Neumoencéfalo como complicación de bloqueo regional epidural por radiculopatía lumbosacra / Pneumocephalus as a Complication of Regional Epidural Block Due to Lumbosacral Radiculopathy

Introducción: El neumoencéfalo (sinonimia: aerocele o neumatocele intracerebral), se define como la presencia de gas dentro de cualquiera de los compartimentos intracraneales (intraventricular, intraparenquimatosa, subaracnoidea, subdural y epidural). Objetivo: Describir los hallazgos clínicos, estudios complementarios, conducta terapéutica y evolución de un caso con neumoencéfalo como complicación de bloqueo regional epidural por radiculopatía lumbosacra. Presentación de caso: Se presentó un paciente masculino de 57 años de edad que comenzó con un cuadro súbito de desorientación, excitabilidad psicomotriz y convulsiones tónico-clónicas, a partir de una inyección epidural de metilprednisolona como método analgésico. Conclusiones: El caso presentado exhibió manifestaciones neurológicas inespecíficas, la aparición súbita posterior al proceder invasivo hizo sospechar en un evento neurológico agudo o fenómeno tromboembólico. Los estudios complementarios como la tomografía axial computarizada craneal simple, permitió su diagnóstico para tener una conducta consecuente. El manejo conservador del neumoencéfalo como complicación del uso de anestesia epidural, constituyó una conducta terapéutica eficaz y repercutió en la satisfactoria evolución del paciente(AU)

Introduction: Pneumocephalus (synonym: aerocele or intracerebral pneumatocele), is defined as the presence of gas within any of the intracranial compartments (intraventricular, intraparenchymal, subarachnoid, subdural and epidural). Objective: To describe the clinical findings, complementary studies, therapeutic conduct and evolution of a case with pneumocephalus as a complication of regional epidural block due to lumbosacral radiculopathy Case presentation: A 57-year-old male patient was presented who began with a sudden episode of disorientation, psychomotor excitability and tonic-clonic seizures, following an epidural injection of methylprednisolone as an analgesic method. Conclusions: The case presented exhibited non-specific neurological manifestations, the sudden appearance after the invasive procedure raised suspicion of an acute neurological event or thromboembolic phenomenon. Complementary studies such as simple cranial computed axial tomography, allowed its diagnosis to have a consistent conduct. The conservative management of pneumocephalus as a complication of the use of epidural anesthesia constituted an effective therapeutic approach and had an impact on the patient's satisfactory evolution(AU)

Pneumoencephalography in the workup of neuropsychiatric illnesses: a historical perspective.

Throughout history, neurosurgical procedures have been fundamental in advancing neuroscience; however, this has not always been without deleterious side effects or harmful consequences. While critical to the progression of clinical neuroscience during the early 20th century, yet, at the same time, poorly tolerated by patients, pneumoencephalography is one such procedure that exemplifies this juxtaposition. Presented herein are historical perspectives and reflections on the role of the pneumoencephalography in the diagnosis and treatment of neuropsychiatric illnesses.

Cisternografía radioisotópica con 99Tc-DTPA para confirmación diagnóstica de la hidrocefalia oculta normotensa / 99 Tc-DTPA radionuclide cisternography to confirm the diagnosis of normal pressure hydrocephalus

Se presenta el caso clínico de una paciente que ingresó en el Hospital Clinicoquirúrgico Hermanos Ameijeiras con antecedentes de etilismo crónico y cuadro clínico progresivo de deterioro cognitivo-conductual, trastornos de la marcha y esfinterianos, a quien se le realizó una cisternografía radioisotópica con el objetivo de comprobar su eficacia en el estudio de la dinámica del líquido cefalorraquídeo para diagnosticar la hidrocefalia oculta normotensa. La resonancia magnética de cráneo evolutiva evidenció hidrocefalia y la cisternografía radioisotópica confirmó el diagnóstico de hidrocefalia oculta normotensa. A la paciente se le realizó una derivación ventrículo peritoneal con la que se obtuvo una respuesta clínica evolutiva favorable. Se concluye que la cisternografía radioisotópica continúa siendo una herramienta útil para confirmar este diagnóstico y predecir la respuesta al tratamiento derivativo(AU)

A female patient who was admitted to Hermanos Ameijeiras Clinical and Surgical Hospital is presented here. She had a history of chronic alcohol abuse and progressive clinical deterioration of cognitive behavioral, abnormal gait and sphincter disorders. This patient had a radioisotope cisternography in order to test its effectiveness in the study of the dynamics of cerebrospinal fluid, and to diagnose normotensive hidden hydrocephalus. This MRI revealed hydrocephalus and skull evolutionary radioisotope cisternography confirmed the diagnosis of normal pressure hidden hydrocephalus. This patient received a shunt with a favorable evolutionary clinical response. It is concluded that cisternography radioisotope remains a useful tool to confirm this diagnosis and predict response to derivative treatment(AU)

Cisternografía radioisotópica con 99Tc-DTPA para confirmación diagnóstica de la hidrocefalia oculta normotensa / 99 Tc-DTPA radionuclide cisternography to confirm the diagnosis of normal pressure hydrocephalus

Se presenta el caso clínico de una paciente que ingresó en el Hospital Clinicoquirúrgico Hermanos Ameijeiras con antecedentes de etilismo crónico y cuadro clínico progresivo de deterioro cognitivo-conductual, trastornos de la marcha y esfinterianos, a quien se le realizó una cisternografía radioisotópica con el objetivo de comprobar su eficacia en el estudio de la dinámica del líquido cefalorraquídeo para diagnosticar la hidrocefalia oculta normotensa. La resonancia magnética de cráneo evolutiva evidenció hidrocefalia y la cisternografía radioisotópica confirmó el diagnóstico de hidrocefalia oculta normotensa. A la paciente se le realizó una derivación ventrículo peritoneal con la que se obtuvo una respuesta clínica evolutiva favorable. Se concluye que la cisternografía radioisotópica continúa siendo una herramienta útil para confirmar este diagnóstico y predecir la respuesta al tratamiento derivativo(AU)

A female patient who was admitted to Hermanos Ameijeiras Clinical and Surgical Hospital is presented here. She had a history of chronic alcohol abuse and progressive clinical deterioration of cognitive behavioral, abnormal gait and sphincter disorders. This patient had a radioisotope cisternography in order to test its effectiveness in the study of the dynamics of cerebrospinal fluid, and to diagnose normotensive hidden hydrocephalus. This MRI revealed hydrocephalus and skull evolutionary radioisotope cisternography confirmed the diagnosis of normal pressure hidden hydrocephalus. This patient received a shunt with a favorable evolutionary clinical response. It is concluded that cisternography radioisotope remains a useful tool to confirm this diagnosis and predict response to derivative treatment(AU)

XXXVII Reunión Anual de la Sociedad de Neurología del País Vasco. Comunicaciones / XXXVII Reunión Anual de la Sociedad de Neurología del País Vasco. Communications

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Diagnóstico prenatal de atresia ileal asociada a peritonitis meconial / Prenatal diagnosis of ileal atresia jounted to meconial peritonitis

La atresia ileal aislada es una situación poco frecuente que cuenta con limitados casos publicados en la bibliografía internacional. Su diagnóstico es complejo y se realiza siempre en el tercer trimestre de gestación. Puede complicarse en un 5% de los casos con peritonitis meconial, la cual empeora el pronóstico. Presentamos un caso de debut tardío de atresia ileal con perforación intestinal y peritonitis meconial en una mujer con buen control gestacional (AU)

Isolated ileal atresia is a rare situation, with few cases reported in the international literature. Its diagnosis is difficult and always occurs on the third trimester of pregnancy. It can be complicated by meconium peritonitis in 5% of the cases, worsening the prognosis. We present a late debut of a case of ileal atresia with bowel perforation and meconium peritonitis in a woman with excellent pregnancy controls (AU)

Neumoencéfalo: una inusual complicación de la artrodesis lumbar. Caso clínico y revision de la literatura / Pneumocephalus: an unusual complication of lumbar arthrodesis. A clinical case and literature review

El neumoencéfalo es una complicación poco frecuente pero grave de la cirugía de la columna vertebral, su manejo y fisiopatología no es ampliamente conocida. La incidencia de neumoencéfalo sintomático a tensión, secundario a una artrodesis vertebral posterior es desconocida. Caso clínico. Presentamos el caso de una paciente mujer de 41 años de edad, con diagnóstico de discopatía L3-L4, L4-L5 y hernia discal izquierda L4-L5. Se realizó una artrodesis vertebral posterior L3-L5, discectomías L3-L4 y L4-L5 y liberación de la raíz L5 izquierda, sin complicaciones aparentes. Transcurridas 24 h después de la cirugía, la paciente inicia cuadro de cefalea generalizada de fuerte intensidad, rigidez de nuca y disartria. Se realizan TAC y RMN que muestran un enorme neumoencéfalo en el espacio subaracnoideo, a predominio del lóbulo frontal izquierdo, sin desplazamiento de la línea media, con origen en el conducto raquídeo lumbar. La paciente fue tratada de forma conservadora, presentando a partir de las 72 h mejoría neurológica progresiva, hasta la normalización clínica y radiológica después de 7 días. Discusión. El neumoencéfalo es una complicación rara pero potencialmente grave de la cirugía de columna, relacionada en la mayoría de los casos con desgarro dural accidental durante la cirugía. La mayoría de las colecciones son pequeñas, se comportan de forma benigna, y responden al tratamiento conservador. En un gran número de pacientes, puede comportarse como cualquier lesión ocupante de espacio, por lo que se necesita un alto grado de sospecha clínica para hacer el diagnóstico y tratamiento oportuno, y prevenir la morbimortalidad no deseadas (AU)

Pneumocephalus is an uncommon but serious complication of spinal surgery and its management and pathophysiology is not widely recognized. The incidence of symptomatic tension pneumocephalus secondary to posterior spinal arthrodesis is unknown. Case report. The case is reported of a rare case of a 41 year old woman with diagnosis of L3-L4, L4-L5 disc disease and left disc herniation L4-L5. A posterior spinal arthrodesis L3-L5, L3-L4 and L4-L5 discectomies and release of the left L5 root, was performed without apparent complications. Twenty-four hours after surgery the patient developed generalized headache, neck stiffness, and dysarthria. MRI and CT scans revealed a huge pneumocephalus in the subarachnoid space, predominantly in the left frontal lobe without midline shift, which originated in the lumbar spinal canal. The patient was treated conservatively, with progressive neurological improvement after 72 hours, and clinical and radiological normalization after 7 days. Discussion. Pneumocephalus is a rare but potentially serious complication of spine surgery related in most cases with inadvertent dural tear during the operation. Most collections are small, behave benign, and respond to conservative therapy. In the present case, an inadvertent dural tear, produced a pneumocephalus. A high degree of suspicion is needed to make the diagnosis, prompt treatment, as well as remedying the source of air to prevent unwanted morbidity and mortality (AU)

Lack of cerebrospinal fluid circulation due to post puncture epidural hemorrhage: An interesting case of radionuclide cisternography / Falta de circulación de líquido cefalorraquídeo secundaria a hemorragia epidural postpunción: un caso interesante de cisternografía isotópica

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Skull base anatomy and CSF rhinorrhea.

The skull base is an intricate interface between the cranium and face allowing the passageway of vital structures. Anatomic conceptualization forms the platform for surgical approaches and solutions to skull base pathology. Understanding embryogenesis provides further depth into the pathophysiology of congenital defects. This chapter aims to highlight skull base anatomy and embryology along with cerebrospinal fluid physiology and diagnostic evaluation of cerebrospinal fluid leaks.

Retained foreign body in ethmoid with bilateral pneumoencephaly.

Intracranial penetrating injury through the nose is rare. We present a case of a 79 year-old patient who had intracranial penetrating injury with a wooden object accompanied by massive bilateral pneumoencephaly with the presence of a foreign body in the ethmoid bone with fracture and displacement of crista galli. This is a hitherto unreported retained foreign body with fractured ethmoid resulting in bilateral pneumoencephaly.

Neumoencéfalo como complicación de punción dural inadvertida en analgesia epidural / No disponible

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Predicting the outcome of shunt surgery in normal pressure hydrocephalus.

We studied retrospectively the effectiveness of the repeated lumbar CSF tap test (RTT), lumbar external CSF drainage (LED) and radioisotope cisternography (RIC) in predicting the outcome of shunt surgery, as well as the diagnostic and prognostic value of periventricular hyperintensity (PVH) and of the classic clinical triad in normal pressure hydrocephalus. Two hundred and seventy patients were referred to the Departments of Neurosurgery, in Nancy, France and in Istanbul, Turkey. The decision to perform surgery was based on the clinical presentation (all patients had at least two symptoms of the classic clinical triad), neuroimaging examinations and the results of the RTT (taps were performed on three consecutive days and at each tap a minimum of 30 to 40 cc of CSF was removed), the LED (drainage was performed for 3 days and the volume of CSF drained daily was a minimum of 150 to 250 cc) or the RIC. After all shunt procedures, postoperative assessments verified improvements in 88% of the RTT group, 91% of the LED group and 66% of the RIC group. Gait disturbance had improved in 90% at the end of the second and twelfth month follow-up. Cognitive dysfunction had improved in 79% at the second and in 77% at the twelfth month follow-up. Urinary incontinence had improved in 66% at the second and in 62% at the twelfth month follow-up. From the surgical point of view, the greatest difficulty is not to make the diagnosis, but rather to identify the appropriate patients to operate on. The decision to perform shunt surgery should be based on strict clinical findings associated with CT and MRI criteria and especially with positive RTT or LED test results.

Neumoencéfalo a tensión tras cirugía intracraneal en posición supina / Tension pneumocephalus after intracraneal surgery in the supine position

El neumoencéfalo a tensión es una complicación grave, poco frecuente, que aparece tras cirugía de la fosa posterior con pacientes en posición sentada. Esta complicación puede amenazar la vida del paciente y requerir tratamiento inmediato. Sin embargo, el neumoencéfalo a tensión tras cirugía intracraneal en posición supina se ha publicado en raras ocasiones. Presentamos un caso de neumoencéfalo a tensión tras una craneotomía para la exéresis de un proceso expansivo frontotemporal izquierdo realizada en posición supina (AU)

Tension pneumocephalus is a rare and severe com¬plication appearing after posterior fossa procedures in the sitting position. This complication may endanger the pacientes life and require immediate treatment. However, tension pneumocephalus after neurosurgical procedure in the supine position have been scarcely reported. We report such a complication occurring in a 14-year-old girl submitted to a frontotemporal cra¬niotomy for removal of an astrocytome performed with the patient supine. We discuss ethiopathogenesis and management of this complication (AU)

Cerebrospinal fluid otorhinorrhea in patients with defects through the lamina cribrosa of the internal auditory canal.

We describe three patients with bilateral cerebrospinal fluid (CSF) otorhinorrhea with unilateral progressive hearing loss in whom CT showed the defect to be located in the lamina cribrosa of the internal auditory canal. CT cisternography showed the CSF fistula in two of the three patients who had Mondini malformation, whereas the CSF fistula was obvious on the plain high-resolution temporal bone CT study in the third patient, who had a posttraumatic (nonsurgical) fracture of the lamina cribrosa. Fast spin-echo T2-weighted coronal MR cisternography also showed the site of leakage in the third patient. In the presence of an intact tympanic membrane, the CSF egressed to the nose via the eustachian tube in all three patients.

[The clinical characteristics of rhinosinusogenic diffuse cerebral arachnoiditis located predominantly in the anterior cranial fossa]. / Klinicheskie osobennosti rinosinusogennogo diffuznogo tserebral'nogo arakhnoidita s preimushchestvennoi lokalizatsiei v perednei cherepnoi iamke.

142 patients with rhinosinusogenic cerebral arachnoiditis (RCA) were investigated. Diagnosis of RCA in all cases was confirmed by results of otorhinolaryngologic and neurologic methods of investigation. Pneumoencephalography was performed in 60 cases. In order to achieve auxiliary contrasting of meninges anterior cranial space the new way of position of patient on the table for X-ray examination were used with a special device. Analysis of pneumoencephalograms of 30 patients, performed with the new position and the new device allowed to detect predominant location and character of meninges pathology in PCA. Diagnostic significance of pneumoencephalography increased because of additional air depot in brain coverings of anterior cranial space. On the basis of clinical and pneumoencephalographic data it was concluded, that in cases with RCA meninges of anterior cranial space are the place of primary location of pathological process. The main topical of RCA was diffuse cerebral arachnoiditis with predominant pathology meninges of anterior cranial space (66.9% of patients). Among the main clinical peculiarities of this form were the following: characteristic of head pain in supraorbital area with the feeling of the pressure on eyes and painful eye movements, frequency of smell and psychic disorders. Analysis of clinical and pneumoencephalographic data demonstrated, that pathological changes in brain meninges and brain matter prevailed at the side of rhinosinusitis or of more damaged sinus in cases with bilateral disease.

[Spontaneous cerebrospinal rhinorrhea: role of computerized opaque cisternography]. / Rhinorrhée cérébro-spinale spontanée: place de la cisternographie opaque computérisée.

Spontaneous CSF rhinorrhoea, secondary to trauma in the great majority of cases, is very rare (3-4%). The authors report a case of spontaneous CSF rhinorrhoea secondary to an ethmoidal osteodural defect, diagnosed by digital cisternography and confirmed by the surgical operation. The value of digital opaque cisternography and its place in the diagnostic arsenal are discussed.

MR cisternography: initial experience in 41 cases.

PURPOSE: To present our initial experience with MR cisternography, an application of fast spin-echo MR with fat suppression, and compare it with routine MR cranial studies in the evaluation of the subarachnoid cisterns and their contents. METHODS: MR cisternography is a heavily T2-weighted fast spin-echo technique with high spatial resolution; it uses fat suppression and video reversal of the images. A small number of individual sections (two to four) are compressed into a composite image by a maximum-intensity projection algorithm, providing better depiction of anatomy in three dimensions. MR cisternography enhances the signal intensity of the cerebrospinal fluid (CSF) with suppression and subtraction of the background. A total of 41 patients were examined during a period of 6 months. MR cisternography was performed as an additional one (n = 31) or two (n = 10) sequences after conventional MR study. RESULTS: Twenty-one cases of disease were examined by MR cisternography, including 8 neoplasms, 4 CSF fistulas, and 3 large intracranial aneurysms. MR cisternography provided information unavailable by conventional MR studies in 17 cases. These included visualization of fistulous tracks in patients with CSF rhinorrhea, origin of a large suprasellar aneurysm, an additional loculus of a posterior fossa aneurysm and its relation to surrounding structures, and proper location of three tumors (intraaxial versus extraaxial). Clear depiction of the pituitary gland separate from the cavernous sinus was noted in 60% of the cases, and a new observation of a CSF sleeve around the third nerve in the posterior cavernous sinus was made in 85% of the cases. CONCLUSION: MR cisternography is superior to conventional MR studies in depicting anatomic structures within the subarachnoid spaces. This technique is recommended in the evaluation of cranial CSF fistulas and suprasellar and posterior fossa masses and in diagnosis of intraaxial versus extraaxial location of intracranial tumors.