Training in Skull Base Endonasal Endoscopic Surgery: Development and Validation of a Novel Low-Cost Simulation with Animal Cadaveric Model.

BACKGROUND: Endoscopic skull base surgery is constantly evolving and its scope has expanded. The acquisition of surgical skills involves a long learning curve with significant risks for the patient. Therefore, training in the laboratory has become essential to achieve appropriate proficiency and reduce the morbidity and mortality associated with these procedures. The objective of our work is to develop and validate a cost-effective and easily replicable simulator for endonasal endoscopy training using a swine cadaveric model. METHODS: We used fresh Pietrain swine heads. Training exercises of increasing complexity were performed. A Specific Technical Skills and Knowledge Scale was created considering the objectives to be assessed in each task. After the simulation, the trainees were required to answer a satisfaction survey. RESULTS: Ten participants were recruited (5 neurosurgery residents and 5 neurosurgeons). The simulator assessment showed statistically significant differences between groups. Performance was better among the group with endoscopic surgery experience. Face validity was assessed through a postsimulation questionnaire showing an overall mean score of 28.7 out of 30, indicating a highly positive overall assessment of the simulator. Furthermore, 100% of the trainees believe that including endoscopy training in their education would be beneficial. CONCLUSIONS: The endonasal endoscopy training simulator using a swine cadaveric model is a useful and accessible tool for enhancing surgical skills in this field. It provides an opportunity for training outside the operating room, reducing the potential risks associated with patient practice, and improving the training of residents.

Derivación ventrículo-atrial por punción percutánea. Enfoque técnico y análisis de casuística / Ventriculo-atrial shunt by percutaneous puncture. Technical approach and casuistry analysis

Introducción: La cirugía de drenaje de líquido cefalorraquídeo al sistema venoso es utilizada como tratamiento de la hidrocefalia en casos de disfunción peritoneal. Objetivos: Describir la punción percutánea para introducir el catéter distal utilizando las herramientas necesarias para su correcta localización atrial. Materiales y métodos: El periodo de estudio se extiende desde enero de 2013 hasta abril de 2019. Incluimos 45 pacientes, 24 de sexo femenino y 21 masculinos. El rango etario es de 6 meses a 18 años. La técnica de Seldinger modificada con asistencia ecográfica y control radioscópico intraquirúrgico se utilizó para introducir el catéter distal al sistema venoso. El seguimiento fue de al menos 1 año en el Hospital de Niños "Ricardo Gutiérrez" de CABA. Resultados: Las causas de hidrocefalia fueron: mielomeningocele 17 casos (38%); congénita 9 (20%); tumoral 7 (16%); postinfecciosa 6 (13%); post-hemorrágica 5 (11%); hiperplasia de plexos coroideos 1 (2%). La obstrucción proximal se dio en 7 casos (15%), infecciones en 5 (11%), disfunción distal en 4 (8%) y migración distal del segmento intravascular 1 (2%). La vena yugular interna derecha fue el sitio para la punción en 37 casos (82%). El acceso al sistema ventricular fue frontal en 23 casos (51%) y occipito-atrial en 22 (49%). Las válvulas que se utilizaron fueron de presión media fija en el 89% de los pacientes. No hubo mortalidad perioperatoria. La indicación quirúrgica fue por insuficiente reabsorción peritoneal en todos los casos. Conclusión: La cirugía de derivación ventrículo atrial por punción percutánea es una técnica segura, aunque no exenta de complicaciones. Estas disminuyen con el correcto orden de los pasos quirúrgicos complementados con radioscopia y ecografía intraoperatoria

Introduction: Cerebrospinal fluid drainage surgery to the venous system is used as a treatment for hydrocephalus in cases of peritoneal dysfunction. We weigh the percutaneous puncture to insert the distal catheter and use the necessary tools for its correct atrial location. Materials and methods: The study period runs from January 2013 to April 2019. The work includes a total of 45 patients, 24 females and 21 males. The age range is 6 months to 18 years. The modified "Seldinger" technique with ultrasound assistance and intraoperative radioscopic control was used to introduce the catheter distal to the venous system. The minimum follow-up was 1 year at the Hospital de Niños "Ricardo Gutiérrez" in CABA. Results: The causes of hydrocephalus were: myelomeningocele, 17 cases (38 %); congenital, 9 (20 %); tumors, 7 (16 %); post-infective, 6 (14 %); post-hemorrhagic: 5 (11 %); choroid plexus hyperplasia: 1 (2 %). Proximal obstruction occurred in 7 cases (15 %), infections in 5 (11 %), distal dysfunction 4 (8 %) and there were 1 patient (2 %) which exhibited distal venous migration of the intravascular segment. The right internal jugular vein was the site of choice for puncture, 37 cases (82 %); there was almost the same distribution in the location of the frontal and occipital-atrial proximal segments, 23 (51 %) 22 (49 %) respectively; fixed medium pressure valves were most frequently used, total of 40 (89 %). There were no cases of perioperative mortality. Surgical indication involved peritoneal engagement in all cases. Conclusion: Atrial ventricle shunt surgery by percutaneous puncture is a safe technique, not free of complications, which decrease with the correct order of your steps and complement radiology and intraoperative ultrasound

Intracranial video-EEG and surgery for focal atonic seizures.

Atonic seizures are epileptic attacks characterised by a sudden loss or diminution of muscle tone. Structures corresponding to inhibitory cortical areas, such as the primary negative motor area or the supplementary negative motor area, could be responsible. We present findings observed in a patient with atonic seizures due to focal epilepsy, who underwent intracranial video-EEG monitoring and epilepsy surgery, and discuss possible underlying mechanisms. [Published with video sequences].

Epilepsy surgery in Argentina: long-term results in a comprehensive epilepsy centre.

RATIONALE: Epilepsy surgery procedures started in Argentina more than 50 years ago. This is the first comprehensive and systematic survey of epilepsy surgery long-term outcome from our country. METHODS: A descriptive cohort study was conducted between 1998 and 2008 for drug-resistant epilepsy surgery with a minimum of 12 months follow-up (n=110). In 84 cases (76.36%) resective surgery was performed, and outcome periodically assessed using the Engel score. Patients were stratified into groups: 12, 13-36, 37-60 and over than 60 months of follow-up. Video-EEG with and without intracranial electrode implants, intraoperative electrocorticograms, Wada tests, pathology reports, use of antiepileptic drugs (AEDs), and surgical complication rates were evaluated. RESULTS: Surgical techniques included: 69 lobectomies (62.7%), 15 lesionectomies (13.6%), 6 callosotomies (5.4%), 6 multiple subpial transection (5.4%), 11 vagus nerve stimulations (10%), 3 hemispherectomies (2.7%). Male: female ratio: 1/1.44. Mean age at time of surgery: 26.2 years. Mean duration of epilepsy: 14 years. Age at seizure onset: 11.5 years. Mean follow-up: 46 months. Pathology findings: mesial temporal sclerosis 32 (35.1%); dual pathology 17 (18.7%); cortical dysplasia 15 (16.4%); non-specific inflammatory changes 11 (12.1%); tumors 7 (7.7%); other 6 (6.8%). Engel scores at 12 months follow-up: 72.6% (61) class I, 16.6% (14) class II and 15.5% (13) class III-IV; 13-36 months after surgery: 68.1% of cases were class I, 15.9% class II and 15.5% class III-IV. After 37-60 months, 74% class I, 14% class II, 14% class III-IV. Over 60 months (n=45) 78% class I, 13.5% class II and 8.1% class III-IV. CONCLUSION: Conducting a successful epilepsy surgery program in a developing country is challenging. These results should encourage specialists in these countries. Long-term outcome results comparable to centres in developed countries can be achieved.

Malformación del desarrollo cortical: nuestra experiencia acerca de 150 casos / Cortical development malformations (CDM): our experience on 150 cases

Objetivo Realizar una evaluación retrospectiva de 150 pacientes de una serie de 570 (26.3%), operados por epilepsia refractaria con diagnóstico de algún tipo de malformación del desarrollo cortical (MDC), desde 1988 a noviembre de 2009. Material y método. 118 niños y 32 adultos; 69 localización temporal (42 niños, 27 adultos) y 81 extratemporal (76 niños y 5 adultos). La evaluación prequirúrgica incluye: características clínico-semiológicas de las crisis epilépticas, EEG de superficie, video EEG, TC y/o RM y evaluación neuropsicológica. Población: varones: 86; mujeres 64; edad, media de 6.7 años (rango: 6 m – 18.9 a) en los niños y media de 31.3 años (rango: 19-59 a) en los adultos. Evolución de epilepsia: media de 4.9 años para los niños (rango: 1 mes a 17 años) y media de 13.8 (rango: 2 meses a 50 años). Aspectos clínicos: tipos de crisis: pudiendo un mismo paciente presentar más de una de ellas, vinculadas a la localización, CPS, ausencias, crisis tónicas, automatismos, crisis versivas, CPC, anopsia transitoria, “drop attacks”, “Startle epilepsia”, escotoma, automatismos masticatorios, crisis clónicas, fotopsia, desviación ocular, “head attacks”. Imágenes: la TC fue normal en 5, y se realizó IRM en todos a partir de 1996

Objective: To evaluate the surgical results in a group of patients with epilepsy associated with cortical development malformations (CDM). Method: A retrospective study in 150 patients of a series of 570 patients (26.3%) who have undergone surgery for intractable epilepsy with a diagnosis of CDM, since 1988. Clinical features,scalp EEG, video EEG, CT scan, MRI and neuropsychological evaluation were assessed. Population: males: 86 patients, females: 64; mean age, children: 6.7 years (range: 0,5-18.9) and adults: 31.3 years (range: 19-59); mean evolution of epilepsy, children: 4.9 years (range: 1mo-17 yr.), adults: 13.8 years (range: 2mo-50 yr.). Clinical manifestations: CPS, absences,tonic crises, automatisms and versive crises, CPS, transitory anopsia, drop attacks and Startle epilepsy, scotoma, masticatory automatisms, clonic crises, photopsia, eye deviation and head attacks. Imaging: CT scan was normal in 5, and MRI was performed since 1996. Twenty of 150 (13.3%) required chronic intracranial electrodes implantation. Surgical procedures: resectives: lesionectomies 63 (wide lesionectomy, 17 and + MST, 5), standard anterior temporal lobectomies (SATL) 37, anteromesial resections (Spencer) 9, corticectomies 11(+MST, 1),amigdalo- hippocampectomies 3, anatomic hemispherectomy 1, lobectomy1 and polectomies 4; disconnecting procedures: functional hemispherectomies (FH) 10, hemispherotomy 4, hemi-hemispherectomy 1, multiple subpial transection (MST) 1 and 2 callosotomies...

Malformación del desarrollo cortical: nuestra experiencia acerca de 150 casos / Cortical development malformations (CDM): our experience on 150 cases

Objetivo Realizar una evaluación retrospectiva de 150 pacientes de una serie de 570 (26.3%), operados por epilepsia refractaria con diagnóstico de algún tipo de malformación del desarrollo cortical (MDC), desde 1988 a noviembre de 2009. Material y método. 118 niños y 32 adultos; 69 localización temporal (42 niños, 27 adultos) y 81 extratemporal (76 niños y 5 adultos). La evaluación prequirúrgica incluye: características clínico-semiológicas de las crisis epilépticas, EEG de superficie, video EEG, TC y/o RM y evaluación neuropsicológica. Población: varones: 86; mujeres 64; edad, media de 6.7 años (rango: 6 m ¹ 18.9 a) en los niños y media de 31.3 años (rango: 19-59 a) en los adultos. Evolución de epilepsia: media de 4.9 años para los niños (rango: 1 mes a 17 años) y media de 13.8 (rango: 2 meses a 50 años). Aspectos clínicos: tipos de crisis: pudiendo un mismo paciente presentar más de una de ellas, vinculadas a la localización, CPS, ausencias, crisis tónicas, automatismos, crisis versivas, CPC, anopsia transitoria, ¶drop attacks÷, ¶Startle epilepsia÷, escotoma, automatismos masticatorios, crisis clónicas, fotopsia, desviación ocular, ¶head attacks÷. Imágenes: la TC fue normal en 5, y se realizó IRM en todos a partir de 1996

Objective: To evaluate the surgical results in a group of patients with epilepsy associated with cortical development malformations (CDM). Method: A retrospective study in 150 patients of a series of 570 patients (26.3%) who have undergone surgery for intractable epilepsy with a diagnosis of CDM, since 1988. Clinical features,scalp EEG, video EEG, CT scan, MRI and neuropsychological evaluation were assessed. Population: males: 86 patients, females: 64; mean age, children: 6.7 years (range: 0,5-18.9) and adults: 31.3 years (range: 19-59); mean evolution of epilepsy, children: 4.9 years (range: 1mo-17 yr.), adults: 13.8 years (range: 2mo-50 yr.). Clinical manifestations: CPS, absences,tonic crises, automatisms and versive crises, CPS, transitory anopsia, drop attacks and Startle epilepsy, scotoma, masticatory automatisms, clonic crises, photopsia, eye deviation and head attacks. Imaging: CT scan was normal in 5, and MRI was performed since 1996. Twenty of 150 (13.3%) required chronic intracranial electrodes implantation. Surgical procedures: resectives: lesionectomies 63 (wide lesionectomy, 17 and + MST, 5), standard anterior temporal lobectomies (SATL) 37, anteromesial resections (Spencer) 9, corticectomies 11(+MST, 1),amigdalo- hippocampectomies 3, anatomic hemispherectomy 1, lobectomy1 and polectomies 4; disconnecting procedures: functional hemispherectomies (FH) 10, hemispherotomy 4, hemi-hemispherectomy 1, multiple subpial transection (MST) 1 and 2 callosotomies...(AU)

Epilepsia refractaria del lobulo temporal secundaria a patología dual: Nuestra experiencia acerca de 32 casos / Refractory temporal lobe epilepsy secondary to dual pathology: Review of 32 cases

Classical dual pathology is the coexistence of temporal mesial sclerosis (TMS) and an ipsilateral extra-hippocampal lesion. The aim of this presentation is to increase the awareness of the existence of this pathology as well as variants as a cause of refractory temporal lobe epilepsy and its difficult pre-op diagnosis. Of the 32 cases here presented, 19 were adults and 13 children. Adults: 17 had TMS + cortical dysplasia (CD) and of the remaining patients, 1 had TMS + oligodendroglioma and 1 TMS+ ganglioglioma. Children: pathology findings were: A) TMS + malformation of cortical development 6; B) TMS + CD + ganglioglioma 2; TMS + ganglioglioma + post-infectious sequelae 1 (“triple pathology”) and C) CD associated with low-grade glioma 1 and with MAV 1.Surgical techniques: LATS and the Spencer variant were the most commonly used techniques. Results: Patients in both groups are in Engel Class I and II. Conclusion: The good results in this series can be attributed to the complete resection of these entities.

Hemisferectomías y hemi-hemisferectomías: nuestra experiencia acerca de 49 casos / Hemispherectomy and hemi-hemispherectomy: Review of 49 cases

Objective. To review the results of hemispherectomy in the treatment of refractive epilepsy. Methodology. Analytic retrospective cohort study including every patient presenting refractive epilepsy to pharmacologic therapy, operated with hemispherectomy techniques from 1988 to 2008 (n=49). Of 507 patients, operated for refractive epilepsy in the last 20 years, in 49 cases we used any kind of hemispherectomy techniques (9,7%). The male/female relationship was 1.13-1, with 53% males and 47% females. The mean age was 8±5 years old, minimum 4 months and maximum 19 years old. The epilepsy time evolution was 3±2 years. The age of initial presentation was 3±1 years old. The more frequent pathologies were: Rasmussen encephalopathy (30,6%) and secuelar lesions (34,7%). Results. The results were evaluated with the Engel score. Using this classification, our patients were distributed in this manner: 40 patients (81,6%) were in class I of Engel; 4 patients (8,2%) in class II of Engel and 5 patients (10,2%) en Engel III and IV. 88% (43 cases) without complications, 4% (2 cases) present hematomas and the same occur with hydrocephalus and postoperative meningitis. One patient died a few days posterior to surgery because of hematologic complications. Conclusion. The hemispherectomy for the management of refractive epilepsy is a safe procedure with high positive results and small morbimortality in selective pathologies.

Resultados de la cirugía de epilepsia en esclerosis tuberosa / Results of surgical treatment of epilepsy in tuberous sclerosis patients

Objective. We review our experience with surgical treatment in tuberous sclerosis and refractory epilepsy. Method. Between june 1995 and june 2008 , surgery was performed in 12 patients with tuberous sclerosis and refractory epilepsy. Median age: 6 years (r=6 months-19 years). 6 males and 6 females. Epilepsy began during the first year of life. They have been studied with RMI and video-EEG. Two patients were studied with intracranial electrodes. Electrocorticography was performed in 7, somatosensory evoked potentials in 2 and cortical stimulation in 1. Epileptogenic region was frontal in 4, temporal in 3, parietal in 2, occipital in 1 and bilateral in 2. Surgical procedures were resection of the epileptogenic regions and associated tuber(s) in 6, temporal lobectomy in 1, callosotomy in 1, parietal lobectomy in 1, frontal polectomy and vagus nerve stimulation in 1. A second surgery was performed in 1 case. Results. The outcome of seizures was classified with Engel’s outcome classification: 7 patients were in class I , 2 in class II and III . Callosotomy and vagus nerve stimulation were performed in 2 patients who had multifocal abnormality , seizure freedom was achieved in more than 60%.

Esclerosis temporomesial en adultos: revisión del síndrome y evalución de resultados / Mesial temporal sclerosis in adults: Revision of the syndrome and assessment of results

Objective: To describe the presentation and the management of the Mesial Temporal Sclerosis (ETM) in adult patients and to evaluate the results of the presented series. Description: the authors selectioned 3 cases among 53 adults who underwent surgical treatment with ETM diagnosis. Case 1: female patient, 32 years old. Antecedents of complex partial crisis since 6 years old, some of the crisis related to febrile episodes. Aura related like unpleasent gastroesophageal sensation, break of contact, right hand dystonia, cephalic turn to right and oroalimentary and manual automatism. RMI and EEG-video: injury compatible with left ETM. Case 2: male patient, 24 years old. Antecedents of complex partial crisis since 13 years old. Breack of contact, verbal automatisms (repeats unintelligible sounds) and sensation of postictal sikness. RMI: increase of signal (FLAIR) in both hippocampus, impressing right atrophy. EEG-video with profund electrodes implanted: start of the crisis on a right mesial temporal level. Case 3: female patient, 21 years old. Antecedents of complex partial crisis since 12 years old. Complex partial crisis with bimanual and oroalimentary automatisms with an episode of generalization. RMI and EEG-video: injury compatible with right ETM. Intervention: case 1 and 2 were resolved by the realization of an anteromesial resection of Spencer. In case 3 a selective amygdalo hippocampectomy was practiced. Conclusion: ETM is the paradigm of the refractory epilepsy in an adult population. Precocious diagnosys and treatment allow to obtain a high index of cure with small amount of significant sequels.

Cirugia en dos tiempos en epilepsia refractaria. Utilidad de los electrodos intracraneanos cronicos. Experiencia en poblacion pediatrica y adulta / Two steps surgery in refractory epilepsy. Usefulnes of chronic intracranial electrodes. Experience in pediatric and adult population

Objetivo: Comunicar la utilidad de la cirugia en dos tiempos con implante de electrodos intracraneales para definir el area epileptogenica primaria. Metodos: se analizaron las historias clinicas de 41 pacientes, 28 niños y 13 adultos estudiados mediante el implante de electrodos intracraneanos con el objetivo de determinar el area epileptogenica primaria (AEP) cuando no fue posible identificarla por estudios no invasivos. Se realizaron cirugias resectivas / desconexion y se analizo evolucion con la Escala de Engel. Resultados: Poblacion pediatrica: se definio lateralidad y el area epileptogenica primaria (AEP) en 26 de 28 casos. El estimulo cortical permitio localizar el area motora en 4 pacientes. En 2 pacientes no pudo definirse lateralidad del AEP. Poblacion adulta: en 12 de 13 pacientes pudo establecerse lataralidad y localizacion del AEP; en un paciente no se logro. A pesar de la dificultad de localizar el AEP en el 14 por ciento de los niños y 16 por ciento de los adultos esta metodologia permitio tratar quirurgicamente ambas poblaciones con una evolucion en Engel I y II del 84 y 72 por ciento respectivamente. El seguimiento promedio fue en la poblacion pediatrica de 6 años y en la poblacion adulta de 6 años y 8 meses. Conclusion: la cirugia en dos tiempos con implante de electrodos intracraneamos es muy util para el diagnostico y tratamiento de epilepsias refractarias complejas en las que la imagen, clinica y video EEG son incongruentes

Cirugia en dos tiempos en epilepsia refractaria. Utilidad de los electrodos intracraneanos cronicos. Experiencia en poblacion pediatrica y adulta / Two steps surgery in refractory epilepsy. Usefulnes of chronic intracranial electrodes. Experience in pediatric and adult population

Objetivo: Comunicar la utilidad de la cirugia en dos tiempos con implante de electrodos intracraneales para definir el area epileptogenica primaria. Metodos: se analizaron las historias clinicas de 41 pacientes, 28 niños y 13 adultos estudiados mediante el implante de electrodos intracraneanos con el objetivo de determinar el area epileptogenica primaria (AEP) cuando no fue posible identificarla por estudios no invasivos. Se realizaron cirugias resectivas / desconexion y se analizo evolucion con la Escala de Engel. Resultados: Poblacion pediatrica: se definio lateralidad y el area epileptogenica primaria (AEP) en 26 de 28 casos. El estimulo cortical permitio localizar el area motora en 4 pacientes. En 2 pacientes no pudo definirse lateralidad del AEP. Poblacion adulta: en 12 de 13 pacientes pudo establecerse lataralidad y localizacion del AEP; en un paciente no se logro. A pesar de la dificultad de localizar el AEP en el 14 por ciento de los niños y 16 por ciento de los adultos esta metodologia permitio tratar quirurgicamente ambas poblaciones con una evolucion en Engel I y II del 84 y 72 por ciento respectivamente. El seguimiento promedio fue en la poblacion pediatrica de 6 años y en la poblacion adulta de 6 años y 8 meses. Conclusion: la cirugia en dos tiempos con implante de electrodos intracraneamos es muy util para el diagnostico y tratamiento de epilepsias refractarias complejas en las que la imagen, clinica y video EEG son incongruentes (AU)