Supramarginal resection of skull base chordomas: proof of concept and preliminary outcomes.

OBJECTIVE: The mainstay of treatment for skull base chordoma (SBC) is maximal safe resection followed by radiotherapy. However, even after gross-total resection (GTR), the recurrence rate is high due to microscopic disease in the resection margins. Therefore, supramarginal resection (SMR) could be beneficial, as has been shown for sacral chordoma. The paradigm of postoperative radiation therapy for every patient has also begun to change, as molecular profiling has shown variability in the risk of recurrence. The aim of this study was to present the concept of SMR applied to SBC, along with an individualized decision for postoperative radiation therapy. METHODS: This is a retrospective analysis of all SBCs operated on by the senior author between 2018 and 2023. SMR was defined as negative histological margins of bone and/or dura mater, along with evidence of bone resection beyond the tumor margins in the craniocaudal and lateral planes on postoperative imaging. Tumors were classified into 3 molecular recurrence risk groups (group A, low risk; group B, intermediate risk; and group C, high risk). Postoperative radiation therapy was indicated in group C tumors, in group B chordomas without SMR, or in cases of patient preference. RESULTS: Twenty-two cases of SBC fulfilled the inclusion criteria. SMR was achieved in 12 (55%) cases, with a mean (range) amount of bone resection beyond the tumor margins of 10 (2-20) mm (+40%) in the craniocaudal axis and 6 (1-15) mm (+31%) in the lateral plane. GTR and near-total resection were each achieved in 5 (23%) cases. Three (19%) tumors were classified as group A, 12 (75%) as group B, and 1 (6%) as group C. Although nonsignificant due to the small sample size, the trends showed that patients in the SMR group had smaller tumor volumes (13.9 vs 19.6 cm3, p = 0.35), fewer previous treatments (33% vs 60% of patients, p = 0.39), and less use of postoperative radiotherapy (25% vs 60%, p = 0.19) compared to patients in the non-SMR group. There were no significant differences in postoperative CSF leak (0% vs 10%, p = 0.45), persistent cranial nerve palsy (8% vs 20%, p = 0.57), and tumor recurrence (8% vs 10%, p = 0.99; mean follow-up 15 months) rates between the SMR and non-SMR groups. CONCLUSIONS: In select cases, SMR of SBC appears to be feasible and safe. Larger cohorts and longer follow-up evaluations are necessary to explore the benefit of SMR and individualized postoperative radiation therapy on progression-free survival.

Endoscopic endonasal pituitary sacrifice for select tumors with retrochiasmatic and/or retrosellar extension: surgical anatomy, operative technique, and case series.

OBJECTIVE: Tumors located in the retrochiasmatic region with extension to the third ventricle might be difficult to access when the pituitary-chiasmatic corridor is narrow. Similarly, tumor extension into the interpeduncular and retrosellar space poses a major surgical challenge. Pituitary transposition techniques have been developed to gain additional access. However, when preoperative pituitary function is already impaired or the risk of postoperative panhypopituitarism (PH) is considered to be particularly high, removal of the pituitary gland (PG) might be the preferred option to increase the working corridor. The aim of this study was to describe the relevant surgical anatomy, operative steps, and clinical experience with the endoscopic endonasal pituitary sacrifice (EEPS) and transsellar approach. METHODS: This study comprised anatomical dissections to highlight the relevant surgical steps and a retrospective case series reporting clinical characteristics, indications, and outcomes of patients who underwent EEPS. The surgical technique is as follows: both lateral opticocarotid recesses are exposed laterally, the limbus sphenoidale superiorly, and the sellar floor inferiorly. After opening the dura, the PG is detached circumferentially and mobilized off the medial walls of the cavernous sinuses. The descending branches of the superior hypophyseal artery are coagulated, and the stalk is transected. After removal of the PG, drilling of the dorsum sellae and bilateral posterior clinoidectomies are performed to gain access to the hypothalamic region, interpeduncular, and prepontine cisterns. RESULTS: From 2018 to 2023, 11 patients underwent EEPS. The cohort comprised mostly tuberoinfundibular craniopharyngiomas (n = 8, 73%). Seven (64%) patients had partial or complete anterior PG dysfunction preoperatively, while 4 (36%) had preoperative diabetes insipidus. Because of the specific tumor configuration, the chance of preserving endocrine function was estimated to be very low in patients with intact function. The main reasons for pituitary sacrifice were impaired visibility and surgical accessibility to the retrochiasmatic and retrosellar spaces. Gross-total tumor resection was achieved in 10 (91%) patients and near-total resection in 1 (9%) patient. Two (18%) patients experienced a postoperative CSF leak, requiring surgical revision. CONCLUSIONS: When preoperative pituitary function is already impaired or the risk for postoperative PH is considered particularly high, the EEPS and transsellar approach appears to be a feasible surgical option to improve visibility and accessibility to the retrochiasmatic hypothalamic and retrosellar spaces, thus increasing tumor resectability.

[Arteriovenous Malformations - checking and descriptive analysis of 52 AVMs treated for the 2000-2010 period]. / Malformaciones arteriovenosas revisión y análisis descriptivo de 52 mavs tratadas durante el periodo de 2000-2010.

BACKGROUND: To describe our experience in treating AVMs based on age, sex, reasons for consultation and symptoms, localization and clinical diagnosis, size, types, relation with aneurysms, endovascular procedures used, postoperative results and complications. METHODS: We present 52 patients with AVMs, analysing Neurological Exam, Ct, Irm and Brain Arteriography. RESULTS: Average age: 37.71 years. Male patients 61.53% females 38.46%. Reasons for consultation Cephalea: 63.46%, hemorrhagic events: 59.61%, seizures 26.92%. AVM location: supratentorial: 92.85%, infratentorial: 7.15%. AVMs frequency: grade 2: 30.76%, grade 3: 30.76%. Of the total number 50%, presented associated aneurysms. 32.69% of them presented hemorrhagic events. Of the total of AVMs, 59.61% showed bleeding, 26.92% showed seizures and 13.46% showed neurological deficit. 30.76% of the patients received endovascular treatment 23.07% improved their clinical condition, 57.69% showed no changes, and 19.23% experienced deterioration during the postoperative period. There were 13.46%. Mortal cases. CONCLUSION: We agree with the authors that the group mostly affected is (20- 40 years). As regards sex distribution: male patients (61.53%) female ones (38.46%). AVM location was mostly supratentorial, but also that cephalea, hemorrhagic events and seizures were the most frequent symptoms and reasons for consultation. Hemorrhagic CVA, cephalea, epileptic seizures and neurological deficit represented the most common admission diagnoses. We believe that the subgroup of AVMs grade III, IV and V has unique features that requiring extreme care when making decisions. The mortal cases in the postoperative period coincided with those mentioned in the bibliography consulted.

Malformaciones arteriovenosas. Revisión y análisis estadístico de 52 MAVs tratadas durante el período de 2000-2010. Tercera parte / Arteriovenous malformations. Review and statistical analysis of 52 MAVs treated during the period 2000-2010. Third part

INTRODUCCIÓN: describir nuestra experiencia en el tratamiento de las MAVs analizando: procedimientos endovasculares utilizados, resultados postoperatorios y complicaciones asociadas, estadificación según escalas de Barthel y Rankin modificadas. MATERIAL Y MÉTODOS: la población de estudio se constituyó por 52 pacientes con MAVs la cual fue analizada y estudiada mediante examen neurológico pre y postoperatorio, TC cerebral, RM cerebral y arteriografía de 4 vasos de cuello, la totalidad fue tratada mediante cirugía convencional en nuestro Servicio durante el período comprendido entre los años 2000 a 2010. RESULTADOS: recibieron tratamiento endovascular previo a la cirugía 16 MAVs (30,76 %). Todas fueron operadas. Doce pacientes mejoraron en el postoperatorio (23,07 %), 30 pacientes (57,69%) no sufrieron modificaciones y 10 de ellos (19,23%) empeoraron durante el postoperatorio. La mortalidad fue de 7 casos (13,46 %). CONCLUSIÓN: consideramos a los procedimientos endovasculares y la radiocirugía una herramienta de indudable valor terapéutico. Creemos que el subgrupo de MAVs grados III, IV y V representa una entidad singular que las distingue del resto, como una subtipo que requiere más aun de una compleja toma de decisiones. Tuvimos las mayores complicaciones postoperatorias en MAVs grados III y IV. Nuestra mortalidad postoperatoria coincide con la bibliografía consultada

INTRODUCTION: to describe our experience in treating AVMs based on the endovascular procedures used, postoperative results and associated complications, staging according to Barthel Index and modified Rankin Scale. PATIENTS AND METHOD: we present 52 patients with AVMs which were analysed and studied by Pre and Post-Surgery Neurological exam, brain CT, Brain IRM and four Neck vessels arteriography. All the patients were treated by conventional Surgery at our Department of Neurosurgery for the 2000­2010 period. RESULTS: Sixteen patients with AVMs (30.76%) underwent endovascular treatment prior to surgery. 100% were operated. 12 patients (23.07%) improved their clinical condition in the postoperative period, 30 patients (57.69%) showed no changes, and 10 of them (19.23%) experienced deterioration during the postoperative period. There were 7 mortal cases (13.46%). CONCLUSION: we believe that endovascular procedures and radiosurgery are tools of immense therapeutic value. We also consider that the subgroup of AVMs grade III, IV and V have unique features that distinguish them among the rest as a subtype, thus requiring extreme care when making decisions. Most postoperative complications occurred with AVMs grade III and IV. The mortal cases in the postoperative period coincided with those mentioned in the bibliography consulted

Malformaciones arteriovenosas - segunda parte. revisión y análisis estadístico de 52 MAVs tratadas durante el período de 2000-2010 / Arteriovenous malformations - part two. review and statistical analysis of 52 MAVs treated during the period 2000-2010

Objetivo: Describir nuestra experiencia en el tratamiento de las MAVs analizando: tamaño, tipo de MAV más frecuentes, relación entre aneurismas arteriales y/o venosos asociados con eventos de sangrado crisis comiciales y déficit neurológico. Material y Métodos: la población de estudio se constituyó por 52 pacientes con MAVs la cual fue analizada y estudiada mediante examen neurológico pre y postoperatorio, TC cerebral, IRM cerebral y arteriografía de 4 vasos de cuello, la totalidad fue tratada mediante cirugía convencional en nuestro servicio durante el periodo comprendido entre los años 2000 a 2010. Resultados: las MAVs más frecuentes fueron grado 2: 30,76% y grado 3: 30,76%. De la totalidad de la muestra el 50% presentaron aneurismas arteriales o venosos asociados. El 32,69% de los pacientes portadores de aneurismas sean estos arteriales o venosos debutaron con eventos vasculares hemorrágicos. Del total de las MAVs, el 59,61% debutó con sangrado, 26,92% con crisis convulsivas y el 13,46% con déficit neurológico no relacionado con crisis comiciales o eventos vasculares hemorrágicos, de estas últimas el 71,42% correspondieron al grupo comprendido por las MAVs grado III y IV. Conclusión: el evento vascular hemorrágico fue la presentación más frecuente 59,61% (31 casos). La presencia de aneurismas asociados representa un factor predisponente para dicho debut. Las crisis comiciales y el déficit neurológico siguen en orden de frecuencia al evento hemorrágico como forma de comienzo, en concordancia con la bibliografía las crisis comiciales prevalecieron en los grados II y III. Las MAVs que sangraron con mayor frecuencia fueron las grado I y V.

Purpose: To describe our experience in treating AVMs based on size, most frequent types of AVMs, the relationship between arterial and/or venous aneurysms associated with bleeding events, epileptic seizures and neurological deficit. Method: we present 52 patients with AVMs treated at our Department in the 2000 – 2010 period.Results: the most frequent AVMs were grade 2 in 30.76% of the cases and grade 3 in 30.76% of them. Of the total number of all the cases, 50% presented associated arterial or venous aneurysms. 32.69% of the patients with either arterial or venous aneurysms presented hemorrhagic vascular events as an early symptom. Of the total number of AVMs, 59.61% of the cases showed bleeding, 26.92% of them showed seizures and 13.46% showed neurological deficit not related to seizures or hemorrhagic vascular events. Of the latter group, 71.42% corresponded to AVMs grade III and IV.Conclusion: hemorrhagic vascular event was the symptom most frequently observed: 31 cases (59.61%). Associated aneurysms are predisposing factors to such events. Epileptic seizures and neurological deficit are the second most common events after hemorrhagic ones as early symptoms. We agree with the authors consulted that epileptic seizures corresponded mostly to grade II and III. The AVMs that bled more frequently were grade I and V.

Malformaciones arteriovenosas (primera parte) / Arteriovenous malformations (part one)

Objetivo: describer nuestra experience en el manejo de las MAVs analizando: edad, sexo, motivo de consulta y síntomas más frecuentes, así como localización y diagnóstico al ingreso. Material y método: la población de estudio dada por 52 pacientes con MAVs, en quienes utilizamos como método de análisis el examen neurológico, la TAC de cerebro, IRM y arteriografía cerebral de 4 vasos. La totalidad de los pacientes fueron tratados mediante cirugía convencional en nuestro Servicio durante el periodo comprendido entre los años 2000 al 2010. Resultados: el promedio de edad fue 37.7 años. El porcentaje según sexo: varones 61.53%; mujeres 38.46%. Los síntomas y motivos de consulta más frecuentes fueron: cefalea 63.46%, eventos vasculares hemorrágicos 59.61%, convulsiones 26.92%. Localización de las MAVs: supratentoriales 92.85%, infratentoriales 7.15%. Conclusión: concordamos con la bibliografía consultada respecto a que el grupo poblacional más afectado está entre los 20 y 40 años. En relación a la distribución por sexo encontramos una prevalencia más elevada en el sexo masculino: 61.53% vs 38.46% respectivamente. Respecto a la localización concordamos con los autores en la mayor prevalencia supratentorial. En cuanto a los síntomas de presentación y motivo de consulta coincidimos en que la cefalea, los eventos de sangrado y las crisis convulsivas fueron los más habituales. Concordamos también en los diagnósticos de ingreso más frecuentes siendo el ACV hemorrágico, la cefalea, las crisis comiciales y el déficit neurológico los más comunes.

Malformaciones arteriovenosas (primera parte) / Arteriovenous malformations (part one)

Objetivo: describer nuestra experience en el manejo de las MAVs analizando: edad, sexo, motivo de consulta y síntomas más frecuentes, así como localización y diagnóstico al ingreso. Material y método: la población de estudio dada por 52 pacientes con MAVs, en quienes utilizamos como método de análisis el examen neurológico, la TAC de cerebro, IRM y arteriografía cerebral de 4 vasos. La totalidad de los pacientes fueron tratados mediante cirugía convencional en nuestro Servicio durante el periodo comprendido entre los años 2000 al 2010. Resultados: el promedio de edad fue 37.7 años. El porcentaje según sexo: varones 61.53%; mujeres 38.46%. Los síntomas y motivos de consulta más frecuentes fueron: cefalea 63.46%, eventos vasculares hemorrágicos 59.61%, convulsiones 26.92%. Localización de las MAVs: supratentoriales 92.85%, infratentoriales 7.15%. Conclusión: concordamos con la bibliografía consultada respecto a que el grupo poblacional más afectado está entre los 20 y 40 años. En relación a la distribución por sexo encontramos una prevalencia más elevada en el sexo masculino: 61.53% vs 38.46% respectivamente. Respecto a la localización concordamos con los autores en la mayor prevalencia supratentorial. En cuanto a los síntomas de presentación y motivo de consulta coincidimos en que la cefalea, los eventos de sangrado y las crisis convulsivas fueron los más habituales. Concordamos también en los diagnósticos de ingreso más frecuentes siendo el ACV hemorrágico, la cefalea, las crisis comiciales y el déficit neurológico los más comunes. (AU)

Schwannomas intracraneanos: nuestra experiencia (2000-2009) / Intracraneal schwannomas: our experience (2000-2009)

Objective. To present and evaluate the surgical results in the treatment of intracranial schwannomas. Method. We present 26 patients with intracranial schwannomas for a period of 10 years treated with surgery, analyze kind ofpresentation and postoperative results. Results. One of the cases corresponded to schwanoma of III pair, another case to schwanoma of the V pair, two other cases corresponded to schwanoma of the IX pair and twenty two cases corresponded to schwanomas of the VIII pair. Average age was 51,95 años (19-73). Total resection was made in 25 patients, partial resection was made in other. Facial nerve preservation was made in the remaining 22 patients. Preservation auditory nerve function was made in all the cases. We had 3 cases of cerebrospinal fluid leak.There were no mortal cases associated to the surgical procedure. Conclusion. The goal of treatment of intracranial schwanomas is total resection with anatomical and functional preservation of neurological structures around. This could be accomplished by retrosigmoid approach by experienced neurosurgeons.

Síndromes de compression neurovascular descompresión microvascular: nuestra experiencia (2003-2009) / Neurovascular compression syndroms microvascular decompression: our experience (2003-2009)

Objective. To present and evaluate the surgical results of microvascular decompression in the treatment of trigeminal neuralgia, glossopharyngeal neuralgia and hemifacial spasm. Material and Method. We present 15 patients with compressive syndrome of cranial nerve during a period of 6 years: 11 patients with trigeminal neuralgia, 2 patients with glossopharyngeal neuralgia and 2 patients with hemifacial spasm. Results. We achieved total improvement in 8 patients and partial in 4. The most frequent symptom after surgery was hypoesthesia in V2 in patients with trigeminal neuralgia. 3 patients presented temporary facial paresis. Conclusion. Microvascular decompression is an effective treatment with low morbidity in patients with compressive syndrome of cranial nerves. The goal of treatment should be complete disappearance of symptoms.

Neuralgía del glosofaríngeo: presentación de dos casos / Glosspharyngeal neuralgia: report of two cases

Objective. To present 2 cases of glossopharyngeal neuralgia treated by microvascular decompression. Description. Case one. 37-year- old male suffering pain in the posterior region of the left half of the tongue for 3 years. The diagnosis was left glossopharyngeal neuralgia. We performed microvascular decompression with Teflon felt. The patient has improved however he is still under medication. Case two. 59-year-old female suffering pain in the posterior third of the left half of the tongue. The diagnosis was left glossopharyngeal neuralgia. We performed microvascular decompression with Teflon. Symptoms completely disappeared. Conclusion. Glossopharyngeal neuralgia is infrequent. It can be treated with microvascular decompression with good results.

Schwannomas intracraneanos: nuestra experiencia (2000-2009) / Intracraneal schwannomas: our experience (2000-2009)

Objective. To present and evaluate the surgical results in the treatment of intracranial schwannomas. Method. We present 26 patients with intracranial schwannomas for a period of 10 years treated with surgery, analyze kind ofpresentation and postoperative results. Results. One of the cases corresponded to schwanoma of III pair, another case to schwanoma of the V pair, two other cases corresponded to schwanoma of the IX pair and twenty two cases corresponded to schwanomas of the VIII pair. Average age was 51,95 años (19-73). Total resection was made in 25 patients, partial resection was made in other. Facial nerve preservation was made in the remaining 22 patients. Preservation auditory nerve function was made in all the cases. We had 3 cases of cerebrospinal fluid leak.There were no mortal cases associated to the surgical procedure. Conclusion. The goal of treatment of intracranial schwanomas is total resection with anatomical and functional preservation of neurological structures around. This could be accomplished by retrosigmoid approach by experienced neurosurgeons.(AU)

Síndromes de compression neurovascular descompresión microvascular: nuestra experiencia (2003-2009) / Neurovascular compression syndroms microvascular decompression: our experience (2003-2009)

Objective. To present and evaluate the surgical results of microvascular decompression in the treatment of trigeminal neuralgia, glossopharyngeal neuralgia and hemifacial spasm. Material and Method. We present 15 patients with compressive syndrome of cranial nerve during a period of 6 years: 11 patients with trigeminal neuralgia, 2 patients with glossopharyngeal neuralgia and 2 patients with hemifacial spasm. Results. We achieved total improvement in 8 patients and partial in 4. The most frequent symptom after surgery was hypoesthesia in V2 in patients with trigeminal neuralgia. 3 patients presented temporary facial paresis. Conclusion. Microvascular decompression is an effective treatment with low morbidity in patients with compressive syndrome of cranial nerves. The goal of treatment should be complete disappearance of symptoms.(AU)

Neuralgía del glosofaríngeo: presentación de dos casos / Glosspharyngeal neuralgia: report of two cases

Objective. To present 2 cases of glossopharyngeal neuralgia treated by microvascular decompression. Description. Case one. 37-year- old male suffering pain in the posterior region of the left half of the tongue for 3 years. The diagnosis was left glossopharyngeal neuralgia. We performed microvascular decompression with Teflon felt. The patient has improved however he is still under medication. Case two. 59-year-old female suffering pain in the posterior third of the left half of the tongue. The diagnosis was left glossopharyngeal neuralgia. We performed microvascular decompression with Teflon. Symptoms completely disappeared. Conclusion. Glossopharyngeal neuralgia is infrequent. It can be treated with microvascular decompression with good results.(AU)

Variante poco frecuente de meningiomas: meningiomas quísticos / Uncommon type of meningioma: cystic meningioma

Objective. To describe two (2) unusual cases of intracranial cystic meningioma whose diagnosis before surgery represents a great challenge. Description. Case Nº 1: male, 43 years old with generalized seizure. Ct scan shows a right frontal cystic tumor. Case Nº 2: female, 44 years old, with behavioral disorder and right brachiocrural palsy. Ct scan shows a left frontal cystic tumor. Intervention. In both cases surgery was performed with total resection of the tumor and the diagnosis was cystic meningioma. Very good results were obtained after surgery. Conclusion. Before surgery the diagnosis of cystic meningioma is seldom made. For this kind of cases, the treatment is, even now, a surgical procedure and in some cases radiotherapy.