Alteration of major vault protein in human glioblastoma and its relation with EGFR and PTEN status.

Glioblastoma (GBM) is the most frequent and malignant primary brain tumor. Conventional therapy of surgical removal, radiation and chemotherapy is largely palliative. Major vault protein (MVP), the main component of the vault organelle has been associated with multidrug resistance by reducing cellular accumulation of chemotherapeutic agents. With regard to cancer, MVP has been shown to be overexpressed in drug resistance development and malignant progression. The aim of the present study was to evaluate the MVP gene dosage levels in 113 archival samples from GBM and its correlation with patients' survival and epidermal growth factor receptor (EGFR) and phosphatase and tensin homolog (PTEN) gene dosages. Fluorescent in situ hybridization revealed polysomy of chromosome 7 in 76.1% of the GBMs and EGFR amplification in a 64.6% of the tumors. Genetic status of EGFR, PTEN and MVP copies was determined by multiplex ligation-dependent probe amplification (MLPA) technique. 31% of the tumors showed the EGFR is variant III mutation (EGFRvIII) mutation and 74.3% of them presented amplification of MVP gene. Amplification of EGFR and MVP was found in a 63.7% and 56.6% of the GBM, respectively. An inverse correlation between MVP and PTEN dosage values was observed. Besides, an inverse relationship between the survival of the patients treated with chemotherapy and the levels of MVP copies was determined. In conclusion, our study reveals an important role of MVP, together with EGFRvIII and PTEN, in the progression of GBM and proposes it as a novel and interesting target for new treatment approaches.

[Treatment of a giant serpentine type middle cerebral artery aneurysm with a high-flow bypass from the petrous internal carotid artery]. / Tratamiento de un aneurisma serpentino gigante de arteria cerebral media conbypass de alto flujo desde la arteria carótida interna petrosa.

A case report of a giant serpentine type aneurysm arising from the M1 segment of the middle cerebral artery (MCA) treated with a high-flow external saphenous vein graft from the petrous segment of the internal carotid artery is presented. The steps and challenges of this demanding surgical technique are also described. The elements to be taken into consideration in the indication, design and realization of the bypass surgery in the treatment of the MCA aneurysms are discussed.

Tratamiento de un aneurisma serpentino gigante de arteria cerebral media con bypass de alto flujo desde la arteria carótida interna petrosa / Treatment of a giant serpentine type middle cerebral artery aneurysm with a high-flow bypass from the petrous internal carotid artery

Se presenta un caso de aneurisma gigante del segmento M1 de la arteria cerebral media (ACM), de tipo serpentino, tratado mediante bypass de alto flujo con vena safena externa desde la arteria carótida interna petrosa. Se describen los pasos de la cirugía y se destacan las dificultades de la técnica. Se discuten los elementos a considerar en la toma de decisiones para la indicación, diseño y realización del bypass en el tratamiento de los aneurismas de la ACM (AU)

A case report of a giant serpentine type aneurysm arising from the M1 segment of the middle cerebral artery (MCA) treated with a high-flow external saphenous vein graft from the petrous segment of the internal carotid artery is presented. The steps and challenges of this demanding surgical technique are also described. The elements to be taken into consideration in the indication, design and realization of the bypass surgery in the treatment of the MCA aneurysms are discused (AU)

[Management and microsurgical treatment of infundibular dilatations of the posterior communicating artery. Series of nine cases and review of the literature]. / Manejo y traramiento microquirurgico de las dilataciones infundibulares de la arteria comunicante posterior. Seri de nueve casos y revision de la literatura.

INTRODUCTION: The infundibular dilatation (ID) of the posterior communicating (PCom) artery is defined as the conic, triangular or infundibular shaped, less than 3mm wide, origin of the PCom artery from the internal carotid artery. The purpose of this paper is to present the personal experience in the microsurgical management of the ID, to review the literature and to propose some algorithms to improve its clinical and microsurgical management. MATERIAL AND METHODS: Nine cases of ID have been operated on through a pterional approach. In four patients with subarachnoid hemorrhage (SAH) the ID was considered as the potential source of the bleeding; in four cases the ID was treated after a SAH due to the rupture of an aneurysm; finally, an ID was treated in patient with diagnosis of pseudoxantoma elasticum. RESULTS: In eight cases the ID was clipped and the Pcom artery subsequently occluded and in the remaining case the ID was associated with a fetal PComA and the ID was reinforced. There were no complications excepting a transitory third cranial nerve paresis. The Glasgow Outcome Scale was 5 in all cases at discharge and one year later. CONCLUSIONS: The true significance of the ID remains unknown, but in some instances it is necessary to consider its management: 1. In patients with ruptured aneurysms submitted to microsurgical clipping and with an ipsilateral ID, the lesion must be explored and treated; 2. In patients with ruptured aneurysms treated with endovascular procedures or harbouring an ID contralateral to a microsurgically treated aneurysm, the microsurgical indication will be done after considering all risk factors; 3. In patients with SAH and an ID as the only potential source of the bleeding there would be an indication for microsurgical exploration; 4. The incidental finding of an ID should be indication for observation in absence of major risk factors.

Manejo y tratamiento microquirúrgico de las dilataciones infundibulares de la arteria comunicante posterior. Serie de nueve casos y revisión de la literatura / Management and microsurgical treatment of infun-dibular dilatations of the posterior communicating artery. Series of nine cases and review of the literature

Introducción. La dilatación infundibular (DI) de la arteria comunicante posterior (AComP) se define como la dilatación cónica, triangular o en forma de embudo, menor de 3 mm, en el origen de la AComP de la arte­ria carótida interna. El propósito del presente trabajo es presentar la experiencia propia en el tratamiento microquirúrgico de la DI de la AComP, revisar la biblio­grafía y proponer algoritmos para optimizar su manejo clínico y microquirúrgico. Material y métodos. Se han estudiado nueve casos de DI intervenidos a través de un abordaje pterional. En cuatro pacientes con hemorragia subaracnoidea (HSA) la DI se consideró la única causa del sangrado; en otros cuatro pacientes la DI se intervino tras una HSA por ruptura de otra lesión aneurismática; finalmente, en un paciente con pseudoxantoma elástico la DI se intervino de forma preventiva. Resultados. En ocho casos se procedió al clipaje de la DI y cierre de la AComP y en uno al reforzamiento de la DI al tratarse de una AComP del tipo fetal. No aparecie­ron complicaciones salvo una paresia transitoria del III par. El Glasgow Outcome Scale al alta y al año fue de 5 en todos los casos. Conclusiones. La DI de la AComP es una lesión de significado no aclarado, pero que plantea la necesidad de considerar su tratamiento en algunas ocasiones: 1. En pacientes con aneurismas rotos sometidos a cirugía y DI homolateral se recomienda explorar y tratar la lesión; (..) (AU)

Introduction. The infundibular dilatation (ID) of the posterior communicating (PCom) artery is defined as the conic, triangular or infundibular shaped, less than 3mm wide, origin of the PCom artery from the internal carotid artery. The purpose of this paper is to present the personal experience in the microsurgical manage­ment of the ID, to review the literature and to propose some algorithms to improve its clinical and microsurgi­cal management. Material and methods. Nine cases of ID have been operated on through a pterional approach. In four patients with subarachnoid hemorrhage (SAH) the ID was considered as the potential source of the bleeding; in four cases the ID was treated after a SAH due to the rupture of an aneurysm; finally, an ID was treated in patient with diagnosis of pseudoxantoma elasticum. Results. In eight cases the ID was clipped and the Pcom artery subsequently occluded and in the remai­ning case the ID was associated with a fetal PComA and the ID was reinforced. There were no complications excepting a transitory third cranial nerve paresis. The Glasgow Outcome Scale was 5 in all cases at discharge and one year later. Conclusions. The true significance of the ID remains unknown, but in some instances it is necessary to con­sider its management: 1. In patients with ruptured aneurysms submited to microsurgical clipping and with an ipsilateral ID, the lesion must be explored and treated; 2. In patients with ruptured aneurysms treated with endovascular procedures or harbouring an ID contralateral to a microsurgically treated aneurysm, the microsurgical indication will be done after conside­ring all risk factors; 3. In patients with SAH and an ID as the only potential source of the bleeding there would be an indication for microsurgical exploration; 4. The incidental finding of an ID should be indication for (..) (AU)

[Olfactory groove meningiomas. Radical microsurgical treatment through the bifrontal approach]. / Meningiomas del surco olfatorio. Tratamiento microquirúrgico radical por via bifrontal.

OBJECTIVES: To describe the microsurgical technique for the radical removal of olfactory groove meningiomas through the bifrontal approach. To review the diagnostic elements to be taken into account in the selection of the surgical approach to these tumours. MATERIALS AND METHODS: A microsurgical series of 35 olfactory groove meningiomas operated on through a bifrontal craniotomy is reviewed. RESULTS: The mean tumoral volume was 85cc (4.4cm diameter). A relevant peritumoral brain edema was found in 65.7% of cases, hyperostosis in the implantation base in 80% and paranasal sinus invasion in 28.6%. A Sipmson grade 1 resection was achieved in every case. A patient died due to a postoperative pneumonia. Postoperative hospitalization time was between 3 and 20 days and at discharge all patients had a Glasgow Outcome Scale grade 4-5. The mean follow-up was 55.2 months. Two patients had postoperative transient rhinolicuorrhea and an additional patient developed hydrocephalus. An asymptomatic recurrence have been identified in a patient four years after surgery. CONCLUSIONS: In our experience the bifrontal approach allowed the radical removal of huge olfactory groove meningiomas. The microdissection of the anterior cerebral artery A2 segments is possible thanks to the arachnoidal plane between vessels and tumor. Tumoral blood flow is secured by the early approaching of the base of the tumor and preoperative embolization is not necessary. Bifrontal approach allows an aggressive treatment of the hyperostosis, bone infiltration and paranasal sinus invasion. Anterior fossa reconstruction is done using a vascularized periosteal flap.

[Treatment of intrinsic brain tumors located in motor eloquent areas. Results of a protocol based in navigation, tractography and neurophysiological monitoring of cortical and subcortical structures]. / Tratamiento de los tumores cerebrales intrínsecos de áreas motoras elocuentes. Resultados de un protocolo basado en la navegación, tractografía y monitorización neurofisiológica de estructuras corticales y subcorticales.

OBJECTIVES: The role of the microsurgical management of intrinsic brain tumors is to maximize the volumetric resection of the tumoral tissue minimizing the postoperative morbidity. The purpose of our paper has been to study the benefits of an original protocol developed for the microsurgical treatment of tumors located in eloquent motor areas where the navigation and electrical stimulation of motor subcortical pathways have been implemented. MATERIALS AND METHODS: A total of 17 patients operated on for resection of cortical or subcortical tumors in motor areas were included in the series. Preoperative planning for multimodal navigation was done integrating anatomic studies, motor functional MRI (f-MRI) and subcortical pathways volumes generated by diffusion tensor imaging (DTI). Intraoperative neuromonitorization included motor mapping by direct cortical and subcortical electrical stimulation (CS and sCS) and localization of the central sulcus using cortical multipolar electrodes and the N20 wave inversion technique. The location of all cortical and subcortical stimulated points with positive motor response was stored in the navigator and correlated with the cortical or subcortical motor functional structures defined preoperatively. RESULTS: The mean tumoral volumetric resection was 89.1±14.2% of the preoperative volume, with a total resection (≥100%) in twelve patients. Preoperatively a total of 58.8% of the patients had some motor deficit, increasing 24 hours after surgery to 76.5% and decreasing to 41.1% a month later. There was a great correlation between anatomic and functional data, both cortically and subcortically. However, in six cases it was not possible to identify the central sulcus and in many cases fMRI gave contradictory information. A total of 52 cortical points submitted to CS had positive motor response, with a positive correlation of 83.7%. Also, a total of 55 subcortical points had positive motor response, being in these cases 7.3±3.1 mm the mean distance from the stimulated point to the subcortical tract. CONCLUSIONS: The integration of preoperative and intraoperative anatomic and functional studies allows a safe functional resection of the brain tumors located in eloquent areas, compared to the tumoral resection based on anatomic imaging studies. Multimodal navigation allows the integration and correlation among preoperative and intraoperative anatomic and functional data. Cortical motor functional areas are anatomically and functionally located preoperatively thanks to MRI and fMRI and subcortical motor pathways with TDI and tractography. Intraoperative confirmation is done with CS and N20 inversion wave for cortical structures and with sCS for subcortical pathways. With this protocol we achieved a mean of 90% of volumetric resection in cortical and subcortical tumors located in eloquent motor areas with an increase of neurological deficits in the immediate postoperative period that significantly decreased one month later. Ongoing studies will define the safe limits for functional resection taking into account the intraoperative brain shift. Finally, it must be demonstrated if this protocol has any benefit for patients concerning disease free or overall survival.

Tratamiento de los tumores cerebrales intrínsecos de áreas motoras elocuentes. Resultados de un protocolo basado en la navegación, tractografía y monitorizaciónneurofisiológica de estructuras corticales y subcorticales / Treatment of intrinsic brain tumors located in motor eloquent areas. results of a protocol based in navegation, tractography and neurophysiological monitoring of cortical and subcortical structures

Objetivos. El papel actual del tratamiento microquirúrgicode los tumores cerebrales intrínsecos se basaen alcanzar la máxima resección volumétrica del tumorminimizando la morbilidad postoperatoria. El propósitodel trabajo es estudiar los beneficios de un protocolodiseñado para tratar tumores localizados en áreaselocuentes motoras, en el que se incluye la navegación yla estimulación de tractos motores subcorticales.Material y métodos. Se han incluido 17 pacientescon tumores corticales y subcorticales de área motoratratados quirúrgicamente. Para la planificación preoperatoriase fusionaron en el sistema de navegaciónestudios anatómicos, de resonancia funcional motora(RNM-f) y los tractos subcorticales generados porestudios de tensor de difusión (DTI). La monitorizaciónintraoperatoria incluía el mapeo motor por estimulacióncortical y subcortical directa (ECD y EsCD) e identificacióndel surco central por inversión de la onda N20con electrodos corticales multipolares. La localizaciónde los puntos con respuesta positiva a la ECD o EsCD secorrelacionaba con las áreas corticales o tractos funcionalesmotores definidos en los estudios preoperatoriosgracias al navegador.Resultados. La resección volumétrica tumoral mediafue del 89.1±14.2% del volumen tumoral calculado enlos estudios preoperatorios, con resección total (≥100%)en doce pacientes. En el preoperatorio había focalidadneurológica deficitaria motora en el 58.8% de lospacientes, que aumentó al 76.5% a las 24 horas de lacirugía y se redujo a los 30 días al 41.1%. Hubo una (..) (AU)

Objectives. The role of the microsurgical managementof intrinsic brain tumors is to maximize the volumetricresection of the tumoral tissue minimizing thepostoperative morbidity. The purpose of our paper hasbeen to study the benefits of an original protocol developedfor the microsurgical treatment of tumors locatedin eloquent motor areas where the navigation and electricalstimulation of motor subcortical pathways havebeen implemented.Materials and methods. A total of 17 patients operatedon for resection of cortical or subcortical tumors inmotor areas were included in the series. Preoperativeplanning for multimodal navigation was done integratinganatomic studies, motor functional MRI (f-MRI)and subcortical pathways volumes generated by diffusiontensor imaging (DTI). Intraoperative neuromonitorizationincluded motor mapping by direct corticaland subcortical electrical stimulation (CS and sCS) andlocalization of the central sulcus using cortical multipolarelectrodes and the N20 wave inversion technique.The location of all cortical and subcortical stimulatedpoints with positive motor response was stored in thenavigator and correlated with the cortical or subcorticalmotor functional structures defined preoperatively.Results. The mean tumoral volumetric resection (..) (AU)

[Using thermal diffusion flowmetry in the assesment of regional cerebral blood flow in cerebral aneurysm microsurgery]. / Flujometría por difusióón termal para la medida del flujo sanguíneo cerebral regional en la cirugía de los aneurismas cerebrales.

INTRODUCTION: the thermal diffusion flowmetry (TDF) is a technique that allows the measurement of the regional cerebral blood flow (rCBF) through an implanted microprobe in a cerebral region of interest. The monitoring is continuous, real-time and quantitative (ml/100g/min). The purpose of our clinical work has been to show the technical details and preliminary results by using this monitoring technique during the microsurgical management of cerebral aneurysms and along the postoperative period. The aim of the monitoring of the rCBF is to identify and evaluate ischemic events related with the temporary artery clipping or malposition of the final clip. CLINICAL MATERIALS: a total of five patients have been monitored (4 woman and one man with an average age of 50.8 years). Two patients harboured one aneurysm in the middle cerebral artery, other two patients had two aneurysms each one on the internal carotid artery in the exit of the posterior communicating and anterior choroidal artery and the fifth harboured a paraclinoid internal carotid artery aneurysm. All patients were operated on using standard microsurgical techniques through a pterional approach. Surgery was done under neurophysiological monitoring and direct microdoppler fluometry assesment. Just before craniotomy the TDF microprobe was inserted 2.5 cm deep into the white matter through a small burr-hole placed on the coronal line and 2 cm away the midline to measure in the anterior cereral artery vascular sector and 6cm away of the midline to measure in the middle cerebral artery territory. Patients were under continuous monitoring during surgery and along the postoperative period in the recovery unit. A total of 14 temporary artery clippings (between 2-4) with an average total clipping time of 7.2 minutes (ranging 1.6 to 16) and 16 definitive clip replacements (ranging 2 to 8) were done at surgery. Patient with paraclinoid aneurysm was operated on using the retrograde aspiration technique and the internal carotid artery was kept closed 45 mimutes. keeping Some illustrative cases and demonstrative records are presented. CONCLUSIONS: the use of TDF allows a quantitative real-time measurement of the rCBF in the areas of interest monitored during the microsurgical management of the cerebral aneurysms which leads to detect ischemic events helpping to avoid ischemic sequelae. The detection of ischemic events in real time would make possible the use of therapeutic measures ealier and more efficienty.

Flujometría por difusión termal para la medida del flujo sanguíneo cerebral regionalen la cirugía de los aneurismas cerebrales / Using thermal diffusion flowmetry in the assesment of regional cerebral blood flow in cerebral aneurysm microsurgery

Introducción. La flujometría por difusión termal(FDT) es una técnica que permite, mediante la implantación de una microsonda en una región cerebral de interés, determinar el flujo sanguíneo cerebral regional (FSCr) y su monitorización cuantitativa (ml/100g/min), continua y en tiempo real. El objetivo de nuestro trabajo es mostrar los detalles técnicos y resultados preliminares de esta técnica de monitorización durante la cirugía y el postoperatorio del tratamiento microquirúrgico de los aneurismas cerebrales, donde tendría valor para detectar y cuantificar fenómenos isquémicos relacionados con el clipaje temporal arterial o malposición del clip definitivo. Material clínico. Han sido monitorizados cinco pacientes(4 mujeres y 1 hombre; edad media de 50.8 años),dos de ellos con aneurismas de arteria cerebral media, otros dos con sendos aneurismas de arteria comunicante posterior y coroidea anterior y uno con aneurisma de carótida interna paraclinoideo. Los pacientes fueron intervenidos con técnica microquirúrgica y clipaje de los aneurismas a través de un abordaje pterional. Se utilizó monitorización neurofisiológica peroperatoria y flujometría con microdoppler. Inmediatamente antes de la craneotomía se procedió a la colocación de la microsonda de FDT a través de un minitrépano sobrela línea coronal, en territorio de la arteria cerebral anterior (2 cm de línea media) o de la cerebral media(6 cm de línea media) y en sustancia blanca, a unos 2.5cm de profundidad. Los pacientes fueron monitorizados durante la cirugía y el tiempo en que estuvieron en la Unidad de Reanimación. Se realizaron un total de 14 clipajes temporales (rango 2-4) con un tiempo medio de clipaje de 7.2 min (rango 1.6-16) (..) (AU)

Introduction. The thermal diffusion flowmetry(TDF) is a technique that allows the measurement of the regional cerebral blood flow (rCBF) through an implanted microprobe in a cerebral region of interest.The monitoring is continuous, real-time and quantitative(ml/100g/min). The purpose of our clinical work has been to show the technical details and preliminary results by using this monitoring technique during the microsurgical management of cerebral aneurysms and along the postoperative period. The aim of the monitoring of the rCBF is to identify and evaluate is chemicevents related with the temporary artery clipping or malposition of the final clip.Clinical materials. A total of five patients have been monitored (4 woman and one man with an average age of 50.8 years). Two patients harboured one aneurysm in the middle cerebral artery, other two patients had two aneurysms each one on the internal carotid artery in the exit of the posterior communicating and anterior choroidal artery and the fifth harboured a paraclinoid internal carotid artery aneurysm. All patients were operated on using standard microsurgical techniques through a pterional approach. Surgery was done under neurophysiological monitoring and direct microdoppler fluometry assesment. Just before craniotomy the TDF micropro be was inserted 2,5 cm deep into the white matter through a small burr-hole placed on the coronalline and 2 cm away the midline to measure in the anterior cereral artery vascular sector and 6 cm away of the midline to measure in the middle cerebral artery territory. Patients were under continuous monitoring during surgery and along the postoperative period in the recovery unit. A total of 14 temporary artery clippings (between 2-4) with an average total (..) (AU)

[Microsurgical treatment of internal carotid bifurcation aneurysms]. / Tratamiento microquirúrgico de los aneurismas de la bifurcación de la carótida interna.

Clinical and imaging findings of a series of 14 internal carotid artery bifurcation aneurysms microsurgically treated are presented. A total of 10 lesions were diagnosed before rupture and 4 patients presented with subarachnoidal hemorrhage and frontobasal intracerebral bleeding. Diagnosis was done using neuroimaging (CT scan, angio-CT-3D, angio-MRI, angiography) but patients with ruptured aneurysms were treated with the sole information provided by the angio-CT-3D. The average fundus size was 8.4mm (3-13.3) and the average neck size was 6.8mm (3-9.6), being the fundus-to-neck ratio 1.32 (0.46-2.05). All lesions were microsurgically treated through a pterional approach with the help of temporary clipping of the afferent vessels in all cases. We used peroperative neuroprotective, neuromonitorization and micro-doppler cerebral flow measurement. Clinical results were excellent with 13 patients GOS grade 5 and one grade 4 three month afterwards of hospital discharge and complete exclusion of the lesion in angiographic controls done solely in patients with ruptured lesions.

Tratamiento microquirúrgico de los aneurismas de la bifurcación de la carótidainterna / Microsurgical treatment of internal carotid bifurcation aneurysms

Se presentan los hallazgos clínicos y de imagen deuna serie de 14 aneurismas de bifurcación de la arteriacarótida interna tratados microquirúrgicamente. Untotal de 10 lesiones no se habían roto y las 4 restantesse presentaron con hemorragia subaracnoidea y hematomafrontobasal. El diagnóstico se realizó con técnicasde neuroimagen (TAC, angio-TAC-3D; angio-RNM,angiografía), aunque los pacientes con aneurismasrotos fueron intervenidos con los hallazgos proporcionadospor el angio-TAC-3D. El tamaño medio del sacoera de 8.4mm (3-13.3) y el del cuello 6.8mm (3-9.6),con una relación saco/cuello de 1.32 (0.46-2.05). Laslesiones se trataron por vía pterional sin incidencias ycon ayuda de clipaje temporal en todos los casos. Seutilizaron técnicas peroperatorias de neuroprotección,neuromonitorización y determinación de flujo vascularcon micro-doppler. Los resultados clínicos han sidoexcelentes, con 13 pacientes con GOS 5 y uno con GOS4 a partir de los tres meses del alta y exclusión del aneurismaen los controles angiográficos postquirúrgicosrealizados en los pacientes con aneurisma roto (AU)

Clinical and imaging findings of a series of 14 internalcarotid artery bifurcation aneurysms microsurgicallytreated are presented. A total of 10 lesions werediagnosed before rupture and 4 patients presented withsubarachnoidal hemorraghe and frontobasal intracerebralbleeding. Diagnosis was done using neuroimaging(CT scan, angio-CT-3D, angio-MRI, angiography) butpatients with ruptured aneurysms were treated withthe sole information provided by the angio-CT-3D. Theaverage fundus size was 8.4mm (3-13.3) and the averageneck size was 6.8mm (3-9.6), being the fundus-to-neckratio 1.32 (0.46-2.05). All lesions were microsurgicallytreated through a pterional approach with the help oftemporary clipping of the aferent vessesl in all cases.We used peroperative neuroprotective, neuromonitorizationand micro-doppler cerebral flow measurement.Clinical results were excellent with 13 patients GOSgrade 5 and one grade 4 three month afterwards ofhospital discharge and complete exclusion of the lesionin angiographic controls done solely in patients withruptured lesions (AU)

[Trigonal cavernous angioma: case report]. / Angioma cavernoso del trígono ventricular. Caso clínico.

The authors report on an intraventricular cavernous angioma located at the right trigone in a 25-year-old male patient presented with a predominantly intralesional haemorrhage. Neuroimaging led to an accurate preoperative diagnosis although the typical low intensity perilesional ring of gliosis and hemosiderin was not present. The lesion was microsurgically removed using an stereotactically guided posterior temporal transsulcal approach.

[Intradural anterior clinoidectomy. Anatmoclinical study and its usefulness in the treatment of trans-segmentary C5-C6 trans-segmentary paraclinoid aneurysms]. / Clinoidectomía anterior intradural. Estudio anatomo-clínico y utilidad en eltratamiento de los aneurismas paraclinoideos trans-segmentarios C5-C6.

OBJECTIVE: To present an anatomoclinical study of the intradural anterior clinoidectomy and to evaluate the usefulness of this procedure in the microsurgical management of paraclinoid aneurysms. To describe two cases of a subtype of paraclinoid aneurysms arising from and with their fundus growing both in the clinoidal and subarachnoidal segments of the internal carotid artery (paraclinoid trans-segmentary C5-C6 aneurysms). MATERIAL AND METHODS: The microanatomy of the clinodal region has been studied in dried and fixed specimens. The steps of the intradural anterior clinoidectomy are showed. The imaging and microsurgical findings in two cases of trans-segmentary C5-C6 aneurysms are also described. RESULTS: The C5 clinoid segment of the internal carotid artery is exposed intradurally after anterior intradural clinoidectomy. The transtion between the C5 clinoid and C6 ophthalmic is also exposed and it is movilized only after the section of the carotid distal ring. These manoeuvres allows the microsurgical management and dipping of the trans-segmentary C5-05 aneurysms. CONCLUSIONS: The nomenclature of the internal carotid artery segments and paraclinoid aneurysms remains confuse. Therefore, each lesion should be idetified by the location of the neck (extradural: C4 and C5 segments; intradural: C6 segment), fundus projection and location (intradural / extradural). The microsurgical clipping of the paraclinoid aneurysms is made easier after intradural anterior clinoidectomy, but this manoeuvre is mandatory for trans-segmentary C5-C6 lesions.

Clinoidectomía anterior intradural. Estudio anatomo-clínico y utilidad en el tratamiento de los aneurismas paraclinoideos trans-segmentarios C5-C6 / Intradural anterior clinoidectomy. Anatmoclinical study and its usefulness in the tratatment of trans-segmentary C5-C6 trans-segmentary paraclinoid aneurysms

Objetivo. Realizar un estudio anatomo-clínico dela clinoidectomía anterior intradural y evaluar su utilidad en el tratamiento microquirúrgico de los aneurismas paraclinoideos. Presentar dos casos de un subtipo de aneurismas paraclinoideos, con el cuello y saco ocupando tanto el espacio clinoideo como el subaracnoideo (aneurismas para clinoideos trans-segmentariosC5-C6).Material y métodos. Se ha realizado un estudio microanatómico de la región clinoidea en cráneos secos y espécimenes fijados. Se describen los pasos dela clinoidectomía anterior y los elementos anatómicos que se pueden identificar. Se describen los hallazgos de imagen y quirúrgicos de dos casos de aneurismas para clinoideos trans-segmentarios C5-C6.Resultados. El segmento C5 o clinoideo de la carótida interna se convierte en intradural tras la clinoidectomía anterior intradural, con lo que se expone la transición de los segmentos C5 o clinoideo y el C6 u oftálmico, que se moviliza tras la sección del anillo distal de la carótida. Estas maniobras permiten la identificación microquirúrgica del cuello y saco de los aneurismas trans-segmentarios C5-C6 y su exclusión mediante clipaje. Conclusiones. La nomenclatura de los segmentos de la carótida interna y de los subtipos de aneurismas paraclinoideos permanece confusa y debería unificarse. Las lesiones deberían identificarse por la localización de su cuello (extradural: segmentos C4 y C5;intradural: segmento C6), la proyección del saco y donde está la cúpula (intradural o extradural). El clipaje de los aneurismas para clinoideos se beneficia dela clinoidectomía anterior intradural, que es ineludible para tratar los aneurismas trans-segmentarios C5-C6

Objective. To present an anatomoclinical study of the intradural anterior clinoidectomy and to evaluate theusefulness of this procedure in the microsurgical management of paraclinoid aneurysms. To describe two cases of a subtype of paraclinoid aneurysms arising from and with their fundus growing both in the clinoidal and subarachnoidal segments of the internal carotid artery (paraclinoid trans-segmentary C5-C6 aneurysms).Material and methods. The microanatomy of the clinodal region has been studied in dried and fixed specimens. The steps of the intradural anterior clinoidectomy are showed. The imaging and micro surgicalfindings in two cases of trans-segmentary C5-C6 aneurysms are also described. Results. The C5 clinoid segment of the internal carotid artery is exposed intradurally after anteriorintradural clinoidectomy. The transtion between theC5 clinoid and C6 ophthalmic is also exposed and it ismovilized only after the section of the carotid distal ring.These manoeuvres allows the microsurgical management and dipping of the trans-segmentary C5-05 aneurysms. Conclusions. The nomenclature of the internal carotidartery segments and paraclinoid aneurysms remains confuse. Therefore, each lesion should be idetified by the location of the neck (extradural: C4 and C5 segments; intradural: C6 segment), fundus projection and location(intradural / extradural). The microsurgical clipping of the paraclinoid aneurysms is made easier afte rintradural anterior clinoidectomy, but this manoeuvreis mandatory for trans-segmentary C5-C6 lesions

[Facial nerve palsy due to cavernous angioma of the petrous bone. Case report]. / Parálisis facial por angioma cavernoso del peñasco. Caso clínico.

The facial nerve palsy due to extrinsic tumoral compression of the facial nerve at the geniculate ganglium is very rare. We present the case of a patient with a temporal bone cavernoma and symptoms of a torpid peripheral facial House-Brackmann grade IV nerve palsy with dry eye and loss of stapedial reflex. The routine computed tomographic and magnetic resonance imaging studies showed no abnormalities, but the same imaging techniques done after the clinical suspiction identified a less that 1cm lesion that was compatible with an osseous cavernous angioma. The lesion was approached and removed through a microsurgical middle fossa extradural approach with a good postoperative recovery (House-Brackmann grade II).

[Giant intracranial aneurysms]. / Aneurismas cerebrales gigantes.

AIM: Terminology, concept, pathology and phisiopathology, clinical presentation, imaging diagnosis and treatment of the giant intracranial aneurysms are reviewed. DEVELOPMENT: Saccular, fusiform, dissecting and serpentine giant aneurysms are discussed. Giant saccular aneurysms are developed from small regular congenital lesions growing far away of their critical rupture size due to the reinforcement of their wall. Fusiform and dissecting aneurysms are formed after a wide rupture of some of their wall layers and, therefore, both of them are considered to have some similarities. Finally, serpentine aneurysms are rare lesions and their growing mechanism is still under discussion. CONCLUSION: Any type of giant aneurysm represents a great deal for the neurosurgical management.

Meningitis caused by Enterococcus gallinarum after lumbar drainage of cerebrospinal fluid.

We report a rare case of meningitis caused by Enterococcus gallinarum, a bacterium characterized by its ability to express low-level resistance to vancomycin. As in the three other previously reported cases, this one occurred in a patient with a cerebrospinal fluid drainage catheter and properly responded to antimicrobial therapy and removal of the drain.

[Development of the anterior cervical postdiscectomy arthrodesis: bone graft, plate, intersomatic cage and plate-cage]. / Evolución de la artrodesis cervical postdiscectomía: injerto óseo, placa, caja intersomática y placa-caja.

The surgical techniques for anterior cervical postdiscectomy arthrodesis are reviewed, including bone graft, cervical plates, intervertebral cages and plate-cage systems. The biomechanical advantages of each method are discussed. An alternative to arthrodesis are simple discectomy and arthroplastia with disc prosthesis. Integrated plate-cage systems are the final result in the evolution of the cervical arthrodesis developments. The available plate-cage systems are described.