[Olfactory groove meningiomas. Radical microsurgical treatment through the bifrontal approach]. / Meningiomas del surco olfatorio. Tratamiento microquirúrgico radical por via bifrontal.

OBJECTIVES: To describe the microsurgical technique for the radical removal of olfactory groove meningiomas through the bifrontal approach. To review the diagnostic elements to be taken into account in the selection of the surgical approach to these tumours. MATERIALS AND METHODS: A microsurgical series of 35 olfactory groove meningiomas operated on through a bifrontal craniotomy is reviewed. RESULTS: The mean tumoral volume was 85cc (4.4cm diameter). A relevant peritumoral brain edema was found in 65.7% of cases, hyperostosis in the implantation base in 80% and paranasal sinus invasion in 28.6%. A Sipmson grade 1 resection was achieved in every case. A patient died due to a postoperative pneumonia. Postoperative hospitalization time was between 3 and 20 days and at discharge all patients had a Glasgow Outcome Scale grade 4-5. The mean follow-up was 55.2 months. Two patients had postoperative transient rhinolicuorrhea and an additional patient developed hydrocephalus. An asymptomatic recurrence have been identified in a patient four years after surgery. CONCLUSIONS: In our experience the bifrontal approach allowed the radical removal of huge olfactory groove meningiomas. The microdissection of the anterior cerebral artery A2 segments is possible thanks to the arachnoidal plane between vessels and tumor. Tumoral blood flow is secured by the early approaching of the base of the tumor and preoperative embolization is not necessary. Bifrontal approach allows an aggressive treatment of the hyperostosis, bone infiltration and paranasal sinus invasion. Anterior fossa reconstruction is done using a vascularized periosteal flap.

[Trigonal cavernous angioma: case report]. / Angioma cavernoso del trígono ventricular. Caso clínico.

The authors report on an intraventricular cavernous angioma located at the right trigone in a 25-year-old male patient presented with a predominantly intralesional haemorrhage. Neuroimaging led to an accurate preoperative diagnosis although the typical low intensity perilesional ring of gliosis and hemosiderin was not present. The lesion was microsurgically removed using an stereotactically guided posterior temporal transsulcal approach.

[Facial nerve palsy due to cavernous angioma of the petrous bone. Case report]. / Parálisis facial por angioma cavernoso del peñasco. Caso clínico.

The facial nerve palsy due to extrinsic tumoral compression of the facial nerve at the geniculate ganglium is very rare. We present the case of a patient with a temporal bone cavernoma and symptoms of a torpid peripheral facial House-Brackmann grade IV nerve palsy with dry eye and loss of stapedial reflex. The routine computed tomographic and magnetic resonance imaging studies showed no abnormalities, but the same imaging techniques done after the clinical suspiction identified a less that 1cm lesion that was compatible with an osseous cavernous angioma. The lesion was approached and removed through a microsurgical middle fossa extradural approach with a good postoperative recovery (House-Brackmann grade II).

[Giant intracranial aneurysms]. / Aneurismas cerebrales gigantes.

AIM: Terminology, concept, pathology and phisiopathology, clinical presentation, imaging diagnosis and treatment of the giant intracranial aneurysms are reviewed. DEVELOPMENT: Saccular, fusiform, dissecting and serpentine giant aneurysms are discussed. Giant saccular aneurysms are developed from small regular congenital lesions growing far away of their critical rupture size due to the reinforcement of their wall. Fusiform and dissecting aneurysms are formed after a wide rupture of some of their wall layers and, therefore, both of them are considered to have some similarities. Finally, serpentine aneurysms are rare lesions and their growing mechanism is still under discussion. CONCLUSION: Any type of giant aneurysm represents a great deal for the neurosurgical management.

Cerebral solitary Langerhans cell histiocytosis: report of two cases and review of the literature.

Cerebral solitary Langerhans cell histiocytosis (LCH) is a very uncommon condition. We describe two new cases: a 30-year-old man with seizures and a tumour in the left frontal lobe, which was composed of a polymorphic infiltrate with a predominance of histiocytes and eosinophils; and a 65-year-old man with headaches and dysarthria, with a left parietal tumour, which showed a diffuse proliferation of histiocytic cells and areas of necrosis. In both cases, the histiocytes were strongly positive for S-100 and CD1a, and Birbeck's granules were demonstrated by electron microscopy in the first case. Both patients underwent a complete excision of their lesions. The second patient received additional postoperative radiotherapy. They were asymptomatic after 26 and 27 months, respectively. It seems that cerebral solitary LCH is a clinicopathological entity with a good outcome. Only 15 cases of this rare process have been previously reported in the English literature.

[Neurosurgical treatment of acoustic neuromas without indication for radiosurgery]. / Tratamiento neuroquirùrgico de los neurinomas del acùstico sin indicación de tratamiento con radiocirugía

The aim of this paper is to review the specific problems of the microsurgical management of the acoustic neuromas not suitable for radiosurgical treatment , that is measuring more than 8 cc in volume or 2.5 cm in maximum diameter in the cerebelopontine angle. A total of 18 lesions have been included with a mean volume of 27.4 cc, representing a lesion measuring 3.8 cm in its three main diameters. The mean follow-up has been 48.7 months. There has been no mortality. All lesions were completely excised without recurrences. The anatomic conservation of the facial nerve was achieved in the 66.7% of the cases but the functional recovery (House-Brackmann grades I-II) was reached only in the 27.8%, without any grade I case. As permanent deficit all patients had postoperative cophosis, two had trigeminal hyposthesia with corneal anesthesia and one had a cerebellar deficit. The main conclussion is that the microsurgical radical resection of large acoustic neuromas not suitable for radiosurgical treatment is followed by a high postoperative morbidity mainly related with the facial nerve lesion. Therefore, it seems rationale to design specific strategies directed to reduce and alleviate these permanent deficits.

[Retropleural paraspinal approach in the treatment of anterolateral thoracic spinal diseases]. / Vía paraespinal retropleural en el tratamiento de la patología anterolateral de la columna torácica.

The personal experience in the treatment of the spinal and paraspinal thoracic pathology using the paraspinal retropleural approach is presented. A total of 18 patients with neoplastic, traumatic and discal lesions were operated on. Improvement of neurological disturbances and pain was noted in all patients. The surgical technique for spinal cord and root decompression and also for anterior and/or posterior stabilization of the spine is described. The paraspinal retropleural approach is compared with the anterior transthoracic approach. The advantages of the paraspinal retropleural approach are: low rate of complications; allows a very wide decompression of the neurological elements as well as an anterior and/or posterior stabilization of the spine by a single approach; and it can be easily tailored for each lesion. These advantages are enhanced in the management of lesions located in the upper thoracic or thoracocervical levels.

[Assessment of the degree of resection of high grade supratentorial gliomas with early postoperative magnetic resonance]. / Valoración del grado de resección de los gliomas supratentoriales de alto grado con resonancia magnética postoperatoria precoz.

UNLABELLED: In this paper we report the results of a prospective study in which we evaluate the degree of tumor removal of 25 supratentorial high grade gliomas by means of an MRI performed in the early postoperative period. In all cases, there was preoperative enhancement 8 patients had been previously operated on while the others had their first operation. In all cases the postoperative early MRI was performed within the first week and in 15 within the first 3 days. In order to evaluate the degree of tumor removal the presence or not of enhancement was considered and if it existed, classified as linear or nodular. RESULTS: To avoid postsurgical artifacts it is important to perform the MRI as soon as possible after surgery, especially within the first 3 days. Generally, linear enhancement disappeared on subsequent follow-up examinations, showing that it probably does no represent residual, tumor while nodular enhancement usually does. Survival with the high-grade tumors was slightly higher in the group without postoperative enhancement or linear one than in the group with nodular enhancement but the difference was not significant.

[Post-discectomy cervical fusion. Clinico-radiological study comparing iliac crest bone graft, anterior cervical plate with bone graft and cage-plate GD]. / Fusión cervical postdiscectomía. Estudio clínico-radiológico comparando el injerto óseo de cresta iliaca, placa cervical anterior con injerto óseo y placa-caja GD.

OBJECTIVE: To compare clinical and radiologically three methods of cervical arthrodesis after anterolateral one-level discectomy for non-traumatic disk disease. MATERIALS AND METHODS: Three groups of patients were studied retrospectively. In group 1 (20 patients) a tricortical autologous iliac crest bone interbody graft was used. In group 2 (10 patients) the bone graft was associated to an anterior cervical plate (Stryker). In group 3 (10 patients) a cage-plate filled with iliac crest trabecular bone was implanted (plate-cage GD). Clinical and radiological parameters were recorded preoperatively and 6-9 months postoperatively. RESULTS: There was a significant clinical improvement in all three groups, with similar complications and hospitalization time. There were not hard-ware failures. There was a significant increase in the disc height in group 3 when compared with group 1 and a significant correction of the preoperative kyphosis in group 3 in relation to both group 1 and 2: There was a significant increase in postoperative radiological stability rate and also in the operative time in groups 2 and 3 when compared with group 1. CONCLUSIONS: Cervical arthrodesis after discectomy is an useful method for treatment of cervicobrachialgia. Arthrodesis with internal fixation achieves best clinical and radiological results and it has some other advantages in relation to bone graft artrhodesis. GD cage-plate minimizes the surgical and clinical problems associated with use of bone graft and cervical plate and reaches the best radiological performances.

Microsurgical management of cerebral aneurysms based in CT angiography with three-dimensional reconstruction (3D-CTA) and without preoperative cerebral angiography.

OBJECTIVE: To study the possibilities of the microsurgical management of ruptured intracranial aneurysms with the sole preoperative information provided by computed tomography angiography with three-dimensional reconstruction (3D-CTA). METHODS: Patients were studied with 3D-CTA after diagnosis of subarachnoid hemorrhage. If the study had an adequate quality and revealed an aneurysm congruent with the clinical findings or neurological examination and/or with the location of the bleeding on computed tomography (CT) scan an early microsurgical clipping of the lesion was done. When the quality of the 3D-CTA study was not adequate or the quality being adequate displayed no lesions or the findings were not accurate enough to warrant direct microsurgical treatment, the patient was studied with cerebral digital subtraction (DS) angiography. A total of 44 consecutive patients harbouring a total of 47 intracranial aneurysms diagnosed by 3D-CTA and without preoperative DS angiography were submitted to microsurgical clipping and included in the study. RESULTS: The overall mortality was 15.9% and the favourable results evaluated 6 months after discharge by means of the Glasgow Outcome Scale reached 70.4%. All lesions were successfully clipped. Surgery was done a mean of 4.1 days after the admission bleeding. A total of four microlesions undiagnosed by 3D-CTA were found at surgery and clipped. Postoperative DS angiography and necropsy findings were also used as control of the 3D-CTA findings but no additional information was provided excepting the finding in DS angiography of an asymptomatic intracavernous aneurysm. Therefore the sensitivity of the 3D-CTA for diagnosis of symptomatic aneurysms was 100% and the overall sensitivity 90.4%. CONCLUSIONS: We have reached similar results in patients operated on with or without preoperative angiography. 3D-CTA provides very valuable anatomical information, which has an additional value in the microsurgical treatment of aneurysms of the anterior communicating artery complex. Finally, selected cases of ruptured intracranial aneurysms can be successfully managed with the preoperative information provided by 3D-CTA and without DS angiography.

Surgical treatment of multiple neurofibromas of the ulnar nerve in segmental neurofibromatosis. Case report.

The case of an 18-year-old man with numerous neurofibromas along his left ulnar nerve is described. The patient had a painful mass in the medial third of the internal aspect of his left forearm, and two additional symptomatic painful masses were identified during clinical examination: one in the distal portion of the retroepitroclear groove and another near the Guyon tunnel in the wrist. The main symptom was neurogenic pain; however, sensory and motor disturbances were also present. No other stigma of neurofibromatosis (NF) was found, and no cases of NF were known in the patient's family. During surgery many neurofibromas were found; the three painful neurofibromas and some of the other larger lesions were microsurgically excised. The patient's symptoms fit the criteria for segmental NF or NF5. This is a very rare form of NF characterized by lesions located in a particular area of the body.