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Peruvian Journal of Neurosurgery
Advantages of intraoperative videoangiography with fluorescein integrated to the microscope in cerebrovascular pathology. Initial experience at Dos de Mayo National Hospital
JOSÉ LUIS ACHA S., MIGUEL AZURÍN, ADRIANA BELLIDO.
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Introduction: Fluorescein sodium (FNa) is a fluorescent substance used to evaluate cerebral blood flow. We present our first cases of vascular microsurgery using microscope-integrated intraoperative fluorescein video angiography. We review the practical applications and benefits of this technique in vascular microsurgery.
Clinical cases: A 63-year-old woman, Glasgow: 9 on admission, with subarachnoid hemorrhage (SAH) Fisher IV. A ruptured anterior communicating aneurysm was diagnosed. After stabilization in the ICU, she underwent surgery, undergoing microsurgical clipping guided by intraoperative videoangiography. The postoperative evolution was favorable.
A 33-year-old man with a history of epilepsy on carbamazepine treatment. After suspension and irregular treatment 2 years ago, seizures reappear. An angiography and magnetic resonance imaging were performed, and he was diagnosed with a left posterior temporal arteriovenous malformation (AVM) close to Wernicke's area, for which he underwent surgery using tractography and videoangiography in real-time integrated into Neuronavigation. In both cases, the benefits of using the integrated microscope were observed thanks to the vascular anatomical assessment in real-time with fluorescein.
Conclusion: Videoangiography with FNa allows examining afferent and efferent vessels during surgery for arteriovenous malformations, checking the persistence of flow in a microvascular anastomosis, and evaluating flow during clipping of an aneurysm. It has the advantages of being able to be repeated during surgery, allowing surrounding anatomical visualization, as well as allowing any surgical correction in real-time.
Keywords: Fluorescein Angiography, Microsurgery, Aneurysm, Arteriovenous Malformations (Source: MeSH NLM)
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Transsphenoidal endoscopic surgical treatment of pituitary tumors at the Cayetano Heredia National Hospital in Lima Peru: outcomes of a series of cases
JUAN GARAY H, GONZALO ROJAS D, WESLEY ALABA G, JERSON FLORES C, RÓMULO RODRIGUEZ C, YVAN SALCEDO F.
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Introduction: In recent years, transsphenoidal endoscopic surgery has become a surgical procedure of choice for the treatment of pituitary tumors. The objective of the present study was to describe the demographic, clinical characteristics, complications, and postoperative results of the patients who underwent transsphenoidal endoscopic resection.
Methods: A descriptive case series study of patients with pituitary tumors operated through a transsphenoidal endoscopic approach was carried out from January 2016 to August 2018 in the Neurosurgery Department of the Cayetano Heredia National Hospital. Data were obtained by reviewing the medical records.
Results: A total of 20 endoscopic surgeries were performed, of which 08 were for pituitary macroadenomas, 07 for giant pituitary adenomas, and 05 for other tumor lesions. Of the total number of operated patients, 11 were male (55%) and the most frequent age group was between the 3rd to 5th decade of life (70%). Regarding the postoperative results, a total and subtotal resection was performed in 60% of the patients and partial resection in 20%. Regarding postoperative complications, 45% of patients had transient diabetes insipidus. 1 patient died (5%) due to septic symptoms.
Conclusions: Endoscopic transsphenoidal surgery provides several advantages over microscopic transsphenoidal surgery, such as providing greater anatomical detail, direct visualization of the tumor, and cerebrospinal fluid leak sites, which allows achieving better results in terms of disease control and the prevention of complications. However, studies with a larger number of patients are necessary.
Keywords: Pituitary Neoplasms, Endoscopy, Neurosurgical Procedures, Diabetes Insipidus. (source: MeSH NLM)
Endoscopy-assisted microsurgery in the resection of epidermoid tumor of the pontocerebellar angle
JERSON FLORES C., GONZALO ROJAS D., WESLEY ALABA G., RÓMULO RODRIGUEZ C.
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Introduction: Intracranial epidermoid tumors are rare, slow-growing, and histologically benign congenital neoplasms. The microsurgical approach with endoscopic assistance is described as a minimally invasive technique that facilitates the work of the neurosurgeon in the complete resection of an epidermoid tumor located in the cerebellopontine angle.
Clinical Case: 62-year-old woman, with a 3-year disease characterized by pain on the right side of the face. Symptoms increase in the following 2 years, becoming disabling and only partially improving with pregabalin and oxcarbazepine. Brain MRI showed a hypointense lesion with a cystic appearance at the level of the prepontine cistern with expansion to the right cerebellopontine angle that compressed the right trigeminal nerve (V). Retromastoid craniotomy and a right cerebellopontine angle approach were performed. Under the microscopic vision, the trigeminal nerve was identified which was pulled by the tumor, the cranial nerve complex VII-VIII, and vessels such as the superior petrous vein and the anteroinferior cerebellar artery. With the support of the endoscope, the tumor was better visualized in inaccessible areas, the prepontine cistern was accessed and total resection of the tumor was achieved. The patient evolved favorably with remission of pain on the right side.
Conclusion: The microsurgical technique assisted by endoscopy allows safe removal of the tumor, and it is immensely helpful in the resection of tumors from regions not visible under the microscope.
Keywords: Brain Neoplasms, Trigeminal Nerve, Endoscopy, Cerebellopontine Angle. (source: MeSH NLM
Microsurgical resection of a pontine cavernoma through a far lateral infratentorial supracerebellar approach
CARLOS VASQUEZ P., GONZALO ROJAS D., JOSÉ CALDERÓN S., YELIMER CAUCHA M.
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Introduction: Cavernomas on the posterolateral pontomesencephalic surface can be approached from an extreme lateral supracerebellar infratentorial corridor, although the theory is scarce. The brainstem has a dense concentration of nuclei and fibers that are responsible for a high rate of morbidity when treating brainstem lesions. The objective of this work is to demonstrate the safe microsurgical resection technique for the complete removal of a pontine cavernoma.
Clinical Case: 27-year-old woman with a 5-month history of disease; characterized by headache, left facial paresis, and right half body paresis. Magnetic resonance imaging (MRI) showed a hemorrhage in the middle cerebellar peduncle compatible with a ruptured cavernoma, initially receiving medical treatment. Subsequently, due to an increase in the motor deficit and the presence of keratopathy in the left eye, surgery was decided. A retromastoid craniotomy and an extreme lateral supracerebellar infratentorial approach were performed. A safe entry zone was identified and the cavernoma was completely excised. In the postoperative period, she did not present additional neurological deficit, being extubated at 24 hours, with a score on the Glasgow scale of 15 points. Postoperative brain tomography (CT) showed the absence of the cavernoma.
Conclusion: The far lateral supracerebellar infratentorial approach is safe for the excision of cavernomas with a middle cerebellar peduncle. When combined with the significant reverse Trendelenburg position it results in minimal cerebellar retraction as the cerebellum descends with gravity.
Keywords: Hemangioma, Cavernous, Pons, Middle Cerebellar Peduncle, Craniotomy (source: MeSH NLM)
Intracerebral hematoma caused by Moyamoya disease: a case report
JOHN VARGAS URBINA, GIANCARLO SAAL Z., FERNANDO PALACIOS S.
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Introduction: Moyamoya disease is a chronic occlusive cerebrovascular disease of unknown etiology, characterized by bilateral stenotic and occlusive changes in the terminal portion of the internal carotid, as well as the presence of an abnormal vascular network at the base of the brain. The diagnosis is made with magnetic resonance (MRI) and digital subtraction angiography (DSA), SPECT is useful in the therapeutic decision. The surgical treatment of choice is revascularization.
Clinical Case: A 50-year-old female patient from China, with the Glasgow Coma Scale (GCS) of 9, and a clinical picture of stroke. An admission brain tomography (CT) revealed a right temporal hematoma. Surgical evacuation of the intracerebral hematoma was performed. Cerebral angiography revealed distal stenosis of the internal carotid artery and its branches, being diagnosed with Moyamoya disease. The evolution was favorable, neither a motor deficit nor a decreased level of consciousness (GCS:15) was observed at the time of discharge. A subsequent revascularization surgery was indicated.
Conclusion: Moyamoya disease is a rare cause of intracerebral hematoma but should be suspected in adults of Asian descent. MRI and angiography are the diagnostic methods of choice. Surgical treatment is revascularization, which improves the prognosis.
Keywords: Moyamoya Disease, Cerebral Hemorrhage, Stroke, Cerebral Angiography (Source: MeSH NLM)
Tension pneumocephalus after surgical evacuation of chronic subdural hematoma: case report and pathophysiological mechanism
FERNANDO CELI, GIANCARLO SAAL Z.
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Introduction: Pneumocephalus is a frequent complication following neurosurgical procedures. The diagnosis is based on tomographic findings and the clinical evolution of the patient. Therefore, we detail the physiopathological mechanisms that trigger this complication.
Clinical Case: We present the clinical case of an 85-year-old man who underwent a keyhole craniotomy and subdural drainage placement due to the diagnosis of a chronic subdural hematoma (CSDH) and subsequently developed sudden tension pneumocephalus which triggered the death of the patient due to intracranial hypertension.
Conclusion: Tension pneumocephalus is a life-threatening complication that must be suspected early and must be treated as an emergency.
Keywords: Hematoma, Subdural, Chronic, Pneumocephalus, Drainage, Craniotomy (Source: MeSH NLM)
Extramedullary intradural capillary hemangioma in a patient of 03 months of life: a case report
JOSÉ LUIS URQUIZO, ALFONSO BASURCO C, WILLIAM ANICAMA, ROCÍO TORRES
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Introduction: Capillary hemangioma is an extremely rare endothelial cell neoplasm as an extramedullary intradural tumor. Its presentation in infants is anecdotal and only 2 cases have been previously reported in the literature.
Clinical case: a 03-month-old infant with severe abrupt-onset paraparesis. Spinal magnetic resonance imaging (MRI) showed an intraspinal tumor at the T7, T8, and T9 levels, which captures contrast. A T7-T9 laminectomy and microsurgical resection of the extramedullary spinal tumor were performed. The pathology was reported as lobulated angiomatous proliferation with focal vascular thrombus, with positive immunohistochemistry for CD 31 and 34, compatible with capillary hemangioma. The neurological evolution was favorable. Post-surgical MRI and spinal angiography showed little residual tumor and hydrosyringomyelia in remission.
Conclusion: Capillary hemangioma is a rare pathology in infants, this case being the 3rd case reported. Its diagnosis and surgical resection are important since most patients present an improvement in the neurological deficit after surgery. Surgical treatment avoids the risk of acute bleeding
Keywords: Hemangioma, Capillary, Spinal Cord Neoplasms, Infant, Laminectomy. (Source: MeSH NLM)
Neurosurgical treatment of unstable cervical spine due to rheumatoid arthritis: case series
JORGE ZUMAETA S, ELAR CARI C, ALFONSO BASURCO C, CESAR POLO D, JESUS CABREJOS B, PABLO PINO L, JUAN SALAS G, EDUARDO LAOS P, ROBERT BURGOS C.
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Introduction: Rheumatoid arthritis (RA) is a systemic disease characterized by synovitis, which causes damage to the ligaments and joints. The cervical region is the region of the spine most affected, with neck pain the most frequent symptom. The three forms of presentation are atlantoaxial subluxation, cranial settlement, and subaxial subluxation. The clinical evolution of patients treated conservatively is poor, with surgery being a key element to prevent the progression of neurological deterioration.
Methods: A retrospective study of 10 patients with RA operated between 2015 and 2019 was carried out. Ranawat criteria were used for clinical classification and imaging studies were performed to confirm cervical instability. Anterior and posterior cervical arthrodesis techniques were used. Control after surgery was performed by tomography and the Ranawat score was determined in the outpatient control.
Results: In the period 2015 and 2019, 10 patients with RA who presented symptoms of cervical instability were operated on. All patients were female, aged between 52 and 73 years. The most frequent symptom was neck pain. Most of the patients presented inflammatory markers (ESR, CRP) in high values. The most frequent cervical involvement was atlantoaxial instability. The most common surgical technique used was posterior C1-C2 arthrodesis via the inter-articular approach. Ranawat's classification improved in 90% of patients after surgery. Complications were surgical site infections and rupture of occipitocervical fixation bars, which were adequately resolved.
Conclusions: Surgery for patients with vertebral instability due to RA should be aimed at treating intractable pain and stopping the progression of cervical instability, with the aim of promoting neurological recovery and reducing mortality.
Keywords: Spine, Arthritis, Rheumatoid, Joint Instability, Synovitis, Neck Pain, Arthrodesis. (source: MeSH NLM)
Recurrent lumbar disc prolapse, causative factors and outcome in bangladeshi people
MOSHIUR RAHMAN, MD, EZEQUIEL GARCIA-BALLESTAS, MD, LUIS RAFAEL MOSCOTE-SALAZAR, MD
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Introduction: Recurrent lumbar disc prolapses (RLDP) is not uncommon after surgery. The incidence of RLDP varies from 5-18% across the different populations in the world. The exact cause of recurrence is not known but the weakness of the annular tissue due to previous surgery, exposure to repetitive lifting, heavy work causing axial load, advanced age, smoking, are some of them. RLDP can be managed conservatively, but if that fails, such cases are candidates for surgery. Various surgeries can be done- open versus minimally invasive surgeries, fusion versus non-fusion surgeries are debatable. The study aims to evaluate the causative factors of RLPD and the outcome of surgeries in Bangladeshi peoples.
Methods: A total of 126 cases of RLDP in 1800 lumbar disc surgery patients were included in the study. This study was retrospective and multicenter data were analyzed from 4 private hospitals. The male-female ratio was 3:2. The study period was from 2009 to 2018. The Minimum follows up period was 1 year.
Results: There was a significant risk of RLDP in sex, smoking habit, BMI, and heavy workers. By using these differences, a logistic regression analysis showed that males increased BMI, heavy workers, residual disc particularly under posterior longitudinal ligament, indiscipline life, and smoker could predict lumbar disc herniation recurrence. Minimally invasive surgeries had better outcomes than open surgical methods. Fusion surgeries with stabilization were encouraging.
Conclusions: Patients who are male, increased BMI, heavy workers, indiscipline life, and smoker could predict lumbar disc herniation recurrence. Minimally invasive surgeries under illumination have a better outcome than open surgical methods. Residual disc, particularly under posterior longitudinal ligament, is associated with a high recurrence of symptoms. Patient selection, clinical examination, investigations, and understanding the indications for surgery in recurrent cases is the key to success.
Keywords: Lumbar, Disc, Prolapse, Recurrence (source: MeSH NML)
Hydrocephalus in pediatric population. Experience in the Neurosurgery Department of the Baca Ortiz Pediatric Hospital, Quito-Ecuador, 2016-2019
CARLOS MORALES T., ALICIA TORRES M., JESUS CASTRO V., JOSE BERNAL C., ALEJANDRO CASTRO S.
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Introduction: Hydrocephalus is one of the most common pathologies in the daily care of a Pediatric Neurosurgery Service, so it is important to document the context of its presentation to improve therapeutic behavior. The objective of the present study was to describe the demographic variables, as well as the type, treatment, morbidity, and mortality of patients with hydrocephalus.
Methods: Cross-sectional, retrospective, and descriptive study of children with hydrocephalus who underwent surgery in the Neurosurgery Service of the Baca Ortiz Pediatric Hospital, from January 2016 to December 2018, using the records of the clinical records from the Department of Statistics and archives of the Neurosurgery Service of our Institution.
Results: From January 2016 to December 2018, 287 patients with a diagnosis of hydrocephalus underwent surgery, presenting 63.7% as a congenital cause and 36.2% acquired; with a predominance of males (57.2%). The most common sign for which patients attended the consultation was macrocephaly (52%). Infectious dysfunctions were 10.1% vs. mechanical dysfunctions 4%. Mortality was not related to hydrocephalus, 1% of deaths were associated with systemic infection, and 0.6% with a respiratory infection.
Conclusions: Hydrocephalus in pediatric patients constitutes a frequent pathology that can be accompanied by various comorbidities, hence the importance of its timely diagnosis and adequate treatment.
Keywords: Hydrocephalus, Child, Neurosurgical Procedures, Hospitals, Pediatric. (Source: MeSH NLM)
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Vertebral hydatidosis: case report
JOHN VARGAS U, OSMAR ORDINOLA C, EDUARDO LAOS P, ALFONSO BASURCO C.
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Introduction: Vertebral hydatid cyst is a rare disease with an incidence rate of 0.2-1%. In the spinal cord, it can cause pain and severe disability due to compression and instability. Magnetic resonance imaging (MRI) shows characteristic lesions in T1 and T2. The combination of medical anthelmintic treatment and surgery for cyst excision is the most used strategy.
Clinical Case: A 47-year-old woman with a history of surgery for hepatic hydatidosis associated with intraoperative rupture, with a 7-month history of the disease characterized by oppressive back pain, belt-like back pain, and of increasing intensity up to 10/10, associated with paresthesia in the lower limbs and urinary retention. The MRI revealed a multicystic process in the D5 vertebral body with the invasion of the posterior mediastinum and the spinal canal. The diagnosis was confirmed serologically with IgM and IgG. A D5 corpectomy and excision of the cystic lesion were performed using a D5-D6 costotransversectomy; in addition, a D3-D4 and D6-D7 transpedicular fixation and a D5 body replacement with cylindrical mesh were performed. The evolution was favorable without evidence of recurrence one month after surgery.
Conclusion: Vertebral hydatidosis is a rare pathology that requires surgical management combined with prolonged medical treatment with albendazole. Surgery is complex because the presence of multicystic lesions makes extensive surgical resection without rupture of the cyst membrane difficult. Close monitoring of these patients allows detection of recurrence and favors its early management.
Keywords: Echinococcosis, Spinal Cord, Back Pain, Albendazole, Surgical Mesh (Source: MeSH NLM)
Langerhans cells histiocytosis in the dorsal spine in a pediatric patient
ANNEL MURGA V., ROBERTO BURGOS., ALFONSO BASURCO C., ELAR CARI C., JESÚS CABREJOS B., EDUARDO LAOS P., CÉSAR POLO DE LA P., JUAN SALAS G.
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Introduction: Langerhans cell histiocytosis (LCH) is a rare histiocytic disorder and its incidence is not exactly known. It occurs in all age groups but is more common in the pediatric population. It is characterized by single or multiple osteolytic-type lesions caused by clonal proliferation of cells histologically like Langerhans cells; its clinical presentation is heterogeneous.
Clinical case: An 11-year-old man with a 6-month history of back pain and walking limitation. Magnetic Resonance Imaging (MRI) showed a lesion of the dorsal spine in D8, D9, and D10 and flat vertebra D9 that caused spinal compression. The diagnosis was made based on the histopathological study of the vertebral body with the finding of eosinophilic granuloma, being treated with outpatient chemotherapy, external fixation with a plaster corset, and physical therapy. The clinical evolution was favorable, achieving improvement in muscle strength and walking with support at discharge.
Conclusion: Langerhans cell histiocytosis with vertebral involvement is a highly relevant pathology, despite being rare. Timely diagnosis and adequate treatment are essential since it allows to prevent or limit the spinal cord involvement caused by this pathology.
Keywords: Histiocytosis, Langerhans-Cell, Spine, Back Pain, Eosinophilic Granuloma (Source: MeSH NLM)
Successful management of ruptured cavernous malformation of the pons
JOHN VARGAS U., FERNANDO PALACIOS S., EDUARDO ROMERO V.
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Introduction: Brain stem cavernomas constitute 18-35% of intracranial cavernomas and have the highest bleeding rate of all brain cavernomas. Its annual rebleeding rate is 21 to 60%. Asymptomatic injuries should be treated conservatively, while symptomatic and accessible injuries surgery is recommended. Surgical resection prevents neurological deterioration caused by recurrent bleeding.
Clinical Case: We present the case of a 10-year-old female patient with headache, ataxic gait, left LV PC paresis, and vertigo. A magnetic resonance imaging of the brain (MRI) was carried out, where a ragged expansive process was evidenced in T2 in the posterior protuberance region with intra-tumoral and extra-tumoral hemosiderin deposits. Brain angiography was negative. A medial suboccipital craniotomy with a telovelar approach was performed, achieving total cavernoma resection. The patient was extubated on the 2nd postoperative day. Non-contrast brain tomography (CT) showed no acute complications, only minimal bleeding from the operative bed. Post-surgical brain MRI showed the absence of the lesion. At 7 months, she continued without motor deficit, with adequate gait and Glasgow 15 points.
Conclusion: Brain stem cavernomas are a rare disease with high morbidity. Proper patient choice, surgical approach, and time to surgery decrease post-surgical morbidity.
Keywords: Hemangioma, Cavernous, Central Nervous System, Brain Stem, Craniotomy (Source: MeSH NLM)
Experience in the surgical treatment of pituitary adenomas at the Guillermo Almenara Hospital in 2019-2020
JOHN VARGAS U, GIAN FRANCO REYES N, FERNANDO PALACIOS S, MARCO MEJIA T, JERSON FLORES C, CAMILO CONTRERAS C, MANUEL LAZÓN A, KENNET LOPEZ G, JOHN MALCA B, JOSE-DANIEL FLORES S, EDUARDO ROMERO V.
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Introduction: Pituitary adenomas constitute 25% of the primary benign neoplasms of the brain and can be functional or non-functional, or depending on their size they can be microadenomas, macroadenomas, and giant adenomas. They are mainly treated by surgery using a transcranial or transsphenoidal approach.Objective: To know the experience in the surgical treatment of pituitary adenomas in the Guillermo Almenara National Hospital from January 2019 to May 2020.Methods: Descriptive, retrospective, cross-sectional epidemiological study. 84 cases of patients operated on for pituitary adenoma were found. The data was collected from the medical history and images in the hospital's PACS system. Chi-square was applied as a statistical test.Results: Of the total of patients, 50% were operated by transcranial surgery and 50% by transsphenoidal surgery. Hypertension, Cushing's disease, and acromegaly were statistically significant in favor of transsphenoidal resection. 69.05% were macroadenomas in transsphenoidal resection (TSR) and 61.90% in transcranial resection (TCR). In the TSR there were 4.76% of intraoperative complications, and in the TCR it was 19.05%. The total resection grade was greater than 50% in both groups.Conclusions: Pituitary adenomas are a frequent pathology and can be treated by transcranial or transsphenoidal approach, with good resection rates. Prospective studies are required to determine the causal relationship between the variables. Keywords: Pituitary Neoplasms, Acromegaly, Craniotomy, Endoscopy (Source: MeSH NLM)
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Malfunction of the valvular shunting system in children. Experience in the Neurosurgery Department of the Baca Ortiz Pediatric Hospital, Quito-Ecuador, 2016-2019
JUAN ALEMÁN-IÑIGUEZ, ALICIA TORRES M, JESUS CASTRO V, JOSE BERNAL C.
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Introduction: The prevalence of valve dysfunction (VD) in pediatric centers is high. A descriptive observational study was carried out, the objective of which was to find factors: epidemiological characteristics of hydrocephalus and other derivatives of the ventricle-peritoneal shunt system (VPSS) associated with VD.Methods: All the diagnoses of VD for 3 years in the Neurosurgery Service of the Baca Ortiz Pediatric Hospital (BOPH) were collected, clinical-epidemiological variables associated with hydrocephalus and shunting were selected. VD was defined as the revision of the referral in patients using VPSS for malfunction. Multi-categorical variables and the prevalence of qualitative variables were analyzed using statistical analysis.Results: A total of 376 children were initially subjected to VPSS placement between August 2016 and August 2019. 71 patients with VD were treated, of whom 60 were included in the study; of these 48 were treated at BOPH. Infectious dysfunction was found to be more frequent in children < 1-year, mechanical dysfunction in children > 5 years (64% and 38% respectively p <0.002). Also, the permanence of the VPSS <1 year was more frequent in infectious dysfunctions and the permanence of 1 to 5 years was more related to mechanical dysfunction (72 and 46% respectively p 0.03). The distal catheter dysfunction was more important in mechanical and mixed etiology (65.41 respectively p <0.001) and that of the ventricular catheter in infectious etiology (81% p <0.001). No independent association of VD was found with the etiology of hydrocephalus, the ventricular catheter site or with the Lansky scale.Conclusions: Valvular dysfunction in pediatric hydrocephalic patients is an important complication that warrants further investigation.Keywords: Hydrocephalus, Catheters, Neurosurgical Procedures, Hospitals, Pediatric. (Source: MeSH NLM) |
