Bilateral non-superselective embolization with particles under transient occlusion of the internal carotid artery in the management of juvenile nasopharyngeal angiofibroma: technical note.

Juvenile nasopharyngeal angiofibroma (JNA) is a rare histologically benign tumor, highly vascularized, with usually aggressive behavior, and can extend from the nasal cavity to neighboring structures. We present the case of a 14-year-old male harboring a JNA, presenting with an active severe and persistent epistaxis. Two previous surgical attempts of removal were unsuccessful, because of profuse intraoperative bleeding. Angiography showed a highly vascularized neoplasm with multiple branches arising from both internal carotid arteries, with absence of branches from the external carotid due to previous surgical ligation. Direct puncture tumor embolization was not possible because removal of nasal packing triggered major hemorrhage. The only option for embolization was a technique of non-superselective embolization with particles under transient occlusion of the internal carotid artery. The procedure was performed uneventfully from either side, the tumor was subsequently removed, and the patient had no recurrence 2 years after the initial treatment.

Carotid-cavernous fistula treatment with ethylene vinyl alcohol (onyx) exclusively through anterior venous approach.

The type of venous drainage of a direct carotid-cavernous fistula is an important issue to consider for the endovascular therapeutic decision. In case of an inadequate posterior drainage associated with a good anterior drainage, the facial vein is a useful alternative. The exclusive embolization with ethylene vinyl alcohol (EVOH Onyx), arterial and/or venous via the internal carotid artery (ICA) occlusion has been used successfully, in a few cases until now. Nevertheless, the use of this method through anterior transvenous approach has not been previously described. Presented here is the case of a 13-year-old female patient with left posttraumatic carotid-cavernous fistula, with predominant anterior drainage, as well as carrier of traumatic occlusion of the contralateral ICA. The treatment was by means of a transvenous approach with transient occlusion of the left ICA.

Hybrid carotid stent for the management of a venous aneurysm of the sigmoid sinus treated by sole stenting.

We describe the case of a 59-year-old female presenting with a disabling pulsatile tinnitus caused by a venous aneurysm of the sigmoid sinus. This is the first successful case of sole stenting, using a closed-cell design in the central part of the stent, leading to the occlusion of the aneurysm and the cure of the tinnitus. Venous aneurysms of the dural sinuses are rare causes of pulsatile tinnitus and the sole stenting technique provides a simpler, safe, and effective approach.

[Cavernous angioma of the second cranial nerve and chiasmatic apoplexy]. / Angioma cavernoso del segundo nervio craneal y apoplejía quiasmática.

We present the case of a female patient who developed chiasmatic apoplexy and menstrual alterations. CT scanning showed a suprasellar hemorrhage. She underwent surgery with the presumptive diagnosis of pituitary tumor. At surgery, we find a brown-grayish lesion involving left optic nerve and chiasm. Cavernous angioma was diagnosed by histopathology. Cavernous angiomas constitute nearly 15% of all central nervous system vascular malformations. Location at the optic pathway is very rare, but must to be ruled out in the diagnosis of a patient with chiasmatic and/or optic apoplexy. Surgery is useful in preventing worsening of the previous deficit or a new visual defect.

Réplica. Algunas reflexiones sobre la utilidad de la angiografía por resonancia magnética en la cirugía de aneurismas intracraneales rotos / Reply. Some reflections on the value of magnetic resonance angiography in the surgical treatment of ruptured intracranial aneurysms

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Microsurgical considerations of the anterior spinal and the anterior-ventral spinal arteries.

BACKGROUND: There are few data describing the microanatomy of the anterior-ventral spinal (AVSA) and anterior spinal arteries (ASA) and discussing their clinical and surgical implications. We describe the anatomical features of this arterial complex, and highlight their use when planning and performing surgical approaches to lesions involving the ventral aspect of the medulla and the foramen magnum. METHOD: The microsurgical anatomy and branching pattern of the AVSA and the ASA from fifty human cadaver brain stems is described using a surgical microscope. RESULTS: We found one anterior-ventral spinal artery at each side in 30 of the brain stems (60%). The ASA was a direct branch emerging from the left vertebral artery (VA) in 15 (30%), from the right VA in 4 (8%), and from the basilar artery (BA) in one brain stem (2%). The previously described as "typical pattern" of the junction of the AVS arteries from both sides, was observed only in 9 brain stems (18%). The anterior communicating spinal artery (ACoSA) was observed in 15 brain stems (30%). Also multiple ACoS arteries were described in one brain stem. Both, the AVSA and the ASA were observed to send long circumferential branches that supplied irrigation to the olive in 42 (84%) brain stems. CONCLUSIONS: This anatomical study gives important information for a better understanding of the clinical picture of ischemic lesions of the brain stem, such as the medial medullary syndrome, and highlights the remarkable role of the AVSA and ASA as anatomical landmarks during the surgical approaches to lesions involving the ventral aspect of the medulla and the foramen magnum.

[Usefulness of magnetic resonance angiography in surgery of ruptured intracranial aneurysms]. / Utilidad de la angiografía por resonancia magnética en la cirugía de aneurismas intracraneales rotos.

INTRODUCTION: Cerebral angiography (CA) is considered as the gold standard in diagnosis of intracranial aneurysms; nevertheless, the magnetic resonance angiography (MR-angiography) is wide spread used in detection of unruptured aneurysm. For this reason, several authors had proposed that MR-angiography could replace CA in the diagnosis of ruptured aneurysms. AIMS: To asses the efficacy of MR-angiography in diagnosis of ruptured intracranial aneurysms, and in addition to determine the safeness of its surgical management with MR-angiography alone. PATIENTS AND METHODS: We studied prospectively 52 patients with subarachnoid haemorrhage admitted at Teodoro Maldonado Carbo and Alcívar Guayaquil hospitals of Guayaquil, Ecuador, in a 5 years period. We compared the results of MR-angiography with CA and surgical findings in the diagnosis and categorization of intracranial aneurysms. RESULTS: We made diagnosis of 100% of 54 aneurysms with MR-angiography, while 98% with CA. The surgical findings were similar to the characteristics showed by MR-angiography. CONCLUSIONS: MR-angiography is an excellent no invasive method in the diagnosis of ruptured intracranial aneurysms, and could replace CA in selected cases.

Utilidad de la angiografía por resonancia magnética en la cirugía de aneurismas intracraneales rotos / Usefulness of magnetic resonance angiography 1 N surgery of ruptured inracranial aneurysms

Introduction. Cerebral angiography (CA) is considered as the gold standard in diagnosis of intracranial aneurysms; nevertheless, the magnetic resonance angiography (MR-angiography) is wide spread used in detection of unruptured aneurysm. For this reason, several authors had proposed that MR-angiography could replace CA in the diagnosis of ruptured aneurysms. Aims. To asses the efficacy of MR-angiography in diagnosis of ruptured intracranial neurysms, and in addition to determine the safeness of its surgical management with MR-angiography alone. Patients and methods. We studied prospectively 52 patients with subarachnoid haemorrhage admitted at Teodoro Maldonado Carbo and Alcívar Guayaquil hospitals of Guayaquil, Ecuador, in a 5 years period. We compared the results of MR-angiography with CA and surgical findings in the diagnosis and categorization of intracranial aneurysms. Results. We made diagnosis of 100% of 54 aneurysms with MR-angiography, while 98% with CA. The surgical findings were similar to the characteristics showed by MR-angiography. Conclusions. MR-angiography is an excellent no invasive method in the diagnosis of ruptured intracranial aneurysms, and could replace CA in selected cases (AU)

Introducción. La angiografía cerebral (AC) es la técnica de referencia en el diagnóstico de aneurismas intracraneales; no obstante, la angiografía por resonancia magnética (angio-RM) se utiliza con gran efectividad para la detección de aneurismas en pacientes que no han presentado hemorragia subaracnoidea (HSA). Por lo tanto, algunos autores han propuesto que la angio-RM puede suplantar a la AC, incluso en el tratamiento de aneurismas rotos. Objetivos. Valorar la utilidad de la angio-RM comparada con la AC y la observación quirúrgica en el diagnóstico de aneurismas intracraneales rotos, además de determinar la seguridad del tratamiento quirúrgico con angio-RM como único método diagnóstico. Pacientes y métodos. Se estudiaron prospectivamente 52 pacientes con HSA aguda por ruptura de aneurisma en los hospitales Teodoro Maldonado Carbo y Alcívar Guayaquil, de la ciudad de Guayaquil, Ecuador, en un período de 5 años. Comparamos los resultados de la angio-RM con la AC y los hallazgos quirúrgicos en el diagnóstico y caracterización de aneurismas intracraneales. Resultados. Diagnosticamos el 100% de 54 aneurismas intracraneales con angio-RM, mientras que con la AC, el 98%. Los hallazgos quirúrgicos fueron similares a lo mostrado en la angio-RM. Conclusiones. La angio-RM es un método no invasivo y libre de contraste nefrotóxico óptimo en el diagnóstico de aneurismas intracerebrales rotos y puede reemplazar a la AC en casos seleccionados(AU)

[Intracranial trigeminal schwannoma with extension to infratemporal fossa, parapharyngeal space, orbit, maxillary sinus and nasal fossa]. / Schwannoma trigeminal intracraneal con extensión a la fosa infratemporal, espacio parafaríngeo, órbita, seno maxilar y fosa nasal. A propósito de un caso.

Schwannomas reach 8 to 10% of all intracranial tumors. Most originate at the vestibular root of VIII cranial nerve, but trigeminal tumors are infrequent. We present the case of a patient admitted at the National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (Mexico City) with a mass occupying the infratemporal fossa with involvement of nearby structures. Schwannomas with extension to the infratemporal fossa are rare. We review the anatomy of this region, the surgical approaches, which have been used and propose a different approach.

[Non-surgical potentially reversible dementias]. / Demencias potencialmente reversibles no quirúrgicas.

AIMS: In this study, we review dementias that are potentially reversible. The paper summarises the causes that essentially require management by medical means, while causes of a surgical nature will be dealt with in a second article. These papers attempt to avoid mistaken diagnoses and labels in patients with a high potential to improve their cognitive disorder and to guide us towards a more suitable management. DEVELOPMENT: Dementia is a public health problem, mainly in countries with long life expectancy. It has an incidence of 3-11% in patients over the age of 65, and 20-50% in those over 85 years old. Most of them (50-70%) have Alzheimer-type dementia, followed by the vascular type (20%); there is a smaller percentage of cases of the so-called subcortical dementias and also those secondary to medical and/or surgical conditions that suggest potential reversibility. These latter cases are not easy to recognise and their incidence, depending on the series, ranges from 0 to 37%. Once they have been diagnosed, it is still difficult to state whether they will in fact turn out to be reversible. Their most common causes, such as deficiencies, metabolic disorders, chronic diseases, toxins, and so on, must be detected as early as possible, which can be done by means of clinical observation and use of the laboratory. CONCLUSIONS: Although the potential to improve in patients with a diagnosis of reversible dementia is still subject to discussion, this brief review guides us in the search for their causes and their management, since late detection and management are very likely to be the cause of a poor progression.

Schwannoma trigeminal intracraneal con extensión a la fosa infratemporal, espacio parafaríngeo, órbita, seno maxilar y fosa nasal. A propósito de un caso / Intracraneal trigeminal schwannoma with extension to infratemporal fossa, parapharingeal space, orbit, maxillary sinus and nasal fossa

Los schwannomas constituyen del 8 al 10% de los tumores intracraneales. Su asiento principal es la rama vestibular del VIII nervio craneal, siendo los trigeminales de escasa frecuencia. Presentamos el caso de una paciente admitida en el Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez" de la ciudad de México con una masa en la fosa infratemporal con extensión importante a estructuras vecinas. Los schwannomas con extensión a la fosa infratemporal son raros. Revisamos la anatomía de la fosa infratemporal, los accesos quirúrgicos hacia dicha región, analizamos la serie de casos junto al nuestro y proponemos una modalidad quirúrgica distinta

Schwannomas reach 8 to 10% of all intracranial tumors. Most originate at the vestibular root of VIII cranial nerve, but trigeminal tumors are infrequent. We present the case of a patient admitted at the National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez" (Mexico City) with a mass occupying the infratemporal fossa with involvement of nearby structures. Schwannomas with extension to the infratemporal fossa are rare. We review the anatomy of this region, the surgical approaches, which have been used and propose a different approach