[Intracranial hemorrhage due to aneurysms and arteriovenous malformations during pregnancy and puerperium]. / Hemorragia intracraneal por aneurismas y malformaciones arteriovenosas duranteel embarazo y el puerperio.

INTRODUCTION: Subarachnoid hemorrhage for aneurysms and arteriovenous malformations is most frequent during pregnancy and puerperium. We analyzed behavior and management of this patients and the effect on it of our Maternal Health Program. PATIENTS AND METHODS: There were 437 pregnancy and 717 puerperal complicated patients between january 1996 to december 2005, 41 maternal deaths of all causes and 14 indirect maternal deaths. There were operated on 454 patients with intracranial aneurysms and arteriovenous malformations in this period. Pregnant patients and fetus were evaluated to select mode of delivery. A specialized medical team managed precociously these patients. Vascular lesions were clipped by microsurgical methods. Anesthetic management considered pregnancy and fetal complexities. We did not use endovascular methods. Postoperative management was performed on intensive care unit. RESULTS: There were eight pregnant and puerperal patients with subarachnoid hemorrhage due to aneurysms and arteriovenous malformations. 2% of all patients were operated on by this cause. Six harboured intracranial aneurysms and two arteriovenous malformations. We performed seven surgical procedures, five for aneurysms and two for malformations. There was a delivery rate of 2.1 and seven normal newborn. Four patients achieved a complete neurological recovery, two a partial recovery and there were two deceased. This cause constituted 14% of all indirect maternal deaths. CONCLUSION: A precocious clinical diagnosis, neuroimaging studies and interdisciplinary management that involve intensive therapy, obstetric attention and neurovascular surgical treatment determined an increment in the diagnosis of these lesions that require opportune microsurgical or endovascular treatment to prevent maternal death and fetal damage.

Hemorragia intracraneal por aneurismas y malformaciones arteriovenosas durante el embarazo y el puerperio / Intracranial hemorrhage due to aneurysms and arteriovenous malformations during pregnancy and puerperium

Introducción. La hemorragia subaracnoidea por aneurismas y malformaciones arteriovenosas es másfrecuente en gestantes y puérperas. Analizamos el comportamientode estas pacientes, su manejo y el efectosobre ellas de nuestro Programa Nacional Materno Infantil.Pacientes y métodos. Hubo 437 gestantes y 717 puérperas complicadas en el periodo de enero de 1996 a diciembre del 2005, 41 muertes maternas por todas las causas y 14 defunciones maternas indirectas.Fueron intervenidos 454 pacientes con aneurismas intracraneales y malformaciones arteriovenosas intracraneales. El obstetra evaluó las pacientes complicadas y el feto, para decidir la forma del parto. Las pacientes fueron manejadas precozmente por un colectivo médico interdisciplinario. Las lesiones vasculares fueron clipadaspor métodos microneuroquirúrgicos. El manejo anestésico consideró los problemas inherentes a la gestacióny al feto. No utilizamos métodos endovasculares. El seguimiento postoperatorio fue en la sala de TerapiaIntensiva. Resultados. Hubo un total de ocho pacientes, entre gestantes y puérperas con hemorragia ubaracnoideapor aneurismas o malformaciones arteriovenosas intracraneales.Seis tenían aneurismas intracraneales ydos malformaciones arteriovenosas. Realizamos siete intervenciones quirúrgicas, cinco en aneurismas y dosen malformaciones. Cuatro pacientes lograron una recuperación neurológica completa, dos una recuperación parcial y hubo dos fallecidas. Esta enfermedad constituyó el 14 por ciento de todas las causas de muertes maternas indirectas.Conclusión. Un mejor diagnóstico clínico, los estudios por imágenes y el manejo interdisciplinario precoz que vincula la terapia intensiva, la atención obstétricay los servicios de neurocirugía vascular determinan un incremento en el diagnóstico de estas lesiones que requieren un tratamiento microneuroquirúrgico o endovascular rápido y oportuno para evitar la muertematerna y el grave daño del feto(AU)

Introduction. Subarachnoid hemorrhage for aneurysms and arteriovenous malformations is most frequentduring pregnancy and puerperium. We analyzed behavior and management of this patients and the effect on it of our Maternal Health Program. Patients and methods. There were 437 pregnancyand 717 puerperal complicated patients between january 1996 to december 2005, 41 maternal deaths of allcauses and 14 indirect maternal deaths. There were operated on 454 patients with intracranial aneurysmsand arteriovenous malformations in this period. Pregnant patients and fetus were evaluated to select modeof delivery. A specialized medical team managed precociously these patients. Vascular lesions were clipped bymicrosurgical methods. Anesthetic management considered pregnancy and fetal complexities. We did not use endovascular methods. Postoperative management was performed on intensive care unit. Results. There were eight pregnant and puerperal patients with subarachnoid hemorrhage due to aneurysms and arteriovenous malformations 2 percent of allpatients were operated on by this cause. Six harboured intracranial aneurysms and two arteriovenous malformations.We performed seven surgical rocedures, five for aneurysms and two for malformations. There was a delivery rate of 2.1 and seven normal newborn. Four patients achieved a complete neurological recovery, twoa partial recovery and there were two deceaseds. This cause constituted 14 percent of all indirect maternal deaths.Conclusion. A precocious clinical diagnosis, neuroimaging studies and interdisciplinary management that involve intensive therapy, obstetric attention and neurovascular surgical treatment determined an increment in the diagnosis of these lesions that require opportune microsurgical or endovascular treatment toprevent maternal death and fetal damage(AU)

[Ophthalmic artery aneurysms]. / Aneurismas de la región de la arteria oftálmica.

INTRODUCTION: Ophthalmic artery aneurysms are infrequent lesions and they have very specific particularities. OBJECTIVE: to present the anatomoclinical and surgical characteristic of our patients with ophthalmic aneurysms and to analyze our surgical results. PATIENT AND METHODS: 604 patients with intracranial aneurysms were operated on between January 1982 and December 2004. There were 50 patients with ophthalmic artery aneurysms. Average age was 52 years, 80% were women, 60% harbored multiple aneurysms and 20% were giant lesions. 12% had bilateral ophthalmic aneurysms. 20% of ophthalmic aneurysms were incidental. 50% had ophthalmological manifestations; however, this presentation occurred in 100% of the patients with large and giant aneurysms. Initially, 12% of ophthalmologic disorders were missed. We utilized unilateral or bilateral pterional approach associated to others in multiple aneurysms. We performed retrograde decompression- suction technique modified for large and giant aneurysms. RESULTS. Thirty patients (60%) obtained a complete recovery, fourteen patients (28%) an incomplete recovery and two were seriously disabled. There were not patients in vegetative state. There were four deaths (8%). 50% of postoperatory deficits disappeared and 64% of ophthalmologic disorders improved three months later. CONCLUSION: Microsurgical method allowed to treat unique, multiple, bilateral, large and giant ophthalmic aneurysms with good recovery of neurological and visual deficits.

Aneurismas de la región de la arteria oftálmica / Ophthalmic artery aneurysms

Introducción. Los aneurismas de la arteria oftálmica son lesiones poco frecuentes y con particularidades específicas. Objetivo. Presentar las características anatomoclínicas, quirúrgicas y los resultados del tratamiento microquirúrgico de nuestros pacientes con aneurismas de esta región. Pacientes y métodos. 604 pacientes con aneurismas intracraneales fueron llevados al quirófano entre enero de 1982 y diciembre del 2004. Hubo 50 pacientes con aneurismas de la región de la arteria oftálmica. El promedio de edad fue de 52 años, el 80 porciento fueron mujeres, el 60 porciento presentaban aneurismas múltiples y un 20 porciento gigantes. El 12 porciento poseían lesiones aneurismáticas bilaterales. El 20 porciento de los aneurismas fueron incidentales. El 50 porciento tenían manifestaciones oftalmológicas y la frecuencia se elevó al 100 porciento en los aneurismas grandes y gigantes. El 16 porciento de los trastornos visuales fueron ignorados o confundidos inicialmente. En aneurismas múltiples empleamos la ruta pterional uni o bilateral asociada a otros abordajes. En los aneurismas oftálmicos grandes o gigantes utilizamos la técnica de descompresión-succión retrógrada modificada. Resultados. Treinta pacientes (60 porciento) obtuvieron una recuperación completa, catorce pacientes (28 porciento) una recuperación incompleta y dos incapacidad grave. No hubo pacientes en estado vegetativo. Hubo cuatro fallecidos (8 porciento). El 50 porciento de los déficit postoperatorios desaparecieron y el 64 porciento de los trastornos visuales mejoraron a los tres meses. Conclusión. El método microquirúrgico permitió tratar aneurismas de la región de la arteria oftálmica únicos, múltiples, bilaterales, grandes y gigantes con buena recuperación de los déficit neurológicos y de los trastornos visuales(AU)

Introduction. Ophthalmic artery aneurysms are infrequent lesions and they have very specific particularities. Objective. to present the anatomoclinical and surgical characteristic of our patients with ophthalmic aneurysms and to analyze our surgical results. Patient and methods. 604 patients with intracranial aneurysms were operated on between January 1982 and December 2004. There were 50 patients with ophthalmic artery aneurysms. Average age was 52 years, 80 percent were women, 60 percent harbored multiple aneurysms and 20 percent were giant lesions. 12 percent had bilateral ophthalmic aneurysms. 20 percent of ophthalmic aneurysms were incidental. 50 percent had ophthalmological manifestations; howewer, this presentation occurred in 100 percent of the patients withlarge and giant aneurysms. Initially, 12 percent of ophthalmologic disorders were missed. We utilized unilateral or bilateral pterional approach associated to others in multiple aneurysms. We performed retrograde decompression-suction technique modified for large and giantaneurysms. Results. Thirty patients (60 percent) obtained a complete recovery, fourteen patients (28 percent) an incomplete recovery and two were seriously disabled. There were not patients in vegetative state. There were four deaths (8 ). 50 percent of postoperatory deficits disappeared and 64 percent of ophthalmologic disorders improved three months later. Conclusion. Microsurgical method allowed to treat unique, multiple, bilateral, large and giant ophthalmicaneurysms with good recovery of neurological and visual deficits(AU)

[The interview with the relatives of the neurosurgical patient]. / La entrevista con los familiares del paciente neuroquirúrgico.

INTRODUCTION: Information of diagnosis, therapeutic managements and inabilities are a very difficult task for neurosurgeons and very important for relatives. The interview is the best instrument that the neurosurgeon has to inform integrally; but many young physicians are not well prepared to deal with medical information and the educational work to achieve it still is insufficient. OBJECTIVE: To provide some general, organized and practical experiences on how to develop the interview with the relatives of the neurosurgical patient. DEVELOPMENT: The importance of the interview demands of: a) knowledge of the patient's data, b) reaching a specific diagnosis and appropriate therapy, c) accurate selection of the participants in the interview and d) specify when and where we will met the relatives. Most families prefer a physician that maintains an attitude of trust and sincerity and expresses clearly and slowly his thought. The explanations should be direct and simple. Repeated interviews can be concerted and we will perform a similar interview in emergent cases. CONCLUSIONS: The interview should be carried out as soon as possible and as soon as results of the medical investigations were available. The pessimism should be avoided and support will be given, without losing the contact with the reality. Information, which is sacrificed frequently in the art of the Medicine to give more importance to the science, indeed germinates much of the criticism to neurosurgeons and neurosurgical centers in the last two or three decades. We should not conform with the signature of an elementary and insufficient informed consent.

[Surgical treatment of múltiple intracraneal aneurysms]. / Tratamiento quirúrgico de los anurismas intracraneales múltiples.

INTRODUCTION: Surgical treatment of multiple intracranial aneurysms is always a complex task. OBJECTIVE: To analyze aneurysms characteristics, therapeutic possibilities and surgical outcomes in a series of patients with multiple intracranial aneurysms. PATIENTS AND METHOD: Among 514 patients with intracranial aneurysms, there were 113 with multiple aneurysms (21.5%) and 256 sacs: 244 located at the carotid system and 12 in the vertebrobasilar system. Patients were classified in three groups according to Orz criteria. Surgical treatment was performed in one or two stage operations. Patients were at I or II Grades of the World Federation Scale. The Glasgow Outcome Scale was used for evaluating surgical results. RESULTS: Patients sacs rate was 2.3. The location of aneurysms was high in the posterior communicating artery and very low at the middle cerebral artery. 100% of the lesions in Orz group 1, 82% in group 2 and 33% in group 3 were operated on in one stage operation. Postoperative follow-up showed that 79 % of the patients made a completely recovery. Mortality rate was 4.4%. CONCLUSIONS: Results were determined by the peculiar characteristics of this series, good preoperative condition and high proportion of one-stage operations.

[Distal anterior cerebral artery aneurysms surgery]. / Cirugía de los aneurismas de la arteria cerebral anterior distal.

INTRODUCTION: Distal anterior cerebral artery is the portion of the anterior cerebral artery located distal to the anterior communicating artery. Aneurysms of that territory represent 0.35 - 4.5% of all intracranial aneurysms. MATERIAL AND METHODS: 524 patients with intracranial aneurysms were operated on between January 1981 and April 2002. We treated 20 patients with distal anterior cerebral artery aneurysms. They were classified as infracallosa, located at the genu of the corpus callosum and supracallosal. Specialized anesthetic methods, Sugita head holder, and microsurgical techniques were utilized. Approaches were modified regarding aneurysm localization and multiplicity. Patients were evaluated six months after surgery. Glasgow Outcome Scale was applied. RESULTS: Thirteen patients (65%) were between 31 and 45 years of age. All were operated on at Grade I or II of the World Federation Neurological Surgeon Scale. There were multiple aneurysms in 35% of the cases. All of the aneurysms were 11 mm long or less in diameter. The segment of the distal anterior cerebral artery next to the genu of the corpus callosum was the most commonly involved (65%). 16 (80%) patients made a complete postoperative recovery of. There were not deaths. CONCLUSION: Distal anterior, cerebral artery aneurysms were not frequent and they needed special management. Their high tendency to multiplicity and early bleeding were two main characteristics. As they are midline located, they permit to perform small size craniotomy. Cerebral retractors were avoided to reduce postoperative morbidity.

[Giant supratentorial intracranial aneurysms. Analysis of 22 cases]. / Aneurismas intracraneales supratentoriales gigantes. Análisis de 22 casos.

INTRODUCTION: Giant intracranial aneurysms represent 2 to 5% of all aneurysms. They are well characterized from the anatomical and clinical point of view. Their natural history shows its potential lethality. Surgical treatment of giant aneurysms is a challenge for neurosurgeons. MATERIAL AND METHODS: Twenty-two patients were operated on through pterional craniotomy, specialized neuroanesthesia and microneurosurgical technics. Auxiliary methods like transitory clipping and retrograde decompression-suction technique were applied. Patients were followed at intensive care units and they were evaluated three months after the operation. Nineteen patients were in the fourth and sixth decade of life. Seventeen were females. Aneurysms were located at middle cerebral artery bifurcation; paraclinoidal carotid artery; proximal anterior cerebral artery and carotid bifurcation. Ninety one percent of aneurysms were clipped. Retrograde decompression-suction technique was performed in thirteen cases. RESULTS: Seventeen patients had good outcome and one patient died (4.5%). There were 6 postoperative complications and in four disappeared three months later. CONCLUSIONS: Giant aneurysms were operated on following main neurosurgical rules helped by auxiliar procedures to reduce aneurysms size and wall, aneurysms tension. New knowledge about giants aneurysms and the development of new techniques will permit better results.

[Familial intracranial aneurysms in Camagüey]. / Aneurismas intracraneales familiares en Camagüey.

INTRODUCTION: Genetic etiology in suggested in intracranial aneurysms. Such hypothesis is supported on familial aggregation, ocurrence in identical twins or associated to genetic diseases like adult polycystic renal disease. OBJECTIVE: To identify biological features in familial aneurysms different to sporadic ones. PATIENTS AND METHODS: Camag ey province is one of the most ancient in Cuba. Motionless population at the beginning had its sources in Spanish and African people. It has 800,000 inhabitants. 497 patients with intracranial aneurysms were operated at Manuel Ascunce Domenech Hospital between January 1982 and August 2001. We identified 15 families with intracranial aneurysms. RESULTS: 31 patients were operated on of 42 intracranial sacs at the carotid territory. There were 34% of multiplicity ant three mirror aneurysms. Three patients (9.7 %) have adult polycystic renal disease. 87 % of patients present aneurysms rupture and mortality was 32 %. This last figure was related to poor admission clinical grade. CONCLUSIONS: Frequency of familial aneurysms was 6.2% Familial aggregation, aneurysms between twins associated with genetic linked disease, early age rupture, high frequency between women, posterior communicating and middle cerebral artery bifurcation preference, mirror aneurysms and high general mortality associated to massive intracranial bleeding identified this clusters of familial aneurysms and would justify imaginological screening of high risk patients before the rupture.

[Intracranial carotid artery bifurcation aneurysms]. / Aneurismas de la bifurcación de la carótida intracraneal.

INTRODUCTION: Intracranial carotid artery bifurcation aneurysms are infrequent but its clinical behavior, high risk of bleeding and complex anatomic relationships of the sac permit to consider these lesions as a challenge cases. PATIENTS AND METHODS: 497 patients harboring intracranial aneurysms were operated on at Manuel Ascunce Domenech Hospital, Camagüey, Cuba between January 1982 to august 2001. We utilized microsurgical procedures, optical magnification, specialized neuroanesthesia and Intensive Care Unit postoperatory following. All patients were evaluated clinically with World Federation Neurological Surgeon Scale and Glasgow Outcome Scale. RESULTS: There were 16 patients with intracranial carotid artery bifurcation aneurysms (3.2 %). 12 patients were under 40 years and 50% were between 16 and 30 years old. All patients present intracranial bleeding. There was 87.5% of total or partial recuperation. There was one death only. Postoperative deficit were observed at 44% but 31% disappeared three month later. CONCLUSION: Intracranial carotid artery bifurcation aneurysms are complex anatomoclinical lesions. Clinically, we observed high tendency to bleed and multiplicity. Anatomically, these sacs have complex arterial relationship that difficult dissection and clipping. They have frequent postoperative morbidity. Multiple or bilateral aneurysmal sacs will be clipped by one surgical procedure.

[Aneurysms surgery in the patients aged seventy to eighty years]. / La cirugía de los aneurismas intracraneales en la séptima y octava décades de la vida.

Elderly patients are a growing population group in developing countries because of optimal health care. 13% of Cuba population is older than sixty years and it is expected to grow to 20% in 2005. Subarachnoid hemorrhage secondary to ruptured aneurysms in geriatric patients carries a high mortality but a few patients are selected for surgical treatment. Manuel Ascunce Domenech Hospital attended 1112 patients older than 60 years between January 1994 and December 2001. Of these there were 96 patients with symptomatic intracranial aneurysms and we selected 30 for surgical treatment. They were all in clinical grades I and II of the WFNS scale. They had good health to face surgery and familiar consent. The size and location of the aneurysms were not considered among the exclusion criteria. Aneurysms were mainly localized at posterior communicating and middle cerebral arteries. There were two deaths, one due to a medical cause an the other to the surgical procedure. 74% of the patients obtained satisfactory outcome six month after the operation. The clue is to not consider age as a negative point for surgery. Surgical procedures can be performed in patients with good clinical grade (WFNS). New technical advances, stroke units, accurately selected patients and minimal invasive surgical methods will help to obtain good results.

[Ogilvie's syndrome. A report of 3 cases]. / Síndrome de Ogilvie. Presentación de 3 casos.

INTRODUCTION: Lumbar spine surgery represents a common procedure in Neurosurgery. Ogilvie's Syndrome is an infrequent complication of lumbar disc surgery, characterized by acute paralytic ileum as a result of acute colonic dilatation without mechanical obstruction. CLINICAL CASES: We present the clinical data, surgical findings and evolution of three patients operated on for large lumbar disc herniation. They presented with unilateral lumbociatic pain related with physical effort and monoradicular deficit. Diagnosis was established by CT scan and all patients were operated on through a standard laminectomy. Abdominal pain, distention and lack of bowels sounds began on the second postoperatory day. This complication was avoided by conservative treatment and parenteral administration of neostigmine. Ogilvie's Syndrome appeared in 3 cases out of more than 1000 patients undergoing lumbar disc surgery and is characterized by acute colonic dilatation including cecal distention. Other lumbar disc surgery complications such as gastrointestinal perforation, urethral injury or intra-abdominal vessels damage were excluded. Conservative treatment including parenteral neostigmine was always sucessful.