el estado del arte]]> desde el desarrollo de la neuromodulación. Podemos dividir su historia en 3 etapas: la primera comienza en los inicios
de la psicocirugía y termina con el desarrollo de las técnicas estereotácticas, cuando comienza la segunda etapa.
Ésta se caracteriza por la realización de lesiones estereotácticas. Nos encontramos transitando la tercera etapa, que
comienza cuando la estimulación cerebral profunda (ECP) empieza a ser usada en CTC.
Objetivo: el propósito de este artículo es realizar una revisión no sistemática de la historia, indicaciones actuales,
técnicas y blancos quirúrgicos de la CTC.
Resultados: a pesar de los errores graves cometidos en el pasado, hoy en día, la CTC está renaciendo. Los trastornos
psiquiátricos que más frecuentemente se tratan con cirugía y los blancos estereotácticos preferidos para cada uno de
ellos son: cápsula interna/estriado ventral para trastorno obsesivo-compulsivo, cíngulo subgenual para depresión y
complejo centromediano/parafascicular del tálamo para síndrome de Tourette.
Conclusión: los resultados de la ECP en estos trastornos parecen alentadores. Sin embargo, se necesitan más
estudios randomizados para establecer la efectividad de la CTC. Debe tenerse en cuenta que una apropiada selección
de pacientes nos ayudará a realizar un procedimiento más seguro así como también a lograr mejores resultados
quirúrgicos, conduciendo a la CTC a ser más aceptada por psiquiatras, pacientes y sus familias. Se necesita mayor
investigación en varios temas como: fisiopatología de los trastornos del comportamiento, indicaciones de CTC y
nuevos blancos quirúrgicos.]]> Objective: This article reviews the history, current indications, techniques and surgical targets of SBD.
Results: Despite serious errors committed in the past, SBD is now re-emerging as an accepted therapeutic approach. The psychiatric disorders that are most frequently treated by surgery and the preferred stereotactic targets for treating them are: the internal capsule/ventral striatum for obsessive-compulsive disorder; the subgenual cingulate for treatment-resistant depression; and the centromedianum/parafascicularis complex of the thalamus for Tourette syndrome.
Conclusions: Early results for DBS in these disorders are encouraging. However, more randomized trials are needed to establish the effectiveness of SBD. It must be taken into account that ensuring proper patient selection will enhance both procedural safety and effectiveness, leading to SBD being more accepted by psychiatrists, patients and their families. Further research is needed in several areas, like the physiopathology of behavioral disorders, indications for SBD, and new surgical targets. ]]>
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    • ]]>         Casos Clínicos: se presenta el caso de una paciente de sexo femenino de 57 años con cuadro de un año de evolución con parestesias en las extremidades y debilidad del hemicuerpo derecho, el diagnóstico de Hernia Medular Transdural Idiopática se hizo con imágenes de Resonancia Magnética y con una Mielografía por TAC.
    En el segundo caso una paciente de 46 años con dolor cervical y parestesias en los miembros inferiores. Los estudios con Resonancia Magnética demostraron una Hernia Medular Transdural. En los dos casos dado que no presentaban síntomas limitantes ni progresivos se decidió manejo conservador.
    Conclusión: la Hernia Medular Transdural es una patología que se debe considerar como diagnóstico diferencial en los pacientes con clínica de compromiso medular progresivo, el diagnóstico adecuado y el manejo oportuno puede beneficiar a los pacientes otorgándoles un buen pronóstico.]]>     Case Reports: we present two cases. The first was a 57-year old female with a year-long history of numbness in all extremities and weakness in the right side of her body, in whom the diagnosis of ISCH was made by MRI and CT myelography. The second patient was a 46-year old female with neck pain and lower limb paresthesia. Additional MRI studies revealed ISCH. Due to the non-progressive nature of symptoms, conservative management was provided to both patients.
    Conclusion: idiopathic spinal cord herniation is a pathology that must be considered among differential diagnoses in patients with clinical evidence of progressive spinal compromise. An accurate diagnosis and prompt treatment often leads to a good clinical outcome. ]]>
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    • COMENTARIO
    La hernia medular idiopática (HMI) es un hecho poco frecuente, de patogenia desconocida (aunque existen varias hipótesis al respecto) que se caracteriza por un desplazamiento ventral de la médula espinal a través de un defecto dural ventral o ventro-lateral, predominantemente en la columna torácica.1-3
    En una revisión reciente1 se identificaron 159 tratados con cirugía y 15 casos tratados sin cirugía. La presencia de progresión en los síntomas mielopáticos sería el motivo por el cual se indicaría la cirugía, con una evolución favorable en algo más del 70% de los casos reportados.
    La mayoría de las publicaciones son sobre casos aislados o series pequeñas de casos (no más de 12).1-3 Su historia natural no es muy conocida. Debido a ello, resulta difícil establecer una conducta de acuerdo con los postulados de la medicina basada en la evidencia. Las decisiones terapéuticas dependerían, entonces, del criterio médico, las experiencias pasadas y/o el estado del paciente en cada caso.
    Los autores, Jacobo y col., han descripto 2 nuevos casos que, tanto en la clínica como en las imágenes, no se diferencian de los ya publicados. No explicaron por qué una HMI a nivel dorsal produciría compromiso de los miembros superiores; sería interesante conocer cómo podrían haberse afectado los dermatomas cervicales (¿tracción?, ¿isquemia?) en los casos descriptos.
    Ellos optaron por no operarlos argumentando falta de evolutividad. Esta conducta tiene sustento en la bibliografía pero, de acuerdo con lo publicado recientemente, la decisión de no operar implica no mejorar en el 100% de los casos.1 Como los autores no hacen referencia al seguimiento, no sabemos durante cuánto tiempo han permanecido estables. En la literatura, el seguimiento promedio de los casos no operados fue de 33 meses, período durante el cual no hubo empeoramientos.1
    La publicación de casos como éste, ayudan a mantenernos alertas sobre las patologías raras y a generar experiencia para saber cómo conducirnos.

    Juan José Mezzadri

    BIBLIOGRAFÍA

    1. Summers JC, Balasubramani YV, Chan PCH, Rosenfeld JV. Idiopathic spinal cord herniation: clinical review and report of three cases. Asian J Neurosurg 2013; 8:97-105.
    2. Nakamura M, Fujiyoshi K, Tsuji O, Watanabe K, Tsuji T, Ishii K, Matsumoto M, Toyama Y, Chiba K. Long-term surgical outcomes of idiopathic spinal cord herniation. J Orthop Sci 2011; 16:347–51.
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    ]]>         Descripción: Paciente de 33 años de edad con antecedentes de historia progresiva de debilidad motora de 6 meses de evolución. Al examen se constató paraparesia asimétrica con anestesia por debajo del dermatoma T8, constituyendo un síndrome de Brown Sequard. En las imágenes de resonancia magnética se observó herniación ventral de la medula espinal a nivel T7-8.
    Intervención: se realizó abordaje extrapleural posterolateral a la columna torácica. Con técnica microquirúrgica se encontró el defecto dural en la duramadre ventral, y la herniación medular correspondiente en el nivel T7-8. Se encontraron, asimismo, cuerpos osteocartilaginosos en dicho nivel. Se procedió a disecar la interface médula espinal del defecto dural, ampliando el mismo y liberando la médula espinal, sin necesidad de retracción medular por esta vía. Luego de reponer en su correcta posición a la médula se procedió al cierre dural primario con microsutura.
    Conclusión: las hernias medulares transdurales torácicas el abordaje posterolateral extracavitario es una opción válida, permitiendo tener una mejor visión microquirúrgica de la duramadre ventral, con la ventaja de no requerir tracción ni rotación neural como se requiere en el caso de la laminectomía tradicional. ]]>     Description: the patient was a 33-year-old female with a 6-month history of progressive motor weakness. Neurologic examination revealed asymmetric paraparesis with anesthesia below the T8 dermatome, consistent with Brown-Séquard Syndrome. Magnetic resonance imaging (MRI) of the thoracic spine demonstrated a spinal cord that was displaced and herniated ventrally, with loss of the normal overlying cerebrospinal fluid space between T7 and T8.
    Intervention: a lateral extra-pleural approach was used to access the thoracic spine. With microsurgery, we identified a defect in the ventral dura, with transdural spinal cord herniation. Osteocartilaginous bodies also were observed. Microsurgical un-tethering of the spinal cord herniation was performed along with primary repair of ventral dural defect. To un-tether the herniation without spinal cord manipulation, an incision was made on one side of the defect; with this maneuver, the diameter of the defect was increased, avoiding any traction on neural structures. Once the herniated spinal cord was freed, the ventral dura was repaired via non-interrupted closure.
    Conclusion: the posterolateral extra-pleural approach is a good option to treat spinal cord herniation in the thoracic spine, providing a better optical corridor to detect ventral dural defects than with a thoracic laminectomy, and avoiding any neural traction or rotation.]]>
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    • ]]>         Presentación de caso y revisión de bibliografía]]> Caso clínico: paciente masculino de 25 años con diagnóstico de leucemia linfática aguda en tratamiento quimioterápico que presentó neumonitis por metotrexate por lo que inicia tratamiento con corticoides. Posteriormente agregó cervicalgia y con el diagnóstico de osteomielitis cervical se realiza punción bajo tomografía computada (TC) sin aislarse gérmenes. Se colocó Halo Vest e inició tratamiento antibiótico empírico. Posteriormente presentó afasia de expresión secundaria a lesión frontal izquierda. Se realizó evacuación de absceso cerebral aislando A. fumigatus. El tratamiento antibiótico específico posterior permitió una buena respuesta clínica y radiológica.
    Conclusión: la presencia de lesiones en el SNC de pacientes inmunocomprometidos debe incluir a las micosis como diagnóstico diferencial. La evacuación quirúrgica permite llegar rápidamente al diagnóstico mejorando la respuesta posterior al tratamiento antibiótico. Para evaluar la respuesta terapéutica y posibles recaídas se debe realizar un seguimiento periódico clínico radiológico. ]]>     Case report: a 25-year old male was receiving chemotherapy for acute lymphocytic leukemia when he developed pneumonitis secondary to methotrexate and was started on corticosteroids. He subsequently developed cervicalgia, prompting a needle biopsy of the fourth vertebrae, after which a diagnosis of osteomyelitis was made. Even though the biopsy culture was negative, empirical antibiotics were initiated. A parietal lobe lesion was treated surgically months later after the patient presented with three episodes of transient aphasia. After A. fumigatus grew in culture, the patient’s antibiotic regimen was changed to treat the specific agent with a good response.
    Conclusion: IA must be considered a possibility whenever an immunocompromised patient presents with a new brain lesion. These lesions require surgical evacuation, a procedure that allows for diagnostic confirmation and enhances prognosis. Appropriate anti-fungal therapy must be started as soon as the diagnosis is confirmed. In addition, the patient’s neurological exam must be repeated and images obtained periodically to monitor treatment and detect possible recurrences.]]>
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    • ]]>         Descripción: posición: existen 3 posiciones descritas para la realización de este abordaje, semisentada, decubito dorsal y en banco de plaza. Incisión: se extiende desde la parte superior del pabellón auricular hasta 2 cm por debajo del vertice mastoideo, y 1 cm medial a la ranura digástrica. Disección de partes blandas: se realiza una disección subperiostica, teniendo especial cuidado con la vena hemisaria mastoidea (posible fuente de embolia aérea). Craniectomía: es necesario identificar previamente algunos puntos anatómicos de referencia para la ubicación de los senos transverso y sigmoides. En la etapa final de la remoción ósea, se procede al fresado de la porción más superior y lateral del abordaje, con la necesaria exposición de la porción inferior del seno transverso y de la porción medial del seno sigmoides. Apertura dural: se realiza una apertura en forma de letra “C” (lado izquierdo), o letra “C invertida” (lado derecho), con base medial, comenzando en la porción superior y medial de duramadre expuesta. Disección microquirúrgica: dependiendo de la ubicación de la patologia a abordar se debe realizar una retracción gentil del hemisferio cerebeloso hacia medial. En la mayoría de los casos es necesario abrir la cisterna cerebelobulbar, con el objeto de evacuar LCR.
    Conclusión: el refinamiento alcanzado actualmente hace que el abordaje retrosigmoideo sea el más utilizado para el tratamiento de las múltiples patologías ubicadas en la región del ángulo pontocerebeloso. El acceso que proporciona esta vía a la mayoría de los nervios craneales que se encuentran en la fosa posterior, y a sus complejos neurovasculares correspondientes, lo convierte en un abordaje de obligatorio aprendizaje para todo neurocirujano.]]>     Description: patient position: three potential positions have been described for this approach: semi-sitting, dorsal decubitus and park bench. Incision: The incision extends from the top of the ear to 2 cm below the mastoid apex, and 1 cm medial to the digastric groove. Soft tissue dissection: A subperiosteal dissection is performed, taking special care to avoid the mastoid emissary vein. Craniotomy: At the outset, it is necessary to identify certain anatomical landmarks to localize the transverse and sigmoid sinuses. Dural opening: The dural incision is made in the shape of the letter “C” on the left side or an inverted letter “C” on the right. Microsurgical dissection: Depending on the location of the pathology being treated, it may be necessary to perform gentle cerebellar retraction medially.
    Conclusions: the refinements now achieved with the retrosigmoid approach make it the most widely-used approach for the treatment of lesions located within the CPA. The access provided by this approach to the vast majority of the cranial nerves in the posterior fossa, as well as their neurovascular complexes, makes it a mandatory approach for all neurosurgeons to learn.]]>
  • Avci E, Kocaogullar Y, Fossett D, Caputy A: Lateral posterior fossa venous sinus relationships to surface landmarks. Surg Neurol 2003; 59:392-8.
  • Campero A, Ajler P, Emmerich J: Abordaje suboccipital lateral. 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 85-81.
  • Della Pepa G M, Montano N, Lucantoni C, Alexandre AM, Papacci F, Meglio M: Craniotomy repair with the retrosigmoid approach: the impact on quality of life of meticulous reconstruction of anatomical layers. Acta Neurochir 2011; 153:2255-8.
  • Elhammady MS, Telischi FF, Morcos JJ: Retrosigmoid approach: indications, techniques, and results. Otolaryngol Clin N Am 2012; 45:385–98.
  • Heros RC: Lateral suboccipital approach for vertebral and vertebrobasilar artery lesions. J Neurosurg 1986; 64:559-62.
  • Hitotsumatsu T, Matsushima T, Inoue T: Microvascular decompression for treatment of trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia: three surgical approach variations: technical note. Neurosurgery 2003; 53:1436-41.
  • Machinis TG, Fountas KN, Dimopoulos V, Robinson JS: History of acoustic neurinoma surgery. Neurosurg Focus 2005; 18(4).
  • Martínez F, Laxague A, Vida L, Prinzo H, Sgarbi N, Soria VR, Bianchí C: Anatomía topográfica del asterion. Neurocirugía 2005; 16:441-6.
  • Teo MK, Eljamel MS: Role of craniotomy repair in reducing postoperative headaches after a retrosigmoid approach. Neurosurgery 2010; 67:1286-92.
  • Uucerler H, Govsa F: Asterion as a surgical landmark for lateral cranial base approaches. Journal of Cranio-Maxillofacial Surgery 2006; 34:415–20.
    • ]]>         Técnica, indicaciones y anatomía microquirúrgica en 3D
    Premio Junior Neuropinamar 2013]]>     Objetivos: resaltar y sistematizar las indicaciones, detalles técnicos-anatómicos en el abordaje supracerebeloso infratentorial en base a nuestra experiencia quirúrgica y la revisión de la anatomía microquirúrgica de la región Pineal.
    Material y métodos: se realizó un estudio descriptivo retrospectivo analizando las historias clínicas de 7 pacientes intervenidos quirúrgicamente a través de un abordaje supracerebeloso infratentorial, entre septiembre 2010 hasta septiembre 2013 en nuestro servicio. Las imágenes intraquirúrgicas y de preparados anatómicos fueron adquiridas en 3D. La revisión bibliográfica se realizó en Pub Med utilizando las palabras claves: Abordaje Supracerebeloso Infratentorial; Región Pineal; Craniectomía Suboccipital.
    Resultados: durante el período 2010-2013 fueron intervenidos 7 pacientes. A todos se le practicó un abordaje supracerebeloso infratentorial. Fueron tratados 5 tumores de la región pineal, 1 glioma del culmen cerebeloso y 1 MAV de la fisura cerebelo mesencefálica.
    Se estandarizaron los siguientes pasos para la realización del abordaje supracerebeloso infratentorial de Stein: preparación prequirúrgica, posición sentado, posición de la cabeza, marcación y antisepsia cutánea, colocación de campos estériles, incisión de piel y tejido celular subcutáneo, disección de plano muscular, craneotomía, apertura dural, preparación del corredor supracerebeloso, disección intradural y anatomía microquirúrgica de la región pineal y consideraciones sobre el cierre.
    Conclusiones: se sistematizó el abordaje supracerebeloso infratentorial con el que pudimos acceder a tumores pineales y también a lesiones vasculares en la región. En todos los casos la exposición anatómica fue suficiente para tratar en forma adecuada las patologías mencionadas, con mínima retracción de las estructuras del SNC.]]>     Objectives: to enhance the indications and technical details of the supracerebellar infratentorial approach, based upon our experiences, we review the microsurgical anatomy of the pineal region that is exposed via this approach.
    Materials and methods: a retrospective descriptive study was conducted by analyzing the records of seven patients who had been operated on using this approach at our institution between September 2010 and September 2013. The images shown were obtained in 3D.
    Results: the indications for surgery in these seven patients were a pineal gland tumor in five patients, and a culmen glioma and mesencephalic-fissure AVM in one patient each. The following steps were standardized according to Stein’s description of the supracerebellar infratentorial approach: pre-surgical preparation, sitting position, head position, incision drawing and anti-sepsis, surgical field, collocation, skin and hypodermis incision, muscular dissection, hemostatic control, craniotomy, dural opening, supracerebellar corridor preparation, intradural dissection, microsurgical anatomy study, and considerations regarding closure.
    Conclusions: via this approach, we not only have been able to access pineal gland tumors but also vascular lesions in this region. The anatomical exposure achieved was enough to treat these lesions successfully, with minimal manipulation of the CNS.]]>
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