[Combined supra and infratentorial presigmoideo approach for lesions of the petrous and clival regions]. / Abordaje combinado suprainfratentorial presigmoideo en las lesiones de la región petrosa y clival.

INTRODUCTION: Petrous and petroclival lesions may be surgically treated with combinations of suprainfratentorial presigmoideo approach and microsurgical techniques. OBJECTIVE: To demonstrate the utility and to present our surgical experiences with this approach. PATIENTS AND METHODS: Thirteen patients with lesions of the clival, petrous region and of the cerebellopontine angle with extension toward the anterior portion of brainstem were taken to the operative room. There were nine women and four men. Eleven were adults and two children. The main clinical manifestations were headache (100%), dysfunction of cranial nerves (90%), ataxia (90%) hemiparesis (75%). There was papiledema in 45%. Petroclival meningiomas and schwannomas were the more frequent lesions. There were three patients with intraxial brainstem tumors and two arteriovenous malformations. There were not aneurysms. We performed nine retrolaberintic, three translaberintic and one transcochlear approach. RESULTS: There was not severe incapacity, vegetative or dead patients. The surgical complications were facial nerve paresis (31%), cerebrospinal fluid leak (23%), decreased gag reflex (15%), abducens nerve paresis, hemiparesis and Claude Bernard Horner syndrome (8%). 50% of these complications disappeared three months later. CONCLUSIONS: The suprainfratentorial presigmoidal approach and their surgical variations could be utilized to obtaining a low morbimortality, in the treatment of different neoplasm and vascular diseases of the petrous and petroclival region.

Abordaje combinado suprainfratentorial presigmoideo en las lesiones de la región petrosa y clival / Combined supra-and infratentorial presigmoideo approach for lesions of the petrous and clival regions

Introducción. Las lesiones de la región petrosa y clival pueden intervenirse quirúrgicamente con la combinación del abordaje suprainfratentorial presigmoideo (ASITPS) y de las actuales técnicas microquirúrgicas. Objetivos. Demostrar la utilidad y presentar nuestras experiencias con este abordaje . Pacientes y métodos. Se llevaron al quirófano 13 pacientes con lesiones de la región clival, petrosa y del ángulo pontocerebeloso con extensión hacia la porción anterior del tronco. Hubo nueve mujeres y cuatro hombres; 11 eran adultos y dos niños. Las principales manifestaciones clínicas fueron la cefalea (100 por ciento), la disfunción de nervios craneales (90 por ciento), la ataxia (90 por ciento) y los déficit motores (75 por ciento). Hubo papiledema en el 45 por ciento. Los meningiomas petroclivales y los schwannomas fueron las lesiones más frecuentes. Hubo tres pacientes con neoplasias intraaxiales de tronco cerebral y dos malformaciones arteriovenosas. No hubo lesiones aneurismáticas. Realizamos nueve abordajes retrolaberínticos, tres translaberínticos y uno transcoclear. Resultados. No hubo pacientes gravemente incapacitados, vegetativos o fallecidos. Las complicaciones quirúrgicas fueron paresia facial periférica (31 por ciento), fístula de LCR (23 por ciento), reducción del reflejo de deglución (15 por ciento), paresia del nervio abducens (8 por ciento), hemiparesia y síndrome de Claude Bernard Horner (8 por ciento). El 50 por ciento de estas complicaciones desaparecieron en menos de tres meses. Conclusiones. El ASITPS y sus variantes quirúrgicas pueden utilizarse en el tratamiento quirúrgico de enfermedades tumorales y vasculares diversas de esa región y obtener una morbimortalidad baja (AU)

Introduction. Petrous and petroclival lesions may be surgically treated with combinations of suprainfratentorial presigmoideo approach and microsurgical techniques. Objectives, To demonstrate the utility and to present our surgical experiences with this approach. Patients and methods. Thirteen patients with lesions of the clival, petrous region and of the cerebellopontine angle with extension toward the anterior portion of brainsteam were taken to the operative room. There were nine women and four men. Eleven were adults and two children. The main clinical manifestations were headache (100%), dysfunction of cranial nerves (90%), ataxia (90%) hemiparesis (75%). There was papiledema in 45%. Petroclival meningiomas and schwannomas were the more frequent lesions. There were three patients with intraxial brainsteam tumors and two arteriovenous malformations. There were not aneurysms. We performed nine retrolaberintic, three translaberintic and one transcochlear approach. Results. There was not severe incapacity, vegetative or dead patients. The surgical complications were facial nerve paresis (31%), cerebrospinal fluid leak (23%), decreased gag reflex (15%), abducens nerve paresis, hemiparesis and Claude Bernard Horner syndrome (8%). 50% of these complications disappeared three months later. Conclusions. The suprainfratentorial presigmoidal approach and their surgical variations could be utilized to obtaining a low morbimortality, in the treatment of different neoplasm and vascular diseases of the petrous and petroclival region (AU

[Familial intracranial aneurysms in Camagüey]. / Aneurismas intracraneales familiares en Camagüey.

INTRODUCTION: Genetic etiology in suggested in intracranial aneurysms. Such hypothesis is supported on familial aggregation, ocurrence in identical twins or associated to genetic diseases like adult polycystic renal disease. OBJECTIVE: To identify biological features in familial aneurysms different to sporadic ones. PATIENTS AND METHODS: Camag ey province is one of the most ancient in Cuba. Motionless population at the beginning had its sources in Spanish and African people. It has 800,000 inhabitants. 497 patients with intracranial aneurysms were operated at Manuel Ascunce Domenech Hospital between January 1982 and August 2001. We identified 15 families with intracranial aneurysms. RESULTS: 31 patients were operated on of 42 intracranial sacs at the carotid territory. There were 34% of multiplicity ant three mirror aneurysms. Three patients (9.7 %) have adult polycystic renal disease. 87 % of patients present aneurysms rupture and mortality was 32 %. This last figure was related to poor admission clinical grade. CONCLUSIONS: Frequency of familial aneurysms was 6.2% Familial aggregation, aneurysms between twins associated with genetic linked disease, early age rupture, high frequency between women, posterior communicating and middle cerebral artery bifurcation preference, mirror aneurysms and high general mortality associated to massive intracranial bleeding identified this clusters of familial aneurysms and would justify imaginological screening of high risk patients before the rupture.

Aneurismas intracraneales familiares en Camagüey / Familial intracranial aneurysms in Camagüey

Introducción. Se sugiere una posible etiología genética en los aneurismas intracraneales (AIC). Esta hipótesis se apoya en la aparición de varios pacientes en una misma familia, en gemelos idénticos o en personas con enfermedades genéticas asociadas, como la enfermedad renal poliquística del adulto (ERPQA). Objetivo. Identificar las características biológicas de los aneurismas familiares (AF) que lo diferencian de los esporádicos. Pacientes y métodos. La provincia de Camagüey es una de las más antiguas de Cuba. Su población, inmóvil en los inicios, es de origen español y africano.Tiene unos 800.000 habitantes. Un total de 497 pacientes con AIC fueron operados en el quirófano del Hospital Manuel Ascunce Doménech en el período de enero de 1982 a agosto de 2001. Se identificaron en ellos 15 familias con pacientes con AIC. Resultados. Se intervinieron quirúrgicamente 31 pacientes de 15 familias, los cuales tenían 42 aneurismas del territorio carotídeo. Hubo un 34 por ciento de multiplicidad, y en tres pacientes las lesiones eran en `espejo'. Tres pacientes (9,7 por ciento) tenían ERPQA. El 87 por ciento de los aneurismas se manifestaron como hemorragias intracraneales. La mortalidad fue del 32 por ciento debido al pobre estado clínico de los pacientes al ingreso. Conclusiones. La frecuencia de AF fue del 6,2 por ciento. La agrupación familiar, la aparición en hermanos gemelos, la asociación a enfermedades genéticas, la tendencia a la ruptura en edades tempranas, la mayor frecuencia en mujeres, la localización predominante en la región de la comunicación posterior y la bifurcación de la arteria cerebral media o en sacos en `espejo' y la elevada mortalidad, caracterizan a este grupo de aneurismas. Esto justifica el estudio de familiares con riesgo elevado antes de que ocurra el sangrado (AU)

Introduction. Genetic etiology in suggested in intracranial aneurysms. Such hypothesis is supported on familial aggregation, ocurrence in identical twins or associated to genetic diseases like adult polycystic renal disease. Objective. To identify biological features in familial aneurysms different to sporadic ones. Patients and methods. Camagüey province is one of the most ancient in Cuba. Motionless population at the beginning had its sources in Spanish and African people. It has 800,000 inhabitants. 497 patients with intracranial aneurysms were operated at Manuel Ascunce Domenech Hospital between January 1982 and August 2001. We identified 15 families with intracranial aneurysms. Results. 31 patients were operated on of 42 intracranial sacs at the carotid territory. There were 34% of multiplicity ant three ‘mirror’ aneurysms. Three patients (9.7 %) have adult polycystic renal disease. 87 % of patients present aneurysms rupture and mortality was 32 %. This last figure was related to poor admission clinical grade. Conclusions. Frequency of familial aneurysms was 6.2% Familial aggregation, aneurysms between twins associated with genetic linked disease, early age rupture, high frequency between women, posterior communicating and middle cerebral artery bifurcation preference, ‘mirror’ aneurysms and high general mortality associated to massive intracranial bleeding identified this clusters of familial aneurysms and would justify imaginological screening of high risk patients before the rupture (AU)

[Intracranial carotid artery bifurcation aneurysms]. / Aneurismas de la bifurcación de la carótida intracraneal.

INTRODUCTION: Intracranial carotid artery bifurcation aneurysms are infrequent but its clinical behavior, high risk of bleeding and complex anatomic relationships of the sac permit to consider these lesions as a challenge cases. PATIENTS AND METHODS: 497 patients harboring intracranial aneurysms were operated on at Manuel Ascunce Domenech Hospital, Camagüey, Cuba between January 1982 to august 2001. We utilized microsurgical procedures, optical magnification, specialized neuroanesthesia and Intensive Care Unit postoperatory following. All patients were evaluated clinically with World Federation Neurological Surgeon Scale and Glasgow Outcome Scale. RESULTS: There were 16 patients with intracranial carotid artery bifurcation aneurysms (3.2 %). 12 patients were under 40 years and 50% were between 16 and 30 years old. All patients present intracranial bleeding. There was 87.5% of total or partial recuperation. There was one death only. Postoperative deficit were observed at 44% but 31% disappeared three month later. CONCLUSION: Intracranial carotid artery bifurcation aneurysms are complex anatomoclinical lesions. Clinically, we observed high tendency to bleed and multiplicity. Anatomically, these sacs have complex arterial relationship that difficult dissection and clipping. They have frequent postoperative morbidity. Multiple or bilateral aneurysmal sacs will be clipped by one surgical procedure.

Aneurismas de la bifurcación de la carótida intracraneal / Intracranial carotid artery bifurcation aneurysms

Introducción. Los aneurismas de la bifurcación carótida (ABC) son poco frecuentes, pero su comportamiento clínico, con elevada tendencia al sangrado y las complejas relaciones arteriales de estos sacos, los hacen particularmente interesantes. Pacientes y métodos. Un total de 497 pacientes con aneurismas intracraneales fueron operados en el Hospital Manuel Ascunce Doménech, en Camagüey (Cuba), en el período de enero de 1982 a agosto del 2001. Se usaron métodos microneuroquirúrgicos, magnificación óptica, neuroanestesia especializada y seguimiento postoperatorio en terapia intensiva. Los pacientes se evaluaron clínicamente con la escala de la Federación Mundial de Neurocirujanos, y los resultados, con la escala de pronósticos de Glasgow. Resultados. Hubo 16 pacientes con ABC (3,2 por ciento), 12 tenían menos de 40 años y el 50 por ciento se encontraban entre 16 y 30 años. Todos los pacientes presentaron manifestaciones de sangrado. En el 87,5 por ciento hubo recuperación total o parcial. Sólo falleció un paciente. Los déficit postoperatorios aparecieron en el 44 por ciento, pero el 31 por ciento mejoraron tres meses después. Conclusiones. Los ABC intracraneal presentan complejidades anatomoclínicas elevadas. Clínicamente son aneurismas que sangran a edades muy tempranas y pueden ser múltiples. Las complejidades quirúrgicas se deben a sus numerosas relaciones arteriales, que dificultan la disección. Esto eleva la morbilidad postoperatoria. En casos de aneurismas múltiples uni o bilaterales deben graparse todas las lesiones en un sólo proceder quirúrgico (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).

Absceso cerebral hiperdenso. A propósito de un caso / Hyperdense cerebral abscess. A case report

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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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