Hemorragia intracraneal por aneurismas y malformaciones arteriovenosas durante el embarazo y el puerperio / Intracranial hemorrhage due to aneurysms and arteriovenous malformations during pregnancy and puerperium

Introducción. La hemorragia subaracnoidea por aneurismas y malformaciones arteriovenosas es másfrecuente en gestantes y puérperas. Analizamos el comportamientode estas pacientes, su manejo y el efectosobre ellas de nuestro Programa Nacional Materno Infantil.Pacientes y métodos. Hubo 437 gestantes y 717 puérperas complicadas en el periodo de enero de 1996 a diciembre del 2005, 41 muertes maternas por todas las causas y 14 defunciones maternas indirectas.Fueron intervenidos 454 pacientes con aneurismas intracraneales y malformaciones arteriovenosas intracraneales. El obstetra evaluó las pacientes complicadas y el feto, para decidir la forma del parto. Las pacientes fueron manejadas precozmente por un colectivo médico interdisciplinario. Las lesiones vasculares fueron clipadaspor métodos microneuroquirúrgicos. El manejo anestésico consideró los problemas inherentes a la gestacióny al feto. No utilizamos métodos endovasculares. El seguimiento postoperatorio fue en la sala de TerapiaIntensiva. Resultados. Hubo un total de ocho pacientes, entre gestantes y puérperas con hemorragia ubaracnoideapor aneurismas o malformaciones arteriovenosas intracraneales.Seis tenían aneurismas intracraneales ydos malformaciones arteriovenosas. Realizamos siete intervenciones quirúrgicas, cinco en aneurismas y dosen malformaciones. Cuatro pacientes lograron una recuperación neurológica completa, dos una recuperación parcial y hubo dos fallecidas. Esta enfermedad constituyó el 14 por ciento de todas las causas de muertes maternas indirectas.Conclusión. Un mejor diagnóstico clínico, los estudios por imágenes y el manejo interdisciplinario precoz que vincula la terapia intensiva, la atención obstétricay los servicios de neurocirugía vascular determinan un incremento en el diagnóstico de estas lesiones que requieren un tratamiento microneuroquirúrgico o endovascular rápido y oportuno para evitar la muertematerna y el grave daño del feto(AU)

Introduction. Subarachnoid hemorrhage for aneurysms and arteriovenous malformations is most frequentduring pregnancy and puerperium. We analyzed behavior and management of this patients and the effect on it of our Maternal Health Program. Patients and methods. There were 437 pregnancyand 717 puerperal complicated patients between january 1996 to december 2005, 41 maternal deaths of allcauses and 14 indirect maternal deaths. There were operated on 454 patients with intracranial aneurysmsand arteriovenous malformations in this period. Pregnant patients and fetus were evaluated to select modeof delivery. A specialized medical team managed precociously these patients. Vascular lesions were clipped bymicrosurgical methods. Anesthetic management considered pregnancy and fetal complexities. We did not use endovascular methods. Postoperative management was performed on intensive care unit. Results. There were eight pregnant and puerperal patients with subarachnoid hemorrhage due to aneurysms and arteriovenous malformations 2 percent of allpatients were operated on by this cause. Six harboured intracranial aneurysms and two arteriovenous malformations.We performed seven surgical rocedures, five for aneurysms and two for malformations. There was a delivery rate of 2.1 and seven normal newborn. Four patients achieved a complete neurological recovery, twoa partial recovery and there were two deceaseds. This cause constituted 14 percent of all indirect maternal deaths.Conclusion. A precocious clinical diagnosis, neuroimaging studies and interdisciplinary management that involve intensive therapy, obstetric attention and neurovascular surgical treatment determined an increment in the diagnosis of these lesions that require opportune microsurgical or endovascular treatment toprevent maternal death and fetal damage(AU)

[Ophthalmic artery aneurysms]. / Aneurismas de la región de la arteria oftálmica.

INTRODUCTION: Ophthalmic artery aneurysms are infrequent lesions and they have very specific particularities. OBJECTIVE: to present the anatomoclinical and surgical characteristic of our patients with ophthalmic aneurysms and to analyze our surgical results. PATIENT AND METHODS: 604 patients with intracranial aneurysms were operated on between January 1982 and December 2004. There were 50 patients with ophthalmic artery aneurysms. Average age was 52 years, 80% were women, 60% harbored multiple aneurysms and 20% were giant lesions. 12% had bilateral ophthalmic aneurysms. 20% of ophthalmic aneurysms were incidental. 50% had ophthalmological manifestations; however, this presentation occurred in 100% of the patients with large and giant aneurysms. Initially, 12% of ophthalmologic disorders were missed. We utilized unilateral or bilateral pterional approach associated to others in multiple aneurysms. We performed retrograde decompression- suction technique modified for large and giant aneurysms. RESULTS. Thirty patients (60%) obtained a complete recovery, fourteen patients (28%) an incomplete recovery and two were seriously disabled. There were not patients in vegetative state. There were four deaths (8%). 50% of postoperatory deficits disappeared and 64% of ophthalmologic disorders improved three months later. CONCLUSION: Microsurgical method allowed to treat unique, multiple, bilateral, large and giant ophthalmic aneurysms with good recovery of neurological and visual deficits.

Aneurismas de la región de la arteria oftálmica / Ophthalmic artery aneurysms

Introducción. Los aneurismas de la arteria oftálmica son lesiones poco frecuentes y con particularidades específicas. Objetivo. Presentar las características anatomoclínicas, quirúrgicas y los resultados del tratamiento microquirúrgico de nuestros pacientes con aneurismas de esta región. Pacientes y métodos. 604 pacientes con aneurismas intracraneales fueron llevados al quirófano entre enero de 1982 y diciembre del 2004. Hubo 50 pacientes con aneurismas de la región de la arteria oftálmica. El promedio de edad fue de 52 años, el 80 porciento fueron mujeres, el 60 porciento presentaban aneurismas múltiples y un 20 porciento gigantes. El 12 porciento poseían lesiones aneurismáticas bilaterales. El 20 porciento de los aneurismas fueron incidentales. El 50 porciento tenían manifestaciones oftalmológicas y la frecuencia se elevó al 100 porciento en los aneurismas grandes y gigantes. El 16 porciento de los trastornos visuales fueron ignorados o confundidos inicialmente. En aneurismas múltiples empleamos la ruta pterional uni o bilateral asociada a otros abordajes. En los aneurismas oftálmicos grandes o gigantes utilizamos la técnica de descompresión-succión retrógrada modificada. Resultados. Treinta pacientes (60 porciento) obtuvieron una recuperación completa, catorce pacientes (28 porciento) una recuperación incompleta y dos incapacidad grave. No hubo pacientes en estado vegetativo. Hubo cuatro fallecidos (8 porciento). El 50 porciento de los déficit postoperatorios desaparecieron y el 64 porciento de los trastornos visuales mejoraron a los tres meses. Conclusión. El método microquirúrgico permitió tratar aneurismas de la región de la arteria oftálmica únicos, múltiples, bilaterales, grandes y gigantes con buena recuperación de los déficit neurológicos y de los trastornos visuales(AU)

Introduction. Ophthalmic artery aneurysms are infrequent lesions and they have very specific particularities. Objective. to present the anatomoclinical and surgical characteristic of our patients with ophthalmic aneurysms and to analyze our surgical results. Patient and methods. 604 patients with intracranial aneurysms were operated on between January 1982 and December 2004. There were 50 patients with ophthalmic artery aneurysms. Average age was 52 years, 80 percent were women, 60 percent harbored multiple aneurysms and 20 percent were giant lesions. 12 percent had bilateral ophthalmic aneurysms. 20 percent of ophthalmic aneurysms were incidental. 50 percent had ophthalmological manifestations; howewer, this presentation occurred in 100 percent of the patients withlarge and giant aneurysms. Initially, 12 percent of ophthalmologic disorders were missed. We utilized unilateral or bilateral pterional approach associated to others in multiple aneurysms. We performed retrograde decompression-suction technique modified for large and giantaneurysms. Results. Thirty patients (60 percent) obtained a complete recovery, fourteen patients (28 percent) an incomplete recovery and two were seriously disabled. There were not patients in vegetative state. There were four deaths (8 ). 50 percent of postoperatory deficits disappeared and 64 percent of ophthalmologic disorders improved three months later. Conclusion. Microsurgical method allowed to treat unique, multiple, bilateral, large and giant ophthalmicaneurysms with good recovery of neurological and visual deficits(AU)

[Simultaneous cephalic migration of a ventriculoperitoneal shunt into the intraventricular and subdural spaces. A case report]. / Migración cefálica simultánea al espacio intraventricular y subdural en una derivación ventriculoperitoneal. Presentación de un caso.

INTRODUCTION: Hydrocephaly is defined as a hemodynamic disorder in which the production, circulation or reabsorption of cerebrospinal fluid is involved. Migration, in a cephalic direction, into the subdural and intraventricular spaces of the proximal ends (shunt malfunction), is very unusual and perhaps not yet reported. It probably involves movement of the craniospinal region of the patient which leads to a follow on effect due to an underlying disorder. CLINICAL CASE: We report the case of a polytraumatized baby (non hospital birth, subarachnoid hemorrhage, porencephaly and subsequent hydrocephaly), who had had multiple shunts inserted. On her most recent admission the shunt was not working properly, as confirmed on plain radiological examination. This showed migration of the catheter, in cephalic direction, into the intraventricular and subdural space. CONCLUSIONS: In order that such migration could occur, conditioning factors would be necessary: such as detachment of the shunt at the distal end (technical fault), underlying disease (porencephaly), dynamic factors causing expulsion (abdominal peristaltic movements) dynamic translocation factor (neck movements), dynamic attraction factor (increased CSF reabsorption) and unishunt catheter (offering no resistance to passage through the trepanation orifice).

Migración cefálica simultánea al espacio intraventricular y subdural en una derivación ventriculoperitoneal. Presentación de un caso / Simultaneous cephalic migration of a ventriculoperitoneal shunt into the intraventricular and subdural spaces. A case report

Introducción. La hidrocefalia se define como un trastorno hemodinámico en el cual queda afectada la producción, la circulación o la reabsorción del líquido cefalorraquídeo. La migración en sentido cefálico al espacio subdural e intraventricular de los extremos proximal y distal, respectivamente, en una derivación ventriculoperitoneal, origina la obstrucción del shunt (malfuncionamiento del shunt), es un caso totalmente infrecuente y quizás aún no comunicado; probablemente involucra al movimiento de la región craneoespinal del paciente, que crea el efecto de remolque condicionado por alguna patología de base. Caso clínico. Presentamos el caso de una lactante con numerosos traumas (parto no institucional, hemorragia subaracnoidea, porencefalia e hidrocefalia subsecuente), derivada en múltiples ocasiones. En su último ingreso presenta disfunción del sistema derivativo, corroborado por examen radiológico simple, donde presenta migración del catéter en sentido cefálico al espacio intraventricular y subdural. Conclusiones. Para que la migración sea posible tienen que existir factores que la condicionen como: el desprendimiento de la fijación del shunt en el extremo opuesto (fallo técnico), enfermedad de base (porencefalia), factor dinámico de expulsión (movimientos peristálticos abdominales), factor dinámico de traslación (movimientos cervicales), factor dinámico de atracción (aumento de la reabsorción de LCR) y catéter unishunt (no provee de obstáculo a su paso por el trépano) (AU)

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