Estudio comparativo de cierre de cuero cabelludo en neurocirugías supratentoriales: intradérmica vs. surget / Comparative study of scalp closure in supratentorial neurosurgery: intradermal vs. surget

Introducción: El cierre de cuero cabelludo en neurocirugías supratentoriales mediante sutura intradérmica es una técnica poco difundida en la actualidad. En contraste, es común que se efectúen suturas de alta tensión con el fin de evitar dehiscencias, fístula de líquido cefalorraquídeo (LCR) y sangrado durante el período posquirúrgico, pero que no tienen buen resultado estético. Objetivo: Comparar las complicaciones relacionadas al cierre de cuero cabelludo que se presentaron en neurocirugías supratentoriales en un período de 19 meses, para determinar si utilizar un cierre de menor tensión y con mejor resultado estético, es igual de seguro que las técnicas de cierre habituales. Materiales y Métodos: Se incluyeron 84 casos de neurocirugías supratentoriales electivas. En 43 casos (control) se realizó el cierre mediante sutura continua tipo surget y en 41 casos (experimental) el cierre fue mediante sutura intradérmica. Resultados: Se presentaron 2 casos de infecciones, 1 en cada grupo (p= 0,97) y 1 caso de sangrado en el grupo control (p= 0,32). No se presentaron dehiscencias ni casos de fístula de LCR. Conclusiones: El cierre de cuero cabelludo mediante sutura intradérmica fue un método seguro que no generó una mayor incidencia de complicaciones y logró un mejor resultado estético a corto y largo plazo.

Background: Scalp closure by means of intradermal suture in patients who underwent supratentorial neurosurgeries is currently an uncommon technique. In contrast, it is usual to perform high tension sutures to avoid skin dehiscence, cerebrospinal fluid leak (CSF) and postoperative bleeding; however it usually results in unsatisfactory aesthetic results. Aim: Comparing complications, over a two year period, related to scalp closure occurred in supratentorial neurosurgeries. The goal is to establish if the intradermal suture is as safe as the current high tension closure technique.Materials and Methods: Eighty-four patients were included. In forty-three cases (control) continuous high tension suture (surget) was performed. The other forty-one cases (experimental) underwent intradermal suture. Results: Two infection cases occurred, one from each group (p= 0, 97). There was one case of bleeding that took place in the control group (p= 0,32). Neither dehiscence nor CSF leak occurred in any of the trial cases.Conclusions: Intradermal suture performed for scalp closure was as safe as surget in terms of complications occurrence and obtained better cosmetic results in the short and long term.

Nuestra experiencia en el manejo de los cavernomas de tronco, de tálamo y de ganglios basales / Our experience in the management of trunk, thalamus and basal ganglia cavernomas

OBJETIVO: Presentar nuestra experiencia en el manejo de los cavernomas de tronco cerebral, de tálamo y de ganglios basales. MATERIAL Y MÉTODO: Analizamos una serie de 16 pacientes asistidos en nuestra Institución, entre enero de 1990 y diciembre del año 2013. De ellos, 9 fueron varones y 7 mujeres. El rango de edad osciló entre 3 y 61 años. RESULTADOS: Siete debutaron con hemorragia cerebral, de ellos 4 se localizaban en protuberancia y 3 en el bulbo raquídeo. Siete pacientes tuvieron cavernomas múltiples, de ellos 3 tenían familiares con la misma enfermedad. El procedimiento diagnóstico de elección fue la resonancia nuclear magnética de cerebro en todos, y en los pacientes con cavernomas múltiples se completó el estudio con resonancia nuclear magnética de médula espinal. El tratamiento fue conservador en 9 enfermos, quirúrgico en 6 y radiocirugía estereotáctica en 1 enfermo; a éste paciente hubo necesidad de operarlo 6 meses después del tratamiento radiante por un resangrado voluminoso en la protuberancia. DISCUSIÓN: La cirugía es exitosa cuando el cavernoma se ubica a 2 mm de la piamadre, o del epéndimo. La radiocirugía puede ser causante de resangrado y de mayor volumen que las hemorragias previas. Por último, el tratamiento conservador sigue teniendo vigencia en los pacientes que se recuperaron neurológicamente y cuando se ubican en la profundidad del tronco cerebral, tálamo óptico o ganglios basales. CONCLUSIÓN: Cada paciente debe evaluarse individualmente para decidir el tipo de tratamiento, teniendo en cuenta la edad, la recuperación de los signos neurológicos, el volumen y la localización precisa del cavernoma

Objective: To present our experience in the management of brainstem, thalamus and basal ganglia cavernous malformations. Material and Method: We analyzed a series of 16 patients admitted to our Institution between January 1990 and December 2013. Nine of them were male and 7 female. Age ranged between 3 and 61. Results: Seven patients presented brainstem hemorrhage, 4 being pontine and the remaining 3 were medullary. Seven patients had multiple cavernomas, and 3 of them had a family background with the disease. The chosen diagnostic procedure was brain MRI in all patients; in patients with multiple cavernomas spine MRI was also requested. Nine patients received conservative treatment, 6 patients underwent surgery and one was treated with stereotactic radiosurgery but had to be operated on six months after radiation treatment due to voluminous re-bleeding at protuberance. Discussion: Surgery is successful when the cavernous malformation is placed 2 mm away from pia mater or ependyma. Radiosurgery can cause re-bleeding and of a greater volume than previous hemorrhages. Finally, conservative treatment is useful in patients who get neurologically recovered and when malformations are placed deep in brainstem, optic thalamus or basal ganglia. Conclusion: Each patient has to be individually assessed to individually assessed to make a decision regarding the type of treatment, taking into account age, recovery of neurological signs, volume, and precise location of cavernous malformation

Interstitial stereotactic radiosurgery of pilocytic astrocytomas in paediatric patients.

OBJECTIVE: To evaluate the clinical presentation, tumour response, clinical improvement and complications in 12 children and young people with a pilocytic astrocytoma, WHO I grade 1, who were treated with interstitial radiosurgery using Iodine-125 seed implants. PATIENTS AND METHODS: Retrospective analysis of 12 patients aged under 18 years (mean 8.4 years, ranging from 8 months to 17 years of age) with a pilocytic astrocytoma treated between 1993 and 2006. Iodine-125 seeds were used as temporary implants with low-dose rate (

Management of child optic pathway gliomas: new therapeutical option.

OBJECTIVE: To present our experience in the treatment of child optic pathway gliomas in the last 25 years. MATERIAL AND METHODS: Seventeen children under 10 years of age have been analyzed and assessed from clinic, ophthalmologic, endocrinologic, neurological, neuropathologic, and imaginologic points of view. RESULTS: Predominance of female patients, 10 girls and 7 boys between 6 and 122 months old; mean age was 3 years and 8 months. The most frequent symptoms have been ophthalmologic and visual alterations in all 17 patients, endocrine alterations in 10, and neurological signs in 6. One of the patients presented neurofibromatosis type 1 (NF1), another patient had Down syndrome. Diagnosed using computed tomography or/and magnetic resonance imaging, histological studies showed pilocytic astrocytomas in 13 cases and a fibrillary astrocytoma grade II in 1 case. There were three patients without histological diagnosis; one of them had NF1. The treatment consisted of surgery, external beam radiotherapy, chemotherapy, and brachytherapy with iodine 125, separately or combined. Five patients died; the causes were secondary tumors in two children, tumor recurrence in one, sepsis secondary to respiratory and urinary tract infections in the child with Down syndrome, and finally, hydrocephaly due to hyperproteinorachia of tumor origin in one. Average survival was 89 months. CONCLUSION: Chemotherapy and brachytherapy are therapeutic methods to be considered, especially in children under 5. Marsupialization of the residual cyst into the ventricular system postradio or oncolytic treatment through endoscopic or stereotactic techniques is useful in the treatment of endocranial hypertension and/or hypothalamic compression in these patients.

Cerebellar astrocytomas: a 24-year experience.

INTRODUCTION: Cerebellar astrocytomas are the most benign tumors of the CNS. Seventy to eighty percent are found in children. METHODS AND RESULTS: We report on 38 children under 18 who had cerebellar astrocytoma in the posterior fossa and were treated by a multidisciplinary team in our Neurosurgical Department from January 1974 to December 1997. We included all patients in whom the histopathological diagnosis was astrocytoma, regardless of malignancy. The diagnostic methods used were pneumoventriculography, cranial X-rays, CT scan, and MRI. All patients were treated surgically. Neither radiotherapy nor chemotherapy was indicated in patients with pilocytic or fibrillary astrocytomas. A greater prevalence was observed in female (25/38; 66%) than in male (13/38; 34%) patients. Histopathological results revealed 27 (71%) pilocytic astrocytomas, 8 (21%) diffuse fibrillary astrocytomas, 1 (2%) anaplastic astrocytoma and 2 (6%) glioblastomas. These tumors were more frequently located in the right cerebellar hemisphere; increased intracranial pressure syndrome was the most frequent form of clinical presentation. Total tumor resection was obtained in 29 (83%) cases and subtotal resection in 9 (17%). In 6 (16%) cases, ventriculoperitoneal shunts were placed to control persistent hydrocephalus after tumor excision. CONCLUSION: The most frequent complication was increased ataxia. The mortality rate was 8.5%.

Nuestra experiencia en el manejo de los angiomas cavernosos del sistema nervioso central / Our experience in the management of cavernomas

El objetivo del presente trabajo es analizar nuestra experiencia en el manejo de los cavernomas del sistema nervioso central (SNC). Se analizaron, retrospectivamente, aspectos epidemiológicos, clínicos, diagnósticos y terapéuticos de 22 pacientes admitidos al Servicio de Neurocirugía del Sanatorio Allende entre enero de 1985 y diciembre de 1999 con diagnóstico de cavernoma del SNC. La muestra está compuesta por nueve pacientes menores de 15 años y 13 adultos, 13 varones y 9 mujeres. Se incluyen 3 pacientes de sexo masculino familiares directos (cavernomatosis familiar). Doce pacientes consultaron por convulsiones (3 de ellos con epilepsia refractaria), ocho por déficit neurológico, uno por cefalea y otro asintomático miembro de la familia portadora de cavernomas múltiples. En todos los casos el diagnóstico se realizó con RNM. De 18 pacientes a los que se les realizó TAC, en seis casos el estudio reveló anomalias, en cinco se observaron calcificaciones, en otros cinco se observaron signos de sangrado agudo y en uno se demostró una lesión hipodensa en el sitio donde posteriormente se confirmó el cavernoma. En cuanto a la localización 13 casos fueron supratentoriales (5 temporales, 4 parietales, 2 frontales, 1 occipital y 1 de ganglios basales) y 2 medulares cervicales. Doce pacientes fueron operados, 7 por convulsiones (3 con epilepsia refractaria) y los cinco restantes por déficit neurológico; 6 recibieron sólo drogas antiepilépticas y en 4 casos la observación fue la única medida. En el postoperatorio inmediato un paciente falleció por hematomas cerebrales múltiples diagnosticándose histopatológicamente amiloidosis cerebral primaria, uno presentó hipo incoercible, uno hemianopsia homónima y otro presentó una fístula del LCR tratada médicamente. Los pacientes con epilepsia refractaria lograron controlar las crisis y uno se encuentra actualmente sin medicación alguna. La media de seguimiento clínico fue de 72 meses y el rango 1 a 180 meses

Postraumatic intracranial hematomas in infancy. a 16-year experience.

OBJECTS: The objective of this study is to analyze some of the epidemiological aspects in patients with post-traumatic intracranial hematomas (post-traumatic ICH) in infancy. These patients were treated at the Hospital Infantil Municipal de Córdoba, Argentina, between April 1980 and April 1996. METHODS: A retrospective descriptive analysis was conducted on the 113 case histories of children with post-traumatic ICH, all of whom required surgical intervention during this period. Relevant information such as age, sex, mechanism of injury causing craniocerebral trauma (CCT), and data on clinical presentation on admission, diagnosis, morbidity and mortality rates were collected. CONCLUSIONS: The series revealed a greater incidence of post-traumatic ICH in boys (73.5%), whose average age was 6 years 5 months +/- 4 years 10 months (range 1 day to 15 years). Fifty-three percent of the girls suffered post-traumatic ICH before the age of 3, while 54% of the children were 7 years of age or older (P<0.05). Falls were the most frequent mechanism of injury causing CCT (36.3%), followed by vehicle accidents (33.6%) and unknown causes (15.9%), the latter mainly in children under 3 years old (31%). The most frequent symptoms were vomiting (58.6%), loss of consciousness (47.1%) and headaches (24.1%). Of all these children, 93.8% presented signs and symptoms at the time of hospital admission, alterations in the level of consciousness (66%), vomiting (47.2%) and headaches (26.4%) being among the most frequent. The hemorrhagic complications observed in the 113 patients took the form of extradural hematomas (EDH) in 75 (66.4%), of subdural hematomas (SDH) in 35 (31.0%), of hemorrhagic contusions (Hc) in 19 (16.8%), and of intracerebral hematomas (Ich) in 11 (9.7%). In 13 patients the site of the hematoma was the posterior cranial fossa (11.5%), and 22.1% of patients presented more than one type of hemorrhagic complication. Morbidity rates were 9.7% and mortality rates 17.7%.

Posteroventral pallidotomy in Parkinson's disease.

OBJECTIVE: We analyse the clinical aspects, results and reliability of posteroventral pallidotomy (PVP) carried out as treatment for the principal symptoms and treatment induced complications in patients with Parkinson's disease (PD). PATIENTS AND METHODS: Between August 1995 January 1998, 17 patients with PD were treated surgically, 13 patients with PVP. A pre- and post-surgical clinical evaluation was carried out. Riechert's Stereotactic System (MHT, Freiburg, Germany) was used. Ventriculography under stereotactic conditions was used in the PVP procedures, Laitinen's co-ordinates as anatomical target, and electrical stimulation for physiological determination. 3 4 radiofrequency lesions were made at 83 degrees C for 20". The mean age was 60 +/- 10.8 years, ages ranging from 45-79 years. 8 (60.5%) of the patients were male. The cardinal symptoms of the series were bradykinesia and rigidity. The duration of the illness ranged from 8.6 +/- 3.7 years with a range of 4-15 years. 7 (53.8%) presented with a duration of 10 years or more. 6 (46,2%) of the patients underwent left PVP, the remaining 7 (53.8%) right PVP. Only one patient received treatment with right PVP and ipsilateral thalamotomy in the same surgical procedure. The mean post-surgical follow up was 16 +/- 7 months, with a range of 2 to 26 months. RESULTS: An up to date evaluation was carried out on all patients showing significant changes after PVP in UPDRS motor (P < 0.005), complete rigidity relief (P < 0.005), bradykinesia relief (P < 0.005) and complete tremor relief (P < 0.005). An important improvement in contralateral dyskinesia was noted after PVP. A subjective evaluation of the results showed excellent results in 4 (30.8%) patients, good in 6 (46.2%) and fair in 3 (23%). No significant correlation was found between age and duration of illness (P = 0.7). Two patients suffered slight side effects, one patient with worsening of hypophonia whilst the other suffered subjective visual impairment controlled by normal post operative ophthalmological examinations. There was no peri-operative mortality. CONCLUSION: PVP is considered a safe and effective surgical method for the treatment of both the principal symptoms of PD and the complications of DOPA medication.

Stereotactic neurosurgery in children and adolescents.

Between March 1992 and January 1998, 100 stereotactic procedures were carried out in our Stereotactic Department. Of these, 24 were performed on patients under 18 years of age, 22 of them under a local anaesthetic and sedation. The ages of these patients ranged between 4 months and 18 years. The stereotactic procedures carried out were: 15 cerebral biopsies, 5 iodine-125 implants, 4 implantations of Rickham reservoirs with ventricular catheter, with additional holes to establish a connection between the cyst content and the ventricular system (internal drainage): 2 of these patients had arachnoidal cysts in the pineal region, 1 a thalamic neuroepithelial cyst and 1 a cystic craniopharyngioma, with excellent control of hydrocephalus. All cerebral biopsies were positive, including 3 in which brain stem tumours were detected. Of the 5 patients treated by brachytherapy, 4 had pilocytic astrocytomas and 1 an anaplastic astrocytoma. The sites of the tumours for which implants were used were the thalamus in 4 cases, and the basal ganglia (corpus striatum) in 1. In only 2 cases was there some transistory morbidity, and mortality was nil. The stereotactic procedures in this varied group were well tolerated, with low morbidity and mortality rates, which proves that this method is effective and safe for patients. It can also be used for the diagnosis of brain stem tumours. Midline cysts can also be treated by means of internal drainage with catheters (a minimally invasive form of surgery).

Valvular infections in patients with hydrocephalus: preventive aspects.

Shunt infections in children have become a serious problem. In order to solve this, we have been using antibiotic therapy with Rifampicin (Rifampin) for the last 2 years; the dosage is 20 mg/kg per day 1 h before surgery and then for 48 h after the surgical procedure. We have had experience with 203 children operated on between January 1987 and December 1988. The result was a significant decrease in the number of children with shunt infections. In 1980 we reported an incidence of 10%, while by 1988 the rate had gone down to 1%.

Intracranial arteriovenous malformations in infancy and adolescence.

Fifteen children and adolescents with intracranial arteriovenous malformations are reviewed and their data analyzed; their ages varied between 1 day and 15 years and there was a slight predominance of males (9 male and 6 female patients). In this series, the arteriovenous malformations appeared clinically as cerebral hemorrhage in 9 cases, epilepsy in 3, mental retardation with epilepsy in 1, subarachnoid hemorrhage in 1, and cardiac insufficiency at birth in the other. The diagnostic procedures used were computerized transmission tomography (CTT) of the cerebrum in 14 cases, cerebral panarteriography in 15, and EEG in 4 cases. Treatment took the form of surgery, radiation therapy, or medication. The last was administered to patients with epilepsy, either as a complement to other modes of treatment or as the only treatment. In all, 4 cases died, 2 for reasons to do with their operations, 1 from a lesion of the brain stem in a hematoma of the cerebellum that had not been surgically treated, and the other from an intraventricular hemorrhage 4 months after surgery. In the last patient, necropsy revealed remnants of the arteriovenous malformation. The overall mortality was thus 26% and the surgical mortality, 12.6%. Of the 11 surviving patients only 3 received anticonvulsant drugs; each of them had a good I.Q. and good marks at school, as did the other 8 survivors.

Epilepsy and brain tumors in infancy and adolescence.

Four boys and four girls with brain tumors who were admitted to our department in the last 8 years are herein described. They presented with epileptic fits, which began before the age of 14 years, with neither intracranial hypertension nor localizing signs during the first 6 months of the illness. The length of time between the first fit and the diagnosis of a tumor ranged from 2 months to 11 years (median of 3 years), during which period all patients but one received anticonvulsant therapy. The nontreated patient was under psychiatric treatment for 1 year. The electroencephalographic evolution was disconcerting, showing asymmetry of the recording with association of slow polymorphic waves and acute irregular waves, suggesting encephalitis. The neuroradiological diagnosis was made by cerebral arteriography in one patient and in the others by angiography and CT scans (which revealed hypodense cerebral areas in five cases and hyperdense areas in the other two). The histology of the tumor was that of a grade I astrocytoma in six cases; a grade III oligondendroglioma in one case, and a meningioma in the other. All patients underwent surgical treatment. Four also received radiation therapy, two for a partially excised astrocytoma and one each for an oligodendroglioma and a meningioma. Postoperatively, all patients were put on anticonvulsant drug therapy. There were no mortalities. To date, only one astrocytoma has recurred. The sequellae observed were hemiparesis in one case and marked psychomotor deficit in another. These two patients also still have epileptic fits. The others are all psychologically and neurologically normal, and two are now off antiepileptic drugs.

Porencephalic congenital cysts with hydrocephalus.

UNLABELLED: The therapeutic criteria according to tomographic findings are reviewed. 10 children, 6 male and 4 female, with porencephalic congenital cysts were studied. Early symptoms began within the first 6 months of life in 9 cases, and at the age of 5 years in 1. The most frequent symptoms were: seizures in 3; motor deficit in 5; retarded psychomotor development in 7; endocranial hypertension syndrome in 7; symmetric macrocrania in 7; paresis of the motor ocular nerves in 4. Preoperative studies: X-ray films-1 each patient-showed diastasis of sutures in 6 and cranial asymmetry in 2. Electroencephalograms-6 patients-were abnormal and diffuse in 3, hipsarrhythmic in 2, and focal in 1. CT-1 each patient-showed porencephalic cysts in all the patients; ventricular dilatation in 9; a single ventricle in 1, and a shift of the midline in 5. Postoperative studies: EEG, 1 each patient; CT, 1 each patient. SURGICAL TREATMENT: 8 patients underwent peritoneal shunts and 2 atrial shunts. Plastic surgery of the dysraphy was also performed. Postsurgical treatment: Rehabilitation and anti-convulsive treatment-4 patients. There were no deaths among the patients. The morbidity improved.