Trabajo Premio Senior Neuropinamar 2015]]> RESUMEN
Objetivo: Describir la anatomía microquirúrgica y los abordajes a la región temporal mesial (RTM), en relación a cavernomas de dicho sector
Material y Método: Cinco cabezas de cadáveres adultos, fijadas en formol e inyectadas con silicona coloreada, fueron estudiadas. Además, desde enero de 2007 a junio de 2014, 7 pacientes con cavernomas localizados en la RTM fueron operados por el autor.
Resultados: Anatomía: la RTM fue dividida en 3 sectores: anterior, medio y posterior. Pacientes: 7 enfermos con cavernomas de la RTM fueron operados por el autor. De acuerdo a la ubicación en la RTM, 4 cavernomas se ubicaron en el sector anterior, 2 cavernomas se localizaron en el sector medio y 1 cavernoma se ubicó en el sector posterior. Para el sector anterior de la RTM se utilizó un abordaje transsilviano-transinsular; para el sector medio de la RTM se utilizó un abordaje transtemporal (lobectomía temporal anterior); y para el sector posterior de la RTM se utilizó un abordaje supracerebeloso-transtentorial.
Conclusión: Dividir la RTM en 3 sectores nos permite adecuar el abordaje en función a la localización de la lesión. Así, el sector anterior es bien abordable a través de la fisura silviana; el sector medio a través de una vía transtemporal; y el sector posterior por un abordaje supracerebeloso.

Palabras clave: Abordaje; Anatomía; Cavernoma; Cuerno Temporal; Lóbulo Temporal

ABSTRACT
Objective: To describe the microsurgical anatomy and approaches to the mesial temporal region (MTR), in relation with cavernomas.
Material and Method: Five adult cadaveric heads, fixed in formol and injected with colored silicon were studied. Since January 2007 and June 2014, the author operated 7 patients with cavernomas located in the MTR.
Results: Anatomy: the MTR was divided in 3 portions: anterior, middle and posterior. Patients: the author operated 7 patients with MTR cavernomas. Four cavernomas were located in the anterior portion, 2 were located in the middle portion, and 1 cavernoma was located in the posterior portion. The transsylvian-transinsular approach was used for the anterior portion of the MTR; the transtemporal approach (anterior temporal lobectomy) was used for the middle portion of the MTR; and the supracerebellar-transtentorial approach was used for the posterior portion of the MTR.
Conclusion: The idea of divide the MTR in 3 portions help to select the correct approach.

Key words: Anatomy; Approach; Cavernoma; Temporal Horn; Temporal Lobe

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    • ]]>         Trabajo Premio Junior Neuropinamar 2015]]> RESUMEN
    Objetivo: Analizar en forma prospectiva la viabilidad de una neurorrafia mediante técnicas microquirúrgicas, en un modelo experimental con diferentes grados crecientes de pérdida de tejido nervioso periférico.
    Introducción: Para reparar un nervio periférico que tiene pérdida de tejido, clásicamente este defecto se suple por un injerto autólogo. Sin embargo, se produce comorbilidad en el sitio dador y sus resultados siempre son inferiores a la sutura directa sin tensión. Existe una opción para evitar el uso de injertos cuando el defecto es escaso, colocando puntos epineurales distales (PED) a la neurorrafia, eliminando así la tensión en dicha unión.
    Materiales y métodos: Se utilizaron 40 ratas Wistar, dividiéndose aleatoriamente en 4 grupos. Bajo anestesia general se abordó al nervio ciático y se efectuó sección trasversal y sutura simple con nylon 10.0 al grupo A (control). Se realizó exéresis de 2 mm de nervio al grupo B, de 4 mm al grupo C y de 6 mm al grupo D; para luego realizar PED. Se realizaron determinaciones de índice de función ciático (análisis de las huellas), velocidad de conducción (electrofisiología) e índice de regeneración (histopatología) para evaluar la viabilidad de la neurorrafia. Se confrontaron los diferentes grupos planteados con ANOVA, considerando significativo un valor de p < 0.05.
    Conclusiones:La neurorrafia simple no evidencia diferencias estadísticamente significativas con la reparación de 2mm de pérdida de tejido mediante PED en la rata Wistar.

    Palabras Claves: Neurorrafia con Tensión; Experimentación en Sistema Nervioso Periférico; Puntos Epineurales Distales; Injertos Nerviosos

    ABSTRACT
    Objective: To analyze, in a prospective way, the viability of a neurorraphy by a microsurgical technique, in an experimental model with different increasing grades of peripheral nerve tissue loss.
    Introduction: In order to repair a peripheral nerve that has experienced some grade of substance loss, autologous grafts have been used by most neurosurgeons. However, comorbidities in the donor site are produced, and the results obtained are always inferior compared to the ones achieved by using a direct suture without tension. There is an option to avoid using grafts when the defect is scarce, which is the confection of distal epineural sutures (DES) to the neurorraphy, discarding any tension in this junction site.
    Materials and methods: We have used 40 Wistar rats, randomly separated into 4 groups. In ‘Group A’, under complete anesthesia, the sciatic nerve was dissected and transversely sectioned and then sutured with a 10.0 nylon suture. Furthermore we made a 2 mm extirpation in ‘Group B’, a 4 mm one in ‘Group C’ and a 6 mm one in ‘Group C’, in order to perform a DES technique. Our group also ran a sciatic nerve function test (footprint analysis), conduction speed (by electrophysiology), and even determined the nerve regeneration index (histopathology) to estimate the viability of the neurorraphy. The different groups were confronted with ANOVA, considering a value of p<0.05 as statistically significative.
    Conclusions: Simple neurorraphy exposed no statistically significative differences in comparison to the reparation of a 2 mm tissue loss with DES technique, in the Wistar rat model.

    Key Words: Tension Neurorraphy; Peripheral Nervous System Experimentation; Distal Epineural Sutures; Nervous Grafts

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    96. Vazquez-Jimenez JF, Sachweh JS, Seipelt R, Seghaye MC, Messmer BJ. Aortopexy reduces anastomosis stress after repair of coarctation. Ann Thorac Surg. 2001;72(1):294–5.
    ]]>         Premio Video Neuropinamar 2015]]> RESUMEN
    Objetivo: Descripción de la resolución quirúrgica de un aneurisma complejo, gigante de circuito posterior (arteria cerebelosa posteroinferior), embolizado previamente, y la evolución postoperatoria.
    Descripción: Paciente de 48 años de edad con antecedentes de hidrocefalia obstructiva, e hipertensión de fosa posterior, la cual fue tratada por vía endovascular hace 4 años, con colocación de derivación ventricular, y craniectomía descompresiva de fosa posterior, con evolución progresiva de déficit de pares craneales bajos, y síndrome de hipertensión endocraneana.
    Intervención: Se realizó abordaje extremo lateral con drilado parcial del cóndilo occipital, control proximal de la arteria vertebral, y reconstrucción de la pared aneurismática del sector arteria vertebral- arteria cerebelosa posteroinferior (PICA), mediante microcirugía, con posterior apertura del saco dural y remoción de coils y trombosis intraaneurismática, removiendo el efecto de masa aneurismático.
    Conclusión: El tratamiento microquirúrgico con la técnica de la reconstrucción parietal del aneurisma y el control proximal del mismo, en conjunto con abordajes de base de cráneo permiten el definitivo y adecuado tratamiento para los aneurismas gigantes de la pica.

    Palabras Claves: Aneurisma Cerebral; Aneurisma PICA; Abordaje Extremo Lateral; Circuito Posterior; Tratamiento Neuroquirúrgico

    ABSTRACT
    Objective: To describe the surgical treatment for complex, giant, embolized, PICA aneurysm and the follow up.
    Description: 48 years old, female patient with clinical history of obstructive hydrocephalus and posterior fossa´s hipertension. The treatment was endovascular surgery with coils and venricular shunt with posterior fossa´s deccompresive surgery 4 years ago. The clinical evolution was poor. Due to low cranial nerves déficit and progressive posterior fossa´s hipertension, we performed microsurgical treatment
    Intervention: We performed extreme lateral approach with partial drilling of occipital condile, wiht proper proximal vascular vertebral control, and vascular parietal artery reconstruction in the vertebral-posterior inferior cerebellar artery (PICA) aneurysmatic segment,with microsurgery, posterior opening of the dome and coils remotion.
    Conclusion: Microsurgical treatment with reconstruction parietal technique, proximal vascular control and skull base approaches are the definitive and more adecuated treatment for giant PICA aneurysms.

    Key Words: Cerebral Aneurysm; Pica Aneurysm; Extreme Lateral Approach; Posterior Circulation; Neurosurgical Treatment

    ]]>     BIBLIOGRAFÍA

    1. Abdulrauf S.I. EC-IC bypass for giant aneurysms. En Abdulrauf S.I., ed. Cerebral revascularization. Philadelphia. Elsevier Saunders, 2011: 231-245.
    2. Ausman JI, Diaz FG, Sadasivan B, Gonzeles-Portillo M Jr, Malik GM, Deopujari CE. Giant intracranial aneurysm surgery: the role of microvascular reconstruction. Surg Neurol. 1990;34(1):8-15.
    3. Hosobuchi Y. Giant intracranial aneurysms. En: Wilkins RH, Rengachary SS, eds. Neurosurgery. New York, NY: McGraw-Hill; 1985:1404-1414.
    4. Kodama N, Suzuki J. Surgical treatment of giant aneurysms. Neurosurg Rev. 1982; 5(4):155-160.
    5. Lawton MT, Spetzler RF. Surgical management of giant intracranial aneurysms: experience with 171 patients. Clin Neurosurg. 1995;42:245-266.
    6. Ljunggren B, Brandt L, Sundbarg G, Saveland H, Cronqvist S, Stridbeck H. Early management of aneurysmal subarachnoid hemorrhage. Neurosurgery. 1982;11(3): 412-418.
    7. Lozier AP, Kim GH, Sciacca RR, et al. Microsurgical treatment of basilar apex aneurysms: perioperative and long-term clinical outcome. Neurosurgery 2004;54:286–96.
    8. Ogilvy CS, Carter BS. Stratification of outcome for surgically treated unruptured intracranial aneurysms. Neurosurgery 2003;52:82–87.
    9. Parkinson R, Eddleman C, Batjer H, Bendok B. Giant cranial aneurysms: endovascular challenges. Neurosurgery 2006 59: s3103-112.
    10. Peerless S, Wallace M, Drake C. Giant intracranial aneurysms. En: Youmans JR, ed. Neurological Surgery: A Comprehensive Reference Guide to the Diagnosis and Management of Neurological Problems. 3 ed. Philadelphia, PA:WB Saunders; 1990: 1764-1806.
    11. Rivas J.; Domínguez J.; Bravo P.; Pérez J., Avila A. Aneurisma disecante de la arteria cerebelosa posteroinferior. Neurocirugía 2007; 18: 232-237.
    12. Sullivan BJ, Sekhar LN, Duong DH, et al. Profound hypothermia and circulatory arrest with skull base approaches for treatment of complex posterior circulation aneurysms. Acta Neurochir (Wien) 1999;141:1–11.
    13. Sundt TM. Results of surgical management. En: Sundt TM Jr, ed. Surgical Techniques for Saccular and Giant Intracranial Aneurysms. Baltimore, MD: Williams and Wilkins; 1990:19-23.
    14. Symon L, Vajda J. Surgical experiences with giant intracranial aneurysms. J Neurosurg. 1984;61(6):1009-1028.
    15. Yasargil M. Giant intracranial aneurysms. En: Yasargil MG, ed. Microneurosurgery, Volume 2: Clinical Considerations: Surgery of the Intracranial Aneurysms and Results. New York, NY: Thieme-Stratton; 1984:296-304.
    ]]>         Premio Póster Neuropinamar 2015]]> Premio AANC para Global Spine]]> RESUMEN
    Objetivo: Realizar osteotomías cervicales en preparados cadavéricos, siguiendo la clasificación moderna de 7 grados según Ames y colaboradores, tomando fotos 3D para poner en evidencia la magnitud de resección ósea de cada uno de los subtipos.
    Material y Métodos: Se utilizaron dos preparados cadavéricos formolizados con inyección vascular, realizándose imágenes fotográficas en 3 dimensiones de los mismos. Las fotografías fueron tomadas con una camara Nikon D90, con lente 50 mm Af 1.8G, flash Nikon SB700, y una barra regulable para fotografía. Se realizó sobre las preparaciones cadavéricas la disección cervical con incisión en línea media posterior y abordaje por vía anterior segun Smith y Robinson. Se efectuó la exposición muscular y esquelitización ósea con exposición de láminas, apófisis espinosas, facetas articulares, ligamentos, discos, apófisis unciformes y cuerpos vertebrales. Mediante la utilización de un drill neumático de alta velocidad se realizaron 8 osteotomías, 4 por vía posterior y 4 por vía anterior.
    Resultados: Las osteotomías realizadas por vía anterior fueron la discectomía anterior completa (denominada osteotomía grado I anterior), la corpectomía parcial o total incluyendo discectomía superior e inferior (denominada osteotomía grado III), la resección completa de la unión uncovertebral o articulación de Luschka (denominada osteotomía grado IV) y la resección vertebral completa o espondilectomía (denominada osteotomía grado VII). Por vía posterior, se realizaron la facetectomía parcial (denominada osteotomía grado I posterior), la facetectomía total u osteotomía de Ponte (denominada osteotomía grado II), la osteotomía de apertura angular (denominada osteotomía grado V) y la osteotomía de cierre angular o de sustracción pedicular (denominada osteotomía grado VI). Las imágenes fotográficas obtenidas fueron procesadas con los siguientes softwares con técnica anaglífica: Anaglyph Maker versión 1.08 y StereoPhoto Maker versión 4.54.
    Discusión: Las osteotomías vertebrales constituyen gestos quirúrgicos útiles para la corrección de las deformidades espinales cervicales. A pesar de las distintas variantes técnicas de las mismas, no existía hasta hace poco un sistema que permitiera su nomenclatura y clasificación. Ames y colaboradores proponen en 2013 una nomenclatura para este tipo de maniobras, clasificándolas en 7 grupos con distintos. El aporte de la anatomía en 3D permitió mejorar la compresión del grado de resección ósea necesario para cada tipo de osteotomía, y visualizar las estructuras nerviosas y vasculares en riesgo en cada tipo de abordaje.

    Palabras Claves: Osteotomías Cervicales; Osteotomía De Ponte; Osteotomía 3D; Deformidad Cervical

    ABSTRACT
    Objective: To perform cervical osteotomies in cadaveric specimens, following the new classification of Ames et al. 3D pictures were taken to show the amount of bone resection on each subtype.
    Material & methods: Using two formolized cadaveric specimens with vascular injection, we took 3D pictures of osteotomies following the Ames et al classification of cervical osteotomies. The pictures were taken with a Nikon D90 camera, with a 50 mm lens Af 1.8G, Nikon SB700 flash, and an adjustable titanium frame designed to take 3D pictures. Anterior cadaveric dissections were made based on the Smith & Robinson technique. We also performed a posterior approach to expose laminar surfaces, spinous processes, facets complexes, ligaments, discs, uncovertebral joints and vertebral bodies. With the aid of a pneumatic drill, 8 osteotomies (4 anterior and 4 posterior) were progressively made and pictured.
    Results: The anterior osteotomies were: discectomy, corpectomy, discectomy with uncovertebral resection and spondilectomy. Posterior osteotomies were: partial facetectomy, complete facetectomy (Ponte), open wedge osteotomy and closing wedge osteotomy (pedicle substraction). Pictures were processed and fused with Anaglyph Maker 1.08 and StereoPhoto Maker 4.54.
    Conclusions: Cervical osteotomies are useful surgical maneuvers to correct spinal deformities. 3D anatomy helps to understand the degree of bone resection needed to make each osteotomy, exposing nervous and vascular structures at risk in these procedures.

    Key Words: Cervical Osteotomies; Ponte Osteotomy; 3D Osteotomies; Cervical Deformities

    ]]>     BIBLIOGRAFÍA

    1. Abumi K, Shono Y, Taneichi H, Ito M, Kaneda K: Correction of cervical kyphosis using pedicle screw fixation systems. Spine (Phila Pa 1976) 24:2389-2396, 1999.
    2. Ames CP, Blondel B, Scheer JK, Schwab FJ, Le Huec JC, Massicotte EM, et al: Cervical radiographical alignment: comprehensive assessment techniques and potential importance in cervical myelopathy. Spine (Phila Pa 1976) 38:S149-160, 2013.
    3. Ames CP, Smith JS, Scheer JK, Shaffrey CI, Lafage V, Deviren V, et al: A standardized nomenclature for cervical spine soft-tissue release and osteotomy for deformity correction: clinical article. J Neurosurg Spine 19:269-278, 2013.
    4. Kim HJ, Piyaskulkaew C, Riew KD: Anterior cervical osteotomy for fixed cervical deformities. Spine (Phila Pa 1976) 39:1751-1757, 2014.
    5. O'Shaughnessy BA, Liu JC, Hsieh PC, Koski TR, Ganju A, Ondra SL: Surgical treatment of fixed cervical kyphosis with myelopathy. Spine (Phila Pa 1976) 33:771-778, 2008.
    6. Robinson R, Smith G: Anterolateral cervical disc removal and interbody fusion for cervical disc syndrome. Bull Johns Hopkins Hosp 96:223-224, 1955.
    7. Samudrala S, Vaynman S, Thiayananthan T, Ghostine S, Bergey DL, Anand N, et al: Cervicothoracic junction kyphosis: surgical reconstruction with pedicle subtraction osteotomy and Smith-Petersen osteotomy. Presented at the 2009 Joint Spine Section Meeting. Clinical article. J Neurosurg Spine 13:695-706, 2010.
    8. Scheer JK, Tang JA, Smith JS, Acosta FL, Jr., Protopsaltis TS, Blondel B, et al: Cervical spine alignment, sagittal deformity, and clinical implications: a review. J Neurosurg Spine 19:141-159, 2013.
    9. Simmons ED, DiStefano RJ, Zheng Y, Simmons EH: Thirty-six years experience of cervical extension osteotomy in ankylosing spondylitis: techniques and outcomes. Spine (Phila Pa 1976) 31:3006-3012, 2006.
    10. Tang JA, Scheer JK, Smith JS, Deviren V, Bess S, Hart RA, et al: The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery. Neurosurgery 71:662-669; discussion 669, 2012.
    11. Wollowick AL, Kelly MP, Riew KD: Pedicle subtraction osteotomy in the cervical spine. Spine (Phila Pa 1976) 37:E342-348, 2012.
    12. Zdeblick TA, Bohlman HH: Cervical kyphosis and myelopathy. Treatment by anterior corpectomy and strut-grafting. J Bone Joint Surg Am 71:170-182, 1989.
    ]]>         RESUMEN
    Objetivo: describir, paso a paso, la realización de un abordaje pterional (AP).
    Descripción: Posición: El paciente es colocado en decúbito dorsal, con la cabeza rotada contralateral y deflexionada. Incisión: se extiende desde la línea media hasta el borde inferior del arco cigomático, 1 cm adelante del trago. Disección interfascial: tiene varios referentes anatómicos: la arteria temporal superficial, el reborde orbitario y al arco cigomático en su porción inferior. La incisión se inicia en la línea temporal superior, 2 cm posterior del reborde orbitario, y se extiende en dirección al sector medio del arco cigomático. Desinserción del músculo temporal: se procede a realizar un corte muscular hasta alcanzar el plano óseo, y se realiza una disección subperióstica. Craneotomía: la remoción ósea debe lograr una exposición suficiente de la fisura silviana, con mayor exposición del lóbulo frontal; así, deben exponerse los giros frontales medio e inferior y el giro temporal superior. Apertura dural: en dos colgajos, uno frontal y otro temporal.
    Conclusión: el AP constituye aún hoy día una técnica actual y vigente, que se resiste a ser olvidada, cuya aplicación juiciosa permite acceso a un gran numero de patologías de la base de cráneo anterior y media.

    Palabras clave: Abordaje Pterional; Base de Cráneo; Fisura Silviana; Microcirugía

    ABSTRACT
    Objective: the aim of this study is to describe, step by step, the pterional approach.
    Description: position: the patient is placed supine, and the head rotated and also deflected. Incision: from the midline to de zygomatic arch, 1 cm in front of the tragus. Interfascial dissection: the landmarks: superficial temporal artery, orbital rim and zygomatic arch. The incision started at the level of the superior temporal line, 2 cm posterior to the orbital rim, and is pointed to the middle portion of the zygomatic arch. Temporal muscle displacement: after a transversal section of the upper portion of the muscle, it is detached in a subperiosteal fashion. Craniotomy: the osseous removal should expose the sylvian fissure and the middle and inferior frontal gyrus and also the superior temporal giri. Dural opening: in two flaps (frontal and temporal).
    Conclusion: the pterional approach is still, nowadays, a valid and current technique. This approach allows treating many lesions located in the anterior and middle cranial fossa.

    Keywords: Microsurgery; Pterional Approach; Skull Base; Sylvian Fissure

    ]]>     BIBLIOGRAFÍA

    1. Altay T, Couldwell WT: The frontotemporal (pterional) approach: an historical perspective. Neurosurgery 2012; 71:481-92.
    2. Campero A, Socolovsky M, Martins C, Yasuda A, Torino R, Rhoton AL: Facial-zygomatic triangle: a relationship between the extracranial portion of facial nerve and the zygomatic arch. Acta Neurochir (Wien) 2008; 150:273-8.
    3. Campero A, Martins C, Socolovsky M, Torino R, Yasuda A, Domitrovic L, Rhoton AJr: Three-piece orbitozygomatic approach. Neurosurgery 2010; 66(3 Suppl Operative):E119-20.
    4. Campero A, Campero AA, Socolovsky M, Martins C, Yasuda A, Basso A, Rhoton A: The transzygomatic approach. J Clin Neurosc 2010; 17:14233.
    5. Campero A, Ajler P, Emmerich J: Abordaje Pterional. En: Campero A, Ajler P, Emmerich J, editores. Abordajes neuroquirurgicos al cerebro y la base del cráneo. Primera Edición, Buenos Aires, Ediciones Journal, 2013; pp
    6. Chaddad Neto F, Carvalhal Ribas G, de Oliveira E: A craniotomia pterional, descriçao passo a passo. Arq Neuropsiquiatr 2007; 65:101-6.
    7. Coscarella E, Vishteh AG, Spetzler RF, Seoane E, Zabramski JM: Subfascial and submuscular methods of temporal muscle dissection and their relationship to the frontal branch of the facial nerve, J Neurosurg 2000; 92:877-80.
    8. Kadri PA, Al-Mefty O: The anatomical basis for surgical preservation of temporal muscle, J Neurosurg 2004; 100:517-22.
    9. Yasargil MG, Fox JL, Ray MW: The operative approach to aneurysms of the anterior communicating artery. En: Krayenbül H editores. Advances and technical standards in neurosurgery. Springer-Verlag, 1975; pp 114-70.
    ]]>         BIBLIOGRAFÍA

    1. Blümcke I,Thom M, Aronica E, Armstrog DD, Vinters HV, et al. The clinicopathologic spectrum of focal cortical dysplasia: A consensus classification proposed by an ad hoc Task Force of the ILAE Diagnostic Method Commission. Epilepsia 2011; 52(1): 158 – 174.
    2. Benbadis SR, Wyllie E, Bingaman WE.Intracranial Electroecephalography and Localization Studies. In:Wyllie E (ed): The Treatment of Epilepsy. Philadelphia. Lippincott Williams and Wilkins. 2006; chapter 77; pp. 1059 – 1067.
    3. Engel J (Jr), Van Ness PC, Rasmussen TB, Ojeman LM: Outcome with respect to epileptic seizures. In: Engel J (Jr) (ed): Surgical Treatment of the Epilepsies. Raven Press. New York. 1993. Chapter 52 pp. 609 – 21d.
    4. González Martinez JA, Najm IM, Bingaman WE, Ruggieri P: Epilepsy Surgery in Focal Malformation of Cortical Development. In: Wyllie E (ed): The treatment of epilepsy. Lippincott Williams and Wilkins.2006; chapter 8, pp. 1103 – 1110.
    5. Hamer HM, Snake S. The epileptogenic lesion: general principles. In: Lüders HO (ed): Epilepsy Surgery. Informa Healthcare 2008. Chapter 81, pp. 711 – 715.
    6. Herrera EJ, Palacios C, Suárez JC, Pueyrredón FJ, Surur A, Theaux R, Perez Fonticiella S, Viano JC. Epilepsy Surgery in MRI Negative Patient. J Bras Neurocirurg 2012; 23(4): 328 – 331.
    7. Hetherington HP, Pan JW, Spencer DD. 1H and 31P spectroscopy and bioenergetics in the lateralization of seizures in temporal lobe epilepsy. J Magn Reson Imaging 2002; 16: 477 – 483.
    8. Knake S, Grant PE. Magnetic resonance imaging techniques in the evaluation for epilepsy surgery. In: Wyllie E (ed): The treatment of epilepsy. Principles and Practice. Philadelphia. Lippincott Williams and Wilkins. 2004.
    9. Lubienieck F, Sandrone S, Bartuluchi M, Pomata H, Taratuto A. Patología de las malformaciones del desarrollo cortical en pacientes con epilepsia refractaria. Experiencia en un Hospital Pediátrico. Rev. Argent. Neuroc 2010; 24: S83 – S92.
    10. Palacios C, Suárez JC, Nieto F, Herrera EJ, Pueyrredón FJ, Surur A, Theaux R, Ryan JM, Viano JC. Cirugía de epilepsia con electrocorticografía intraoperatoria. Rev Arg de Neurocirur 2014; 28(2): 63-67.
    11. Petre CA, Pomata HB. Cirugía en dos tiempos en epilepsia refractaria. Utilidad de los electrodos intracraneanos crónicos. Experiencia en población pediátrica y adulta. Rev Argnt Neurocirug 2004; 18: 51 – 56.
    12. Pomata HB, Bartuluchi M, Lubienieck F, Pociecha J, Caraballo R, Cáceres E, Vazquez C, Petre C, D´Giano C.: Malformación Del Desarrollo Cortical.Nuestra experiencia acerca de 150 casos. Rev.Argent. Neurocir. 2010; 24: S93 – S103.
    13. Pomata HB. Cirugía de la Epilepsia. Parte 1. Rev.Argent.Neuroc. 1999; 13: 39 – 45.
    14. Spencer S. The relative contributions of MIR, SPECT and PET imaging in epilepsy. Epilepsia 1994; 35 (suppl 6): S72 – S89.
    15. Suárez JC, Palacios C, Herrera EJ, Pueyrredón FJ, Surur A, Theaux R, Suárez MS, Ryan JM, Viano JC. Cirugía de epilepsia lesional en niños y adolescentes. Rev. Argent Neuroc 2012; 26, pp. 119 – 124.
    16. Suárez JC, Palacios C, Herrera EJ, Nieto F, Pueyrredón FJ, Surur A, Theaux R, Suárez MS, Ryan JM, Viano JC. Cirugía de la epilepsia lesional en adultos. Revista Neurotarget, 2013; vol 8 (1): 15 – 21.
    17. Thom M, Sisodiya S: Pathology of neocortical epilepsy. In: Lüders HO (ed): Epilepsy Surgery. Informa Healthcare 2008. Chapter 142, pp. 1338 - 1348.
    ]]>         Revisión sistemática cualitativa]]> RESUMEN
    El tratamiento de la Enfermedad Metastásica Cerebral única es paliativo y multimodal desconociéndose con certeza la modalidad o combinación terapéutica óptima. Se planteó como objetivo determinar las diferencias entre la Radioterapia Holocraneal, Radiocirugía, y Resección Quirúrgica en cuanto a la Sobrevida Global, Sobrevida Con Independencia Funcional, Control Local, Muerte Neurológica y Neurocognición en los pacientes con enfermedad metastásica cerebral única con tumor primario controlado. Se realizó un estudio retrospectivo del tipo revisión sistemática cualitativa. Se incluyeron Ensayos Clínicos Aleatorizados que compararon la Cirugía (con o sin Radioterapia Holocraneal), con la Radiocirugía (con o sin Radioterapia Holocraneal) en la Enfermedad Metastásica Cerebral Única independientemente de la localización del tumor primario. La búsqueda encontró inicialmente 971 artículos, de ellos 19 Ensayos Clínicos Aleatorizados. Al aplicar la herramienta de riesgo de sesgos de Cochrane se derivó una muestra de 14 Ensayos Clínicos que presentaron bajo riesgo de sesgos. La combinación de RQ y RTH ofreció mayor SG que la RTH sola. La combinación de RTH y RC ofreció un mejor CL que la RQ y RTH. La combinación de RTH Y RC ofreció un mejor CL y SG que la RTH sola. No se encontraron diferencias significativas entre la RTH y RC versus RC sola. Los resultados en cuanto a la neurocognición y SIF fueron inconsistentes. El tratamiento óptimo de los pacientes con EMC aún no está bien definido constituyendo aún un tema controvertido.

    Palabras clave: Metástasis Cerebral; Metástasis Solitaria; Metástasis Única; Tratamiento Multimodal; Radiocirugía; Radioterapia Holocraneal; Resección Quirúrgica

    ABSTRACT
    The treatment of Isolated Cerebral Metastatic Disease is both multimodal and palliative. At present, the optimal treatment protocol is unknown. The objective of the present study was to determine outcome differences between Whole Brain Radiotherapy (WBRT), Radiosurgery (RS), and Surgical Resection (SR) or a combination of them, regarding Global Survival, Functional Independent Survival, Local Control, Neurological Death & Cognitive Status in patients with a unique cerebral metastasis and a controlled primary tumor. A retrospective study with a systematic qualitative literature review was performed. Randomized clinical trials comparing surgery (with or without whole brain radiotherapy), disregarding the localization of the primary tumor, were searched, resulting in 971 studies, only 19 of them being randomized. After applying Cochrane´s Risk of Bias Tool, only 14 studies showed a low risk of bias. The combination of SR & WBRT showed a longer survival, while WBRT & RS showed a better local control when compared with SR & WBRT. No statistical differences where found between WBRT & RS versus RS alone. Results regarding Cognitive Status & Functional Independent Survival were inconsistent. The optimal treatment in Isolated Metastatic Cerebral Disease still remains controversial.

    Key words: Cerebral metastasis, Isolated Metastasis, Unique Metastasis, Multimodal treatment, Radiosurgery, Whole Brain Radioterapia, Surgical Resection.

    ]]>     BIBLIOGRAFÍA

    1. Tsao MN, Rades D, With A, Lo SS, Danielson BLl Laurie G et al. Radiotherapeutic and surgical management for newly diagnosed brain metastasis (es): An American Society for Radiation Oncology evidence-based guideline. Practical Radiation Oncology. 2012; 2 issue3: 210-225.
    2. Brown PD, Pugh S, Laack NN, Weffel JS, Khuntia D, Meyers C et al. Memantine for the prevention of cognitive dysfunction in patients receiving Whole-brain radiotherapy: a randomized, double-blind, placebo-controlled trial. Neuro Oncol 2013 Oct; 15(10): 1429-1437.
    3. RTOG-0933. A Phase II trial of hippocampal avoidance during whole brain radiotherapy for brain metastases. Ongoing Study.
    4. Kazda T, Jancalek R, Pospisil P, Sevela O, Prochazka T, Vrzal M et al. Why and how to spare the hippocampus during brain radiotherapy: the developing role of hippocampal avoidance in cranial radiotherapy. Radiation Oncology 2014; 9: 139.
    5. Kocher M, Soffietti R, Abacioglu U, Villa S, Fauchon F, Baumert BG et al. Adjuvant whole-brain radiotherapy versus observation after radiosurgery or surgical resection of one to three cerebral metastasis: Results of the EORTC 22952-26001 Sudy. J Clin Oncol 2011; 29: 134-41.
    6. Yoo H, Kim YZ, Nam BH, Shin SH,Yang HS,Lee JS et al. Reduced local recurrence of a single brain metastasis through microscopic total resection. J Neurosurg 2009; 110; 730-6.
    7. Jarvis LA, Simmons NE, Bellerive M, Erkmen K, Eskey CJ, Glastone DJ et al. Tumor bed dynamics after surgical resection of brain metastases implications for postoperative radiosurgery. Int J Radiat Oncol Biol Phys 2012; 84, 943-8.
    ]]>