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Peruvian Journal of Neurosurgery

Curative transvenous embolization of a challenging ruptured thalamic arteriovenous malformation using Onyx: Case report.

PAUL CARRANZA V, WALTER DURAND C, RICARDO VALLEJOS T, DANTE VALER G, JESÚS FLORES Q, GIANCARLO SAAL-ZAPATA, RODOLFO RODRÍGUEZ V.
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ABSTRACT

 

Introduction: Arteriovenous malformations (AVM) are typically treated by arterial approach. In selected cases, venous embolization is an option with good results.
Clinical case: We present the case of a ruptured thalamic arteriovenous malformation treated successfully with transvenous embolization using Onyx, achieving complete obliteration of the nidus.
Conclusion: In selected cases, transvenous embolization is an option for the treatment of arteriovenous malformations
      Keywords: Arteriovenous Malformation, Arteries, Embolization, Therapeutic, Polyvinyls. (source: MeSH NLM)
 
 

Revascularization with first generation bypass plus carotid reconstruction with tandem clipping of complex paraclinoid aneurysm. First case in the Dos de Mayo National Hospital in Lima - Peru.

JOSÉ LUIS ACHA S, HÉCTOR YAYA-LOO, PEDRO SOTO P, JORGE MURA C, JOAQUÍN CORREA, DAVID YABAR B.
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ABSTRACT

 

Introduction: Cerebral aneurysms are formed due to a weakness in the arterial wall, this cause a dilation and the subsequent risk of rupture, conditioning subarachnoid hemorrhage, being one of the causes of cerebrovascular disease with higher risk of morbidity or death. We presented the first brain revascularization microsurgery for the treatment of a complex cerebral aneurysm performed at the Dos de Mayo National Hospital.

Clinical case: Woman with a ruptured left paraclinoid giant aneurysm, from Piura, who underwent revascularization by means of an extra-intracranial first generation bypass, between superficial temporal artery and silvian branch of M2, using a mini-interfascial approach, sphenoid wing drilling, anterior extradural clinoidectomy, opening of the canal, distal dural ring and tandem clipping for reconstruction of the carotid artery, excluding the complex aneurysm, was the surgical strategy chosen.

Conclusion: Post-surgical evolution was favorable, with radiological evidence of complete tandem clipping and permeability of the internal carotid and bypass.

      Keywords:  Intracranial Aneurysm, Cerebral Revascularization, Carotid Arteries, Microsurgery. (source: MeSH NLM

    

Mini-pterional craniotomy for clipping of anterior circulation Aneurysms

JERSON FLORES C, ALFREDO FUENTES-DAVILA M †, WESLEY ALABA G.
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ABSTRACT

 

Objectives: The pterional approach is the most common approach in vascular neurosurgery, but in recent years has been an increasing interest in minimally invasive surgery or keyhole surgery. We present preliminary results from the use of Mini-pterional Craniotomy in surgery for cerebral aneurysms performed in the Cayetano Heredia Hospital in 2009.
Methods: We performed a Mini-pterional Craniotomy of 2.5 x 3 cm from a curved incision of approximately 5-6 cm behind the hairline and centered on the orbitofrontal and posterior aneurysm clipping, in patients with PComA, bifurcation ICA and MCA aneurysms, during the late period, Hunt and Hess I-III, without edema, vasospasm or associated hematoma.
Results: From January to December 2009 six patients were operated by Mini-pterional Craniotomy, 4 with PComA aneurysms (66%), 1 with ICA (17%) and 1 with MCA (17%). All were operated on late and Hunt and Hess was I in 3 cases (50%) III in 2 cases (33%) and II (17%). There were no operative complications and the outcome was favorable in most cases: Rankin 1 (50%) and Rankin 2 (33%).
Conclusions: Mini-pterional Craniotomy is a minimally invasive surgery for brain aneurysms, which maintains the advantages of the standard pterional approach, but it minimizes the exposure of brain parenchyma and soft tissue manipulation. It is a valid surgical alternative in selected cases, mainly from PComA and MCA aneurysms.
  Key words:  Intracranial Aneurysm, Craniotomy, Minimally Invasive Surgical Procedures. (source: MeSH NLM)

 

 

Epidemiological, clinical and laboratory profile of patients submitted to micro-surgical treatment by multiple aneurysms at the Guillermo Almenara Hospital

JOHN F. VARGAS U, FERNANDO PALACIOS S, ALFREDO TUMI F, DANIEL FLORES S, JOSÉ GARCÍA V, JORGE ROMERO V, JORGE ZUMAETA S, JOSÉ URQUIZO R.
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ABSTRACT

 

Objective: Multiple aneurysms are common in patients with subarachnoid hemorrhage, their characteristics influence the prognosis of the patient, so their study and analysis are relevant. The objective of this study was to know the epidemiological, clinical and lab characteristics of patients with multiple aneurysms in a surgical treatment in the Guillermo Almenara Irigoyen National Hospital (HNGAI) from January 2010 to August 2017.
Methods: This study was descriptive, cross-sectional retrospective study with epidemiological type. We found 311 cases of patients with aneurysm clipping procedure of which 57 corresponded to a multiple aneurysm.
Results: Of the total number of patients, 71.93% were 50 or older, 75.44% were women and 82.46% were from the coast of the country. It was found that 28% of the patients had previous hypertension. 64.91% of patients had a Glasgow scale of 14-15 on admission, 47.37% were in the Hunt Hess II stage and 45.62% in the Fisher IV Scale.  The most frequent location of the multiple aneurysms was the combination of middle cerebral artery - middle cerebral artery and the combination of middle cerebral artery - posterior contralateral communicating artery.
Conclusions: Multiple aneurysms are a frequent pathology related to female sex, advanced age and history of hypertension. The predominant affectation is the middle cerebral artery, bilaterally.
     Keywords: Subarachnoid Hemorrhage, Intracranial Aneurysm, Middle Cerebral Artery. (source: MeSH NLM)
 
 

Severe intracranial hypertension treated with 7.5% hypertonic solution in a subarachnoid hemorrhage case by rupture of aneurysm

OSCAR SALDARRIAGA R, ELAR CARI C, GRACIELA NUÑEZ Z.
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ABSTRACT

 

Introduction: All patients with subarachnoid hemorrhage (SAH) admitted to our department are managed in intensive care unit; in the last years there has been a tendency to treat aneurysms in early stage by craniotomy or embolization, however the clinical evolution of patients is difficult in some cases because the neurosurgical critical care staff face with cerebral edema, intracranial hypertension, cerebral hypoperfusion and cerebral vasospasm among others but this early treatment has reduce the rate of rebleeding. 
Clinical case: We report the case of a 52-year-old woman with a diagnosis of subarachnoid hemorrhage who was monitored with an intracranial pressure (ICP) sensor and transcranial Doppler (TCD) and who received treatment with hypertonic solution at 7.5% presenting a good evolution.
Conclusion: This case show us how the clinical monitoring, ICP, TCD as well as treatment with hypertonic saline solutions are good complement to take correct decisions in shortest time, because “time is brain”.
     Keywords:  Subarachnoid Hemorrhage, Intracranial Pressure, Hypertonic Solutions. (source: MeSH NLM)
 
 

Aneurysm associated with fenestration of Basilar artery treated by embolization with coils

ZINDYA G. BARRIENTOS M, RODOLFO RODRIGUEZ V, WALTER DURAND C, RICARDO VALLEJOS T, DANTE VALER G, JESUS FLORES Q.
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ABSTRACT

 

Introduction: Aneurysms of the vertebrobasilar junction are rare, but when present, they are often associated with fenestration of the basilar artery. Frequently, the endovascular treatment is the first choice due to the complex anatomy of the posterior fossa.
Clinical case: A 68-year-old man from Lima, who denies important antecedents, was admitted to the emergency unit with intense holocranial headache, diplopia, posterior cervical pain and vomiting, without loss of consciousness. The neurological exam showed: score of 15 in the Glasgow coma scale (GCS), no pupillary alteration, no motor or sensitivity deficit, palsy of the left sixth cranial nerve and Hunt-Hess grade II. For decision making, the patient underwent digital subtraction angiography (DSA) through the right femoral artery with 3D reconstruction (03-08-2018) which showed evidence of fenestration of the basilar artery associated with saccular aneurysm. An aneurysm coil embolization was performed without complications. The patient was discharged maintaining diplopia, with paralysis of the left sixth cranial nerve, but without any other complaints or neurological symptoms.
Conclusion: Fenestrated basilar artery aneurysms are rare and complex vascular diseases and their treatment improved with the advent of the 3D angiography and the development of the endovascular techniques. The endovascular treatment by coil embolization is the first option although other endovascular techniques have also been described.
    Keywords:  Intracranial Aneurysm, Basilar Artery, Endovascular Procedures. (source: MeSH NLM)
 
 

Penumbra Coil and Stent: An option in large aneurysms of width neck

JOHN VARGAS U, RODOLFO RODRÍGUEZ V, WALTER DURAND C, JESÚS FLORES Q, DANTE VALER G, RICARDO VALLEJOS T.
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ABSTRACT

 

Introduction: Endovascular treatment of cerebral aneurysms is an appropriate option. In patients with wide neck can be chose embolization with coils with stent assisted or flow diverter. In complex aneurysms, endovascular treatment has incomplete occlusion rates, so alternatives are sought as the Penumbra® coil, which is a thicker coil, therefore it has a potential effect of being more efficient for packaging and more cost effective, because better packaging is achieved with fewer coils and faster.
Clinical case: Presents itself the case of a 48-year-old patient, a time of illness of 8 months, with a decreased visual acuity in the left eye, sporadic headache, oppressive and global type with AVS 4/10. The cerebral angiography evidenced a saccular aneurysm of the ophthalmic segment of the left internal carotid of 15.04x11.53mm, with a 9.78mm wide neck, not broken, Barami type IA. They decide to embolize with 7 Penumbra® coils with previous placement of an LVIS® stent, achieving adequate compaction and total occlusion of the aneurysm as evidenced by immediate postoperative angiography at 6-month control, yielding the patient's clinic without any complications.
Conclusion: Penumbra® coils are an efficient alternative and cost effective of embolization in large aneurysms, and the use of stent is an ideal aid in cases of associated wide neck.
     Keywords: Intracranial Aneurysm, Cerebral Angiography, Stents, Embolization Therapeutic. (source: MeSH NLM)
 
 

Endovascular treatment with coil Penumbra of a large aneurysm of the right ophthalmic segment

GONZALO ROJAS D, RODOLFO RODRÍGUEZ V, WALTER DURAND C, RICARDO VALLEJOS T, DANTE VALER G, JESÚS FLORES Q, GIANCARLO SAAL-ZAPATA
Abstract (Spanish) || Full Text || PDF (Spanish) || PDF (English)

ABSTRACT

 

Introduction: Coiling is the most common endovascular technique used for the treatment of aneurysms. Different types are available and Penumbra coils are a new option in the endovascular armamentarium.

Case report: We report the case of 63year-old female with a ruptured type IA paraclinoid aneurysm according to Barami classification, treated with 3 Penumbra coils successfully.

Conclusion: Penumbra coils seems to be an adequate option in cases of large and ruptured aneurysms of anterior circulation.

     Keywords:  Aneurysm Ruptured, Endovascular Procedures, Female (source: MeSH NLM)

 

 

CSF leakage and bone erosion caused by cysts in basal cistern neurocysticercosis treated by endoscopy

JOHN MALCA B, JOSE-DANIEL FLORES S.
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ABSTRACT

 

Introduction: The extraparenchymal neurocysticercosis and the racemose form are very predisposed to complications. Subarachnoid sellar cysts are rare, are associated with intracranial hypertension and disorders visual fields.

Clinical case: A 63-year-old male patient with racemose neurocysticercosis, hydrocephalus and cerebrospinal fluid fistula. He underwent transnasal endoscopy, removal of cysts from the sphenoid sinus, sellar, suprasellar, and prepontine regions, and fistula closure. He also presented erosion in the temporal bone and dural fistula, which were closed through microsurgery and endoscopy. The patient had a favorable initial evolution, with spastic quadriparesis, which improved with rehabilitation. Subsequently he presented episodes of ventriculoperitoneal shunt system dysfunction.

Conclusion: Neuroendoscopy is a diagnostic and therapeutic method of various forms of neurocysticercosis. Extraparenchymal neurocysticercosis is able to produce bone and dural erosion, so must be considered in the differential diagnosis of cerebrospinal fluid.

     Keywords Neurocysticercosis, Fistula, Neuroendoscopy, Sphenoid sinus, Cysts (source: MeSH NLM)

First experience using 5-ALA for high grade gliomas in the Almenara Hospital

JOHN VARGAS U, FERNANDO PALACIOS S, EDUARDO ROMERO V.
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ABSTRACT

 

Introduction: The most frequent brain tumors in adults are high-grade gliomas and meningiomas. Having a discouraging prognosis of high-grade gliomas and knowing that the prognosis improves depending on the degree of tumor resection, is that new therapeutic strategies are sought, one of them is the use of 5-aminolevulinic acid (5-ALA) thanks to the fluorescence it produce in the tumor it allows to improve the rate of tumor resection, finally improving the prognosis of the patients. We presented the first experience in Almenara Hospital of the use of 5-ALA in a patient with a diagnosis of high-grade glioma.

Clinical Case: Presents itself the case of a 48-year-old male patient with clinical evidence of motor and sensory deficit contralateral to the lesion, without alteration of the state of consciousness. The magnetic resonance of the encephalon with contrast, a right frontal lesion is evidenced compatible with high-grade glioma. Therefore, it is programmed for guided surgery with fluorescence, where 5-ALA is used, and a total resection of the tumor is performed, obtaining an anaplastic ependymoma as pathological anatomy. The patient presented an increase in the motor deficit, which he later recovered. In the tomographic control with contrast at 4 months, complete tumor resection is evident.

Conclusion: 5-aminolevulinic acid is a drug that helps to properly delimit the edges of a high-grade glioma, by using a modified microscope, and thus increases the degree of tumor resection, ultimately improving the prognosis of the disease.

     Keywords: Glioma, Aminolevulinic acid, Ependymoma, Fluorecense, Prognosis. (source: MeSH NLM)

Prognostic factors in the survival of patients operated of astrocytoma grade II

JERSON FLORES C, ALEJANDRO ROSELL O.
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ABSTRACT

 
Introduction: Astrocytoma are the most common tumors of the CNS and constitute 40 to 50% of all brain tumors. Survival depends on several clinical factors and treatment, and the actual survival of patients operated on astrocytoma grade II in our region is unknown, so the objective of the present study was to know the survival of patients operated on astrocytoma grade II as well as determine What is the impact of pre-surgical and post-surgical prognostic factors on the survival of patients with grade II astrocytoma that were operated at the Guillermo Almenara Hospital between 2003 and 2009.
Methods: A retrospective, observational and longitudinal study of 38 patients operated on astrocytoma grade II at the Guillermo Almenara Hospital between 2003 and 2009. The data was collected from medical records, operative reports and telephone interviews. The patients were classified according to the histological type of astrocytoma and the variables were analyzed: Group of prognostic risk, type of treatment and extension of the surgery. The SPSS 15.0 was used for the analysis.
Results: Of a total of 124 patients with astrocytoma, 30% (38/124) had a grade II astrocytoma, with an average survival of 56.7 months. According to the clinical prognosis group, survival of the low, medium and high-risk groups was 74.8, 46.0 and 31 months respectively. Regarding the type of treatment, the group with the highest survival was radiotherapy + surgery (66.2 months), followed by surgery alone (44.8 months) and the shortest survival time was radiotherapy alone (37.6 months). The longest survival was the total resection group (68.7 months), followed by the single biopsy (39.1 months) and the shortest group survived the partial resection (21.0 months).
Conclusions: Survival of patients operated on Astrocytoma grade II in our hospital is 56.7 months, with the factors of better prognosis being the "low risk" group and the total resection. Its classification into prognostic risk groups based on pre-surgical clinical data helps us predict survival before surgery.
     Keywords: Astrocytoma, Prognosis, Brain Neoplasms, Survival, Risk factors (source: MeSH NLM)
 

Cerebral aneurysm diagnosed with angio-tomography and its surgical correlation at Daniel A. Carrión Hospital in the period May 2004 to November 2007

Yuri Lopez Z. MD
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ABSTRACT

 

Objective: To determine the validity, sensitivity and specificity of multislice spiral CT angiography (ATEM) with a 16-Multislice CT scanner detector lines in the diagnosis of cerebral aneurysms and their most frequent localizations. 

Patients and Methods: We selected 51 patients with nontraumatic subarachnoid hemorrhage due to suspected intracranial aneurysm who underwent surgery in the Hospital Daniel A. Carrión, Callao, for the period May 2004 to November 2007. 

Results: The sensitivity of the ATEM for the detection of intracranial aneurysms in this study was 100%. The resulting specificity was 50%. The positive predictive value (PPV) of ATEM for the diagnosis of cerebral aneurysms was 98%, with 87.8% accuracy of the method for determining the location of the aneurysm and 12.2% of uncertainty in the determination of the location of this anomaly. The average size of the aneurysm at surgery was 11.33 + / - 6.9 mm. While the average size of the aneurysm by ATEM was 8.60 + / - 5.75 mm. The difference between the means of these measurements was significant (p = 0.027). 70.3% of aneurysms in this study were found in posterior communicating segment of both internal carotid and middle cerebral arteries both. 

Conclusion: CT angiography is an excellent noninvasive test for the detection of intracranial aneurysms and to determine its location.                                                            

      Key wordsIntracranial aneurysm, CT Angio (ATEM), aneurysm surgery

 

MRI Spectroscopy (H+) in the differential diagnosis between brain tuberculomas and intra-axial neoplastic process

Carlos Martinot L. MD, Carlos Martinot Del P. MD, Genaro Herrera G. MD, David Alfaro L. MD, Augusto Merello K. MD, et Al.
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ABSTRACT

 

Objective: To study changes in brain metabolites between brain tuberculomas and intra-axial neoplastic process so that we allow an approach to its diagnostic differentiation.
Patients and Methods: A descriptive case series, 24 patients aged between 02 and 72 years who underwent the brain structural and spectroscopic study univoxel with voxel of 20 mm x 20 mm x 20 mm (8 cc ) located at the level of the lesion determined. Resonator was used 1.5-tesla General Electric Smart Speed and Hdx models. Ratios were assessed Choline / creatine, and N-Acetil-Aspartato/Creatina and Mio-inositol/Creatina. All cases were confirmed anatomical - pathological or therapeutic test.
Results: The ratio choline / creatine for intra-axial brain tumors was found to be 1.97 compared with tuberculomas which was 1.15, which is statistically significant (p = 0.017, Mann Whitney). Mio-inositol/creatina ratio for intra-axial brain tumors was 0.89 compared with tuberculomas was 0.55 which is statistically significant (p = 0.008, Mann Whitney). The ratio N-Acetil-Aspartato/Creatina for intra-axial brain tumors was 0.96 compared with tuberculomas was of 1.28 which is statistically significant (p = 0.003, Mann Whitney).
Conclusion: Magnetic resonance spectroscopy allows a more accurate diagnosis of intraparenchymal brain lesions of uncertain etiology and occurs when the lesion is unique, brain neoplasia and tuberculomas, enabling better-targeted treatment for patients.

 
     Key words: Nuclear Magnetic resonance, MR espectroscopy, tuberculoma, brain tumors.
 

Type IV spinal arteriovenous malformations

Jorge A. Lee MD, Alejandro Santillan MD, Andres Plasencia S. MD
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ABSTRACT

 

We present the case of a 32 year old patient with spinal cord compression syndrome of 10 months of evolution. Magnetic resonance imaging showed signal voids causing myelopathy that spinal angiography showed to be a type IVb spinal arteriovenous malformation (perimedular arteriovenous fistula type II) supplemented by a posterior spinal artery that originated next to the Adamkiewicz artery from the segmental artery T11 left. The fistula was successfully eradicated by transarterial embolization with cyanoacrylate and the patient experienced progressive improvement. The relevant literature is reviewed. The endovascular approach is the treatment of choice in spinal arteriovenous malformations types IVb and IVc.

     Key words: AVM, spinal arteriovenous malformation, perimedular arteriovenous fistula, embolization, spinal cord
 

Chronicle of the Department of Neurosurgery of Police Hospital

Humberto Hinojosa MD.
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ABSTRACT

 

Neurosurgery is successively founder Mauricio Dávila in 1944 at the Police Hospital, Esteban Roca in 1947 in the Obrero Hospital, Fernando Cabieses at the Institute of Neoplastic Diseases and Juan Franco the the Institute of Neurological Sciences . After these services have made many more, led by prominent and prestigious Neurosurgeons meeting in what today is the Peruvian Society of Neurosurgery. The academic activity of the neurosurgeons was performed at baseline in 1938 in the Peruvian Society of Neuro-Psychiatry and Legal Medicine which was only shortly after Peruvian Society for Neuro-Psychiatry and when the number of neurosurgeons was higher is nominated Peruvian Society of Psychiatry, Neurology and Neurosurgery.
In 1961 he inaugurated a Police Hospital Central Pavilion and 4 plants with capacity of 500 beds and is given the name of the Central Police Hospital "General Luis N. Saenz. "Humberto Hinojosa travels to the U.S. for graduate studies with Irving Cooper Esterotaxia surgery, to return the Police Hospital becomes the first team in the country Esterotaxia surgery and allows many operations of this type.

 

     Key words: Neurosurgery, historical notes, hospital, medical society.
 

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