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Peruvian Journal of Neurosurgery

Endovascular treatment with coils of aneurysm of the anterior communicating artery, angiographic control, and evolution according to packing density: case series.

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Objective: The goal of this study is to present the outcomes of endovascular treatment performed on a group of patients diagnosed with ruptured aneurysms in the anterior communicating artery. The effectiveness of the treatment will be assessed based on the degree of packing observed in both immediate and subsequent angiography control.
Methods: An observational, retrospective, and descriptive study was conducted at the Guillermo Almenara Hospital to analyze the treatment outcomes of patients with ruptured anterior communicating artery aneurysms, who were solely treated through embolization with coils (without stent or balloon) in the year 2021 and 2022. The degree of packing of the aneurysms was measured and analyzed using the AngioCalc program, while data analysis was performed using Excel.
Results: Three patients with ACom aneurysm were successfully treated using only coils for embolization. Among them, two patients had a Fisher IV subarachnoid hemorrhage (SAH) while one patient had a Fisher III SAH. The volume of the aneurysm was 12.78 mm3 for patient A, 51.65 mm3 for patient B, and 34.06 mm3 for patient C. The degree of packing of the aneurysm was calculated using a formula and found to be 23.79%, 28.7%, and 34.06% for patients A, B, and C respectively. These values were all greater than 24%. The immediate angiography results were classified as RR II for patients A and B, and RR IIIA for patient C. Subsequent angiographic control results were classified as RR IIIA for patient A, RR II for patient B, and RR IIIB for patient C. All patients had a favorable outcome.
Conclusions: The degree of coil packing affects the evolution of an embolized aneurysm, therefore serial angiographic monitoring is necessary to detect recurrence and perform additional endovascular treatment if needed.
      Keywords: Aneurysm, Ruptured, Subarachnoid Hemorrhage, Angiography, Embolization, Therapeutic. (Source: MeSH NLM)

Giant unruptured posterior communicating segment aneurysm embolized in one session with stent and coils.

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Introduction: A giant cerebral aneurysm is one that reaches a size greater than 25 mm in diameter, and whose complications are rupture and a mass effect like a tumor. The complex anatomy of the posterior communicating segment and the size of the aneurysm make it challenging to treat surgically, so the best definitive treatment option for this type of pathology is the Endovascular route, which seeks obliteration and exclusion of the aneurysm.
Clinical case: A 65-year-old female patient with a history of high blood pressure and a religion of being a Jehovah's Witness, was admitted with an illness of 5 months characterized by headache, dizziness, eyelid ptosis, left hemiparesis 4/5, on a Glasgow coma of 15 points. Cerebral angiography showed a giant unruptured aneurysm of the communicating segment of the right internal carotid artery, for which it was embolized with a stent and penumbra coils using the “Jailing” technique, successfully closing the entire aneurysm.
Conclusion: Giant aneurysms are complex lesions, for which Endovascular therapy is a safe and effective alternative with a lower complication rate.
       Keywords: Intracranial Aneurysm, Cerebral Angiography, Stents, Paresis (Source: MeSH NLM)

Aneurysms and other intracranial lesions in polycystic kidney disease: illustrative case and review

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Introduction: Polycystic Kidney Disease (PKD) is a common hereditary kidney disease that can be accompanied by the appearance of intracranial lesions. Among these lesions, cerebral aneurysms are often found in patients with PKD, which can lead to increased morbidity and mortality. These aneurysms can have clinical and surgical implications, making them a serious concern for patients with PKD.
Clinical case: A 52-year-old man who had polycystic kidney disease in the terminal phase, untreated arterial hypertension, polycystic liver disease, and other complications related to kidney disease, was found to have two aneurysms in the anterior cerebral circulation, arachnoid cysts, and spontaneous intracranial hemorrhages. The purpose of the clinical case study and review was to understand the symptoms, risk factors, diagnosis, and management of intracranial lesions.
Conclusion: In patients with PKD, intracranial lesions like cerebral aneurysms should be suspected if there are risk factors, as they can be life-threatening if undiagnosed.
     Keywords: Intracranial Aneurysm, Polycystic Kidney Diseases, Cerebrovascular Circulation (Source: MeSH NLM)

Selective posterior corpus callosotomy in a child with Lennox–Gastaut Syndrome: case report

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Introduction: In epilepsy refractory to medical treatment which presents multiple and bilateral epileptogenic foci such as Lennox Gastaut syndrome (LGS) the surgical alternative is disconnection surgery such as callosotomy. Posterior callosotomy is indicated in cases of atonic seizures with posterior resection, leading to better seizure control especially when resection surgeries of the anterior third or anterior two-thirds of the corpus callosum fail. We present the case of a patient with Lennox Gastaut syndrome who required a posterior callosotomy after a partial anterior callosotomy, finally achieving complete control of atonic seizures.
Clinical case: a 10-year-old male patient with a diagnosis of drug-resistant epilepsy due to Lennox Gastaut syndrome, and a surgical history of a partial callosotomy of the anterior third of the corpus callosum. In March 2021 which achieved only a transient decrease in seizures. The patient had had atonic seizures for 6 years and had been unsuccessfully treated with 5 different anticonvulsant medications such as topiramate clonazepam levetiracetam lamotrigine and valproate. On examination: Awake, alert, moderate to severe psychomotor retardation. Brain MRI was normal. A posterior microsurgical callosotomy was performed without complications. His postoperative clinical evolution was favorable showing an absence of atonic seizures.
Conclusions: Selective posterior callosotomy is an essential tool in controlling seizures in cases of refractory epilepsy in patients with atonic seizures. Our study suggests that posterior callosotomy is likely to be even more effective and safe when resections of different segments of the corpus callosum are combined.
   Keywords:  Corpus Callosum, Seizures, Lennox Gastaut Syndrome, Drug Resistant Epilepsy.  (Source: MeSH NLM)

Central diabetes insipidus post-ventriculostomy. case report

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Introduction: Diabetes insipidus is a rare complication in cerebral vascular pathology. Although its presentation is associated with surgery for pituitary tumors, few cases have been reported after the evacuation of cerebral hemorrhages.
Clinical Case: A 54-year-old male patient was admitted with a clinical picture of intense holocranial headache, Glasgow Coma Scale 8. A brain tomography (TEM) showed ventricular and basal ganglia hemorrhage. She underwent surgery, placing an external ventricular shunt, and was then transferred to the Intensive Care Unit (ICU). The control tomography showed signs of ischemia in the territory of the anterior cerebral artery. Laboratory tests showed severe hypernatremia, polyuria, hypovolemia, and alterations in urinary osmolarity, which is why she was diagnosed with central diabetes insipidus and received treatment with vasopressin, presenting a favorable evolution.
Conclusion: Central diabetes insipidus occurs due to damage to the osmoreceptors of the hypothalamus. Its incidence after brain hemorrhage evacuation surgeries is low. It is recommended to carry out exhaustive monitoring of the internal environment from the moment these patients are admitted to the Neurocritical ICU
    Keywords: Diabetes Insipidus, Hypernatremia, Polyuria, Brain, Intensive Care Units. (Source: MeSH NLM)

Experience in lumbar microdiscectomy at the Guillermo Almenara Irigoyen Hospital 2018 -2021

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Objective: Herniation of the nucleus pulposus (HNP) is the leading cause of sciatica. The standard diagnostic test is magnetic resonance imaging and treatment can be conservative or surgical. The most common surgical technique is lumbar microdiscectomy. The objective of the study was to know the epidemiological and clinical profile, as well as the surgical results of patients undergoing lumbar microdiscectomy at the Almenara Hospital from January 2018 to August 2021.
Methods: Descriptive, retrospective, and cross-sectional epidemiological study. We found 82 patients who underwent lumbar microdiscectomy with complete data in the clinical history. The data was collected from the clinical history of hospitalization and outpatient consultation. Proportions were applied for qualitative variables and mean with confidence interval in quantitative variables.
Results: Of the total number of patients, 69.51% were male, the most frequent age group was 31-50 years, and most came from Lima. The most frequently operated anatomical levels were L4 and L5. Regarding the clinic, 95.12% presented positive Lasegue. The mean preoperative VAS decreased from 7.83 to 2.00. Recurrence was 4.88% and the most frequent complication was inadvertent durotomy.
Conclusions: HNP is the most common cause of sciatica. The most frequent surgical management is lumbar microdiscectomy, which has good clinical results as well as a low rate of complications and recurrence.
   Keywords: Spine, Sciatica, Nucleus Pulposus, Diskectomy, Neurosurgical Procedures. (Source: MeSH NLM)


Beginnings of endoscopy spine surgery in Peru

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In recent years, spinal endoscopy has become increasingly common in our setting; however, its use is not recent. The first reported cases date back to the early 2010s by a team from the Cayetano Heredia Hospital in charge of Drs. Wesley Alaba and Jerson Flores. Although other minimally invasive procedures such as nucleoplasty, nucleolysis, or percutaneous rhizotomies had already been used since the 2000s, it was not until 2011 that endoscopy was used for the first time in a standardized manner in spinal surgery with the endoscope as the only element of vision, successfully resecting a vertebral lesion.
The first cases of vertebral pathology in which endoscopic surgery was used were the resection of a synovial cyst and a tuberculous abscess, followed by the resection of herniated discs at the L5-S1 level and later at the L3-L4 and L4-L5 levels. The first approach was the tubular interlaminar posterior approach, followed by the transforaminal endoscopic approach and the percutaneous posterior interlaminar approach. In the following years, endoscopy has been used not only in resecting herniated discs but also in treating central and lateral canal stenosis, reaching significant experience in this technique.
The development of spinal endoscopy and its increasingly widespread use by neurosurgeons and traumatologists from different hospitals in the country represents an important advance in spinal surgery in Peru, which brings greater benefit to patients.
   Keywords: Endoscopy, Intervertebral Disc Displacement, Endoscopes, Neurosurgeons (source: MeSH NLM)


Spinal tuberculosis: a diagnostic challenge. case report and literature review

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Introduction: Spinal tuberculosis TB represents 1% of all TB cases and 50 - 60 of osteoarticular TB cases.1 Certain atypical clinical and radiological presentations of spinal tuberculosis are described infrequently. 2 The lack of recognition of these presentations can lead to a delay in diagnosis and in the initiation of treatment. 3 We present the case of a patient with atypical vertebral tuberculosis operated on in our hospital.
Clinical case: A 56-year-old male with a history of diabetes mellitus no history of tuberculosis contact with a 3-year history of moderate low back pain without sciatic pain that did not improve with physical therapy The general and systemic physical examination was normal The tests showed PCR 9.8 ESR 24 BK in sputum brucellosis test and ELISA and chest X-ray were normal. A tomography and magnetic resonance imaging of the lumbosacral spine showed an osteolytic lesion involving L2 L3, isointense on T1 with regular punched-out borders sparing the L2 L3 intervertebral disc suggestive of vertebral tuberculosis He received standard tuberculosis treatment for 24 months with no improvement A new open biopsy revealed Mycobacterium tuberculosis GenXpert.
Conclusion: Spinal tuberculosis continues to be a global health problem Diagnosing atypical spinal tuberculosis remains difficult which could lead to inappropriate treatment especially regarding the choice of treatment regimens and surgical options Histopathological confirmation is essential for time management
   Keywords:  Tuberculosis, Spinal, Mycobacterium tuberculosis, Lumbar Vertebrae, Biopsy (Source: MeSH NLM)


Extrapleural transthoracic discectomy without fusion for resection of giant calcified dorsal disc hernia: case report

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Introduction: Calcified thoracic disc herniations are rare and their approach represents a surgical challenge when they are giant and symptomatic Surgery is indicated in cases of intractable back pain with medical management persistent intercostal neuralgia or progressive neurological deficit with the transthoracic extrapleural approach being the one of choice because it has advantages regarding the best view of the operative field We present the case of a patient with a giant calcified thoracic hernia who was successfully operated on in our hospital using an extrapleural transthoracic approach.
Clinical case: A 53-year-old male with dorsal pain in the medial region radiating to the inframammary region and progressive difficulty walking moderate proximal paraparesis T8 sensory level and urinary retention CT and MRI images showed a large calcified T6-7 disc herniation causing severe compression of the spinal cord The patient underwent a T6-7 extrapleural transthoracic discectomy plus a T6 partial corpectomy without fusion The patient tolerated the procedure well with no complications and the postoperative images one month after surgery demonstrated spinal cord decompression At follow-up irradiated back pain sensory level paraparesis and urinary retention improved.
Conclusion: Extrapleural transthoracic discectomy can be considered a safe approach in the case of giant calcified thoracic hernias since it allows resection of the calcified disc fragment and decompression of the spinal cord.
  Keywords: Intervertebral Disc Displacement, Diskectomy, Spinal Cord, Decompression (Source: MeSH NLM)

Ancient thoracic schwannoma: a rare etiology of spinal cord compression. case report

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Introduction: Ancient schwannoma is a rare subtype of spinal schwannomas. It is named for the degenerative changes that it can present. Contrast-enhanced magnetic resonance helps us diagnose, as it can show heterogeneous lesions that capture ring contrast. The treatment is surgical.
Clinical Case: A 67-year-old male patient is presented, with 2 years of the disease characterized by thoracic radicular pain and severe paraparesis in the last 6 months. Contrast-enhanced MRI showed a tumor with heterogeneous uptake, widening the right T2/T3 foramina with right anterior paravertebral extension and severe canal stenosis at the T2 level. A laminectomy plus total resection of the lesion was performed; the pathology study was reported as ancient schwannoma. The evolution was favorable with complete recovery of muscle strength in subsequent months.
Conclusion: Ancient schwannoma is a rare pathology that has peculiar imaging characteristics and whose treatment is surgical.
     Keywords: Schwannoma, spinal neoplasms, paraparesis, laminectomy (Source: MeSH NLM)

Combined treatment “microsurgery-arthrodesis”: total resection of dorsal schwannoma plus dorsal arthrodesis

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Introduction: Schwannomas are benign, unusual, and slow-growing tumors originating in Schwann cells, they constitute 30% of spinal tumors and are more common in women between the fifth and sixth decade. The symptoms depend on the location, degree of spinal cord compression, vertebral erosion, and tumor size. The diagnosis is clinical and imaging. The gold standard of treatment is total excision, to avoid recurrence. Surgical planning must be holistic, and the surgical field must be wide to allow complete excision.
Clinical case: A 65-year-old woman with symptoms of axial pain, with an imaging diagnosis of a spinal tumor, is presented. Total resection of the tumor was performed by means of a hemilaminectomy plus dorsal arthrodesis. The pathology result was spinal schwannoma. The patient evolved favorably without presenting a neurological deficit.
Conclusion: Hemilaminectomy plus posterior arthrodesis with facetectomy constitutes an effective way for total resection of extramedullary intradural tumors at the dorsal level, as was the case we performed in our patient. This allows for a larger operating field and optimizes the surgical approach.
       Keywords: Spinal Cord Neoplasms, Neurilemmoma, Laminectomy, Arthrodesis. (Source: MeSH NLM)


Prognostic factors in the survival of patients operated of astrocytoma grade III at the Guillermo Almenara Hospital Lima- Peru. 2003-2009

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Introduction: Anaplastic astrocytoma (AA) or grade III is a primary brain tumor, astrocytic, malignant, and diffusely infiltrating. The survival of patients depends on several clinical and treatment factors, being this unknown in our environment. The objective of this study was to determine the survival of patients operated on for grade III astrocytoma and the impact of preoperative and postoperative prognostic factors.
Methods: A retrospective, observational and longitudinal study of 35 patients operated on for astrocytoma grade III at Hospital Guillermo Almenara between 2003 and 2009 was carried out. Data were collected from medical records, operative reports, and telephone interviews. Patients with anaplastic astrocytomas were classified according to prognostic risk group, treatment type, and surgery extent. SPSS 25.0 was used for the analysis.
Results: Of a total of 124 patients with astrocytoma, 28.2% (35/124) had a grade III astrocytoma, with an average survival of 34.8 months. According to the clinical prognosis group, the survival of the low, medium, and high-risk groups was 46.7, 28.1, and 8.5 months, respectively. Regarding the type of treatment, the group with the longest survival was surgery + radiotherapy (39.5 months), followed by surgery + radiotherapy + chemotherapy (29.3 months), and the one with the lowest survival was surgery alone (6.5 months). According to the extension of the surgery, the highest survival was obtained by the total resection group (46.2 months), while the lowest survival was for the partial resection group (13.9 months).
Conclusions: The average survival of patients operated on for grade III astrocytomas in our hospital was 34.8 months, with the best prognostic factors being the "low risk" clinical group, the combined treatment of surgery + radiotherapy, and total resection. Its classification into prognostic risk groups based on pre-surgical clinical data helps us predict survival.
      Keywords: Astrocytoma, Prognosis, Brain Neoplasms, Hospitals, Humans (source: MeSH NLM)

Glioma of the optic pathway and hypothalamus in a child: a case report

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Introduction: Gliomas of the optic nerve, visual pathway, and hypothalamus are treated as a single entity, being considered benign neoplasms in pediatric age, grade I according to the WHO. 25% of them are confined to the optic nerve, 40-75% involve the optic chiasm, and 33-60% are posterior lesions. Most do not present symptoms, but in the case of presenting, the most frequent is loss of vision. The gold standard for diagnosis is magnetic resonance imaging (MRI) with contrast. The first line of treatment is chemotherapy, with surgery used for nerve decompression, if necessary.
Clinical case: A 4-year-old woman with a 3-month illness characterized by headache, vomiting, and seizures. The MRI showed a heterogeneous, solid cystic tumor with a solid component that captures contrast. A craniotomy and partial tumor resection were performed, finding both nerves and the optic chiasm thickened. Pathology was reported as pilomyxoid astrocytoma. The patient presented a favorable evolution and was discharged on postoperative day 9.
Conclusion: Gliomas of the optic pathway and hypothalamus are tumors with a benign course in childhood, and their main form of treatment is chemotherapy. Surgery only plays an important role if decompression is required to preserve the patient's visual function.
     Keywords:  Astrocytoma, Optic Chiasm, Decompression, Craniotomy, Visual Pathways. (source: MeSH NLM)

Esthesioneuroblastoma with intracranial invasion, surgical management by double approach: craniotomy and craniofacial. case report

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Introduction: Esthesioneuroblastoma, or olfactory neuroblastoma, is a rare malignant neoplasm of the sinonasal tract that originates in the olfactory neuroepithelium with neuroblastic differentiation. It occurs most frequently in the upper nasal cavity. It is a locally aggressive neoplasm and metastasizes both hematogenously and lymphatic. A multimodal approach, which can combine surgery, chemotherapy, and radiotherapy, is essential for the management of these tumors.
Clinical Case: A 56-year-old female patient with an 18-month illness, characterized by loss of smell, shortness of breath, and frontal headache. Brain tomography showed an extensive tumor in the nasopharynx with intracranial involvement and destruction of the anterior skull base. She was diagnosed with Esthesioneuroblastoma by endonasal endoscopic biopsy. A combined approach was planned first by Neurosurgery, through a bifrontal craniotomy in which the resection of the intracranial portion and the reconstruction of the skull base were achieved. Then, Head and Neck Surgery perform the resection of the tumor in the nasal cavity through right lateral rhinotomy. The patient evolved favorably in the postoperative period without presenting neurological deficit, so she was discharged in the following days after the removal of the tracheostomy cannula. She subsequently received adjuvant chemotherapy and radiation therapy.
Conclusion: In an Esthesioneuroblastoma, obtaining an extensive resection, total, if possible, is a very important factor in the prognosis of a patient, so it is recommended to use the combination of several surgical techniques to achieve this goal.
     Keywords:  Esthesioneuroblastoma, Olfactory, Craniotomy, Nasal Cavity, Skull Base (source: MeSH NLM)

Post-surgical subarachnoid hemorrhage in endonasal endoscopic resection of pituitary macroadenoma without arachnoid opening

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Introduction: Pituitary adenomas represent 90% of tumors in the sellar region. The surgery is performed by transsphenoidal resection (TSR) or transcranial resection (TCR); TSR can be by microscopy or endonasal endoscopy. Subarachnoid hemorrhage (SAH) associated with a pituitary tumor is rare and can be: Preoperative, due to pituitary apoplexy with rupture of the arachnoid into the basal cisterns, Intraoperative, due to vascular injury during surgery or rupture of an unidentified aneurysm; and Postoperative, due to residual tumor hemorrhage, or bleeding from small vessels adhered to the tumor capsule.1, 2
Clinical case: 46-year-old male patient with a clinical picture of bitemporal hemianopsia with left predominance. Magnetic resonance imaging and brain tomography showed a pituitary macroadenoma. Endoscopic endonasal resection of the tumor was performed without intraoperative opening of the arachnoid. On the 1st day, the evolution was favorable with improved visual fields, but on the 2nd day, the patient presented headache and increased visual deficit. Brain CT showed SAH in basal cisterns. Tomography angiography showed no vascular injury. The patient evolved favorably with the improvement of visual fields.
Conclusion: Subarachnoid hemorrhage associated with a pituitary adenoma has various causes that can be preoperative, intraoperative, and postoperative. The incidence of postoperative SAH as a complication of endonasal endoscopic resection is low, but it can affect the patient's prognosis. Excessive traction on the tumor capsule should be avoided.
     Keywords:  Subarachnoid Hemorrhage, Pituitary Neoplasms, Visual Fields, Arachnoid (source: MeSH NLM)