[Endoscopic third ventriculostomy: risk factors for failure and evolution of ventricular size]. / Ventriculostomía endoscópica: influencia de factores predisponentes al fallo y evolución del tamaño ventricular.

INTRODUCTION: Endoscopic third ventriculostomy is the treatment of choice for non communicating hydrocephalus at our institution. Several factors have been associated with failure of endoscopic third ventriculostomy. The goals of the study have been to evaluate the outcome, the influence of factors theoretically prone to failure of ventriculostomy and the evolution of ventricular size. MATERIAL AND METHODS: Fifty-six patients (mean age 48.5 yrs) treated with an endoscopic third ventriculostomy during the period 1997-2002 were analysed retrospectively. Hydrocephalus was classified as acute (68%) and chronic forms. Etiology was classified in space-occupying lesions (59%), primary aqueductal stenosis (34%) and Chiari malformation (7%). The presence of the following factors theoretically prone to failure was considered: age below one year, history of mielomeningocele, cerebrospinal fluid (CSF) infection, intracranial haemorrhage, radiotherapy, craniotomy and previous treatment of hydrocephalus with a shunt. Ventricular size was measured linearly with four ventricular index pre- and postoperatively. RESULTS: The global success rate was 71.4% (mean follow-up 26 months). Endoscopic third ventriculostomy for hydrocephalus secondary to cerebral metastases obstructing CSF pathways was associated with a higher risk of failure (p=0.006). None of the risk factors considered was associated with a higher risk of failure. The evolution of the ventricular size measured with linear methods is associated with outcome. Evans ratio, third ventricle index, cella media index and ventricular score decreased in patients whose outcome is satisfactory and increased in those cases deemed clinical failures (p< 0.05). CONCLUSION: The risk of failure increases in patients with cerebral metastases close to CSF pathways, likely due to the concurrence of mechanisms other than obstruction. Changes in ventricular size are associated with outcome.

Management of intractable spasticity of supraspinal origin by chronic cervical intrathecal infusion of baclofen.

Today it is accepted that chronic infusion of baclofen produces significant relaxation and drastic reduction of spasms, amelioration of cramping pain and improvement of sphincter functions in spasticity of spinal cord origin. Based on these results our group had the opportunity of treating 11 cases with refractory spasticity and dystonic symptoms due to central damage caused by head injury in 8 cases and to cerebral palsy in 3 using cervical intrathecal infusion of baclofen. During the trial period with percutaneous intrathecal infusion of a daily bolus of 12.5-75 micrograms of baclofen through a reservoir, improvement of mentation and speech conditions, marked improvement of dystonic and abnormal movements of the upper limbs and trunk and a notable reduction of hypertonia were observed in all cases, which led to a better performance of motor activities in skilled acts and transfer. With these preliminary results in mind, in all cases the previous cervical subarachnoid catheter was attached to a programmable pump that infused a daily total dose varying from 100 to 190 micrograms of baclofen in a continuous or multistep complex mode. After a mean follow-up of 21 months previous results were long-lasting. Neither overdose side effects nor malfunction of the system were observed.

Arachnoid cysts as a cause of dementia in the elderly.

Arachnoid intracranial cysts are benign lesions which until recently have been considered to be quite uncommon. They are benign congenital lesions usually discovered at an early age. We have recently treated two patients with advanced age and arachnoid cysts, unusual due to their location and extent. Both of them presented clinically with an organic dementia syndrome with some similarities to that seen in normal pressure hydrocephalus. Both recovered fully after surgery. We review the literature and try to emphasize the clinical differences between arachnoid and the more rare neuroepithelial cysts.