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Peruvian Journal of Neurosurgery
Orbital schwannoma, a rare entity. case report
JOHN VARGAS U., CAMILO CONTRERAS C., FERNANDO PALACIOS S., EDUARDO ROMERO V.
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Introduction: Orbital schwannoma is a rare pathology, which constitutes approximately 1 to 6.5% of orbital tumors, and can originate from the ophthalmic branch of the 5th cranial nerve or from perioptic sympathetic nerves. Its diagnosis is made by magnetic resonance imaging (MRI) with contrast. The first-line treatment is surgery, and total resection provides a good prognosis. The time of illness is used to evaluate the visual prognosis in these patients.
Clinical Case: A 12-year-old woman, with a 9-year illness, characterized by a progressive decrease in right visual acuity until reaching amaurosis. Brain MRI with contrast shows an isointense tumor on T1, adhered to the medial aspect of the optic nerve sheath, which captures contrast, slightly hyperintense on T2. Total resection of the lesion is performed, and the diagnosis of schwannoma is confirmed by pathological anatomy. A month after surgery, the patient had slightly recovered her vision, without presenting other complications.
Conclusion: Orbital schwannoma is a rare pathology that must be treated surgically as soon as possible to achieve a better visual prognosis for the patient.
Keywords: Neurilemmoma, Optic Nerve, Orbital Neoplasms, Cranial Nerves, (source: MeSH NLM)
Double aneurysm clipping of true fetal posterior communicating artery by minipterional approach plus control with sodium fluorescein: a case report
CRISTIAN SALAZAR C., ALLEN DIAZ I., RICARDO ROJAS D., MIGUEL GAITAN C., ARMANDO LUCAR F.
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Introduction: True fetal or fetal type posterior communicating artery aneurysms (PComA) are a technical challenge for the neurosurgeon in both endovascular and microsurgical treatment. Microsurgical clipping using minimally invasive approaches is a safe and optimal alternative solution.
Clinical case: a 53-year-old patient who presented subarachnoid hemorrhage, Hunt & Hess scale III, Fisher scale III, and Glasgow Coma Scale of 13. Cerebral angioCT showed two saccular aneurysms in the right true fetal PComA. The patient underwent a right interfacial minipterional craniotomy and clipping of the 2 aneurysms, using sodium fluorescein as a guide. Total occlusion of the aneurysms was achieved, maintaining the patency of the fetal PComA.
Conclusion: The minipterional approach allows adequate access to the fetal PComA and the aneurysms originating from it. It is essential to review the patency of the adjacent vessels, being the use of intraoperative fluorescein is an essential complement to avoid complications such as cerebral infarction.
Keywords: Intracranial Aneurysm, Craniotomy, Fluorescein, Subarachnoid Hemorrhage, Neurosurgeons (Source: MeSH NLM)
Pneumocephalus and CSF leak secondary to skull base fracture by pyrotechnical object: case report
MARCOS VILCA A., CARLOS R. PALACIOS P., SOFIA ROSAS L., ERMITAÑO BAUTISTA C.
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Introduction: Pneumocephalus is mainly associated with traumatic injuries, being a rare complication but with high mortality rates; it behaves like a space-occupying lesion and increases intracranial pressure. The symptoms are not specific, but in the event of trauma it is necessary to suspect this entity to carry out a timely diagnosis and treatment, since being the product of the skull base fracture it can cause communication with the outside, and the appearance of cerebrospinal fluid (CSF) leak.
Clinical Case: a 38-year-old male patient who suffers trauma from a pyrotechnic explosion near his right ear, when handling a pyrotechnic object (whistle) during the New Year, presenting severe pain, slight bleeding in the right ear, feeling faint and holocranial headache that increased in a standing position; likewise, he presents high-flow aqueous secretion (CSF) from the right ear. Brain and skull base tomography (CT) showed air in the intracranial cavity, fracture of the skull base, and the ossicles of the right middle ear. Conservative management was performed using rest and lumbar drainage, presenting a satisfactory evolution.
Conclusion: Pneumocephalus is a frequent and expected complication of trauma with a skull base fracture. Its early and timely diagnosis using skull base CT is essential to define therapeutic measures. Accidents due to the misuse of pyrotechnics continue to be a relevant problem in our country. Knowing and disseminating its consequences can help raise awareness in the population.
Keywords: Pneumocephalus, Skull Base, Intracranial Pressure, Cerebrospinal Fluid Leak. (Source: MeSH NLM)
Choroid plexus coagulation as an isolated procedure in the treatment of hydrocephalus
STEFANO SMOQUINA, S., JOSÉ MANUEL ZULUETA.
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Objectives: The objective of this review is to determine the effectiveness of isolated choroid plexus coagulation (CPC) as a treatment for hydrocephalus in various clinical settings and the variables associated with its success.
Methods: PubMed was searched for the terms (choroid plexus coagulation) OR (choroid plexus cauterization). Those studies published since 1990 were included so that they were relevant to current clinical practice. All studies evaluating the efficacy of CPC as an isolated procedure for treating hydrocephalus were included.
Results: The etiology, approach, and degree of CPC were significantly associated with the effectiveness of the procedure. The greatest effectiveness was reported in patients with hydranencephaly or maximum hydrocephalus (68.9%, p = 0.001276), when a parietal approach was used (74.4%, p = 0.000604), and when the temporal horn plexus was included (64.7 %, p = 0.048068). Furthermore, a case of choroid plexus hyperplasia (CPH) treated effectively with CPC is described. On the other hand, the type of electrode (p = 0.4631), the type of endoscope (p = 0.0699), and the presence of a previous ventriculoperitoneal shunt (p = 0.3241) were not significantly associated with the effectiveness of CPC.
Conclusions: CPC is a viable treatment alternative in the management of hydranencephaly, CPH, and in selected cases of hydrocephalus without the aforementioned characteristics. However, studies are needed to compare CPC with shunt therapies before qualifying it as the first line of treatment.
Keywords: Choroid Plexus, Cautery, Hydrocephalus, Hydranencephaly, Ventriculoperitoneal Shunt. (source: MeSH NLM)
Prognostic factors of success of endoscopic third ventriculostomy with choroid plexus cauterization in the management of hydrocephalus: a narrative review
STEFANO SMOQUINA, S., JOSÉ MANUEL ZULUETA.
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Currently, endoscopic third ventriculostomy with choroid plexus coagulation (ETV / CPC) has been positioned as a reasonable alternative to cerebrospinal fluid (CSF) shunt in the treatment of hydrocephalus, both in developing countries and in non-limited settings of resources. The results show that the short-term outcomes strongly depend on the age of the patient at the time of the procedure, the etiology of the hydrocephalus, anatomical characteristics, and previous procedures. Other predictive factors include postoperative radiographic markers and surgical technique. Consequently, the selection of patients is essential when deciding on the use of this procedure. The objective of this review is to determine the association of prognostic factors with the effectiveness of ETV / CPC, to facilitate decision-making regarding the use of this procedure. Keywords: Ventriculostomy, Choroid Plexus, Hydrocephalus, Cerebrospinal Fluid Shunts. (source: MeSH NLM) |
Extradural minipterional approach in clipping of ruptured and unruptured complex aneurysms in the “Luis N. Saenz” PNP Hospital Complex: case report
CRISTIAN SALAZAR C, ALLEN DIAZ I, RICARDO ROJAS D, MIGUEL GAITAN C, ARMANDO LUCAR F.
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Introduction: The complexity of an intracranial aneurysm is defined by its location, size, previous treatment, presence or absence of collateral circulation, intraluminal thrombus, or calcification of the aneurysm wall. The treatment of these aneurysms must be based on the balance between the associated risks and the benefit for the patient; Within microsurgical techniques, the extradural minipterional approach is described.
Clinical case: a 33-year-old female patient who presented headache, vomiting, and sensorial disorder, being diagnosed with 2 complex aneurysms, one in the ruptured ophthalmic segment and the other in the unruptured right pituitary. She underwent an extradural minipterional craniotomy plus aneurysm clipping with complete occlusion and a favorable outcome.
Conclusion: The knowledge of new microsurgical techniques in the management of complex cerebral aneurysms is crucial to obtain satisfactory results, being the extradural minipterional approach an alternative and key approach for the treatment of these lesions, which represent a challenge for the neurosurgeon.
Keywords: Intracranial Aneurysm, Craniotomy, Collateral Circulation, Neurosurgeons (Source: MeSH NLM)
Experience of endovascular management of a unruptured thalamus-mesencephalic arteriovenous malformation associated with venous aneurysm in a pediatric patient. case report
ANNEL MURGA V., JESÚS FLORES Q., GIANCARLO SAAL Z., OSMAR ORDINOLA C., RODOLFO RODRÍGUEZ V.
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Introduction: The treatment of arteriovenous malformations (AVMs) of the basal ganglia, the thalamus, and the insula is complex, due to the eloquence of the neural structures involved. They constitute between 4.3% and 11% of all AVMs and are associated with a high rate of morbidity and mortality due to the high risk of bleeding due to their inaccessible location Recent advances in endovascular therapy have allowed obtaining good results with curative potential.
Clinical case: 7-year-old male patient with headache, nausea, and left hemiparesis (Daniels 4/5). The cerebral tomography showed an unruptured thalamic-mesencephalic vascular lesion, with slight ventricular dilation due to partial collapse of the Monroe foramen. A brain angioCT showed an arteriovenous malformation with a large bilobed venous aneurysm with mass effect. Subtraction angiography revealed a right thalamic-midbrain AVM with afferents from perforating branches of P1, P2, and right PComA, the largest with a diameter of 0.88 mm, with a single thick venous drainage and a large venous aneurysm, reaching the internal cerebral vein already Galen's vein. It was embolized with Squid ® 4.5cc in a single session via the arterial route, with almost total occlusion (95%) of the nest, as well as the closure of the ostium to the efferent vein.
Conclusion: Embolization is a curative treatment strategy in selected cases of patients with deep AVMs, with good results and complication rates comparable to other therapeutic strategies.
Keywords: Arteriovenous Malformations, Embolization, Therapeutic, Basal Ganglia, Aneurysm (Source: MeSH NLM)
McCune Albright syndrome, craniofacial manifestations, and surgical treatment. pediatric case report
GABRIELA ESPIN O., ALICIA TORRES M., JESUS CASTRO V., RODOLFO BERNAL C.
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Introduction: McCune-Albright syndrome (MAS) is a rare and complex genetic disease that affects the skin, skeleton, and endocrine system. The clinical triad described is composed of polyostotic fibrous bone dysplasia, café-au-lait skin pigmentation, and precocious puberty. When it is associated with myxoma, it is called Mazabraud's syndrome. The variable constellation of symptoms arises from a somatic activating mutation of the GNAS gene, which is present in many types of tissues.
Clinical Case: The case of a 6-year-old patient is presented, with a clinical presentation of a bone lesion in the left superciliary region with progressive growth for 10 months, suggestive of MAS. We focus on the course of the disease and neurosurgical treatment with the Neuronavigation technique, all carried out in our institution.
Conclusion: McCune Albright syndrome is an example of the genetic heterogeneity of polyostotic fibrous dysplasia, it is benign and has a low prevalence, with a great impact on quality of life, therefore treatment must be timely and multidisciplinary.
Keywords: Fibrous Dysplasia, Polyostotic, Puberty, Precocious, Craniofacial Fibrous Dysplasia (Source: MeSH NLM)
Bifrontal epidural hematoma. A case report at 3800 mamsl in Puno, Perú
SAMIR COLQUEHUANCA CH., LIZBETH CORA L., NATALI ABAD ILLACUTIPA M.
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Introduction: Epidural hematomas are one of the most frequent complications of head injuries. Bifrontal epidural hematomas (BEH) are rare, are associated with high-intensity trauma, and are associated with high mortality. We present the clinical case of a patient with bifrontal epidural hematoma with a Glasgow Coma Scale of 6/15 on admission.
Clinical case: A 27-year-old male patient suffered a traffic accident while riding a linear motorcycle without protection, in an apparent alcoholic state. He was diagnosed with a multifragmentary depressed skull fracture and a bifrontal epidural hematoma, which extended to the temporoparietal region of the right side with a volume greater than 215cc and with a high risk of nailing. A bifrontal craniotomy and evacuation of the epidural hematoma were performed. The postoperative evolution was favorable despite a mild neurological sequela.
Conclusion: Bifrontal epidural hematoma is a rare clinical entity, and its prognosis depends on the preoperative neurological situation.
Keywords: Hematoma, Epidural, Cranial, Craniocerebral Trauma, Craniotomy (Source: MeSH NLM)
Esophageal fistula as an infrequent complication of anterior cervical fusion. case report
JOHN VARGAS U., ALFONSO BASURCO C., EDUARDO LAOS P., JESÚS CABREJOS B., RENZO ROMERO
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Introduction: The morbidity of anterior cervical fusion surgery is low and one of the least frequent is an esophageal perforation, but this can bring severe complications such as sepsis, mediastinitis, or death. Optimal treatment is multidisciplinary, although it remains controversial; This consists of primary closure or closure by means of a muscle flap, accompanied by rest of the esophagus and a high protein diet.
Clinical Case: A 27-year-old female patient who, after a car accident, presented a cervical vertebromedullary trauma that required posterior cervical decompression surgery followed by stabilization via the anterior approach on 2 occasions. In the postoperative period, she presented erythema in the operative wound, subcutaneous emphysema, and cervical edema, for which she was re-admitted to the operating room being diagnosed with esophageal fistula. Treatment was performed by placing a muscle flap, antibiotics, esophageal bypass, and a high protein diet by nasogastric tube. The clinical and laboratory evolution was favorable, presenting closure of the esophageal fistula.
Conclusion: Esophageal fistula is a rare complication of anterior cervical surgery and this requires multidisciplinary management.
Keywords: Esophageal Fistula, Esophageal Perforation, Sepsis, Decompression, Spinal Fusion. (Source: MeSH NLM)
Evacuation of intracerebral hematomas by Neuroendoscopy: results in a series of cases
JERSON FLORES C.
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Objectives: Intracerebral (ICH) and intraventricular (IVH) hemorrhage cause severe morbidity and a high mortality rate. Intracranial hypertension and secondary injury in the perihematomal region are associated with a poor prognosis, so early surgical evacuation with minimal damage to brain tissue is essential. Endoscopic evacuation using an Endoport system is a promising technique. The objective of the study is to present the results of the endoscopic evacuation of ICH and IVH in patients operated from 2010-2019 at the Almenara Hospital in Lima-Peru.
Methods: Prospective descriptive study, in a period of 10 years, 48 patients with ICH and IVH underwent endoscopic evacuation in the first 72 hours, using a transparent working channel (Endoport) designed from a 3cc syringe. Postoperative evaluation was done with tomography and neurological follow-up using the Glasgow Coma Scale.
Results: Of a total of 48 cases, 30 were ICH, and 18 were IVH. The most frequent etiology was hypertension (75%), followed by an arteriovenous malformation (19%) and cerebral aneurysm (6%). The most frequent location was the basal nuclei at the putaminal level (29%) and the thalamic region (29%), followed by the subcortical region (17%) and posterior fossa (6%). The evacuation rate was 90% in ICH and 80% in IVH. There were no intraoperative complications, and the most frequent postoperative complication was in-hospital pneumonia (37%). The average time of external drainage in the IVH was 7.6 days. All patients showed improvement in the Glasgow Scale of an average of 4 points (8.8 in the preoperative period to 13.0 in the postoperative period). Overall mortality was 19% (20% in ICH and 16.7% in IVH)
Conclusions: The endoscopic evacuation of an intracranial hematoma is an effective, minimally invasive, and feasible technique to carry out. A modified 3cc syringe can be used as a working channel. This provides enough space for adequate visualization of the hematoma, as well as for the control of intraoperative bleeding.
Keywords: Cerebral Hemorrhage, Hematoma, Endoscopy, Syringes, Intracranial Hypertension. (source: MeSH NLM)
Definitive treatment of cerebral aneurysms at the Cayetano Heredia National Hospital in Lima Peru: a case series results.
GONZALO ROJAS D., JUAN GARAY H., WESLEY ALABA G., CÉSAR RODRIGUEZ C., ROLANDO LOVATON E., RELIX HUAMAN H.
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Objectives: Subarachnoid hemorrhage (SAH) due to rupture of a cerebral aneurysm continues to be a disease with high morbidity and mortality in our setting, despite advances in microsurgery and endovascular therapy. The objective of the present study was to determine the demography, vascular territory, and complications that occur in the perioperative management of patients with ruptured cerebral aneurysms treated at the Cayetano Heredia Hospital.
Methods: An observational descriptive study of patients with cerebral aneurysm undergoing surgical and endovascular treatment was carried out in the Neurosurgery Service of the Cayetano Heredia Hospital from 2016 to 2018. The clinical records and operative reports were reviewed.
Results: In a period of 30 months, definitive treatment was performed in 56 patients with a diagnosis of a ruptured cerebral aneurysm, of which 5 received endovascular treatment and 51 treatment by craniotomy and clipping. 62.5% were women, and 50% of the total were between the fifth and sixth decade of life. In more than 50% of cases, treatment was performed within 96 hours of SAH. Regarding the affected arterial territory, 15 patients (27%) had an aneurysm of the territory of the anterior communicating (AComA) and another 15 (27%) in the posterior communicating artery (PComA). Mortality was 17.8%, 70% being due to direct causes such as cerebral infarction and severe vasospasm.
Conclusions: The treatment of the aneurysms was mainly by microsurgery, the aneurysms of the AComA, PComA, and middle cerebral (MCA) had a similar proportion and, in more than 50% the treatment was carried out in the first 4 days. More state support is required to increase endovascular therapy and obtain more promising results.
Keywords: Intracranial Aneurysm, Microsurgery, Craniotomy, Endovascular Procedures (source: MeSH NLM)
Complex multiple ruptured aneurysms treated with embolization in a single session: case report.
JOHN VARGAS U., RODOLFO RODRÍGUEZ V., WALTER DURAND C., JESÚS FLORES Q., DANTE VALER G., RICARDO VALLEJOS T., GIANCARLO SAAL Z.
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Introduction: Multiple aneurysms are responsible for 15 to 35% of spontaneous subarachnoid hemorrhages, some of them being complex aneurysms. These are characterized by their large size, difficult location, wide neck, weak wall structure, giving rise to branches from the aneurysm, presenting calcifications, or due to ineffective previous treatment. Its management is difficult due to the variation in the anatomical distribution and the difficulty of determining which aneurysm is the ruptured one. The complex aneurysm needs special techniques for its management. Embolization has an acceptable complication rate compared to clipping, with the additional benefit of being a minimally invasive technique with a short hospital stay.
Clinical case: A 50-year-old female patient who presented headache, nausea, vomiting, and sensory disorder, being diagnosed with subarachnoid hemorrhage due to a ruptured aneurysm of the bifurcation of the right internal carotid artery. In addition, 3 other aneurysms were found (left carotid bifurcation, top of the basilar, and communicating segment of the left carotid). We proceeded to embolize the two aneurysms of the carotid bifurcation with coils using the remodeling technique, as well as the one at the top of the basilar with coils assisted with a double “Y” stent. The clinical evolution was good, and the patient was discharged without neurological sequelae.
Conclusion: The embolization of multiple aneurysms in a single session is an effective and safe technique. If the aneurysms are complex, the use of "remodeling" techniques or stent assistance is required to achieve a successful outcome.
Keywords: Aneurysm, Ruptured, Subarachnoid Hemorrhage, Embolization, Therapeutic, Stents. (Source: MeSH NLM)
Magnetic Resonance Tractography integrated to Neuronavigation in the surgical planning of a temporal arteriovenous malformation at the Dos de Mayo National Hospital. Case report.
JOSÉ LUIS ACHA S., MIGUEL AZURÍN, ADRIANA BELLIDO.
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Introduction: Complete resection of a cerebral arteriovenous malformation (AVM) eliminates the risk of bleeding1. Although AVMs that adjoin eloquent areas have been studied with functional neuroimaging or intraoperative mapping, 2 the usefulness of tractography has been limited to case reports or small series. Selecting the patient for surgery for an AVM close to an eloquent area is a challenge. 3 Clinical case: 33-year-old man with a clinical picture of epilepsy for 8 years controlled with carbamazepine. Two years ago, after suspension of treatment, the seizures reappeared, some of the auditory hallucinations "voices asking for help." Brain tomography (CT) showed a hyperdense lesion suggestive of AVM in the left temporal region, which was confirmed with magnetic resonance imaging (MRI) and cerebral angiography. The AVM was completely resected using the tractography integrated into the Neuronavigation. Conclusion: Magnetic resonance tractography integrated into the Neuronavigation allows to assess in real-time the proximity of the nidus of AVM to the arcuate fasciculus tract and the use of intraoperative fluorescein video angiography allows to assess vascularity in real-time. All of this makes it possible to perform total resection without causing injury to the eloquent area by avoiding compromising the fibers of the arcuate fasciculus tract. Keywords: Intracranial Arteriovenous Malformations, Neuronavigation, Fluoresceins (Source: MeSH NLM) |
Intracranial Solitary Plasmacytoma: Case Report
JORGE ZUMAETA S., MANUEL LAZON A., ANNEL MURGA V.
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Introduction: Solitary intracranial plasmacytoma is a rare plasma cell tumor that affects the skull, meninges, and brain. Unlike multiple myeloma, it does not have systemic manifestations. Its symptoms are characterized by a progressively growing tumor that generates local pain. It does not have a pathognomonic image and can be confused with other lesions, being its diagnosis histological. The prognosis is good and the main treatment modalities are surgery and/or radiation therapy.
Clinical Case: 64-year-old female patient with a clinical picture characterized by loss of strength in lower limbs and thermal rise. On examination: Patient awake, Glasgow 15 points, paraparesis 4/5, photoreactive and isochoric pupils. Imaging examinations show an extensive contrast-enhancing lesion involving cerebral meninges at the frontoparietal level bilaterally, with a moderate mass effect. A subtotal resection of the lesion is performed, with the patient presenting a good clinical evolution. The histological result was a plasma cell tumor. In the 6-month follow-up, no residual lesion was observed, maintaining outpatient control by an outpatient clinic. This case shows a rare pathology that is sometimes confused with a meningioma.
Conclusion: Solitary intracranial plasmacytoma is a rare tumor that can easily be confused with other more common lesions. Its diagnosis is only made with a histological study. It has a good prognosis and can be treated by surgical resection and/or radiotherapy.
Keywords: Plasmacytoma, Brain, Meninges, Neoplasms, Plasma Cell (Source: MeSH NLM)
