Revisión Estado actual de la cirugía de la epilepsia en España. Compendio y conciencia / Current status of epilepsy surgery in Spain. Compendium and awareness

INTRODUCCIÓN: La epilepsia refractaria al tratamiento médico afecta a entre un tercio y una cuarta parte de los pacientes con epilepsia. Dentro de este grupo, con peor calidad de vida y altos costes sanitarios, existe una considerable proporción de pacientes con causas de epilepsia potencialmente quirúrgicas, y la cirugía de la epilepsia es una opción terapéutica comprobada. En España no sabemos el número real de pacientes que llegan a tratarse en relación con el total de los casos con epilepsia refractaria que podrían beneficiarse del tratamiento quirúrgico. OBJETIVO: Analizar el número de cirugías de epilepsia realizadas y publicadas en relación con los potenciales casos de epilepsia refractaria candidatos a cirugía en nuestro país. MÉTODO: Se realizó una revisión mediante la búsqueda bibliográfica en PubMed y Cochrane de artículos publicados entre 1990 y 2020, combinando las siguientes palabras y operadores booleanos: epilepsy surgery IN Spain’. Se clasificaron las evidencias y recomendaciones según los criterios pronósticos del Oxford Center for Evidence Based Medicine (2001) y de la European Federation of Neurological Societies (2004) para actuaciones terapéuticas. RESULTADOS: El 75,6% de las publicaciones se originó en las comunidades autónomas de Madrid y Cataluña. El 46,4% de los artículos publicados son de series cortas. Contabilizamos 2.113 intervenciones quirúrgicas (resecciones, cirugías paliativas, implantación de electrodos profundos e implantación de neuroestimuladores), lo que representa el 8,7% de la población estimada con epilepsia refractaria. CONCLUSIÓN: La cirugía de la epilepsia en nuestro medio es una indicación terapéutica infrautilizada y que no se ofrece o no se administra a la mayoría de los potenciales beneficiarios

INTRODUCTION: Drug-resistant epilepsy affects between a third and a quarter of patients with epilepsy. Within this group, with a poorer quality of life and high healthcare costs, there is a considerable proportion of patients with potentially surgical causes of epilepsy, and epilepsy surgery is a proven therapeutic option. In Spain, we do not know the actual number of patients who are treated in relation to the total number of cases of refractory epilepsy that could benefit from surgical treatment. AIM: To analyse the number of epilepsy surgical interventions performed and published in relation to the potential cases of refractory epilepsy who are candidates for surgery in our country. METHOD: A review was carried out through a literature search in PubMed and Cochrane of articles published between 1990 and 2020, combining the following words and Boolean operators: epilepsy surgery IN Spain’. The evidence and recommendations were classified according to the prognostic criteria of the Oxford Centre for Evidence Based Medicine (2001) and of Neurological Societies (2004) for therapeutic actions. RESULTS: The majority (75.6%) of the publications came from the autonomous communities of Madrid and Catalonia and 46.4% of the articles published were short series. We counted 2,113 surgical interventions (resections, palliative interventions, implantation of deep electrodes and implantation of neurostimulators), which represents 8.7% of the estimated population with refractory epilepsy. CONCLUSION. Epilepsy surgery in our country is an underused therapeutic indication that is not offered or administered to the majority of potential beneficiaries

Meningioma Associated with Brain Aneurysm: Report of Two Cases.

The occurrence of brain tumors together with aneurysms has been considered as an uncommon phenomenon. However, its incidence may be underestimated. This coexistence is a diagnostic challenge, but also a therapeutic one as no consensus has been reached. We report two cases of a 71 and 67 years old patient with a meningioma and aneurysm: one noticed and treated before with good outcome and the other without treatment before surgery with fatal outcome. The different outcome of these patients shows the importance of vascular study in surgical planning. Treatments options are changing and although some authors think the pathology that causes symptoms should be treated first, endovascular treatment of the aneurysm is a safe option to prevent aneurysm rupture during surgery.

Analysis of endovascular treatment of ruptured microaneurysms compared with ruptured larger aneurysms.

OBJECTIVE: To retrospectively analyze the complications and outcome of the endovascular treatment of ruptured microaneurysms compared with the treatment of ruptured larger aneurysms. METHODS: 40 ruptured cerebral microaneurysms treated by endovascular techniques were selected retrospectively and compared with 207 larger ruptured cerebral aneurysms treated by endovascular techniques during the same time period. Medical charts and imaging studies were reviewed to analyze baseline clinical and epidemiologic characteristics, procedural complications, and clinical outcomes RESULTS: Cerebral microaneurysms had a higher incidence of intraoperative technical ruptures (13.5% vs 2.9%, p<0.005). The number of thromboembolic complications was not increased. Patient prognosis was similar for the two groups (mean modified Rankin Scale score 1.81 vs 2.09, p>0.1). CONCLUSIONS: Coiling of cerebral microaneurysms has a reasonable safety profile with good clinical outcomes, similar to coiling of larger aneurysms. In our experience, the systematic use of remodeling balloons, operator experience, and the ability to manage complications are the reasons for the satisfactory results.

Anatomical results, rebleeding and factors that affect the degree of occlusion in ruptured cerebral aneurysms after endovascular therapy.

OBJECT: To present a series of ruptured cerebral aneurysms in consecutive non-selected patients treated with endovascular therapy, analyzing the initial degree of occlusion, its anatomical evolution mid-term and the variables that could statistically affect them. METHODS: 251 aneurysms were first treated with coiling (embolization). 203 patients were followed up with conventional angiography for 6-8 months after the initial treatment and 182 were followed up with three-dimensional time of flight MR angiography at 18-24 months. Postoperative and mid-term anatomical results were evaluated anonymously and independently using the modified Montreal Scale. RESULTS: The initial rate of complete occlusion was 70.9%, with rates of neck remnants and aneurysm remants of 18.3% and 10.7%, respectively. The recurrence rate was 13% after 6 months and 2% between 6 months and 2 years. The rate of retreatment was 11%. Statistically, the variables that were found to be related to the initial degree of occlusion were the use of a remodeling balloon technique (p=0.012), the size of the aneurysm neck (p=0.044) and the size of the aneurysm (p=0.004). The recanalization rate at mid-term depended on the size of the aneurysm. Although aneurysms with partial occlusion initially tended to evolve to a worse degree of closure than those with complete occlusion initially, the relationship was not statistically significant (p=0.110). CONCLUSIONS: Embolized aneurysms can develop a worse degree of closure even when the initial occlusion is complete. The degree of occlusion depends directly on morphological factors and the use of balloon-assisted techniques. The recanalization rate at mid-term depends on the size of the aneurysm and probably on the density of the packing achieved with the initial treatment.

Aneurisma cerebral roto tipo «blíster» / Ruptured cerebral artery blister aneurysm

Se presenta el caso clínico de un paciente joven con una hemorragia subaracnoidea bien tolerada clínicamente secundaria a la rotura de un aneurisma carotídeo tipo «blíster». Teniendo en cuenta que estos aneurismas son poco frecuentes, tienen paredes muy frágiles y sin un cuello definido, su tratamiento es controvertido. Inicialmente se planteó el abordaje endovascular mediante la implantación de una endoprótesis semicubierta redireccionadora de flujo, pero la evolución morfológica del aneurisma a los 10 días condicionó un cambio en el plan terapéutico. Finalmente se implantó una endoprótesis convencional cubriendo el cuello y se introdujeron 2 microcoils en el punto de rotura, con buen resultado morfológico. El paciente evolucionó de manera satisfactoria. En el seguimiento después de uno y 6 meses se demostró la estabilidad del tratamiento. Se realiza una breve introducción a esta patología y una pequeña discusión sobre las distintas opciones terapéuticas (AU)

We report the case of a young patient with subarachnoid haemorrhage secondary to a ruptured blister-like aneurysm. Since this kind of aneurysms have fragile walls without a well-defined neck, their treatment is difficult. We initially planned the deployment of a flow-diverter stent, but an angiogram obtained after 10 days revealed a morphological change of the aneurysm. Therefore, we finally deployed a conventional stent and introduced 2 micro coils into the point of rupture, obtaining a good morphological result without rebleeding. Follow-up at 1 and 6 months did not observe regrowth of the aneurysm. We offer a brief introduction and discussion of this pathology and its treatment (AU)

[Ruptured cerebral artery blister aneurysm]. / Aneurisma cerebral roto tipo «blíster¼

We report the case of a young patient with subarachnoid haemorrhage secondary to a ruptured blister-like aneurysm. Since this kind of aneurysms have fragile walls without a well-defined neck, their treatment is difficult. We initially planned the deployment of a flow-diverter stent, but an angiogram obtained after 10 days revealed a morphological change of the aneurysm. Therefore, we finally deployed a conventional stent and introduced 2 micro coils into the point of rupture, obtaining a good morphological result without rebleeding. Follow-up at 1 and 6 months did not observe regrowth of the aneurysm. We offer a brief introduction and discussion of this pathology and its treatment.

Bases patogénicas de la epileptogénesis en los cavernomas cerebrales / Pathogenetic bases of epileptogenesis in cerebral cavernomas

Introducción. Los cavernomas cerebrales son un tipo de malformación arteriovenosa que cursa clínicamente con crisis epilépticas, déficits neurológicos focales y hemorragias intraparenquimatosas. Se cree que las situaciones de hipoxia, neovascularización y algunas endoproteasas están implicadas en la fisiopatología de las crisis. Nuestro estudio pretende valorar esta posible relación, analizando con métodos inmunohistoquímicos la presencia de la subunidad 1α del factor inducible por hipoxia (HIF-1α) y la metaloproteasa de matriz 9 (MMP-9). Pacientes y métodos. Se seleccionaron 17 muestras consecutivas con diagnóstico anatomopatológico de cavernoma en un período de nueve años sobre las que se realizó una tinción inmunohistoquímica para HIF-1α y MMP-9, valorando la relación con las crisis epilépticas según el grado de captación del anticuerpo de los diferentes tejidos encontrados alrededor de las muestras de cavernoma. Resultados. En aquellos pacientes que presentaron crisis, se observó tinción inmunohistoquímica para HIF-1α en el 31% de las muestras en el endotelio vascular, el 17% en el tejido fibroso y el 34% en el tejido inflamatorio. También se observó tinción positiva para MMP-9 en el 86% del endotelio vascular, el 100% del tejido fibroso y el 43% del tejido cerebral. Analizando la muestra, se observa una tendencia positiva en presencia de crisis epilépticas en los pacientes que muestran la presencia de HIF-1α y MMP-9 en el endotelio vascular, tejido fibroso y tejido cerebral, no siendo así para el tejido inflamatorio. Conclusión. La expresión de HIF-1α y MMP-9, evaluada por métodos inmunohistoquímicos, se relaciona positivamente con la presencia de complicaciones de tipo epiléptico (AU)

Introduction. Brain cavernoma are a type of arteriovenous malformation that clinically presenting seizures, neurological deficit or bleeding. Hypoxia, neoangiogenesis and metalloproteasas seems to be involved in seizures physiopathology. Our study aims to assess this potential relation by immunohistochemical methods, analyzing hypoxia inducible factor (HIF-1alpha) and metalloproteasa (MMP-9) in tissue surrounding cavernoma. Patients and methods. We selected 17 consecutive cases anatomopathologically diagnosed as cavernoma during 9 years. Immunohistochemical staining was performed for HIF-1alpha and MMP-9. We evaluated the relation between seizures and the scale of uptake of different tissues surrounding cavernoma. Results. Cases with seizures had HIF-1alpha positive uptake in vascular endothelium in 31%, 17% in fibrous tissue and 34% in inflammatory tissue. Besides, it also shows MMP-9 positive uptake in vascular endothelium in 86%, 100% in fibrous tissue and 43% of brain tissue. Statistical analysis by chi-square and odds ratio shows a positive trend towards seizures and the presence of HIF-1alpha and MMP-9 in vascular tissue, fibrous tissue and brain tissue, but no for inflammatory tissue. Conclusion. HIF-1alpha and MMP-9, valued by immunohistochemical methods, are related to complications as seizures (AU)

"Posterior fossa lesion 45 years after ocular trauma".

We describe a patient who developed an isolated brain metastasis four years after his right eye was treated for conjunctival melanoma by excision and local chemotherapy. He had a history of ipsilateral ocular trauma by coal stuff while working in a mining industry. Conjunctival melanoma represents only 1.6% of all non-cutaneous melanoma. Metastasis of this kind of neoplasm to brain is a rare event, especially without evidence of prior or concurrent regional lymph node involvement.

Neural surfaces coverage with "collagen films and cigarettes": A revisited and modified method of protection and retraction during microsurgical approaches to craniospinal lesions.

OBJECTIVE: Despite the surgical cotton patties application and meticulous manipulation, mechanical contact between the different microsurgical instruments and neurovascular structures may jeopardize its integrity through laceration or cerebrospinal perfusion. We present a technique based on using collagen films and cigarettes, both to protect and retract such structures, and compared it with the cottonoid technique. MATERIALS AND METHODS: During the last 3 years, collagen in "film and cigarette format" has been used in several microsurgical procedures for the treatment of craniospinal lesions by the first author. The collagen films were broken into pieces and adapted to the exposed neural surface measurements to protect and/or retract during microsurgical dissection. At the same time, handmade collagen "cigarettes" were used as retractors to keep open the neural lips of the transsulcal and transfissural corridors. To investigate the relevance of this technique for minimizing surgical morbidity, a blind third-party observer quantified the tissue preservation by a postoperative magnetic resonance imaging (MRI) protocol, in a short series with randomized cotton patty vs. collagen film protection. RESULTS: Only two of the 20 examined "collagen group" cases exhibited areas of additional abnormal signal, as against 16 cases of the "cotton patty group." Furthermore, a statistically significant difference between both the groups based on the radiological results was also demonstrated. CONCLUSION: The results of the present series support the usefulness of the neurovascular coverage and retraction with collagen films and cigarettes, respectively. It seems to be a good alternative to surgical cotton patties and other materials owing to its hemostatic, protection, retraction, and dissection capacity.

72 year-old man with new seizure while dancing.

Metastasis of an extracranial malignant neoplasm to a meningioma is a rare event.We report a case of a 72-year-old man who presented abruptly with a grand mal seizure. Neuroradiological examination revealed an extraaxial lesion located in the posterior right frontal convexity with poorly defined boundaries. Histological and immunohistochemical examination showed that the lesion was a meningothelial meningioma harboring metastatic renal cell carcinoma.The MRI could be indicative but not specific of this type of lesion.Some cases of intracranial meningiomas containing metastatic carcinomas have been published, but to our knowledge only five cases of renal cell carcinoma metastasizing to a meningioma have been reported. Possible explanations for this type of "tumor in tumor" lesion are reviewed.