Patients awaiting surgery for neurosurgical diseases during the first wave of the COVID-19 pandemic in Spain: a multicentre cohort study.

OBJECTIVES: The large number of infected patients requiring mechanical ventilation has led to the postponement of scheduled neurosurgical procedures during the first wave of the COVID-19 pandemic. The aims of this study were to investigate the factors that influence the decision to postpone scheduled neurosurgical procedures and to evaluate the effect of the restriction in scheduled surgery adopted to deal with the first outbreak of the COVID-19 pandemic in Spain on the outcome of patients awaiting surgery. DESIGN: This was an observational retrospective study. SETTINGS: A tertiary-level multicentre study of neurosurgery activity between 1 March and 30 June 2020. PARTICIPANTS: A total of 680 patients awaiting any scheduled neurosurgical procedure were enrolled. 470 patients (69.1%) were awaiting surgery because of spine degenerative disease, 86 patients (12.6%) due to functional disorders, 58 patients (8.5%) due to brain or spine tumours, 25 patients (3.7%) due to cerebrospinal fluid (CSF) disorders and 17 patients (2.5%) due to cerebrovascular disease. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was mortality due to any reason and any deterioration of the specific neurosurgical condition. Second, we analysed the rate of confirmed SARS-CoV-2 infection. RESULTS: More than one-quarter of patients experienced clinical or radiological deterioration. The rate of worsening was higher among patients with functional (39.5%) or CSF disorders (40%). Two patients died (0.4%) during the waiting period, both because of a concurrent disease. We performed a multivariate logistic regression analysis to determine independent covariates associated with maintaining the surgical indication. We found that community SARS-CoV-2 incidence (OR=1.011, p<0.001), degenerative spine (OR=0.296, p=0.027) and expedited indications (OR=6.095, p<0.001) were independent factors for being operated on during the pandemic. CONCLUSIONS: Patients awaiting neurosurgery experienced significant collateral damage even when they were considered for scheduled procedures.

Impact of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients: a nationwide study in Spain.

OBJECTIVE: To assess the effect of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients in Spain. SETTINGS: The initial flood of COVID-19 patients overwhelmed an unprepared healthcare system. Different measures were taken to deal with this overburden. The effect of these measures on neurosurgical patients, as well as the effect of COVID-19 itself, has not been thoroughly studied. PARTICIPANTS: This was a multicentre, nationwide, observational retrospective study of patients who underwent any neurosurgical operation from March to July 2020. INTERVENTIONS: An exploratory factorial analysis was performed to select the most relevant variables of the sample. PRIMARY AND SECONDARY OUTCOME MEASURES: Univariate and multivariate analyses were performed to identify independent predictors of mortality and postoperative SARS-CoV-2 infection. RESULTS: Sixteen hospitals registered 1677 operated patients. The overall mortality was 6.4%, and 2.9% (44 patients) suffered a perioperative SARS-CoV-2 infection. Of those infections, 24 were diagnosed postoperatively. Age (OR 1.05), perioperative SARS-CoV-2 infection (OR 4.7), community COVID-19 incidence (cases/105 people/week) (OR 1.006), postoperative neurological worsening (OR 5.9), postoperative need for airway support (OR 5.38), ASA grade ≥3 (OR 2.5) and preoperative GCS 3-8 (OR 2.82) were independently associated with mortality. For SARS-CoV-2 postoperative infection, screening swab test <72 hours preoperatively (OR 0.76), community COVID-19 incidence (cases/105 people/week) (OR 1.011), preoperative cognitive impairment (OR 2.784), postoperative sepsis (OR 3.807) and an absence of postoperative complications (OR 0.188) were independently associated. CONCLUSIONS: Perioperative SARS-CoV-2 infection in neurosurgical patients was associated with an increase in mortality by almost fivefold. Community COVID-19 incidence (cases/105 people/week) was a statistically independent predictor of mortality. TRIAL REGISTRATION NUMBER: CEIM 20/217.

Posteromedial Hypothalamic Deep Brain Stimulation for Refractory Aggressiveness in a Patient With Weaver Syndrome: Clinical, Technical Report and Operative Video.

BACKGROUND AND IMPORTANCE: Deep brain stimulation of the posteromedial hypothalamus (PMH DBS) appears to be an effective treatment for drug-resistant aggressiveness. Weaver syndrome (WS) is a rare genetic disorder in which patients develop some degree of intellectual disability and rarely severe behavioral alterations that may benefit from this procedure. CLINICAL PRESENTATION: We present the case of a 26-yr-old man diagnosed with WS presenting with uncontrollable self and heteroaggressiveness and disruptive behavior refractory to pharmacological treatment and under severe physical and mechanical restraining measures. The patient was successfully treated with bilateral PMH DBS resulting in affective improvement, greater tolerance for signs of affection, regularization in his sleep pattern and appetite disturbances at 12-mo follow-up. A detailed description and video of the procedure are presented, and a review of the clinical characteristics of WS and the utility and benefits of PMH DBS for refractory aggressiveness are reviewed. CONCLUSION: To our knowledge, this is the first case of refractory aggressiveness described in WS as well as the first patient with WS successfully treated with PMH DBS.

Network Substrates of Centromedian Nucleus Deep Brain Stimulation in Generalized Pharmacoresistant Epilepsy.

Deep brain stimulation (DBS), specifically thalamic DBS, has achieved promising results to reduce seizure severity and frequency in pharmacoresistant epilepsies, thereby establishing it for clinical use. The mechanisms of action are, however, still unknown. We evidenced the brain networks directly modulated by centromedian (CM) nucleus-DBS and responsible for clinical outcomes in a cohort of patients uniquely diagnosed with generalized pharmacoresistant epilepsy. Preoperative imaging and long-term (2-11 years) clinical data from ten generalized pharmacoresistant epilepsy patients (mean age at surgery = 30.8 ± 5.9 years, 4 female) were evaluated. Volume of tissue activated (VTA) was included as seeds to reconstruct the targeted network to thalamic DBS from diffusion and functional imaging data. CM-DBS clinical outcome improvement (> 50%) appeared in 80% of patients and was tightly related to VTAs interconnected with a reticular system network encompassing sensorimotor and supplementary motor cortices, together with cerebellum/brainstem. Despite methodological differences, both structural and functional connectomes revealed the same targeted network. Our results demonstrate that CM-DBS outcome in generalized pharmacoresistant epilepsy is highly dependent on the individual connectivity profile, involving the cerebello-thalamo-cortical circuits. The proposed framework could be implemented in future studies to refine stereotactic implantation or the parameters for individualized neuromodulation.

Language hemispheric dominance analyzed with magnetic resonance DTI: correlation with the Wada test.

OBJECTIVE: Language lateralization is a major concern in some patients with pharmacoresistant epilepsy who will face surgery; in these patients, hemispheric dominance testing is essential to avoid further complications. The Wada test is considered the gold standard examination for language localization, but is invasive and requires many human and material resources. Functional MRI and tractography with diffusion tensor imaging (DTI) have demonstrated that they could be useful for locating language in epilepsy surgery, but there is no evidence of the correlation between the Wada test and DTI MRI in language dominance. METHODS: The authors performed a retrospective review of patients who underwent a Wada test before epilepsy surgery at their institution from 2012 to 2017. The authors retrospectively analyzed fractional anisotropy (FA), number and length of fibers, and volume of the arcuate fasciculus and uncinate fasciculus, comparing dominant and nondominant hemispheres. RESULTS: Ten patients with temporal lobe epilepsy were reviewed. Statistical analysis showed that the mean FA of the arcuate fasciculus in the dominant hemisphere was higher than in the nondominant hemisphere (0.369 vs 0.329, p = 0.049). Also, the number of fibers in the arcuate fasciculus was greater in the dominant hemisphere (881.5 vs 305.4, p = 0.003). However, no differences were found in the FA of the uncinate fasciculus or number of fibers between hemispheres. The length of fibers of the uncinate fasciculus was longer in the dominant side (74.4 vs 50.1 mm, p = 0.05). Volume in both bundles was more prominent in the dominant hemisphere (12.12 vs 6.48 cm3, p = 0.004, in the arcuate fasciculus, and 8.41 vs 4.16 cm3, p = 0.018, in the uncinate fasciculus). Finally, these parameters were compared in patients in whom the seizure focus was situated in the dominant hemisphere: FA (0.37 vs 0.30, p = 0.05), number of fibers (114.4 vs 315.6, p = 0.014), and volume (12.58 vs 5.88 cm3, p = 0.035) in the arcuate fasciculus were found to be statistically significantly higher in the dominant hemispheres. Linear discriminant analysis of FA, number of fibers, and volume of the arcuate fasciculus showed a correct discrimination in 80% of patients (p = 0.024). CONCLUSIONS: The analysis of the arcuate fasciculus and other tract bundles by DTI could be a useful tool for language location testing in the preoperative study of patients with refractory epilepsy.

Bases de la estimulación cerebral profunda / Bases of deep brain stimulation

INTRODUCCIÓN: La estimulación cerebral profunda es una terapia eficaz que está siendo utilizada en un número creciente de indicaciones. Los mecanismos mediante los cuales ejerce efecto terapéutico aún se desconocen en su mayor parte, si bien cada vez se dispone de más datos sobre su influencia en diversos niveles. OBJETIVO: Revisar la bibliografía existente sobre el mecanismo de acción de la estimulación cerebral profunda. Desarrollo. La estimulación cerebral profunda actúa sobre el tejido cerebral estimulado en varios niveles, molecular, celular y de redes neuronales. En su efectividad intervienen factores espaciales, temporales y eléctricos, pero fundamentalmente parece ejercer su función mediante la sustitución de patrones de disparo anómalos, presentes en ciertas enfermedades neurológicas y psiquiátricas. Otros mecanismos, como la neuroprotección o la neurogénesis, permanecen en estudio. CONCLUSIONES: Aunque aún se desconocen muchos efectos por los cuales la estimulación cerebral profunda actúa en el cerebro, parece un tratamiento complejo, con efectos a gran escala, en los que parece primar la corrección de circuitopatías como mecanismo principal

INTRODUCTION: Deep brain stimulation is an effective therapy that is being used in an increasing number of indications. The mechanisms by which it exerts its therapeutic effect are still largely unknown, although there is increasing evidence of its influence at various levels. AIM: To review the existing literature on the mechanism of action of deep brain stimulation. DEVELOPMENT. Deep brain stimulation acts on brain tissue that is stimulated at various levels: molecular, cellular and neural networks. Spatial, temporal and electrical factors are involved in its effectiveness, but it mainly seems to perform its function by replacing anomalous firing patterns, which are present in certain neurological and psychiatric diseases. Other mechanisms, such as neuroprotection or neurogenesis, remain under study. CONCLUSIONS: Although many of the effects by which deep brain stimulation acts on the brain are still unknown, it seems to be a complex treatment, with large-scale effects, in which the correction of circuitopathies seems to prevail as the main mechanism

Estimulación cerebral profunda en la epilepsia farmacorresistente / Deep brain stimulation in drug-resistant epilepsy

INTRODUCCIÓN: La estimulación cerebral profunda (ECP) en la epilepsia farmacorresistente se ha aplicado en varias dianas cerebrales. Sin embargo, su mecanismo de acción no se conoce con exactitud, y la diversidad de dianas hace difícil conocer el grado de evidencia que apoya su utilización. DESARROLLO: Se realiza una revisión bibliográfica sobre la ECP para la epilepsia farmacorresistente. La eficacia de la ECP en la epilepsia farmacorresistente parece mediada por una desincronización de la actividad neuronal en el foco epileptógeno o una modulación de las circuitopatías que existen en la epilepsia, dependiendo de la diana. En la ECP se han utilizado múltiples estructuras corticales y subcorticales, pero solamente la ECP del núcleo anterior del tálamo tiene una evidencia de clase I. CONCLUSIONES: La ECP en la epilepsia es aún objeto de investigación, con evidencia de clase I en la ECP del núcleo anterior del tálamo. El resto de las dianas ha arrojado resultados variables que deben confirmarse con diseños aleatorizados en series de mayor tamaño

INTRODUCTION: Deep brain stimulation (DBS) in drug-resistant epilepsy has been applied to several brain targets. However, its exact mechanism of action is not known, and the diversity of targets makes it difficult to know the degree of evidence that supports its use. DEVELOPMENT: A review of the literature on DBS for drug-resistant epilepsy was conducted. The efficacy of DBS in drug-resistant epilepsy seems to be mediated by a desynchronisation of neuronal activity at the epileptogenic focus or a modulation of the «circuitopathies» that exist in epilepsy, depending on the target. In DBS multiple cortical and subcortical structures have been used, but class I evidence exists only for DBS of the anterior nucleus of the thalamus. CONCLUSIONS: DBS in epilepsy is still under investigation, with class I evidence for DBS of the anterior nucleus of the thalamus. The rest of the targets have yielded variable results that must be confirmed with randomised designs in larger series

Deep brain stimulation for aggressiveness: long-term follow-up and tractography study of the stimulated brain areas.

OBJECTIVE: Initial studies applying deep brain stimulation (DBS) of the posteromedial hypothalamus (PMH) to patients with pathological aggressiveness have yielded encouraging results. However, the anatomical structures involved in its therapeutic effect have not been precisely identified. The authors' objective was to describe the long-term outcome in their 7-patient series, and the tractography analysis of the volumes of tissue activated in 2 of the responders. METHODS: This was a retrospective study of 7 subjects with pathological aggressiveness. The findings on MRI with diffusion tensor imaging (DTI) in 2 of the responders were analyzed. The authors generated volumes of tissue activated according to the parameters used, and selected those volumes as regions of interest to delineate the tracts affected by stimulation. RESULTS: The series consisted of 5 men and 2 women. Of the 7 patients, 5 significantly improved with stimulation. The PMH, ventral tegmental area, dorsal longitudinal fasciculus, and medial forebrain bundle seem to be involved in the stimulation field. CONCLUSIONS: In this series, 5 of 7 medication-resistant patients with severe aggressiveness who were treated with bilateral PMH DBS showed a significant long-lasting improvement. The PMH, ventral tegmental area, dorsal longitudinal fasciculus, and medial forebrain bundle seem to be in the stimulation field and might be responsible for the therapeutic effect of DBS.

Implantación bilateral en dos tiempos para estimulación cerebral profunda en el tratamiento de la enfermedad de Parkinson idiopática bilateral: resultados clínicos / Bilateral two-stage implantation for deep brain stimulation in the treatment of bilateral idiopathic Parkinson's disease: clinical outcomes

Objetivo. La implantación bilateral simultánea de electrodos en el núcleo subtalámico para la enfermedad de Parkinson idiopática (EPI) se asocia a una duración elevada de la intervención, alteraciones del lenguaje y confusión posquirúrgica; además, existe evidencia de mejoría ipsilateral tras la estimulación del núcleo subtalámico. Para optimizar el manejo perioperatorio se realiza un estudio prospectivo con estimulación cerebral profunda (ECP) en el núcleo subtalámico en dos procedimientos unilaterales consecutivos. Pacientes y métodos. Estudio prospectivo de 41 pacientes con EPI bilateral, con implantación de ECP en dos fases quirúrgicas unilaterales. Se analizan sus resultados clínicos según las escalas Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn y Yahr, y Schwab y England, así como sus complicaciones. Resultados. La edad media fue de 61 ± 7 años, 23 hombres. Cinco pacientes (12%) no fueron intervenidos del núcleo subtalámico contralateral por buen control. La media en la UPDRS motora y la Hoehn y Yahr en off farmacológico preoperatorio fue de 44 ± 14 y 3, respectivamente, y de 19 ± 8 y 1,8 a los seis meses de seguimiento. La mejoría media en la escala de Schwab y England en el preoperatorio y a los seis meses fue del 39%. Dos pacientes tuvieron confusión postoperatoria, y uno, disartria transitoria. Conclusiones. La ECP bilateral en dos etapas unilaterales fue una opción eficaz y con escasas complicaciones en nuestra serie de pacientes con EPI. El 10% de los pacientes no precisó electrodos contralaterales. Sería necesario un estudio aleatorizado en pacientes sometidos a cirugía bilateral en uno y dos tiempos para confirmar estos resultados (AU)

Aims. Simultaneous bilateral implantation of electrodes in the subthalamic nucleus for idiopathic Parkinson’s disease (IPD) is associated with long surgery time, language disorders and post-operative confusion. Moreover, there is evidence of ipsilateral improvement after stimulation of the subthalamic nucleus. In order to optimise perioperative management a prospective study is conducted with deep brain stimulation (DBS) in the subthalamic nucleus in two consecutive unilateral procedures. Patients and methods. We conducted a prospective study of 41 patients with bilateral IPD, with DBS implantation in two unilateral surgical phases. Its clinical outcomes are analysed according to the Unified Parkinson’s Disease Rating Scale (UPDRS), the Hoehn & Yahr, and the Schwab & England scales, together with their complications. Results. The mean age was 61 ± 7 years old, 23 males. Five patients (12%) did not undergo surgery of the contralateral subthalamic nucleus due to good control. The mean on the motor UPDRS and the Hoehn & Yahr in preoperative pharmacological off was 44 ± 14 and 3, respectively, and 19 ± 8 and 1.8 at six months’ follow-up. The mean improvement on the Schwab & England scale in the pre-operative period and at six months was 39%. Two patients suffered postoperative confusion, and one of them had transient dysarthria. Conclusions. Bilateral DBS in two unilateral stages was an effective option with few complications in our series of patients with IPD. 10% of the patients did not require contralateral electrodes. It would be necessary to conduct a randomized study in patients who underwent bilateral surgery in one and two stages in order to confirm these results (AU)

Nuevo potencial talámico asociado con potenciales evocados somatosensoriales / New thalamic potential associated with somatosensory evoked potentials

Introducción. La respuesta del tálamo durante el estudio con potenciales evocados somatosensoriales (PESS) no está suficientemente comprendida. Caso clínico. Varón de 30 años intervenido con sedación completa mediante estimulación cerebral profunda en el núcleo centromediano por epilepsia farmacorresistente. Durante la intervención se registraron las respuestas de los núcleos talámicos mediante cuatro microelectrodos a los PESS. Estas respuestas se pueden descomponer en tres tipos: potenciales de campo local (PCL), oscilaciones rápidas de baja amplitud (ORB) y oscilaciones lentas de gran amplitud (OLG). Las ORB están muy extendidas por gran parte de las regiones registradas (> 5 mm) y en los cuatro electrodos simultáneamente. Sin embargo, las OLG están localizadas en un único punto del registro y están íntimamente asociadas con los PCL. Además, el análisis de wavelets muestra un componente espectral y un tiempo de aparición diferentes. Conclusiones. Aunque se ha considerado la presencia de ORB como indicador de la presencia del tálamo sensorial, su amplia extensión por diferentes núcleos talámicos sugiere que se trata de una respuesta poco específica a los PESS. Sin embargo, la localización espacial restringida de los OLG y su asociación con PCL sugiere que estos potenciales de nueva descripción son los marcadores de la presencia del tálamo sensorial. Su identificación puede resultar muy útil en estimulación cerebral profunda talámica en pacientes despiertos y, especialmente, en los que precisen sedación (AU)

Introduction. The response of the thalamus during the study with somatosensory evoked potentials (SSEP) is not sufficiently understood. Case report. A 17-year-old man undergoing surgery for deep brain stimulation in the centromedian nucleus for drugresistant epilepsy under complete sedation. During the intervention, the responses to SSEPs of the thalamic nuclei were recorded by means of four microelectrodes. These responses can be decomposed into three types: local field potentials (LFP), low amplitude fast oscillations (LFO), and high amplitude slow oscillations (HSO). LFO are widespread in much of the registered regions. However, HSOs are located at a single point in the registry and are closely associated with LFPs. Conclusions. Although the presence of LFO has been considered as an indicator of the presence of the sensory thalamus, its wide extension by different thalamic nuclei suggests that it is an unspecific response to SSEPs. However, the restricted spatial location of HSO and their association with LFP suggest that these newly described potentials are the markers for the presence of the sensory thalamus. Their identification may prove very useful in thalamic deep brain stimulation either in awake patients or especially in those requiring sedation (AU)

Radiofrequency Lesions through Deep Brain Stimulation Electrodes in Movement Disorders: Case Report and Review of the Literature.

BACKGROUND: Although there are few reports of radiofrequency lesions performed through deep brain stimulation (DBS) electrodes in patients with movement disorders, experience with this method is scarce. METHODS: We present 2 patients who had been previously treated with DBS of subthalamic nuclei (STN) and the ventral intermediate (VIM) nucleus of the thalamus for Parkinson's disease and essential tremor, respectively, and underwent a radiofrequency lesion through their DBS electrodes after developing a hardware infection. The authors conduct a review of the literature regarding this method. RESULTS: Both patients had a good clinical outcome after 20 and 8 months, respectively, as assessed by a reduction in Fahn-Tolosa-Marin Scale and Unified Parkinson's Disease Rating Scale scores. The second patient underwent a second DBS system implantation surgery after his radiofrequency treatment to optimize his management, achieving optimal clinical control with lower current and drug requirements than before the radiofrequency intervention. No adverse effects were observed. CONCLUSIONS: Radiofrequency lesions through DBS electrodes allow the creation of small and localized lesions. Its effectiveness and low-risk profile, in addition to its low cost, make this procedure suitable and a possible alternative in the therapeutic repertoire for the surgical treatment of movement disorders.

[Not Available]. / Tratamiento quirúrgico de la anorexia nerviosa resistente al tratamiento médico.

Gracias a los avances técnicos en técnicas neuroquirúrgicas, y debido a que el diagnóstico y la clasificación de las enfermedades psiquiátricas han evolucionado significativamente a lo largo de las últimas décadas, se están desarrollando tratamientos a nivel experimental para aquellos pacientes resistentes al manejo conservador.La anorexia nerviosa es una enfermedad de prevalencia creciente, con la tasa de mortalidad más elevada dentro de los trastornos psiquiátricos, y con aproximadamente un 20% de pacientes que presentan una evolución tórpida. Para estos pacientes que no responden a manejo conservador, la estimulación cerebral profunda ha surgido como una alternativa terapéutica, si bien la literatura especializada al respecto es escasa.A continuación presentamos una revisión de la fisiopatología de la anorexia nerviosa, así como de los distintos tratamientos neuroquirúrgicos realizados a lo largo de la historia. Se detalla la perspectiva de tratamiento quirúrgico actual, así como los aspectos éticos que se han de considerar en relación con el surgimiento de estas nuevas terapias.

Tratamiento quirúrgico de la anorexia nerviosa resistente al tratamiento médico / Surgical treatment of medication-resistant anorexia nervosa

Gracias a los avances en técnicas neuroquirúrgicas, y debido a que el diagnóstico y la clasificación de las enfermedades psiquiátricas han evolucionado significativamente a lo largo de las últimas décadas, se están desarrollando tratamientos a nivel experimental para aquellos pacientes resistentes al manejo conservador. La anorexia nerviosa es una enfermedad de prevalencia creciente, con la tasa de mortalidad más elevada dentro de los trastornos psiquiátricos, y con aproximadamente un 20% de pacientes que presentan una evolución tórpida. Para estos pacientes que no responden a manejo conservador, la estimulación cerebral profunda ha surgido como una alternativa terapéutica, si bien la literatura especializada al respecto es escasa. A continuación presentamos una revisión de la fisiopatología de la anorexia nerviosa, así como de los distintos tratamientos neuroquirúrgicos realizados a lo largo de la historia. Se detalla la perspectiva de tratamiento quirúrgico actual, así como los aspectos éticos que se han de considerar en relación con el surgimiento de estas nuevas terapias (AU)

Given the advances experienced in neurosurgical techniques, and because the diagnosis and classifi cation of psychiatric diseases has evolved over the past decades, new experimental treatments are arising to treat a greater number of medication-resistant psychiatric patients. Among psychiatric diseases, anorexia nervosa has the highest mortality rate, and approximately 20% of patients experience torpid outcomes. For these patients who do not respond to conservative management, deep brain stimulation has arisen as an alternative option, although studies are still scarce. We review the pathophysiology of anorexia nervosa, as well as the various neurosurgical treatments that have been performed throughout history. The prospect of current surgical treatments is detailed, as well as the ethical aspects to consider regarding the emergence of these new therapies (AU)

Mielopatía secundaria a un quiste óseo aneurismático espinal dorsal / Myelopathy secondary to an aneurysmal bone cyst of thoracic spine

Introducción. Los quistes óseos aneurismáticos espinales son lesiones osteolíticas benignas muy infrecuentes constituidas por cavidades hemáticas limitadas por septos osteoconectivos y células gigantes tipo osteoclastos. Clínicamente se manifiestan con dolor local, síntomas neurológicos secundarios a compresión medular, así como fracturas, deformidades e inestabilidad vertebral. Presentamos un caso de quiste óseo aneurismático espinal dorsal con sintomatología neurológica, tratado mediante una resección microquirúrgica completa, sin secuelas neurológicas asociadas. Caso clínico. Mujer de 47 años, sin antecedentes traumáticos previos, valorada por presentar un cuadro de parestesias de los miembros inferiores de semanas de evolución. El estudio radiológico de resonancia magnética dorsal demostró la existencia de una lesión lítica de bordes bien delimitados y esclerosis marginal en D4, con afectación de los elementos posteriores vertebrales y compresión del cordón medular subyacente. La lesión fue extirpada en su totalidad, con desaparición de la clínica sensitiva tras la intervención. El diagnóstico anatomopatológico definitivo fue quiste óseo aneurismá- tico espinal. Conclusión. A pesar de su baja incidencia, los quistes óseos aneurismáticos espinales deben considerarse, en el diagnóstico diferencial de los tumores óseos espinales, como una posible causa de mielopatía compresiva subaguda o crónica. La resección tumoral completa se considera el tratamiento de elección, el cual con frecuencia es curativo y asocia un buen pronóstico del paciente a largo plazo (AU)

Introduction. Spinal aneurysmal bone cysts are very infrequent benign osteolytic lesions consisting of blood-filled cavities that are separated by osteo-connective septa and osteoclast-type giant cells. Clinically they manifest with local pain, neurological symptoms secondary to spinal cord compression, and fractures, deformities and vertebral instability. We report a case of an aneurysmal bone cyst in the thoracic spine with neurological signs and symptoms treated by means of a full microsurgical resection, with no associated neurological sequelae. Case report. A 47-year-old woman, with no previous history of traumatic injuries, who was examined following several weeks with clinical signs and symptoms of paraesthesia in the lower limbs. Thoracic magnetic resonance imaging revealed the existence of a lytic lesion with clearly defined edges and marginal sclerosis in T4, in addition to involvement of the posterior vertebral elements and compression of the underlying spinal cord. The whole lesion was removed surgically, and the sensitive clinical symptoms disappeared after the procedure. The definite pathological diagnosis was spinal aneurysmal bone cyst. Conclusion. Despite their low incidence, aneurysmal bone cysts of the spine must be taken into account in the differential diagnosis of spinal bone tumours as a possible cause of subacute or chronic compressive myelopathy. Full surgical removal of the tumour is considered the preferred treatment, which is often curative and is associated with a good prognosis of the patient in the long term (AU)

[Myelopathy secondary to an aneurysmal bone cyst of thoracic spine]. / Mielopatía secundaria a un quiste óseo aneurismático espinal dorsal.

INTRODUCTION: Spinal aneurysmal bone cysts are very infrequent benign osteolytic lesions consisting of blood-filled cavities that are separated by osteo-connective septa and osteoclast-type giant cells. Clinically they manifest with local pain, neurological symptoms secondary to spinal cord compression, and fractures, deformities and vertebral instability. We report a case of an aneurysmal bone cyst in the thoracic spine with neurological signs and symptoms treated by means of a full microsurgical resection, with no associated neurological sequelae. CASE REPORT: A 47-year-old woman, with no previous history of traumatic injuries, who was examined following several weeks with clinical signs and symptoms of paraesthesia in the lower limbs. Thoracic magnetic resonance imaging revealed the existence of a lytic lesion with clearly defined edges and marginal sclerosis in T4, in addition to involvement of the posterior vertebral elements and compression of the underlying spinal cord. The whole lesion was removed surgically, and the sensitive clinical symptoms disappeared after the procedure. The definite pathological diagnosis was spinal aneurysmal bone cyst. CONCLUSION: Despite their low incidence, aneurysmal bone cysts of the spine must be taken into account in the differential diagnosis of spinal bone tumours as a possible cause of subacute or chronic compressive myelopathy. Full surgical removal of the tumour is considered the preferred treatment, which is often curative and is associated with a good prognosis of the patient in the long term.

TITLE: Mielopatia secundaria a un quiste oseo aneurismatico espinal dorsal.Introduccion. Los quistes oseos aneurismaticos espinales son lesiones osteoliticas benignas muy infrecuentes constituidas por cavidades hematicas limitadas por septos osteoconectivos y celulas gigantes tipo osteoclastos. Clinicamente se manifiestan con dolor local, sintomas neurologicos secundarios a compresion medular, asi como fracturas, deformidades e inestabilidad vertebral. Presentamos un caso de quiste oseo aneurismatico espinal dorsal con sintomatologia neurologica, tratado mediante una reseccion microquirurgica completa, sin secuelas neurologicas asociadas. Caso clinico. Mujer de 47 años, sin antecedentes traumaticos previos, valorada por presentar un cuadro de parestesias de los miembros inferiores de semanas de evolucion. El estudio radiologico de resonancia magnetica dorsal demostro la existencia de una lesion litica de bordes bien delimitados y esclerosis marginal en D4, con afectacion de los elementos posteriores vertebrales y compresion del cordon medular subyacente. La lesion fue extirpada en su totalidad, con desaparicion de la clinica sensitiva tras la intervencion. El diagnostico anatomopatologico definitivo fue quiste oseo aneurismatico espinal. Conclusion. A pesar de su baja incidencia, los quistes oseos aneurismaticos espinales deben considerarse, en el diagnostico diferencial de los tumores oseos espinales, como una posible causa de mielopatia compresiva subaguda o cronica. La reseccion tumoral completa se considera el tratamiento de eleccion, el cual con frecuencia es curativo y asocia un buen pronostico del paciente a largo plazo.

Tumores de la región pineal en la edad pediátrica. Presentación de 23 casos y revisión de la bibliografía / Tumours in the pineal region in the paediatric age. Reports of 23 cases and a review of the literature

Introducción. Los tumores de la región pineal se localizan en una encrucijada de estructuras neurovasculares de difícil acceso quirúrgico y limitadas posibilidades de resección; por ello, el manejo de estas lesiones habitualmente requiere la asociación de tratamiento adyuvante radioterápico y/o quimioterápico. Pacientes y métodos. Análisis retrospectivo de las características epidemiológicas, clínicas, neurorradiológicas y anatomopatológicas de 23 pacientes con tumores de la región pineal tratados entre los años 1997 y 2010 en el Hospital Infantil Niño Jesús. Se discuten los factores implicados en el pronóstico de esta cohorte tras el tratamiento quirúrgico o adyuvante. Resultados. El estudio incluyó 6 niñas y 17 niños con edades comprendidas entre los 4 meses y 18 años. El 95% de los pacientes comenzó con signos de hidrocefalia aguda o subaguda, que precisaron la implantación de una derivación ventriculoperitoneal (82%). Se obtuvo una muestra histológica tumoral en todos los casos. Cinco pacientes fueron biopsiadosy 18 fueron intervenidos mediante craneotomía. El germinoma (ocho casos) y el teratoma maduro (un caso) fueron los tumores con mayor supervivencia; los tumores no germinomatosos (tres casos), del parénquima pineal (cuatro casos) y gliomas (cinco casos) presentaron mayor tasa de recidiva y un peor pronóstico. Conclusión. El estudio de marcadores tumorales permite orientar el diagnóstico de determinados tumores de la región pineal. Actualmente, se recomienda realizar una toma histológica tumoral para establecer un diagnóstico preciso y un tratamiento oncológico específico (AU)

Introduction. Tumours in the pineal region are located at a meeting point of several neurovascular structures that are difficult to reach surgically and for which the possibility of resection is limited; as a result the management of these lesions usually requires associated adjunctive treatment with radiotherapy and/or chemotherapy. Patients and methods. This study is a retrospective analysis of the epidemiological, clinical, neuroimaging and pathological characteristics of 23 patients with tumours in the pineal region who were treated between the years 1997 and 2010 in the Hospital Infantil Niño Jesús. The factors involved in the prognosis of this cohort following surgical or adjunctive treatment are also discussed. Results. Subjects included in the study were 6 girls and 17 boys with ages ranging from 4 months to 18 years. It was found that the initial symptoms in 95% of the patients were signs of acute or subacute hydrocephalus, which required the placement of a ventriculoperitoneal shunt (82%). A histological sample of the tumour tissue was collected in all cases. Biopsy samples were taken in the case of five patients and 18 underwent surgery involving a craniotomy. Germinoma (eight cases) and mature teratoma (one case) were the tumours with the longest survival times; non-germinomatous tumours (three cases), those of the pineal parenchyma (four cases) and gliomas (five cases) presented the highest rates of recurrence and a poorer prognosis. Conclusions. The study of tumour markers can be used to guide the diagnosis of certain tumours of the pineal region. At present, the recommended procedure involves taking a histological sample of the tumour in order to establish an accurate diagnosis and a specific oncological treatment (AU)

Quiste óseo aneurismático frontal. Caso clínico y revisión de la bibliografía / Frontal aneurysmal bone cyst. A case report and review of the literature

Introducción. El quiste óseo aneurismático (QOA) craneal es un hallazgo patológico infrecuente, diagnosticado habitualmente en pacientes jóvenes. Se define como una lesión benigna formada por cavidades hemáticas limitadas por septos osteoconectivos y células gigantes tipo osteoclastos; estas características histológicas son comunes a los QOA extracraneales. Clínicamente se manifiestan como tumoraciones craneales en la mayoría de los pacientes, las cuales pueden ser dolorosas y presentan un tamaño variable. Se realiza una revisión bibliográfica de los QOA frontales publicados hasta la fecha, incluyendo un caso tratado recientemente en nuestro servicio. Caso clínico. Mujer de 29 años, sin antecedentes de traumatismo craneoencefálico previo, valorada por presentar una lesión craneal frontal derecha no dolorosa y fija. El estudio radiológico demostró la presencia de una lesión craneal lítica de bordes bien delimitados y esclerosis marginal, con captación periférica y lineal de contraste en el estudio con resonancia magnética cerebral. Se intervino a la paciente y se extirpó la lesión en su totalidad. La evolución postoperatoria transcurrió sin incidencias, y el diagnóstico anatomopatológico definitivo fue QOA craneal. Conclusión. El QOA craneal es una entidad patológica de características histológicas y radiológicas bien definidas, a pesar de que su etiopatogenia actualmente no es completamente conocida. La resección tumoral completa se considera el tratamiento de elección, el cual con frecuencia es curativo y conlleva un buen pronóstico del paciente a largo plazo (AU)

Introduction. Cranial aneurysmal bone cyst (ABC) is a rare pathological finding that is usually diagnosed in young patients. It is defined as a benign lesion made up of intervillous spaces limited by connective bone tissue septa and osteoclast-type giant cells; these histological characteristics are common to extracranial ABC. Clinically, in most patients, they manifest as cranial tumours which may be painful and vary in size. About 100 cases of cranial ABC have been reported in the literature. We present a literature review of the cases of frontal ABC reported to date, including one that was recently treated in our own service. Case report. A 29-year-old female, with no history of traumatic brain injury, who was examined due to the presence of a fixed, painless frontal cranial lesion on the right-hand side. The results of a radiological study revealed the presence of a lytic cranial lesion with well-delimited edges and marginal sclerosis; peripheral and linear contrast enhancement was also observed in the magnetic resonance imaging of the brain. The patient was submitted to a surgical intervention and the entire lesion was removed. There were no incidents in the post-operative period and the definitive pathological diagnosis was cranial ABC. Conclusions. Cranial ABC is a pathological condition with well-defined histological and radiological characteristics, despite the fact that its aetiopathogenesis is still not fully understood. Complete excision of the tumour is considered to be the preferred treatment, which often leads to full recovery of the patient and also offers a good long-term prognosis (AU)

Contribución diferencial de los estudios preoperatorios al diagnóstico en la cirugía de la epilepsia temporal / Differential contribution of preoperatory studies to diagnosis in temporal lobe epilepsy surgery

Introducción. Es preciso conocer el grado de confianza de las pruebas preoperatorias en epilepsia del lóbulo temporal (ELT). Objetivo. Analizar la importancia relativa de diferentes pruebas preoperatorias –videoelectroencefalograma (vEEG), electroencefalograma (EEG), tomografía computarizada por emisión de fotón único (SPECT) y resonancia magnética (RM)–, el grado de concordancia entre ellas y desarrollar un modelo probabilístico bayesiano para el diagnóstico. Pacientes y métodos. Se ha estudiado a 73 pacientes intervenidos de ELT, con un seguimiento postoperatorio mínimo de dos años. Para analizar la capacidad localizadora, se utilizan únicamente pacientes con un grado I de Engel durante todo el tiempo de seguimiento (n = 60). Resultados. Los porcentajes de los grados I, II, III y IV de Engel a los dos años fueron del 87,7, 8,2, 3,0 y 0%, respectivamente. La concordancia preoperatoria fue < 50% para tres pruebas y del 33% para las cuatro. Se encontraron estudios de RM normales en el 33,3% de los casos. Según el índice de localización, el orden es vEEG > RM > SPECT > EEG. La probabilidad condicional de obtener un grado I de Engel por prueba es: vEEG (0,950) > EEG (0,719) > SPECT (0,717) > RM (0,683). Para más de dos pruebas, la probabilidad condicional es ≤ 0,587 (vEEG + RM). La probabilidad de obtener un grado I de Engel a priori es vEEG (0,983) > RM (0,414) > EEG (0,285) > SPECT (0,209). El modelo bayesiano resulta ser muy sólido. Conclusiones. No siempre hay un alto grado de concordancia entre las pruebas, a pesar de lo cual puede obtenerse un buen resultado funcional. La prueba más eficaz es el vEEG (AU)

Introduction. It is necessary to know the degree of concordance of preoperative studies in temporal lobe epilepsy (TLE). Aim. To analyze the relative importance of different preoperative tests (vEEG, EEG, SPECT and MRI), the degree of agreement between them, and to develop a Bayesian probability model for diagnosis. Patients and methods. We analyzed 73 patients operated by TLE, with a minimum postoperative follow-up of two years. To analyze the localization capability of different test, we used only patients with an Engel’s grade I outcome during all the follow-up time (n = 60). Results. Engel’s grades percentages at 2 years were 87.7/8.2/3.0/0.0 (I/II/III/IV, respectively). The preoperative correlation was < 50% for three tests and 33% for the four. MRI studies were found normal in 33.3% of cases. According to the localization index, the arrange was vEEG > RM > SPECT > EEG. The conditional probability of correct localization for a test was vEEG (0.950) > EEG (0.719) > SPECT (0.717) > RM (0.683). Concordance for more than two tests, was ≤ 0.587 (vEEG + MRI). The probability of obtaining a priori correct localization was vEEG (0.983) > RM (0.414) > EEG (0.285) > SPECT (0.209). The Bayesian model is highly reliable. Conclusions. Probably it is not always possible to obtain a high degree of agreement among preoperative test, despite this, it is possible to obtain a good functional result. The most effective test is the vEEG (AU)

Hematoma subdural agudo interhemisférico en un paciente cirrótico / Acute interhemispheric subdural haematoma in a patient with cirrhosis

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[Differential contribution of preoperatory studies to diagnosis in temporal lobe epilepsy surgery]. / Contribución diferencial de los estudios preoperatorios al diagnostico en la cirugia de la epilepsia temporal.

INTRODUCTION: It is necessary to know the degree of concordance of preoperative studies in temporal lobe epilepsy (TLE). AIM. To analyze the relative importance of different preoperative tests (vEEG, EEG, SPECT and MRI), the degree of agreement between them, and to develop a Bayesian probability model for diagnosis. PATIENTS AND METHODS: We analyzed 73 patients operated by TLE, with a minimum postoperative follow-up of two years. To analyze the localization capability of different test, we used only patients with an Engel's grade I outcome during all the follow-up time (n = 60). RESULTS: Engel's grades percentages at 2 years were 87.7/8.2/3.0/0.0 (I/II/III/IV, respectively). The preoperative correlation was < 50% for three tests and 33% for the four. MRI studies were found normal in 33.3% of cases. According to the localization index, the arrange was vEEG > RM > SPECT > EEG. The conditional probability of correct localization for a test was vEEG (0.950) > EEG (0.719) > SPECT (0.717) > RM (0.683). Concordance for more than two tests, was = 0.587 (vEEG + MRI). The probability of obtaining a priori correct localization was vEEG (0.983) > RM (0.414) > EEG (0.285) > SPECT (0.209). The Bayesian model is highly reliable. CONCLUSIONS: Probably it is not always possible to obtain a high degree of agreement among preoperative test, despite this, it is possible to obtain a good functional result. The most effective test is the vEEG.