Microvascular decompression for trigeminal neuralgia: A retrospective analysis of long-term outcomes and prognostic factors / Descompresión microvascular en la neuralgia del trigémino: análisis retrospectivo de los resultados a largo plazo e identificación de factores pronósticos

Introduction: Microvascular decompression is considered to be the most effective and onlyetiological surgical treatment for classical trigeminal neuralgia, relieving the neurovascularcompression found in up to 95% of cases. This study aims to report the long-term outcomesand to identify prognostic factors in a series of patients with trigeminal neuralgia treated bymicrovascular decompression. Methods: A retrospective observational study of 152 consecutive patients operated bymicrovascular decompression with at least six months of follow-up. The surgical results, includ-ing pain relief according to the Barrow Neurological Institute pain scale, complications and themedical treatment during the follow-up period were reviewed. Binary regression analysis wasperformed to identify factors associated with a good long-term outcome. Results: A total of 152 patients with a mean age of 60 years and a mean follow-up of 43 monthswere included. At the final follow-up visit, 83% of the patients had achieved significant reliefof the pain and 63% could reduce the absolute drug doses by 50% or more. The most frequentcomplications were wound infection (4.5%) and CSF fistula (7%). Being over 70 years of age andhaving paroxysmal pain were associated with a long-term pain relief.(AU)

Introducción: La descompresión microvascular se considera el tratamiento quirúrgico etiológico más eficaz de la neuralgia clásica del trigémino, dirigido a aliviar la compresión neurovascular identificada hasta en un 95% de casos. Este estudio tiene como objetivo analizar los resultados quirúrgicos y la evolución a largo plazo de una serie de pacientes con neuralgia del trigémino tratados mediante descompresión microvascular, así como identificar factores pronósticos. Métodos: Estudio observacional retrospectivo de 152 pacientes consecutivos sometidos a descompresión microvascular y con un seguimiento posquirúrgico mínimo de seis meses. Analizamos los resultados quirúrgicos, clasificando el grado de dolor según la escala del Instituto Neurológico de Barrow, las complicaciones y el tratamiento médico requerido durante el período de seguimiento. Realizamos un análisis de regresión binaria para identificar factores asociados con un buen resultado a largo plazo. Resultados: Incluimos 152 pacientes con una edad media de 60 años y un seguimiento medio de 43 meses. En la última visita de seguimiento, el 83% de los pacientes había logrado un alivio significativo del dolor y el 63% pudo reducir la dosis absoluta de fármacos para la neuralgia en un 50% o más. Las complicaciones más frecuentes fueron infección de la herida (4,5%) y fístula de LCR (7%). La edad superior a 70 años y el dolor de predominio paroxístico se asociaron con un mejor pronóstico. Conclusiones: Nuestros resultados apoyan que la descompresión microvascular es una terapia efectiva y segura en pacientes con neuralgia del trigémino. La cirugía temprana puede ser beneficiosa en pacientes refractarios al tratamiento farmacológico.(AU)

Microvascular decompression for trigeminal neuralgia: A retrospective analysis of long-term outcomes and prognostic factors.

INTRODUCTION: Microvascular decompression is considered to be the most effective and only etiological surgical treatment for classical trigeminal neuralgia, relieving the neurovascular compression found in up to 95% of cases. This study aims to report the long-term outcomes and to identify prognostic factors in a series of patients with trigeminal neuralgia treated by microvascular decompression. METHODS: A retrospective observational study of 152 consecutive patients operated by microvascular decompression with at least six months of follow-up. The surgical results, including pain relief according to the Barrow Neurological Institute pain scale, complications and the medical treatment during the follow-up period were reviewed. Binary regression analysis was performed to identify factors associated with a good long-term outcome. RESULTS: A total of 152 patients with a mean age of 60 years and a mean follow-up of 43 months were included. At the final follow-up visit, 83% of the patients had achieved significant relief of the pain and 63% could reduce the absolute drug doses by 50% or more. The most frequent complications were wound infection (4.5%) and CSF fistula (7%). Being over 70 years of age and having paroxysmal pain were associated with a long-term pain relief. CONCLUSIONS: Our results support the notion that microvascular decompression is an effective and safe therapy in patients with trigeminal neuralgia. A multidisciplinary approach with an early referral to a neurosurgical unit many be beneficial in patients who are refractory to pharmacological treatment.

Primary central nervous system angiosarcoma with recurrent acute subdural hematoma / Angiosarcoma cerebral primario del sistema nervioso central con hematoma subdural agudo recurrente

Angiosarcoma is an infrequent tumor among sarcomas, especially presenting as a primary tumor within the central nervous system, which can lead to a rapid neurological deterioration and death in few months. We present a 41-year old man with a right frontal enhancing hemorrhagic lesion. Surgery was performed with histopathological findings suggesting a primary central nervous system angiosarcoma. He was discharged uneventfully and received adjuvant chemotherapy and radiotherapy. At 5 months, the follow-up MRI showed two lesions with an acute subdural hematoma, suggesting a relapse. Surgery was again conducted finding tumoral membranes attached to the internal layer of the duramater around the right hemisphere. The patient died a few days later due to the recurrence of the subdural hematoma.This case report illustrates a rare and lethal complication of an unusual tumor. The literature reviewed shows that gross-total resection with adjuvant radiotherapy seems to be the best treatment of choice (AU)

El angiosarcoma es un tumor infrecuente entre los sarcomas, especialmente cuando se trata de una lesión primaria en el sistema nervioso central, que puede conducir a un rápido deterioro neurológico y a la muerte en pocos meses. Se presenta a un varón de 41 años con una lesión hemorrágica frontal derecha. Se realiza cirugía con resultados histopatológicos que sugieren un angiosarcoma cerebral primario. El paciente recibió tratamiento complementario con quimioterapia y radioterapia. A los cinco meses, el seguimiento con RM mostró dos lesiones y un hematoma subdural agudo, sugiriendo recaída. Se realizó una nueva cirugía hallando membranas tumorales unidas a la cara interna de la duramadre, alrededor del hemisferio derecho. El paciente acabó falleciendo debido a la recurrencia del hematoma subdural. Este caso ilustra una complicación rara y letal de un tumor infrecuente. La literatura revisada muestra que su tratamiento de elección es la resección completa y la radioterapia adyuvante (AU)

Microvascular decompression for trigeminal neuralgia: A retrospective analysis of long-term outcomes and prognostic factors.

INTRODUCTION: Microvascular decompression is considered to be the most effective and only etiological surgical treatment for classical trigeminal neuralgia, relieving the neurovascular compression found in up to 95% of cases. This study aims to report the long-term outcomes and to identify prognostic factors in a series of patients with trigeminal neuralgia treated by microvascular decompression. METHODS: A retrospective observational study of 152 consecutive patients operated by microvascular decompression with at least six months of follow-up. The surgical results, including pain relief according to the Barrow Neurological Institute pain scale, complications and the medical treatment during the follow-up period were reviewed. Binary regression analysis was performed to identify factors associated with a good long-term outcome. RESULTS: A total of 152 patients with a mean age of 60 years and a mean follow-up of 43 months were included. At the final follow-up visit, 83% of the patients had achieved significant relief of the pain and 63% could reduce the absolute drug doses by 50% or more. The most frequent complications were wound infection (4.5%) and CSF fistula (7%). Being over 70 years of age and having paroxysmal pain were associated with a long-term pain relief. CONCLUSIONS: Our results support the notion that microvascular decompression is an effective and safe therapy in patients with trigeminal neuralgia. A multidisciplinary approach with an early referral to a neurosurgical unit many be beneficial in patients who are refractory to pharmacological treatment.

Réplica a la carta al editor «Estudios clínicos controlados y eficacia: a propósito de una investigación en neurocirugía» / Reply to the letter to the editor «Controlled clinical trials and efficacy: Report of a neurosurgical study»

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Valor predictivo de la resonancia magnética para la identificación de compresiones neurovasculares en la neuralgia del trigémino / Predictive value of magnetic resonance for identifying neurovascular compressions in trigeminal neuralgia

Introducción: La descompresión microvascular (DMV) es aceptada como único tratamiento quirúrgico etiológico para la neuralgia del trigémino (NT) clásica refractaria al tratamiento médico. Por ello existe un creciente interés por establecer el valor diagnóstico y pronóstico de la identificación de compresiones neurovasculares (CNV) mediante resonancia magnética (RM) con secuencias tridimensionales de alta resolución en pacientes con NT clásica candidatos a cirugía. Métodos: Este estudio observacional incluye una serie consecutiva de 74 pacientes con NT clásica refractaria intervenidos mediante DMV. En todos los pacientes se realizó una RM tridimensional de alta resolución con secuencias DRIVE preoperatoria para diagnosticar la existencia de una CNV, así como su grado, origen y localización. Los resultados de la RM fueron analizados de forma «ciega» para los hallazgos de la exploración quirúrgica y posteriormente comparados con estos. Se realizó un seguimiento mínimo de 6 meses para comprobar los resultados quirúrgicos, que se clasificaron según la escala de dolor facial del Barrow Neurological Institute (BNI score). El valor pronóstico de la RM preoperatoria se analizó mediante una regresión logística binaria. Resultados: La RM preoperatoria con secuencias DRIVE demostró una sensibilidad del 95% y una especificidad del 87%, con un valor predictivo positivo del 98% y un valor predictivo negativo del 70%. Además se evidenció un buen grado de concordancia mediante el coeficiente kappa (CK) entre los hallazgos radiológicos y quirúrgicos respecto a la existencia de CNV (CK 0,75), al tipo de compresión (CK 0,74) y a la localización (CK 0,72), siendo del grado de concordancia moderado para el grado de compresión (CK 0,48).Tras un seguimiento medio de 29 meses (rango 6-100 meses), el 81% de los pacientes presentaban un control del dolor sin o con medicación (BNI score I-III). Los pacientes con un resultado excelente del tratamiento, es decir aquellos sin dolor trigeminal y sin medicación (BNI score i) fueron el 66% al final del seguimiento. El análisis univariante mediante regresión logística binaria demostró que el diagnóstico de una CNV en la RM preoperatoria era un factor pronóstico favorable que incrementaba significativamente la probabilidad de obtener un resultado excelente (OR 0,17, IC del 95%, 0,04-0,72; p 0,02) o aceptable (OR 0,16, IC del 95%, 0,04-0,68; p 0,01) tras la DMV. Conclusiones: La RM DRIVE presenta una elevada sensibilidad y especificidad para el diagnóstico preoperatorio de CNV en pacientes con NT clásica refractaria candidatos a tratamiento mediante DMV. El hallazgo de una CNV en el estudio de RM preoperatorio es un factor de buen pronóstico para la obtención de alivio del dolor a largo plazo con la DMV

Introduction: Microvascular decompression (MVD) is accepted as the only aetiological surgical treatment for refractory classic trigeminal neuralgia (TN). There is therefore increasing interest in establishing the diagnostic and prognostic value of identifying neurovascular compressions (NVC) using preoperative high-resolution three-dimensional magnetic resonance (MRI) in patients with classic TN who are candidates for surgery. Methods: This observational study includes a series of 74 consecutive patients with classic TN treated with MVD. All patients underwent a preoperative three-dimensional high-resolution MRI with DRIVE sequences to diagnose presence of NVC, as well as the degree, cause, and location of compressions. MRI results were analysed by doctors blinded to surgical findings and subsequently compared to those findings. After a minimum follow-up time of six months, we assessed the surgical outcome and graded it on the Barrow Neurological Institute pain intensity score (BNI score). The prognostic value of the preoperative MRI was estimated using binary logistic regression. Results: Preoperative DRIVE MRI sequences showed a sensitivity of 95% and a specificity of 87%, with a 98% positive predictive value and a 70% negative predictive value. Moreover, Cohen's kappa (CK) indicated a good level of agreement between radiological and surgical findings regarding presence of NVC (CK 0.75), type of compression (CK 0.74) and the site of compression (CK 0.72), with only moderate agreement as to the degree of compression (CK 0.48).After a mean follow-up of 29 months (range 6-100 months), 81% of the patients reported pain control with or without medication (BNI score I-IIII). Patients with an excellent surgical outcome, i.e. without pain and off medication (BNI score i), made up 66% of the total at the end of follow-up. Univariate analysis using binary logistic regression showed that a diagnosis of NVC on the preoperative MRI was a favorable prognostic factor that significantly increased the odds of obtaining an excellent outcome (OR 0.17, 95% CI 0.04-0.72; P=.02) or an acceptable outcome (OR 0.16, 95% CI 0.04-0.68; P = .01) after MVD. Conclusions: DRIVE MRI shows high sensitivity and specificity for diagnosing NVC in patients with refractory classic TN and who are candidates for MVD. The finding of NVC on preoperative MRI is a good prognostic factor for long-term pain relief with MVD

Predictive value of magnetic resonance for identifying neurovascular compressions in trigeminal neuralgia. / Valor predictivo de la resonancia magnética para la identificación de compresiones neurovasculares en la neuralgia del trigémino.

INTRODUCTION: Microvascular decompression (MVD) is accepted as the only aetiological surgical treatment for refractory classic trigeminal neuralgia (TN). There is therefore increasing interest in establishing the diagnostic and prognostic value of identifying neurovascular compressions (NVC) using preoperative high-resolution three-dimensional magnetic resonance (MRI) in patients with classic TN who are candidates for surgery. METHODS: This observational study includes a series of 74 consecutive patients with classic TN treated with MVD. All patients underwent a preoperative three-dimensional high-resolution MRI with DRIVE sequences to diagnose presence of NVC, as well as the degree, cause, and location of compressions. MRI results were analysed by doctors blinded to surgical findings and subsequently compared to those findings. After a minimum follow-up time of six months, we assessed the surgical outcome and graded it on the Barrow Neurological Institute pain intensity score (BNI score). The prognostic value of the preoperative MRI was estimated using binary logistic regression. RESULTS: Preoperative DRIVE MRI sequences showed a sensitivity of 95% and a specificity of 87%, with a 98% positive predictive value and a 70% negative predictive value. Moreover, Cohen's kappa (CK) indicated a good level of agreement between radiological and surgical findings regarding presence of NVC (CK 0.75), type of compression (CK 0.74) and the site of compression (CK 0.72), with only moderate agreement as to the degree of compression (CK 0.48). After a mean follow-up of 29 months (range 6-100 months), 81% of the patients reported pain control with or without medication (BNI score i-iiiI). Patients with an excellent surgical outcome, i.e. without pain and off medication (BNI score i), made up 66% of the total at the end of follow-up. Univariate analysis using binary logistic regression showed that a diagnosis of NVC on the preoperative MRI was a favorable prognostic factor that significantly increased the odds of obtaining an excellent outcome (OR 0.17, 95% CI 0.04-0.72; P=.02) or an acceptable outcome (OR 0.16, 95% CI 0.04-0.68; P=.01) after MVD. CONCLUSIONS: DRIVE MRI shows high sensitivity and specificity for diagnosing NVC in patients with refractory classic TN and who are candidates for MVD. The finding of NVC on preoperative MRI is a good prognostic factor for long-term pain relief with MVD.

Tratamiento microquirúrgico de la neuralgia trigeminal en mayores de 70 años, estudio de eficacia y seguridad / Microsurgical treatment of trigeminal neuralgia in patients older than 70 years: An efficacy and safety study

Introducción: El incremento de la incidencia de la neuralgia del trigémino (NT) con la edad junto con el creciente envejecimiento poblacional obligan a valorar las opciones de tratamiento quirúrgico de la NT refractaria en pacientes mayores. Métodos: Se revisó retrospectivamente una serie consecutiva de pacientes mayores de 70 años con NT refractaria tratados mediante descompresión microvascular (DMV) entre 1997 y 2015. Los resultados según la escala de dolor facial del Barrow Neurological Institute (BNI score), así como las complicaciones quirúrgicas, se compararon con los de pacientes menores de 70 años operados durante el mismo período. Resultados: Fueron intervenidos 40 pacientes mayores de 70 años (media 74,8 años). A los 34 meses de seguimiento medio, el 73% de los pacientes presentaba ausencia completa del dolor sin medicación (BNI I) y el 85% tenía un control del dolor sin o con medicación (BNI I-III). Comparando con 85 pacientes menores de 70 años intervenidos en el mismo período no se demostró una asociación significativa entre la edad y la obtención de un control del dolor (BNI I-III), pero sí entre la edad mayor de 70 años y la desaparición del dolor (BNI I; p = 0,03). La estancia media en mayores de 70 años fue significativamente mayor (p = 0,04), aunque la tasa de complicaciones posquirúrgicas fue similar a la de los pacientes más jóvenes. Conclusiones: Las personas de edad avanzada con NT refractaria pueden beneficiarse de un tratamiento mediante DMV con una probabilidad de éxito y unos riesgos equiparables a los de personas más jóvenes (AU)

Introduction: The increasing incidence of trigeminal neuralgia (TN) with age together with population ageing call for reexamination of surgical treatment options for refractory TN in elderly patients. Methods: Retrospective review of a consecutive series of patients older than 70 who underwent microvascular decompression (MVD) for refractory TN between 1997 and 2015. Outcomes based on the Barrow Neurological Institute pain intensity score (BNI score) and surgical complications were compared to those of patients younger than 70 undergoing MVD in the same period. Results: Forty patients older than 70 (mean = 74.8 years) underwent interventions. At a mean follow-up time of 34 months, 73% of the patients presented complete absence of pain without medication (BNI I) and 85% had good pain control with or without medication (BNI I-III). A comparison of these patients with the 85 patients younger than 70 treated surgically during the same period did not find a significant association between age and achievement of pain control (BNI I-II). However, there was a significant association between age older than 70 and complete pain relief (BNI I; P=.03). The mean hospital stay in patients over 70 was also significantly longer (P=.04), although the postsurgical complication rate was similar to that in younger patients. Conclusions: Elderly patients with refractory TN may benefit from treatment with MVD and the probability of success and surgical risk are comparable to those in younger patients (AU)

Microsurgical treatment of trigeminal neuralgia in patients older than 70 years: An efficacy and safety study. / Tratamiento microquirúrgico de la neuralgia trigeminal en mayores de 70 años, estudio de eficacia y seguridad.

INTRODUCTION: The increasing incidence of trigeminal neuralgia (TN) with age together with population ageing call for reexamination of surgical treatment options for refractory TN in elderly patients. METHODS: Retrospective review of a consecutive series of patients older than 70 who underwent microvascular decompression (MVD) for refractory TN between 1997 and 2015. Outcomes based on the Barrow Neurological Institute pain intensity score (BNI score) and surgical complications were compared to those of patients younger than 70 undergoing MVD in the same period. RESULTS: Forty patients older than 70 (mean = 74.8 years) underwent interventions. At a mean follow-up time of 34 months, 73% of the patients presented complete absence of pain without medication (BNI I) and 85% had good pain control with or without medication (BNI I-III). A comparison of these patients with the 85 patients younger than 70 treated surgically during the same period did not find a significant association between age and achievement of pain control (BNI I-II). However, there was a significant association between age older than 70 and complete pain relief (BNI I; P=.03). The mean hospital stay in patients over 70 was also significantly longer (P=.04), although the postsurgical complication rate was similar to that in younger patients. CONCLUSIONS: Elderly patients with refractory TN may benefit from treatment with MVD and the probability of success and surgical risk are comparable to those in younger patients.

Hidrocefalia por meningitis tuberculosa con líquido cefalorraquídeo ventricular normal / Tuberculous meningitis hydrocephalus with normal ventricular cerebrospinal fluid

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Tratamiento del dolor neuropático por desaferentización mediante lesión DREZ, resultados a largo plaz / Treatment of neuropathic deafferentation pain using DREZ lesions; long-term results

Introducción: El dolor por desaferentización secundario a lesiones medulares, avulsión del plexo braquial y otras lesiones de nervios periféricos, es a menudo refractario a tratamientos convencionales. Este trabajo evalúa la eficacia a largo plazo de la cirugía de lesión DREZ (Dorsal Root Entry Zone) en diversos síndromes de dolor neuropático por desaferentización. Pacientes y métodos: Se presenta una serie de 18 pacientes con dolor refractario por desaferentización tratados mediante lesión DREZ con radiofrecuencia. La eficacia inmediata y a largo plazo se valoró mediante la escala visual analógica (EVA) preoperatoria y postoperatoria, la valoración subjetiva del paciente, la reincorporación laboral y la reducción de la medicación analgésica. Resultados: El dolor en la EVA disminuyó significativamente de 8,6 antes de la cirugía a 2,9 de media al alta (p<0,001). A largo plazo, con un seguimiento medio de 28 meses (6-108), el dolor se mantuvo en 4,7 en la EVA (p<0,002). El porcentaje de pacientes con un alivio moderado a excelente del dolor fue de 77% al alta y 68% a largo plazo. El 67% de los pacientes redujo la medicación analgésica y el 28% se reincorporó al trabajo. Los mejores resultados se obtuvieron en los pacientes con avulsión del plexo braquial con una mejoría significativa del dolor a largo plazo en todos los casos. Conclusiones: La lesión DREZ por radiofrecuencia es un tratamiento eficaz y seguro para el dolor neuropático refractario por desaferentización (AU)

Introduction: Deafferentation pain secondary to spinal cord injury, brachial plexus avulsion and other peripheral nerve injuries is often refractory to conventional treatments. This study evaluates the long-term efficacy of spinal DREZ (Dorsal Root Entry Zone) lesions for the treatment of neuropathic pain syndromes caused by deafferentation.Patients and methodsA series of 18 patients with refractory deafferentation pain treated with radiofrequency DREZ lesions is presented. The immediate and long-term efficacy was measured with the Visual Analogue Scale (VAS) before and after treatment, the patient's subjective evaluation, the percentage of patients returning to work and the reduction in pain medication. Results: Pain on the VAS significantly decreased from 8.6 preoperatively to 2.9 (p<.001) at discharge. Over the long-term, with a mean follow-up of 28 months (6-108) pain remained at 4.7 on the VAS (p<0.002). The percentage of patients with moderate to excellent pain relief was 77% at discharge and 68% at the last follow-up. Pain medication was reduced in 67% of the patients and 28% returned to work. The best results were obtained in patients with brachial plexus avulsion, with a significant long-term pain relief in all cases. Conclusions:Radiofrequency DREZ lesion is an effective and safe treatment for refractory neuropathic pain caused by deafferentation (AU)

Treatment of neuropathic deafferentation pain using DREZ lesions; long-term results.

INTRODUCTION: Deafferentation pain secondary to spinal cord injury, brachial plexus avulsion and other peripheral nerve injuries is often refractory to conventional treatments. This study evaluates the long-term efficacy of spinal DREZ (Dorsal Root Entry Zone) lesions for the treatment of neuropathic pain syndromes caused by deafferentation. PATIENTS AND METHODS: A series of 18 patients with refractory deafferentation pain treated with radiofrequency DREZ lesions is presented. The immediate and long-term efficacy was measured with the Visual Analogue Scale (VAS) before and after treatment, the patient's subjective evaluation, the percentage of patients returning to work and the reduction in pain medication. RESULTS: Pain on the VAS significantly decreased from 8.6 preoperatively to 2.9 (p<.001) at discharge. Over the long-term, with a mean follow-up of 28 months (6-108) pain remained at 4.7 on the VAS (p<0.002). The percentage of patients with moderate to excellent pain relief was 77% at discharge and 68% at the last follow-up. Pain medication was reduced in 67% of the patients and 28% returned to work. The best results were obtained in patients with brachial plexus avulsion, with a significant long-term pain relief in all cases. CONCLUSIONS: Radiofrequency DREZ lesion is an effective and safe treatment for refractory neuropathic pain caused by deafferentation.

[Supratentorial endodermal cyst. Case report]. / Quiste endodérmico supratentorial: caso clínico y revisión de la literatura.

Endodermal cysts (EC) of the central nervous system are very uncommon lesions predominantly located in the spinal canal. Although rare, intracranial EC have been mainly described in the posterior fossa, with the supratentorial location considered exceptional. Apart from the low frequency of these lesions, their pathoembriology still remais unknown. We report a patient with a huge frontal EC and review the literature. A 62-year-old man presented with abnormal behaviour, disorientation and decreased level of consciousness after moderate head injury. Initial cranial CT scan revealed a large cyst in the left frontal region with marked midline shift. Emergency puncture and decompression of the cyst demonstrated a milky fluid with high protein levels. Cranial MRI after patient improvement confirmed the existence of the cystic lesion with less mass effect. Delayed surgery was performed with craniotomy and total removal of the cyst. Pathological examination confirmed the presence of a typical EC. Patient made a complete recovery on follow-up with no recurrence on postoperative MRIs. Differential diagnosis of EC based on radiological data is quite difficult. As aggresive behaviour of this condition has been described following incomplete resections, the treatment of choice is a radical removal of the cyst in one or two stages depending on patient clinical condition.

Quiste endodérmico supratentorial, caso clínico y revisión de la literatura / Supratentorial endodermal cyst. Case report

Los quistes endodérmicos que afectan al sistema nervioso central son lesiones expansivas muy poco frecuentes que se sitúan con mayor frecuencia a nivel espinal. Existen poco casos de localización intracraneal descritos en la literatura, la mayoría de ellos en la fosa posterior. Su etiopatogenia permanece aún desconocida. Presentamos el caso de un varón de 62 años que debuta con un cuadro de desorientación y comportamiento desinhibido tras sufrir un traumatismo craneoencefálico como consecuencia de un accidente de trá- fico. En la TC craneal realizada de urgencia se objetiva una lesión quística frontal izquierda de gran tamaño con importante desplazamiento de línea media. Se punciona y evacua el contenido del quiste obteniéndose un líquido opalino rico en proteínas y elementos celulares no identificados. La RMN nos confirma los hallazgos radiológicos previos. El paciente es intervenido de forma reglada mediante craneotomía, evacuación completa del contenido y extirpación de las paredes de la lesión. El estudio anatomopatológico resulta ser compatible con el diagnóstico de quiste endodérmico. Se han descrito casos de evolución agresiva con diseminación y recidiva tras manipulación quirúrgica de la lesión; por lo tanto, el tratamiento debe consistir en la extirpación completa de la misma. Para ello será necesario realizar el diagnóstico diferencial con otras lesiones quísticas intracraneales con el fin de adecuar el tratamiento a cada caso (AU)

Endodermal cysts (EC) of the central nervous system are very uncommon lesions predominantly located in the spinal canal. Although rare, intracranial EC have been mainly described in the posterior fossa, with the supratentorial location considered exceptional. Apart from the low frequency of these lesions, their pathoembriology still remais unknown. We report a patient with a huge frontal EC and review the literature. A 62-year-old man presented with abnormal behaviour, disorientation and decreased level of consciousness after moderate head injury. Initial cranial CT scan revealed a large cyst in the left frontal region with marked midline shift. Emergency puncture and decompression of the cyst demonstrated a milky fluid with high protein levels. Cranial MRI after patient improvement confirmed the existence of the cystic lesion with less mass effect. Delayed surgery was performed with craniotomy and total removal of the cyst. Pathological examination confirmed the presence of a typical EC. Patient made a complete recovery on follow-up with no recurrence on postoperative MRIs. Differential diagnosis of EC based on radiological data is quite difficult. As aggresive behaviour of this condition has been described following incomplete resections, the treatment of choice is a radical removal of the cyst in one or two stages depending on patient clinical condition (AU)

[Radiation-induced cranial tumors: clinical series and literature review]. / Tumores craneales radioinducidos: serie clínica y revisión de la literatura.

Radiation induced tumors are well-known but rare complications of radiotherapy. Meningiomas are the most common radiation-induced (RI) cranial tumors, followed by gliomas and sarcomas, while other tumors as haemangioblastomas remain extremely exceptional. We present 7 patients with RI brain tumors diagnosed and treated at our institution between 1990 and 2006. Retrospective review of their clinical charts is supplied. All patients were irradiated during childhood as a treatment for another disease, and fulfilled the criteria of RI neoplasia. Four patients developed meningiomas and three developed other tumors (one glioblastoma, one softtissue sarcoma and one hemangioblastoma). In all cases a complete surgical removal was achieved. Preoperative assessment based on MRI supplied the correct diagnosis in six patients. The most important risks factors described in the literature for developing RI tumors are the age at which radiotherapy was administered and the dose of radiation applied. Differential diagnosis of RI tumors includes any tumor appearing after radiotheraphy, especially recurrences of the primary disease, as RI neoplasias are a rare complication. Even in cases with complete surgical resection, prognosis of this clinical entity is basically related to the histology of the RI tumor.

Tumores craneales radioinducidos: serie clínica y revisión de la literatura / Radiation-induced cranial tumors: clinical series and literature review

La inducción de neoplasias constituye una complicaciónbien conocida, aunque poco frecuente, de la irradiacióncraneal. Los meningiomas son las neoplasiascraneales radioinducidas (RI) más frecuentes, seguidasde los gliomas y los sarcomas, siendo extremadamenteraros otros tipos tumorales tales como loshemangioblastomas.Presentamos 7 pacientes con tumores cranealessecundarios a radioterapia, diagnosticados en nuestrohospital entre los años 1990 y 2006. Se realizó unarevisión retrospectiva de sus datos clínicos. Todos lospacientes habían sido irradiados en la infancia comotratamiento de otra enfermedad, y cumplían los criteriosde neoplasia RI.Cuatro pacientes desarrollaron meningiomas, mientrasque los 3 restantes presentaron otros tumores (unglioblastomas multiforme, un hemangioblastoma y unosteosarcoma de partes blandas). En los siete casos selogró una resección quirúrgica completa. El diagnósticopreoperatorio basado en resonancia magnética (RM)coincidió con el diagnóstico histológico en seis casos.Los factores de riesgo más importantes para desarrollaruna neoplasia RI son, según la literatura, la edad enel momento de la irradiación y la dosis administrada.El diagnóstico diferencial de estas neoplasias se planteacon aquellas lesiones que aparezcan tras la irradiacióncraneal, especialmente las recidivas, ya que el desarrollo de neoplasias RI constituye una complicación muy poco frecuente. El pronóstico de esta enfermedad, incluso tras resecciones completas, depende del diagnóstico histológico del tumor RI

Induction of tumors are , although rare , known complicaciónbien of cranial irradiation . Meningiomas are the most common radiation cranial neoplasms (RI ), followed by gliomas and sarcomas , being extremely rare other tumor types such as hemangioblastomas . Present 7 patients with RI brain tumors diagnosed in our hospital between 1990 and 2006. Unarevisión retrospective of his clinical data was performed . All patients were irradiated in childhood for treatment of other diseases , and met the RI criteriosde neoplasia . Four patients developed meningiomas, while the remaining 3 had other tumors ( unglioblastomas multiforme , a hemangioblastoma and a soft tissue osteosarcoma ) . In all cases a complete surgical resection was achieved . Preoperative diagnosis based on magnetic resonance (MR ) coincided with the diagnosis in six cases. The most important risk factors for developing RI tumors are, in the literature, age at irradiation and the dose administered. The differential diagnosis of these neoplasms arise with those injuries that arise after cranial irradiation , especially recurrences , since the development of malignancies RI is a very rare complication . The prognosis of this disease , even after complete resection depends on the histologic diagnosis of tumor RI

[Intraventricular tension pneumocephalus after transsphenoidal surgery: a case report and literature review]. / Neumoencéfalo intraventricular a tensión secundario a cirugía transesfenoidal: presentación de un caso y revisión de la literatura.

Tension pneumocephalus is a rare complication of transsphenoidal approaches. The case of a 37 year old woman with a transsphenoidal resection of a pituitary adenoma who presented self-limited rhinoliquorrhea postoperatively is reported. Three days later the patient developed progressive decreased consciousness, amnesia and headache, showing an intraventricular tension pneumocephalus on CT scan. Urgent treatment with bilateral external ventricular drainage and anterior nasal tamponade was performed with good clinical outcome. Later transsphenoidal sealing of the dural defect was achieved without recurrence. Tension pneumocephalus following transsphenoidal surgery usually occurs after the presentation of a cerebrospinal fluid leak due to an incomplete sealing of the sphenoid sinus. The postoperative insertion of a lumbar drainage seems to be a predisposing condition for this complication. The combined approach of tension pneumocephalus with external ventricular drainage and repair of the sphenoid sinus offers optimal results solving the acute neurological deterioration and avoiding recurrence.

Neumoencéfalo intraventricular a tensión secundario a cirugía transesfenoidal: presentación de un caso y revisión de la literatura / Intraventricular tensión pneumocephalus after transsphenoidal surgery: a case report and literature review

El neumoencéfalo a tensión (NT) es una complicaciónrara de los abordajes transesfenoidales. Se describeel caso de una mujer de 37 años intervenida de unadenoma de hipófisis por vía transesfenoidal que presentórinolicuorrea autolimitada en el postoperatorio.A los tres días la paciente desarrolló un deterioro progresivode conciencia, amnesia anterógrada y cefalea,detectándose en la TC un NT intraventricular. Se realizóun tratamiento urgente con drenaje ventricularexterno bilateral y taponamiento nasal anterior conbuena respuesta clínica. De modo diferido se procedió ala revisión del abordaje esfenoidal lográndose el cierredefinitivo del defecto dural sin recidiva posterior.El NT después de la cirugía por vía esfenoidal sueleocurrir tras la aparición de una fístula de LCR debido alsellado incompleto del seno esfenoidal. La colocación deun drenaje lumbar postoperatorio parece predisponera esta complicación. El enfoque terapéutico combinadodel NT mediante drenaje ventricular externo y reparacióndel seno esfenoidal ofrece un resultado óptimo conuna solución rápida para el deterioro neurológico delpaciente y evita las recidivas

Tension pneumocephalus is a rare complication of transsphenoidal approaches. The case of a 37 yearold woman with a transsphenoidal resection of a pituitaryadenoma who presented self-limited rhinoliquorrheapostoperatively is reported. Three days later thepatient developed progressive decreased consciousness,amnesia and headache, showing an intraventriculartension pneumocephalus on CT scan. Urgent treatmentwith bilateral external ventricular drainage and anteriornasal tamponade was performed with good clinicaloutcome. Later transsphenoidal sealing of the duraldefect was achieved without recurrence.Tension pneumocephalus following transsphenoidalsurgery usually occurs after the presentation of a cerebrospinalfluid leak due to an incomplete sealing of thesphenoid sinus. The postoperative insertion of a lumbardrainage seems to be a predisposing condition for thiscomplication. The combined approach of tension pneumocephaluswith external ventricular drainage andrepair of the sphenoid sinus offers optimal results solvingthe acute neurological deterioration and avoidingrecurrence