Patología Vascular

En esta sección se ponen a disposición de todos los usuarios y pacientes, una lista de publicaciones relacionadas con la Patología Vascular en los que han participado activamente miembros del equipo médico de la Unidad de Neurocirugía

Cavernous angiomas of the lateral ventricles

Rodrigo Carrasco & Manuel Pedrosa & José M. Pascual &Marta Navas & Ricardo Liberal & Rafael G. Sola


Background Cavernous angiomas are vascular malformations which rarely involve the cavities of the lateral ventricles. Knowledge of the specific clinical and neurora- diological features displayed by these lesions is limited by the scarcity of patients included in the reported series. Objective and methods The aim of this study was to compile and analyse the epidemiological, clinical, neurora- diological and surgical characteristics of these lesions as provided by the well-described examples reported in the scientific literature. A total of 49 were gathered, including three patients operated on recently in our Department. Findings and conclusions Cavernomas developing within the ventricular cavities attain a larger size than parenchymal counterpart lesions, causing symptoms and signs derived mainly from the mass effect. The characteristic parenchy- mal hypointense rim is less frequently identified on T2- weighted echo-gradient MRI sequences. Total surgical excision is the treatment of choice for these lesions, yet the surgical routes employed may still be associated with a high rate of neurological complications.

Palabras clave: Cavernoma.Cavernousangioma. Intraventricular tumour . Lateral ventricle

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Surgical treatment of symptomatic cavernous malformations of the brainstem

R. G. Sola, P. Pulido, J. Pastor, M. Ochoa, and J. Castedo


Introduction and objectives. Cavernous malformations (CM) at the level of the brainstem, continue to present a challenge in therapeutic terms and are an important source of controversy. Here we present our experience and the results obtained by adopting surgical treatment.
Materials and methods. The results of a consecutive series of 17 patients were studied. The surgical interven- tion was designed after: 1. A neurological examination. 2. MRI and cerebral angiography. 3. Correlation with anatomical brainstem maps. The surgical intervention was approached from the most damaged zone or through a zone which was functionally least important.
Results. Complete extirpation was achieved in 15 pa- tients without mortality. In a few patients the surgical intervention temporarily aggravated the prior lesion of the cranial nerves (2=17) or damage new sensory tracts (2=17). The functional post-operative recovery was good, in terms of consciousness (4=5), cranial nerves (11=17), the pyramidal tract (3=5) and the cerebellum (2=4). Of the patients that were operated, 14 of 17 returned to their professional activities.
Conclusions. The results of surgery can surpass the morbidity–mortality of the natural history or treatment with radiosurgery. There is a clear consensus in recom- mending surgical intervention for CMs that are super- ficially located, in young patients and in those with a
risk of further bleeding. It is probably best that the surgery is performed during the subacute period, when the MRI offers a clear image confirming the presence of the CM.

Palabras clave: Cavernous malformation; brainstem hem- orrhage; intraoperative neurophysiological monitoring; neuronavigation; radiosurgery.

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La descompresión microvascular en el tratamiento de la neuralgia esencial del trigémino

A. Molina-Foncea, E. García-Navarrete, J.C. Calvo, R.G. Sola


Introduction and objective. We pretend to evaluate the surgical procedure and clinical results of microvascular decompression (MVD) of 21 patients suffering from essential trigeminal neuralgia between 1989 and 1997. Patients and methods. Selection criteria included: ineffectiveness of pharmacological treatment, good general condition, more than five years life expectancy, and do not have undergone ablative-lesive surgical procedures before. Results. After a post-surgical follow-up of between three months and three years, it was obtained a 100% success rate of immediate pain relief, with only a 14.2% recurrence. There were no sequels as those typically found in lesive techniques as paresthesias and dysesthesias, painful and/or corneal anaesthesia and motor disorders. There were no deaths, although there were three cases of post-surgical complications. Conclusions. To evaluate the long-term results of different surgical techniques in the treatment of the essential trigeminal neuralgia is outstanding the patients satisfaction rate, which not only depends on pain relief and absence of recurrence, but also and very specially on the neurological deficiencies following the procedure. So, we consider that MVD is the most effective technique both in symptoms relief and neural functions and structures preservation, even though the possibility of appearance of complications following any major surgery [REV NEUROL 1998; 27: 65-70].

Palabras clave: Long-term results. Microvascular decompression. Radiofrequency rhizotomy. Trigeminal neuralgia.

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Descompresión microvascular de la neuralgia del trigémino causada por dolicoectasia vertebrobasilar

R.G. Sola, M. Escosa-Bage


Introduction. Trigeminal neuralgia due to vertebrobasilar dolichoectasia is an acquired disease whose true inci- dence is not known. Microvascular decompression is the most effective technique both for symptomatic relief and for the conservation of nerve structure and function, in spite of the potential complications of all major surgery. In cases which are drug-resistant and have a life expectancy of over five years, microvascular decompression may be done using several techniques. Clinical cases. We present three cases with drug-resistant trigeminal neuralgia. One patient had a history of previous cere- brovascular ischaemia, another had arterial and pulmonary hypertension. In all cases vertebrobasilar dolichoectasia was seen on magnetic resonance. Microvascular decompression of the trigeminal nerve was done, placing pieces of Teflon between the tentorium and the artery to displace it. Postoperatively the pain disappeared in two cases and was much relieved in the other, making good progress with no complications. Conclusions. Trigeminal neuralgia due to vertebrobasilar dolichoectasia is a progressive acquired disease. The imaging technique of choice is magnetic resonance. Cerebral angiography may be useful for confirmation. This new technique of microvascular decompression avoids excessive manipulation of the ectatic, arteriosclerotic basilar artery and also pulsatile compression, so that the risk of secondary effects is reduced and the efficacy of the decompression maintained. Further cases are needed to confirm the usefulness of this technique. [REV NEUROL 2001; 32: 742-5]

Palabras clave: Megadolichobasilar. Microvascular decompression. Tortuous vertebrobasilar artery. Trigeminal nerve. Trigeminal neuralgia.

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Aneurisma fusiforme de la arteria cerebral media

M. Escosa-Bagé, R.G. Sola, R. Liberal-González, J.L. Caniego, C. Castrillo-Cazón


The main objective of the treatment of intracranial aneurysms is to isolate them from the cerebral blood circulation. A fusiform aneurysm, because of its shape, cannot be treated using the usual techniques and usually requires techniques of arterial reconstruction and revascularization using by-pass. Currently it is possible to find the vascular territories with the greatest risk of causing neurological defects and where revascularization is necessary. Case report. A 20 year old man with no previous history of illness who had several transient ischaemic episodes. Emergency laboratory tests, ECG and plain chest Xray were all normal. Imaging investigations showed the presence of a fusiform aneurysm of the anterosuperior division of the right middle cerebral artery. No associated systemic disease was detected. Wada’s test showed the vascular territory with the greatest risk of neurological deficit. Extra-intra cranial by-pass was done from the right superficial temporal artery to the distal portion of the anteriorsuperior branch of this artery. The operation was done using a right pterion approach with dissection of the superficial temporal artery, and the aneurysm, trapping and termino-lateral anastomosis. Cerebral protectors and mild hypothermia were used during the operation. The post-operative course was uneventful. Anatomo-pathological diagnosis was of an atherosclerotic fusiform aneurysm with osseous and chondroid metaplasia. After six months follow-up the patient remains asymptomatic. Discussion and conclu- sions. Treatment of fusiform cerebral aneurysms is complex and usually requires procedures for cerebral revasculariza- tion. Correct pre-operative evaluation is essential to identify the vascular territory with the greatest risk of causing neurological deficit. Wada’ s test is useful for this, since it permits selective evaluation of the different vascular territories safely and quickly. High or low flow by-pass of these territories prevents cerebral ischaemia and permits the treatment of choice for these aneurysms. [REV NEUROL 2002; 34: 655-8]

Palabras clave: By-pass. Fusiform aneurysm. Intraextracranial by-pass. Transient ischaemic episodes. Wada’ s test.

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Indicaciones quirúrgicas de la hemorragia intracerebral no traumática

M. Escosa-Bagé, R.G. Sola


The treatment of non-traumatic intracerebral hemorrhage is one of the therapeutic challenges at the present time. In spite of present-day technology and advances in understanding its physiopathology, the prognosis is the same as it was fifteen years ago. We review the surgical treatments used to date and their results, and describe new approaches to investigation so as to try to establish the most suitable surgical indications. Development. To date six randomized studies have been done to evaluate surgical treatment as compared with conservative treatment of intracerebral hemorrhage. There is no clear evidence that surgical treatment is better than conservative management. Recent investigations in this field consider cerebral blood flow, oedema and the degradation products of blood. Conclusions. Indications for surgery inintracerebralhemorrhageare: a)cerebralhemorrhage>3cm,withneurologicaldeteriorationorwithsignsofcompression of the brainstem and hydrocephalus due to obstruction of the ventricle; b) hemorrhage associated with an anatomical lesion such as an aneurysm, arteriovenous malformation or cavernous angioma, when the prognosis of the patient is good and the lesion is surgically accessible; c) a young patient with a moderate or large lobular hemorrhage; d) it is recommended that surgery, when applicable, be undertaken during the first 12 hours after onset of the condition; e) when surgery is used, stereotaxic surgery may lead to better results. [REV NEUROL 2001; 32: 1060-2]

Palabras clave: Intracerebral bleeding. Indications. Review. Stroke. Surgical treatment.

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Fístula dural en la unión craneocervical. Presentación de un caso clínico y revisión de la bibliografía

P. Pulido-Rivas, F. Villoria-Medina, F. Fortea-Gil, R.G. Sola


Spinal dural fistulas consist in an artery that penetrates into the dura mater and drains into a perispinal vein. They are most commonly located in the dorsal or lumbar region; a craniocervical position is infrequent. The clinical features presented by these patients involve an progressive ascending myelopathy caused by severe venous hyperten- sion, although they can also start with symptoms of a subarachnoid haemorrhage. Case report. A 62-year-old male with symp- toms of progressive myelopathy due to a dural fistula dependent on meningeal branches of the right PICA, which was treated surgically by fistula clipping performed using an extreme lateral suboccipital approach. In the literature that was reviewed there were 35 cases of dural fistulas located at the craniocervical junction. Conclusions. The existence of clinical features compatible with cervical myelopathy and an anodyne cervical resonance justify the need to perform medullar arteriography owing to a suspected vascular malformation. An early diagnosis of a dural fistula and its proper treatment lead to a dimi- nished morbidity and mortality rate in these patients. [REV NEUROL 2004; 38: 438-42]
Key words.

Palabras clave: Cervical myelopathy. Craniocervical junction. Dural fistula. Extreme lateral approach. Magnetic resonance. Medullar arteriography.

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