[Arteriovenous malformations of the posterior fossa. Clinical features, treatment and results]. / Malformaciones arteriovenosas de fosa posterior. Clínica, tratamiento y resultados.

OBJECTIVES: We present our experience of 20 cases of arteriovenous malformations (MAV) of the posterior fossa. PATIENTS AND METHODS: During the period 1991 1999 we prospectively collected radiological and therapeutic clinical data and the results obtained in all cases of adults whose arterio venous malformations were treated. We selected 20 of those who had MAV of the posterior fossa. RESULTS: The average age was 39.6 years (15 64). Thirteen (65%) were men. Most patients, 16 cases (80%) presented clinically with cerebellar haemorrhage, subarachnoid and/or intraventricular haemorrhage and 6 (30%) of the patients were admitted in coma. On the Spetzler and Martin scale: grade 1, 1 patient (5%); grade 11, 8 patients (40%); grade 111, 8 patients (40%) and grade 1V, 3 patients (15%). One patient had an associated pedicular aneurysm, another a supratentorial MAV and another patient had several cavernomas. Nine patients required external ventricular drainage, which in 4 cases became a permanent CSF drainage system. Endovascular treatment was used in 8 patients, radiosurgery in 2 and surgery in 9. Complete resection of the MAV was only possible in the patients treated by surgery (two patients had been treated previously by embolizations and radiosurgery). In this series there was a mortality of 20%, in all four cases due to recurrence of bleeding. Good results were obtained in 11 (55%) of the patients, but in the other 5 (25%) there were sequelas. CONCLUSION: The high percentage with haemorrhages as the form of presentation, with a much higher mortality than that of supratentorial MAVs makes more aggressive treatment necessary.

[Distal aneurysms of the vertebrobasilar system. A report of five cases]. / Aneurismas distales del sistema vertebrobasilar. Presentación de cinco casos.

INTRODUCTION: Aneurysms distal to the circle of Willis are uncommon. Among the rarest of such aneurysms are those found in the territory of the vertebrobasilar artery. OBJECTIVE: To describe clinico-radiological aspects and the clinico-surgical evolution of five patients with distal aneurysms of the cerebellar arteries. PATIENTS AND METHODS: Five patients (2.5%), with aneurysms of the cerebellar arteries, of a total of 194 patients with cerebral aneurysms admitted to our hospital between 1995 and 1998. RESULTS: All patients presented with subarachnoid hemorrhage. One patient also had an arteriovenous malformation (AVM). One patient refused surgical treatment, three were treated surgically and one using the endovascular approach. The patient who was successfully treated using the endovascular approach to an aneurysm of the antero-inferior cerebellar artery, and who also had an AVM had a further episode of bleeding following partial embolization of his AVM. The patients who were treated surgically and the one who refused surgical treatment made good progress. CONCLUSIONS: A multidisciplinary approach to the treatment of cerebral aneurysms is essential. Microsurgical techniques are very useful, especially in peripheral aneurysms.

Aneurismas distales del sistema vertebrobasilar. Presentación de cinco casos / Distal aneurysms of the vertebrobasilar system. a report of five cases

Introducción. Los aneurismas distales al polígono de Willis son poco frecuentes y de entre ellos son aún más raros los situados en el territorio vertebrobasilar. Objetivo. Describir los aspectos clinicorradiológicos y la evolución clinicoquirúrgica de cinco pacientes con aneurismas distales de las arterias cerebelosas. Pacientes y métodos. Cinco pacientes (2,5 por ciento) con aneurismas localizados en las arterias cerebelosas de un total de 194 pacientes con aneurismas cerebrales ingresados en nuestro hospital durante el período comprendido entre 1995 y 1998, ambos inclusive. Resultados. La forma de presentación de todos los pacientes fue la hemorragia subaracnoidea. Un paciente tenía asociada una malformación arteriovenosa (MAV). Una paciente rechazó el tratamiento quirúrgico, tres se trataron quirúrgicamente y otro por vía endovascular. El paciente que había sido tratado con éxito por vía endovascular de un aneurisma de la arteria cerebelosa anteroinferior, y que era el que asociaba una MAV a su aneurisma, resangró después de realizar una embolización parcial de su MAV. Los pacientes tratados quirúrgicamente y la paciente que rechazó el tratamiento quirúrgico evolucionaron favorablemente. Conclusiones. Es imprescindible el planteamiento terapéutico multidisciplinario en la patología aneurismática cerebral. Las técnicas microquirúrgicas tienen aún un papel muy importante, sobre todo en los aneurismas periféricos (AU)

[Severe craniocerebral injuries with a lucid interval]. / Traumatismos craneoencefálicos graves con intervalo lúcido.

Some variables were analyzed in 35 patients with severe cranioencephalic injuries following a lucid interval according to mortality. The variables analyzed were: age of less than 40 years, interval of time accident-admission (TAA), admission-operation (TAO), level of consciousness (Glasgow scale), associated extracranial lesions, type of intracranial lesion, and tomodensitometric signs of intracranial hypertension. The only variables demonstrating significant statistical differences (p < 0.05) were the level of consciousness (Glasgow scale < 6 points) and the presence of subdural hematoma. Twelve (70.5%) patients who died had less than 6 on the Glasgow scale and in contrast only 5 (27.7%) of the living. Eleven (64.7%) of the group who died and 4 (22.2%) of the living had subdural hematoma. These data suggest that the level of consciousness and the type of lesion are determining factors of the mortality in this type of patients. Early detection and energic treatment of secondary lesions contribute to prognostic improvement of cranioencephalic injuries.

[Predictive factors of mortality in severe craniocerebral trauma]. / Factores predictivos de la mortalidad en los traumatismos craneoencefálicos graves.

BACKGROUND: The prediction of mortality in severe head injury is of interest for the evaluation of patient prognosis and to also permit therapeutic measures to be considered and improve knowledge of this problem. METHODS: A multiple logistic regression model was developed and validated from the data obtained from a series of 231 patients hospitalized for the above mentioned condition. Seventy-five percent of the patients were used to define the model with the remaining 25% validating the same. RESULTS: The variables included in the model were: intraventricular hemorrhage, odds ratio = 20.4 (confidence interval 95%: 3.56-116); compression of basal cistern and/or of the III ventricle, odds ratio = 11.5 (4.43-29.8); mydriatic pupils in both eyes, odds ratio = 5.71 (1.32-24.6); age, odds ratio = 1.03 (1.01-1.05) and Glasgow scale upon admission, odds ratio = 0.57 (0.43-0.75). The maximum global value of the model (84.9%) corresponded to a sensitivity of 84.5% and specificity of 85.2%. The cut-off point of probability of death was found to be 0.475. In the validation of the model the highest global value (84.2%) was also observed at the cut-off point of 0.475 with a sensitivity of 84.2% and specificity of 84.4%. CONCLUSIONS: The predictive factors of mortality in severe head injury are the evidence of hemorrhage in the cerebral ventricles, mydriasis and a low score on the Glasgow scale. The model presented is useful and valid for carrying out the prediction of mortality at the time of admission and is also easy to apply since the variables used are obtained in the initial examination of the patients with severe head injury.

[Decrease in the incidence of epidural hematomas surgically treated during coma after a lucid interval. Is this an index of quality of care?]. / Disminución de la incidencia de hematomas epidurales intervenidos en coma después de un intervalo lúcido. Es un índice de la calidad asistencial?

The level of consciousness prior to surgery has been analyzed in a series of 64 patients suffering epidural hematoma (EDH) who underwent surgery during the period from July 1987 to June 1989. The percentage of cases which underwent surgery in coma after a lucid interval have been compared in different periods of time (1978-80, 1981-82, 1983-84 and July 1987 to June 1989). During the period from July 1987 to June 1989 surgery was performed on: 15 patients (23.5%) in coma from the moment of accident, 8 patients (12.5%) underwent surgery in coma but after a lucid interval and 41 patients (64.1%) were conscious. During the different periods of time the number of patients undergoing surgery in coma after a lucid interval were the following: 1979-80, 9 cases (26.5%); 1981-82, 17 cases (43.6%); 1983-84, 8 cases (20%) and during the last period, 1987-89, 7 cases (15.2%). The difference between the percentage of patients intervened in coma after a lucid interval in the previously referred periods of time was statistically significant (p 0.05).

[Reduction of the mortality from acute subdural hematoma. Comparison of 2 series (1979-1982 and 1987-1989) of patients operated on at the Hospital de la Vall d'Hebron]. / Reducción de la mortalidad en el hematoma subdural agudo. Comparación de dos series (1979-1982 y 1987-1989) de pacientes intervenidos en el Hospital de la Vall d'Hebron.

Several clinical variables from a series of 101 patients with acute subdural hematoma (ASDH) operated on during the period 1979-1989 were compared with those from another group of 43 patients who were operated on during the period 1987-1989. Twenty-seven patients (26.7%) in the earlier period and 15 (34.8%) in the later one were younger than 40 years. The difference was not significant. There was a higher proportion of patients, 41 (40.5%), in the earlier period (1979-1982) who had traffic accidents than in the 1987-1989 period, where trauma was the mechanism in 15 patients (38.8%). However, the difference was not significant. Seven patients (6.9%) from the earlier group and 18 (41.9%) from the later group had a lucid interval. This difference was significant (p less than 0.001). During the 1979-1982 period 80 patients (79.2%) were comatose on admission as compared with 27 (62.7%) during 1987-1989. The difference was significant (p less than 0.05). A small group of 11 patients (10.8%) from the earlier series were operated on by means of craniotomy or trephine; by contrast, this approach was used in 35 (81.3%) patients from the later series. The difference was significant (p less than 0.001). Seventy-nine (78.2%) and 26 (60.4%) patients died in the periods 1979-1982 and 1987-1989, respectively. The difference between the mortality rates of both groups were significant (p less than 0.05). Our data suggest that the earlier diagnosis and the use of wider surgical procedures have contributed to the reduction in mortality.

[Symptomatic chronic subdural hematoma. Analysis of 68 cases treated surgically with small craniotomy and placement of a closed drainage system]. / Hematoma subdural crónico sintomático. Análisis de 68 casos tratados quirúrgicamente con pequeña craneostomía y colocación de sistema de drenaje cerrado.

Sixty eight cases of chronic subdural hematoma (CSDH) surgically treated (December 1984-December 1988) with twist drill craniostomy (3-4 mm) and application of a closed drainage system (CDS) are reviewed. The patients were distributed in four groups depending on the density of the hematoma: hypodense (36 cases), isodense (6 cases), of mixed density (22 cases) and hyperdense (4 cases). In about one third of patients (25 cases) the duration of symptoms was shorter than one week, in 21 cases it was between one week and one month, and in 22 patients it was longer than one month. 77.95% of cases had a preceding head injury. Headache and motor deficits were the leading symptoms, being present in 43 (63.2%) and 42 (61.7%) cases, respectively. Twelve patients (17.6%) were comatose on admission. Twelve patients required reoperation. Six patients died (8.8%). The preoperative neurological status and associated systemic diseases influenced the outcome. We think that limited craniostomy with CDS is the therapy of choice for symptomatic CSDH.

Reappraisal of the intracranial pressure and cerebrospinal fluid dynamics in patients with the so-called "normal pressure hydrocephalus" syndrome.

Fifty-four shunt-responsive patients were selected from a prospective protocol directed to study patients with suspected normal pressure hydrocephalus (NPH). Patients with gait disturbances, dementia, non-responsive L-Dopa Parkinsonism, urinary or faecal incontinence and an Evans ratio greater or equal to 0.30 on the CT scan were included in the study. As a part of their work-up all patients underwent intracranial pressure monitoring and hydrodynamic studies using Marmarou's bolus test. According to mean intracranial pressure (ICP) and the percentage of high amplitude B-waves, patients were subdivided in the following categories: 1) Active hydrocephalus (mean ICP above 15 mmHg), which is in fact no tone normal pressure hydrocephalus; 2) Compensated unstable hydrocephalus, when mean ICP was below 15 mmHg and B-waves were present in more than 25% of the total recording time and 3) Compensated stable hydrocephalus when ICP was lower or equal to 15 mmHg and beta waves were present in less than 25% of the total recording time. The majority of the patients in this study (70%) presented continuous high or intermittently raised ICP (active or unstable compensated hydrocephalus group). Mean resistance to outflow of CSF (Rout) was 38.8 mm Hg/ml/min in active hydrocephalus and 23.5 mm Hg/ml/min in the compensated group (Students t-test, p less than 0.05). Higher resistance to outflow was found in patients with obliterated cortical sulci and obliterated Sylvian cisterns in the CT scan. No statistically significant correlation was found when plotting the percentage of beta waves against pressure volume index (PVI), compliance or Rout. An exponential correlation was found when plotting beta waves against the sum of conductance to outflow and compliance calculated by PVI method (r = 0.79). Patients with the so-called normal pressure hydrocephalus syndrome have different ICP and CSF dynamic profiles. Additional studies taking into consideration these differences are necessary before defining the sensitivity, specificity and predictive value of ICP monitoring and CSF studies in selecting appropriate candidates for shunting.

Intraspinal baclofen in the treatment of severe spasticity and spasms.

Ten patients with severe spasticity were evaluated according to a standardized protocol in order to be treated by intraspinal baclofen. Entry criteria in the protocol were the following: 1) Stable central nervous system lesion, 2) Severe spasticity and/or flexo-extensor spasms not controllable by oral treatment, 3) Normal CSF circulation and 4) Informed consent. All patients received a test dose of twenty-five micrograms of baclofen injected intrathecally. At intervals of at least one day, doses were increased in 10-25 microgram steps until total abolition of spontaneous spasms was achieved in complete spinal cord lesions. In patients with residual motor function, doses were titrated until the optimal dose was found that reduced spasms and enabled performance of maximum daily life activities according to the patient's neurological level. In nine patients a multidose reservoir was implanted to deliver intrathecal baclofen. Effective dosage was 60 +/- 31 micrograms in the entire group. Ashworth score was reduced from 4.6 +/- 0.7 to 1.2 +/- 0.4 (mean +/- SD) (p less than 0.0001) and spasms from 3.2 +/- 0.8 to 0.2 +/- 0.4 (p less than 0.0001). Follow-up of the nine patients in whom a reservoir was implanted has been 18 +/- 9 months. Initial dosage requirements and tolerance were significantly different in complete (Frankel's A grade) or incomplete lesions (Frankel's B, C and D grades). Complete spinal cord lesions required a greater initial dose (156 +/- 43) than incomplete lesions (44 +/- 24), these differences being statistically significant (Student's t-test, p less than 0.05). Tolerance was observed only in patients with complete motor and complete sensory lesions. In incomplete lesions, dose increase was insignificant.

[Spontaneous cerebellar hematoma. Analysis of 23 cases]. / Hematoma cerebelar espontâneo. Análise de 23 casos.

A series of 23 patients with spontaneous cerebellar hematoma is analysed retrospectively. Several degrees of consciousness impairment, and headache occurred in all; 12 patients presented motor deficits among the more important clinical signs. Arterial hypertension (69.5%) and diabetes (34%) stand out in the pathological background, and their association was frequent (30%). Computerized tomography (CT) disclosing severe ventricular dilatation (69.5%) associated or not with intraventricular presence of blood is considered as an unsatisfactory prognosis sign, and indicative for emergency therapy. Emergency external ventricular draining is the best indication for the majority of these cases. Posterior fossa craniectomy for emptying the hematoma may be the indication in severe cases. Death and morbidity in this pathology are high as yet. However, CT contribution for diagnosis is quicker and better than benefits obtained through other methods. Results observed in the present series are illustrative on this statement, when compared to data of other series diagnosed through other methods.

Hematoma cerebelar espontâneo: análise de 23 casos / Stontaneous cerebellar hematoma: analysis of 23 cases

Uma série de 23 pacientess com hematoma espontâneo de cerebelo é analisada retrospectivamente, mostrando que: todos apresentavam algum grau de diminuiçäo do nível de consciência e cefaléia; 12 apresentavam déficits motores dentre os sinais clínicos mais importantes. Dos antecedentes patológicos destacam-se hipertensäo arterial (69,5%) e diabetes (34%), havendo associaçäo de ambos em 30% dos casos. Dos aspectos da tomografia computadorizada (TC) mais relevantes a dilataçäo ventricular aguda, encontrada em 69,5% dos pacientes, associada ou näo a presença de sangue intraventricular, é considerada sinal de mau prognóstico, indicando por si só terapêutica de urgência, reservando a craniectomia da fossa posterior para esvaziamento do hematoma para casos específicos. A mortalidade e a morbilidade desta patología é alta; porém, pela TC o diagnóstico se tornou mais rápido e eficiente. Os pacientess desta série puderam beneficiar-se deste procedimento, como se verifica quando comparados a pacientess de outras séries, diagnosticadas por outros métodos

Clinical observations on sensory effects of trigeminal dorsal root section.

Further clinical and operative support is presented for Dandy's discovery in 1929 of the presence of accessory sensory fibres of the fifth cranial nerve, running a separate course from the main sensory root at its exit from the pons. The advantages are stressed of Dandy's subcerebellar approach in selected cases for sparing those fibres as well as the motor root.