A Case Series of Late Vascular Lesions of Traumatic Etiology: Endovascular and Surgical Approaches.

There is a broad spectrum of pathology in traumatic vascular injury. Arteriovenous fistula (AVF) is an abnormal communication between the high-flow arterial system and the low-flow venous network, directly connecting the afferent artery and nearby draining veins without the regular intervention of the capillary bed. Most of these fistulas occur due to incidental or iatrogenic injury. A retrospective review of procedures performed by an endovascular surgeon in a tertiary center identified 15 cases of vascular injuries that encompassed all these different clinical scenarios, including post-traumatic, iatrogenic, or spontaneous origin. The information collected, including patient age, sex, previous symptoms, and treatment, was gathered from medical records. In addition, information on procedural technique, endovascular devices used, and specific intraprocedural details were collected from procedure notes and angiographic images. A broad spectrum of injuries can present as late trauma complications (over three months); endovascular treatment is a safe and effective approach for intracranial and extracranial injuries. Endovascular treatment can be a sole option or adjuvant to other hybrid therapies and has emerged as essential for treating these lesions as a first option. We have described standard techniques to treat different vascular pathologies, sometimes with limited resources.

Surgical management of a penetrating drill bit injury to the skull base.

BACKGROUND: Low-energy penetrating brain injuries are rarely encountered in neurosurgical practice. Immediate surgical management remains the primary treatment strategy to control potential bleeding and prevents infectious complications. CASE DESCRIPTION: A 28-year-old man presented with an orbital injury with left-sided chemosis, amaurosis, and ophthalmoplegia following an assault. Cranial CT revealed an industrial drill bit causing a penetrating injury to the skull base. The tip of the object reached the petrous apex. CT angiography showed no signs of cerebrovascular damage. The drill bit was visualized through a frontotemporal craniotomy. It was then carefully removed under direct microscopic vision. Postoperative ceftriaxone was administered. The patient was discharged in good condition on postoperative day 6. His vision impairment remained. CONCLUSION: Timely access to neuroimaging diagnostics and microneurosurgical facilities allows for good outcomes in the surgical treatment of low-velocity penetrating brain injuries.

Manejo bimodal de aneurismas asociados a malformaciones arteriovenosas cerebrales. Reporte de caso y breve revisión de la literatura.

La patogénesis de los aneurismas intracraneales asociados a malformaciones arteriovenosas cerebrales no es bien entendida y es aún objeto de discusión. Las decisiones sobre cuándo y cómo tratar los aneurismas intracraneales de estas características siempre han sido un reto terapéutico tanto para neurocirujanos vasculares como para terapistas endovasculares neurológicos. Reportamos el caso de una paciente de 51 años con aneurismas múltiples asociados a una malformación arteriovenosa, así como su manejo neuroquirúrgico, con un análisis comparativo con lo publicado en la literatura médica y científica en los últimos 10 años.The pathogenesis of intracranial aneurysms associated with arteriovenous malformations is not well understood and is still under discussion; the decisions about when and how to treat intracranial aneurysms of these characteristics have always been a therapeutic challenge for both, vascular neurosurgeons and endovascular neurological therapists. We report the case of a 51-year-old patient with multiple aneurysms associated with arteriovenous malformation, as well as her neurosurgical management, with a comparative analysis what has been published in the medical and scientific literature in the last 10 years.

[Preoperative embolization with microspheres of giant supratentorial meningiomas: 5-year experience]. / Embolización preoperatoria con microesferas en meningiomas gigantes supratentoriales: experiencia de 5 años.

BACKGROUND: Preoperative embolization of hypervascular tumours such as meningiomas has proven to be a favorable factor for resection of the latter because it diminishes intraoperative bleeding and the need for blood transfusions. OBJECTIVES: Evaluation of surgical outcomes of preoperative embolization with microspheres of giant supratentorial meningiomas. METHODS: We retrospectively analyzed patient records from 2007 to 2012 with the diagnosis of giant supratentorial meningiomas (> 5 cm) (n= 27) and obtained two samples: those with preoperative embolization (n= 14) and patients without any properative embolization (n= 13). We evaluated and compared statistically significant surgical bleeding, surgical time and resection grade (via Simpson scale). Additionally, we evaluated internal/external vascularization rate and the histopathologic diagnosis. RESULTS: According to the Simpson scale, the mean resection grade was 1.21 for embolized meningiomas, whereas for non-embolized meningiomas it was 1.92 . No differences were found in surgical bleeding and operative time. We used microspheres whose diameters were 40-120 µm, and these were easily observed with common microscopy techniques. In all cases we observed predominance in extracranial vascularization. No morbidity and mortality were recorded with the endovascular procedure. CONCLUSIONS: Embolization with microspheres improves resection rate evaluated by the Simpson scale in patients with giant supratentorial meningiomas.

ANTECEDENTES: la embolización preoperatoria de tumores hipervascularizados, como los meningiomas, ha demostrado ser un factor favorable para su resección quirúrgica en términos de menor sangrado transquirúrgico y transfusiones sanguíneas. OBJETIVOS: evaluar el beneficio quirúrgico de la embolización preoperatoria con microesferas en meningiomas gigantes supratentoriales. MATERIAL Y MÉTODOS: estudio retrospectivo de los expedientes de pacientes postoperados entre 2007 y 2012 con diagnóstico de meningiomas gigantes supratentoriales (>5 cm) (n= 27). La muestra se dividió en dos grupos: pacientes embolizados antes de la intervención (n= 14), y pacientes a quienes no se realizó embolización (n= 13). Se comparó la cantidad de sangrado transoperatorio, el tiempo quirúrgico, y el grado de resección evaluado por la escala de Simpson. Además, se evaluó el tamaño tumoral, la tasa de vascularización de la carótida interna y externa y el diagnóstico histopatológico. RESULTADOS: el promedio de resección de acuerdo con la escala de Simpson para meningiomas embolizados fue de 1.21, mientras que para meningiomas no embolizados fue de 1.92 (t de Student, p= < 0.014). No encontramos diferencias significativas en tiempo quirúrgico o en el sangrado transoperatorio. En más de la mitad de los casos utilizamos microesferas de 40-120 µm de diámetro. Las microesferas se observaron fácilmente con los métodos usuales de microscopia y tinción, su existencia se correlacionó con áreas focales de necrosis. En todos los casos se encontró predominio de vascularización extracraneal, sin que el procedimiento endovascular se asociara con mortalidad. CONCLUSIONES: la embolización de meningiomas gigantes supratentoriales con microesferas mejora el grado de resección quirúrgica evaluada por la escala de Simpson.