Neumoencéfalo, una revisión de literatura / Pneumocephalus, a literature review

El neumoencéfalo corresponde a la presencia de aire intracraneal y, en general, es asintomático y autolimitado. Puede ocurrir posterior a trauma, cirugía craneofacial, defectos congénitos, infección, neoplasia o de forma espontánea. El neumoencéfalo a tensión es una emergencia neuroquirúrgica, en la que se acumula aire intracraneal de forma continua que genera un efecto de masa. Clínicamente, se caracteriza por cefalea y un deterioro neurológico marcado. A pesar de ser poco frecuente, es relevante considerar el neumoencéfalo a tensión como una posible complicación en pacientes con antecedente de neurocirugía y/o cirugía otorrinolaringológica, debido a que es una patología potencialmente grave. El diagnóstico es clínico e imagenológico, y requiere de un alto índice de sospecha. Un manejo oportuno es relevante para prevenir la herniación y la muerte.

Pneumocephalus refers to the presence of air in the cranial cavity, and in general, is self-limited and asymptomatic. It can occur after trauma, craniofacial surgery, due to congenital defects, infection, neoplasia or spontaneously. Tension pneumocephalus is a neurosurgical emergency in which intracranial air accumulates continuously, causing a mass effect. It presents with headache and marked neurological deterioration. Despite being rare, it is relevant to consider tension pneumocephalus as a possible complication in patients with a history of neurosurgery and/or otolaryngology surgery, as it can be life-threatening. Diagnosis requires a high index of suspicion and imagenologic confirmation. Timely management is relevant to prevent herniation and death.

Neumoencéfalo recurrente post quirúrgico, a raíz de dos casos / Post-surgical late pneumoencephalus, based on two cases

El neumoencéfalo es una patología que comúnmente se presenta después de cirugía neuroquirúrgica y ocasionalmente endonasal. Estos se suelen manejar de manera conservadora, sin embargo, se pueden asociar a distintas etiologías las cuales los hacen recurrir. En este reporte presentamos dos casos de neumoencéfalo tardío post quirúrgico asociado a fístulas de LCR de bajo flujo, donde se discute su clínica, etiología y manejo posterior.

Pneumocephalus is a pathology that commonly occurs after endonasal surgery, these are usually managed conservatively, however they can be associated with different etiologies which make them recur. In this report we present two cases of post-surgical late pneumocephalus associated with low-flow CSF fistulae, where its symptoms, etiology, and subsequent management are discussed.

Tratamiento quirúrgico de la epilepsia asociada a tumores neuroepiteliales de bajo grado / Surgical treatment of low-grade epilepsy-associated neuroepithelial tumors

Resumen Los tumores cerebrales son una causa importante de las epilepsias de difícil manejo, corresponden a un 20-30 % de los casos de cirugía de epilepsia refractaria. En este grupo de pacientes los tumores neuroepiteliales de bajo grado asociados a epilepsia (LEAT) son la principal causa, siendo los más frecuentes los tumores neuroepiteliales disembrioplásticos (DNT) y ganglioglioma (GG). En el presente artículo revisamos los cambios en la definición de epilepsia refractaria, avances en el diagnóstico por imágenes y el diagnóstico histopatológico con los nuevos marcadores moleculares, que han permitido un diagnóstico cada vez más precoz y certero. Se revisa también la cirugía resectiva que permite en estos casos una libertad de crisis cercana un 70-90% de los pacientes. Los mejores resultados en términos de control de crisis, se pueden alcanzar cuando la cirugía es precoz.

Brain tumors are an important cause of epilepsy that is difficult to manage, accounting for 20-30% of cases of refractory epilepsy surgery. In this group of patients, low-grade epilepsy-associated neuroepithelial tumors (LEAT) are the main cause and the most frequent being dysembryoplastic neuroepithelial tumors (DNT) and ganglioglioma (GG). In this article, we review the changes in the definition of refractory epilepsy, advances in diagnostic imaging, and histopathological diagnosis with new molecular markers, which have allowed for an increasingly early and accurate diagnosis. Resective surgery is also reviewed, allowing in these cases a seizure freedom close to 70-90% of patients. The best outcome in terms of seizure control can be achieved when early surgery is performed.

Fístula de líquido cefalorraquídeo después de hisopado nasofaríngeo en pandemia COVID-19. A propósito de dos casos

Resumen Uno de los pilares fundamentales en el manejo de la pandemia por SARS-CoV2 es la detección temprana de la presencia del virus en pacientes. El método más utilizado es mediante hisopado nasofaríngeo para amplificar ácidos nucleicos mediante reacción en cadena de polimerasa (PCR). Las complicaciones asociadas a la técnica de hisopado aún no están completamente caracterizadas. Hasta ahora hay un caso reportado internacionalmente de fístula de líquido cefalorraquídeo poshisopado nasofaríngeo. Presentamos dos casos de fístula posterior a dicho examen: el primer caso un paciente de género femenino con sospecha de hipertensión intracraneal idiopática, cuya brecha se reparó quirúrgicamente; el segundo caso un paciente de género masculino con antecedente de hidrocefalia y meningitis neonatal que, al estudio por rinorraquia, se encuentra un meningoencefalocele en el receso frontal derecho, también reparado quirúrgicamente.

Abstract One of the cornerstones in the management of coronavirus pandemic is the early identification of virus presence in patients. The most used test is the nasopharyngeal swab, used to amplify nucleic acids through polymerase chain reaction. Complications with this test have not been completely characterized. Until now, only one international report of cerebrospinal fluid leak has been reported. We present two cases of leak after nasopharyngeal swab test: the first case corresponded to an adult feminine gender patient with suspected idiopathic intracranial hypertension, whose gap was surgically repaired; the second case adult male patient with medical history of hydrocephalus and neonatal meningitis who was further studied for rhinoliquorrhea that showed a meningoencephalocele occupying the right frontal recess.

[Prognostic value of granular pattern of growth hormone secreting tumors]. / Caracterización de tumores secretores de hormona de crecimiento de acuerdo al patrón granular y su rol en el pronóstico.

BACKGROUND: Classification of growth hormone (GH) - secreting tumors by the granular pattern might predict their clinical behavior in acromegalic patients. There are several other prognostic factors. AIM: To compare the features at presentation and cure rates of patients with GH secreting tumors according to the granular pattern, and to define independent prognostic factors for surgical treatment in these patients. MATERIAL AND METHODS: A retrospective, observational study of 85 active acromegalic patients surgically treated in two medical centers. RESULTS: Seventy-four patients (87%) were classified as having densely granulated (DG) and 11 (13%) as sparsely granulated (SG) tumors. The latter were less active biochemically, had a higher rate of macroadenoma and cavernous sinus invasion and had a lower rate of biochemical cure than the DG group. Several characteristics were associated with disease persistence but only age (Odds ratio (OR) = 0.93) and cavernous sinus invasion (OR = 21.7) were independently associated in the logistic regression model. CONCLUSIONS: The sparsely granulated pattern is associated with a more aggressive behavior, but the main determinants of prognosis are age and cavernous sinus invasion.

Caracterización de tumores secretores de hormona de crecimiento de acuerdo al patrón granular y su rol en el pronóstico / Prognostic value of granular pattern of growth hormone secreting tumors

Background: Classification of growth hormone (GH) - secreting tumors by the granular pattern might predict their clinical behavior in acromegalic patients. There are several other prognostic factors. Aim: To compare the features at presentation and cure rates of patients with GH secreting tumors according to the granular pattern, and to define independent prognostic factors for surgical treatment in these patients. Material and Methods: A retrospective, observational study of 85 active acromegalic patients surgically treated in two medical centers. Results: Seventy-four patients (87%) were classified as having densely granulated (DG) and 11 (13%) as sparsely granulated (SG) tumors. The latter were less active biochemically, had a higher rate of macroadenoma and cavernous sinus invasion and had a lower rate of biochemical cure than the DG group. Several characteristics were associated with disease persistence but only age (Odds ratio (OR) = 0.93) and cavernous sinus invasion (OR = 21.7) were independently associated in the logistic regression model. Conclusions: The sparsely granulated pattern is associated with a more aggressive behavior, but the main determinants of prognosis are age and cavernous sinus invasion.

Greywater treatment in an aerobic SBR: sludge structure and kinetics.

In order to have an efficient operation, sequencing batch reactors (SBR) must support granular biomass with high conversion rates, settling properties, and be able to deal with the inherent variability of the composition of real wastewaters. In this study, the effect of the influent composition and the specific organic loading rate (Bx) on the granulation process was evaluated in two SBRs, fed with greywater (GW) and a synthetic medium (SM). The feeding with SM led to the formation of compact granular biomass, with a sludge volume index (SVI) of 22.4 mL g-1, and a zone settling velocity (ZSV) of 13.1 m h-1. In contrast, feeding with GW induced the formation of filamentous granules, with lower settling properties (SVI = 165 mL g-1 and ZSV = 10 m h-1), when the system was operated at high Bx (4.4 kg COD kg VSS-1 d-1). However, the reduction of the average Bx to 2 kg COD kg VSS-1 d-1 induced an improvement in the morphology and properties of the granules (SVI = 98 mL g-1 and ZSV = 13 m h-1). Furthermore, the kinetic analysis indicated that granules cultivated with SM were formed by fast growing microorganisms with a high cell yield, whereas those cultivated in GW presented a much lower cell yield.

[Bacterial colonization in areas of burnt skin and healthy children younger than 15 years, seen COANIQUEM, Santiago, Chile]. / Colonización bacteriana de piel sana versus quemada de niños bajo 15 años tratados en COANIQUEM, Santiago de Chile.

UNLABELLED: Bacterial colonization in patients with burns skin without infection and outpatient management has been poorly studied. OBJECTIVE: To quantify and identify the type of bacteria that colonize healthy body areas homologous location of the skin in children from 1 to 15 years, seen COANIQUEM, Santiago, Chile. Per patient, we studied 204 samples from each zone. The isolated microorganisms were S. epidermidis 35, 3%; others Staphylococcus coagulase negative, 25.8%; S. aureus, 4.4%; and S. viridans group 1.4%. In the subgroup of children who had a count between 1 and 1000 cfu, there was a higher proportion of cfu in burned skin healthy skin (p = 0.0359). The association between depth of the lesion and the bacterial count obtained p = 0.034. CONCLUSION: In outpatient treatment, the microorganisms are expected in healthy skin, burned skin is evident in lower counts probably associated with epithelial damage.

Colonización bacteriana de piel sana versus quemada de niños bajo 15 años tratados en COANIQUEM, Santiago de Chile / Bacterial colonization in areas of burnt skin and healthy children younger than 15 years, seen COANIQUEM, Santiago, Chile

Bacterial colonization in patients with burns skin without infection and outpatient management has been poorly studied. Objective: To quantify and identify the type of bacteria that colonize healthy body areas homologous location of the skin in children from 1 to 15 years, seen COANIQUEM, Santiago, Chile. Per patient, we studied 204 samples from each zone. The isolated microorganisms were S. epidermidis 35, 3%; others Staphylococcus coagulase negative, 25.8%; S. aureus, 4.4%; and S. viridans group 1.4%. In the subgroup of children who had a count between 1 and 1000 cfu, there was a higher proportion of cfu in burned skin healthy skin (p = 0.0359). The association between depth of the lesion and the bacterial count obtained p = 0.034. Conclusion: In outpatient treatment, the microorganisms are expected in healthy skin, burned skin is evident in lower counts probably associated with epithelial damage.

La colonización bacteriana de la piel de pacientes quemados, sin infección y de manejo ambulatorio, ha sido escasamente estudiada. Objetivo: Cuantificar e identificar el tipo de bacterias que colonizan las zonas cruentas y las zonas sanas de localización homóloga de la piel, en niños entre uno y 15 años de edad que son tratados de forma ambulatoria en la Corporación de Ayuda al Niño Quemado (COANIQUEM) en Santiago de Chile. Pacientes y Métodos: Se estudiaron 204 pacientes quemados en los que se tomó una muestra para cultivo desde la zona de la quemadura y otra desde el sitio homólogo sin quemadura. Resultados: Las especies bacterianas aisladas desde ambos tipos de muestra fueron similares: Staphylococcus epidermidis; otras especies de Staphylococcus coagulasa negativa; Staphylococcus aureus, y Streptococcus grupo viridans. El recuento bacteriano de uno a 999 ufc/ 10,5 cm² fue significativamente superior en las muestras de piel sana (p = 0,0359). La asociación entre mayor profundidad de la lesión y el menor recuento bacteriano obtuvo un p = 0,034. Conclusión: En niños quemados de entre uno y 15 años, de manejo ambulatorio, los microorganismos que colonizan la zona quemada fueron los mismos que colonizan la piel sana, pero en recuento inferior.

Primary pituitary lymphoma in immunocompetent patient: diagnostic problems and prolonged follow-up.

Primary pituitary lymphoma in immunocompetent patients is a rare disease and has been described in less than 20 cases. Moreover, low-grade lymphomas constitute only 3% of all primary central nervous system lymphoma. The objective of this report is to report a low-grade primary pituitary lymphoma, diagnostic problems and to give more evidence about the evolution of this rare disease. A 49 y.o. woman was referred to our clinic with symptoms of hypopituitarism. A diagnostic work-up showed mild anemia, an erythrocyte sedimentation rate of 122 mm/h and a negative Elisa test for HIV. Panhypopituitarism was confirmed and the MRI showed a 20 mm sellar and suprasellar enhancing mass with a thickening of the pituitary stalk, chiasmal compression and bitemporal hemianopsia. She underwent transsphenoidal resection only 10 months later for non medical reasons. During this period she was clinically asymptomatic on hormonal replacement therapy. A new MRI showed regression of the suprasellar extension and invasion to the left cavernous sinus. A firm and infiltrative mass was found during transsphenoidal surgery, and only partial resection was performed. Biopsy showed a low-grade lymphoplasmacytic lymphoma. Staging was negative for other localizations. She was given chemotherapy and localized radiotherapy. Four years after surgery, the sellar MRI showed a 10 mm residual sellar mass with the persistence of a cavernous sinus invasion and she is considered to be in remission. The neurosurgeon and clinician should consider primary pituitary lymphoma as a potential cause of a sellar mass, especially in the presence of diabetes insipidus and an enhancing invasive mass. Neurosurgical biopsy is crucial for a correct diagnosis and prognosis could be better than classic CNS primary lymphomas.

[Study of resistance to chemotherapy mediated by ABC transporters in biopsies of glioblastoma multiforme]. / Glioblastoma multiforme y estudio de la resistencia a la quimioterapia mediada por transportadores ABC.

BACKGROUND: Mortality rate is dramatically high in high grade brain tumors. The presence of multiple drug resistance transporters in glioblastoma multiforme, has contributed largely to the poor efficacy of targeted therapy against cancer in the central nervous system. AIM: To analyze the percentage of survival and mortality of patients with glioblastoma multiforme in a cohort of patients in Chile and to co-rrelate the chemo-resistance of these cells with the expression level of multiple drug resistance transporters. MATERIALS AND METHODS: Eighteen biopsies of glioblastoma multiforme were obtained from patients at the Institute of Neurosurgery Dr. Asenjo (INCA). The tumor cells were obtained from primary cultures and the expression and activity of multiple drug resistance transporters was assessed by RT-PCR and immunohistochemistry. Population-based study was performed using the databases of the Department of Neurosurgery of INCA. RESULTS: The number of patients with glioblastoma multiforme increased between 2007 and 2009, from 3.5% to 7.9% of total brain tumors. Mortality of these tumors is 90 % at three years. A high expression and activity of the multiple drugs resistance associated protein 1 (Mrp1) transporter was observed in primary cultures of biopsies. CONCLUSIONS: We propose that Mrp1 activity is responsible for the chemo-resistance of the glioblastoma multiforme and inhibition of this transporter could represent a plausible strategy for the treatment.

Glioblastoma multiforme y estudio de la resistencia a la quimioterapia mediada por transportadores ABC / Study of resistance to chemotherapy mediated by ABC transporters in biopsies of glioblastoma multiforme

Background: Mortality rate is dramatically high in high grade brain tumors. The presence of multiple drug resistance transporters in glioblastoma multiforme, has contributed largely to the poor effcacy of targeted therapy against cancer in the central nervous system. Aim: To analyze the percentage of survival and mortality of patients with glioblastoma multiforme in a cohort of patients in Chile and to co-rrelate the chemo-resistance of these cells with the expression level of multiple drug resistance transporters. Materials and Methods: Eighteen biopsies of glioblastoma multiforme were obtained from patients at the Institute of Neurosurgery Dr. Asenjo (INCA). The tumor cells were obtained from primary cultures and the expression and activity of multiple drug resistance transporters was assessed by RT-PCR and immunohistochemistry. Population-based study was performed using the databases of the Department of Neurosurgery of INCA. Results: The number of patients with glioblastoma multiforme increased between 2007 and 2009, from 3.5 percent to 7.9 percent of total brain tumors. Mortality of these tumors is 90 percent at three years. A high expression and activity of the multiple drugs resistance associated protein 1 (Mrp1) transporter was observed in primary cultures of biopsies. Conclusions: We propose that Mrp1 activity is responsible for the chemo-resistance of the glioblastoma multiforme and inhibition of this transporter could represent a plausible strategy for the treatment.

Utilización inadecuada deun Servicio de UrgenciaHospitalario / No disponible

Objetivo: Determinar la frecuencia de utilización inadecuadade un servicio de urgencias hospitalario (SUH) y elperfil del paciente.Sujetos y métodos:—Diseño: estudio descriptivo retrospectivo.—Ámbito: hospital de tercer nivel.—Sujetos: mayores de 14 años, salvo urgencias ginecoobstétricas,que acudieron a urgencias hospitalarias deenero a marzo de 2005, no precisando ni interconsultas nipruebas complementarias (PC), salvo las accesibles enAtención Primaria como glucemia capilar, análisis con tirareactiva en orina, electrocardiograma, pulsioximetría y tinciónocular con fluoresceína.—Mediciones: se calculó el tamaño muestral para unapoblación finita de 21.560 (prevalencia: 30%, precisión: 5%,pérdidas: 20%), siendo necesarios 396 informes. Selecciónaleatoria de los informes de alta. Variables: datos demográficos,día y hora, síntomas y tiempo de evolución, diagnóstico,PC y medicación.Resultados: De los 1.742 informes de alta revisados, el24,1% (IC95%: 20,04-28,16%) de las consultas fueron inadecuadas.El 70% eran menores de 45 años y un 40% menoresde 30. El día en el que se registra mayor proporción de consultasinadecuadas fue el viernes (30,61%). Un 40,7% acudióen horario de mañana, 36,8% por la tarde y el 22,5% denoche. El 81,8% vivía a menos de 10 km. Y el 86% acudió apetición propia o de un familiar.Los motivos más frecuentes fueron: traumatológicos(15,24%), digestivos (13,33%), generales (9,76%), cardiorrespiratorios(8,33%) y musculares (7,14%). En el 49 % la evoluciónera inferior a 24 horas. El 46,6% requirió medicación (41% analgésicos-antiinflamatorios, 14% benzodiacepinas,11% procinéticos, 9% fármacos inhalados, 7% corticoidessistémicos).Conclusiones: Una de cada cuatro visitas al SUH es inadecuada.Son sujetos jóvenes, que viven cerca, mayoritariamenteacuden en horario de mañana, por decisión propia ymotivos diversos (AU)

Objective: to determine the frequency of inadequate useat a hospital emergency service (HES) and the patients’ characteristics.Subjects and Method:—Design: retrospective descriptive study.—Setting: third-level hospital.—Subjects: older tan 14 years, gyneco-obstrectic emergenciesexcluded, that visited our HES from January toMarch 2005. They didn’t need consultation to other specialistsnor complementary test (CT), except those who can beused in in primary care, such as capillary glycaemia, urinarytest, electrocardiogram, oxymetry and fluorescein staining.—Measurements: the sample size was calculated consideringa limited population of 21,560 (prevalence: 30%, precision:5%, lost: 20%), being needed 396 reports. Randomselectionof all reports. Variables: demographics, date and hour,symptoms and evolution, diagnosis, CT and medication.Results: of the 1,742 reports revised, 24.1% (CI95%:20.04-28.16%) of the visits were inadequate. 70% wereyounger than 45 years old and 40% younger than 30. Themost frequent assistance day was Friday (30.61%). 40,7%came in the morning, 36.8% in the afternoon and 22.5 atnight. 83.5% lived nearer than 10 km. 86% came by theirown decision or by a family decision.They most frequent reasons were traumatic (15.24%),digestive (13.33%), generals (9.76%), cardio-respiratory(8.33%) and muscular (7.14%). In 49% the evolution wasinferior to 24 hours. A 46.6% needed medication (41%analgesic-antiinflammatory, 14% benzodiazepines, 11%procinetics, 9% inhaled drugs, 7% systemic corticosteroids). Conclussions: One of every four visits to our HES is inadequate.The patients are young, live near, come during themorning, by themselves and for different reasons (AU)

Resultados Terapéuticos en pacientes acromegálicos: es tiempo de intervenir / Results of surgical treatment for acromegaly in 53 patients

Background: The treatment of choice for acromegaly is surgery that, according to the literature, is curative in 91 percent of pituitary microadenomas and 73 percent of macroadenomas. Aim: To report the results of surgical treatment in 53 patients with acromegaly. Material and methods: Retrospective review of medical records of all patients with acromegaly, operated between 1984 and 2004. When necessary, patients were contacted by telephone to complete information or to perform biochemical or imaging studies. A normal value of insulin like growth factor I (IGF-1) for age and sex, a growth hormone (GH) nadir of less than 1 ng/ml during a glucose tolerance test or a basal GH of less than 2.5 ng/ml, all assessed three months after surgery, were considered as criteria for cure. Results: Biochemical cure was achieved in 67 percent of patients with pituitary microadenomas and 21 percent of patients with macroadenomas. In 47 percent of patients with neuro-ophtalmological involvement, a partial or total recovery in the visual field defect was achieved. The most common surgical complications were transient diabetes insipidus in 19 percent, persistent diabetes insipidus in 4 percent and cerebrospinal fluid fistula in 4 percent. A lower size of the tumor and lower preoperative growth hormone levels were associated with a better chance of cure. Conclusions: The cure rates obtained in this group of patients are clearly lower than those reported abroad. These results stress the importance of having a national registry of acromegaly and the need to train neurosurgeons in the treatment of pituitary tumors.

Microcalcificaciones BIRADS 4: experiencia de 12 años / BIRADS 4 microcalcifications: 12 years of experience

Objetivo: Conocer el significado clínico y anátomopatológico de la presencia de microcalcificaciones BIRADS 4. Método: Análisis retrospectivo de 204 pacientes con microcalcificaciones BIRADS 4, sometidas a mastectomía parcial uni o bilateral en la Unidad de Patología Mamaria del Hospital Barros Luco-Trudeau, entre enero de 1993 y diciembre de 2004. Las pacientes ingresan a pabellón previa marcación con arpón metálico en zona de microcalcificaciones y control radiológico posterior de la pieza quirúrgica. Resultados: La localización de microcalcificaciones BIRADS 4 fue la mama izquierda en el 52 por ciento (106 casos), la mama derecha 42 por ciento (85 casos), y ambas 6 por ciento (13 casos). En la biopsia diferida destacan 17 casos con cáncer mamario (8,3 por ciento), condición fibroquística 197 casos (96,6 por ciento), hiperplasia sin atipía 49 casos (24 por ciento), hiperplasia con atipía 17 casos (8,3 por ciento), ectasia ductal 7 casos (3,4 por ciento), papilomatosis 6 casos (2,9 por ciento), mastitis crónica 4 casos (2 por ciento), fibroadenoma 4 casos (2 por ciento), galactoforitis 2 casos (1 por ciento) y necrosis grasa 2 casos (1 por ciento). Conclusión: Las microcalcificaciones BIRADS 4 constituyen un hallazgo mamográfico relevante por asociarse con cáncer de mama y lesiones de alto riesgo en un elevado porcentaje.

Malformación vascular arteriovenosa intraventricular - caso clínico / Intraventricular arteriovenous vascular malformation - clinical case

Se expone el caso clínico de una paciente de 16 años con una malformación vascular intraventricular y se discute acerca del manejo de las MAV intraventriculares.