTIVE: To review the surgical approaches, techniques, outcomes, and recurrence rates in a series of 80 olfactory groove meningioma (OGM) patients operated on between 1990 and 2003. METHODS: Eighty patients underwent 81 OGM surgeries. Tumor diameter varied from 2 to 9 cm (average, 4.6 cm). In 35 surgeries (43.2%), the tumor was removed through bifrontal craniotomy; nine operations (11.1%) were performed through a unilateral subfrontal approach; 18 surgeries (22.2%) were performed through a pterional approach; seven surgeries (8.6%) were carried out using a fronto-orbital craniotomy; and 12 procedures (14.8%) were accomplished via a subcranial approach. Nine patients (11.3%) had undergone surgery previously and had recurrent tumor. RESULTS: Total removal was obtained in 72 patients (90.0%); subtotal removal was achieved in 8 patients (10.0%). Two patients, one with total and one with subtotal removal, had atypical (World Health Organization Grade II) meningiomas, whereas 78 patients had World Health Organization Grade I tumors. There was no operative mortality and no new permanent focal neurological deficit besides anosmia. Twenty-five patients (31.3%) experienced surgery-related complications. There were no recurrences in 75 patients (93.8%) 6 to 164 months (mean, 70.8 mo) after surgery. Three patients (3.8%) were lost to follow-up. In two patients (2.5%) with subtotal removal, the residual evidenced growth on computed tomography and/or magnetic resonance imaging 1 year after surgery. One of them had an atypical meningioma. The second, a multiple meningiomata patient, was operated on twice in this series. CONCLUSION: A variety of surgical approaches are used for OGM resection. An approach tailored to the tumor's size, location, and extension, combined with modern microsurgical cranial base techniques, allows full OGM removal with minimal permanent morbidity, excellent neurological outcome, and very low recurrence rates.