Dr. Jorge H. Lyonnet ]]> A Propósito de un Caso con Tumor Primario en Médula Cervical y Multicentricidad en la Presentación]]> Descripción. Se comunican 3 casos de macroadenomas no funcionantes con transformación hemorrágica: un hombre de 73 años con cefaleas y meningismo y dos mujeres de 56 y 64 años con cefaleas y ftalmoplejía completa. Ninguno tenía compromiso visual. Intervención. Fueron tratados en forma conservadora, y seguidos clínicamente y por IRM durante 1,3 y 2 años, respectivamente. En los tres casos se observó una pronta reducción del tamaño tumoral y regresión completa de la oftalmoplejía. No presentaron signos de recidiva y un solo paciente requirió medicación sustitutiva crónica.
Conclusión. La AP puede producir necrosis y regresión espontánea de los macroadenomas, con mejoría clínica. Algunos casos con poca repercusión clínica y sin compromiso visual pueden ser tratados en forma conservadora, con seguimiento clínico y de imágenes ante la posibilidad de recidivas a largo plazo.]]> Intervención. Se realizó ampliación anteroposterior del canal vertebral con laminoplastia bilateral por extracción del arco posterior y su fijación con microplacas de titanio maleables.
Conclusión. Esta variante técnica permite la liberación del canal cervical sin perder las virtudes de la técnica original.]]> ]]> Análisis Etiopatológico, Alternativas Terapéuticas y Asociación con Otras Patologías.]]> Material y método. En el período 2005-2009, fueron intervenidos quirúrgicamente 76 pacientes con diagnostico de Meningtoma, se hallaron cinco con grado 11-111. En ellos se consideraron las siguientes variables: sexo, edad, localización, diagnostico histopatológico, Ki 67. genética y biología molecular, tratamiento quirúrgico, recidiva, radioterapia. terapéutica hormonal y asociación a otras patologías.
Resultados. Los cinco pacientes (7%) con diagnóstico histológico de Mening tomas agresivos, fueron de sexo femenino (I 00% de los casos), con una edad media de 51 años. En cuanto a la localización: 3 casos se originaron en la hoz cerebral, 1 caso a nivel de la convexidad y I caso a nivel columna dorsal. En el 100 % de las muestras se realizo Ki 67. EMA, V1M y receptores a progesterona. La anatomía patológica revelo 4 atípicos y 1 anaplásico. EL 90%de los casos presento recidiva. El tratamientofue resección quirúrgica seguido de radioterapia post recidiva, excepto a nivel espinal .En una paciente se asocio a cáncer de mama y otra a cirugía de absceso cerebral.
Conclusión. Factores genéticos, hormonales y de reparación celular se asocian a laformación de estos tumores. Los actuales avances en biología molecular permitirán tratamientos seleccionados para cada paciente según las características tumorales, hasta la llegada de ese futuro. la cirugía seguida de radioterapia, continua siendo el tratamiento de elección.
Palabras claves: meningiomas malignos; atípicos; anaplásico; biología molecular; terapia hormonal.]]> Descripción. Caso 1: Paciente femenina de 21 años de edad que consulto por oftalmoplejía dolorosa de 72 hs de evolución sin compromiso visual. Se realizó IRM de encéfalo que evidenció el engrosamiento difuso con realce postcontraste del seno cavernoso izquierdo. Se interpretó el cuadro como un STH. Caso 2: Paciente masculino de 45 años de edad que consultó por oftalmoplejía dolorosa de 2 meses de evolución y amaurosis del ojo derecho. Se le solicitó IRM de encéfalo que evidenció el engrosamiento difuso del seno cavernoso derecho. La retinografía evidenció la atrofia de la papila de dicho ojo. El cuadro se interpretó como un STH asociado a una neuritis óptica homolateral.
Intervención. Caso 1. Inicio tratamiento con corticoides y carbemazepina lográndose a los 3 meses recuperación total sin recaídas posteriores. Caso 2. Se inicio tratamiento con corticoides. Actualmente se encuentra en control por consultorios presentando mejoría significativa de los síntomas sin mejoría de la amaurosis de ingreso.
Conclusión. El STH es una entidad poco frecuente, con un probable origen autoinmunitario. Existen diversas causas que pueden simular este síndrome. Es mandatorio el análisis exhaustivo de estos pacientes, a fin de descartar otras patologías.]]> Material and methods: First case: Male patient, 25 years old. The RMN of brain showed a lesion in selar, supra and paraselar location .Second case: female patient, 40 years old. The RMN of brain showed right temporal lesion with adjacent bone commitment.
Results: Both patients were treated surgically, anatomopathologyic diagnosis was giant cells tumor (GCT).
Conclusion: The GCT are generally benign, locally aggressive, the surgical excision has proved to be the most effective treatment. The presentation of this work is due to the scant bibliography reported until the moment on GCT of the skull base.]]> Descripcion: A 22 years old male, complained of headaches, nausea and vomiting. The neurological examination was normal. An MRI showed a small oval tumor in the
quadrigeminal plate with a triventricular hydrocephalus.
Intervention: He was operated through a supracerebelar infratentorial approach. Complete resection was not posible due the to firm adhesions to vascular structures. Debulking and biopsy was performed. Pathology confirmed the diagnosis of lipoma. Conclusion: Intracranial lipomas are rare tumors, located more frecuently at the corpus callosum. Are seen commonly in males, between 10 at 19 years old. Only 50% are symptomatic, epilepsy is the most common form of presentation.]]> Objetivo: comunicar nuestra experiencia con CD para el manejo de HTE aguda en casos seleccionados,
Material: sobre una serte de 619 pacientes neuroquirúrgicos tratados durante el período comprendido entre junio de 1999 y enero de 2001 se presentan 7 pacientes sometidos a CD. Las indicaciones fueron de tratamiento de HTE aguda (pacientes seleccionados: 3 con TEC grave, 3 con stroke isquémico y un caso de hemorragia subaracnotdea).
Resultados: se evaluaron los resultados en cuanto a sobrevtda y pronóstico neurológico a través del Glasgow Outcome Scale al 1°, 3° y 6° mes postoperatorto. GOS de 5: 2 casos, GOS de 3: 3 casos, fallecidos (GOS 1): 2 casos.
Conclusión: las publicaciones actualizadas no presentan aún un nivel de evidencta adecuado para soportar con buen grado de recomendación la indicación de CD, aunque los resultados observados con esta práctica indican que la mtsma puede ser apropiada en casos seleccionados.]]> Proyecto de Regionalización a Nivel Nacional]]> 2. Bosque L, Neira J. El término accidente. En Trauma Prioridades. San Román E, Neira J, Tisminetzky G (eds). Editorial Panamericana. Buenos Aires. 2002 pp 19-20.
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La localización mas frecuente fue la intradural extramedular dorsal, siguiéndole en frecuencia la ubicación cervical.
El resultado quirúrgico fue ampliamente favorable en el 85% de los pacientes, con regresión de la sintomatologia en forma gradual después de meses o años del postoperatorio, siendo más evidente en los pacientes con instalación lenta del cuadro clínico.
Los recursos técnicos actuales (microcirugía, coagulación bipolar, láser, aspiración ultrasónica), han mejorado la posibilidad de resección de un meningioma espinal con expectativas de buena evolución.]]> Durante el mismo se diagnosticaron 130 pacientes con aneurismas (93%), interviniéndose quirúrgicamente 87 (67%).
El objetivo es establecer los factores de mejores resultados en los operados precozmente.
Se ordenaron los casos teniendo en cuenta el día de operado a partir del sangrado —timing quirúrgico— ubicándolos en ciclos de tres días, observándose una mayor frecuencia entre los días 1-3, 7-9, 13-15 y más de 21. Estos ciclos y el grupo total de operados fueron sometidos al análisis discriminativo multivariado, dado por 7 factores considerados, a priori, como elementos potenciales de incidencia en el desenlace; luego se realizó una lectura comparativa en estos factores. Sexo: M, F; HIC: a) 0-30 cc, b) 30-60 cc, c) más de 60 cc. Espasmo: E local y E difuso. Hunt 8 Hess: HH I, HH II, HH HIII, HH IV y HH V. Saco: S = o menor 9 mm y S = o mayor 10 mm. Cuello: C peq., C. med. y C. gde. Resangrado.
En hematomas de tipo "a" se demostró una mayor sobrevida en los días 1-3, 13-15 y más de 21: los hematomas de tipo "c" se observaron en el ciclo 1-3. Para el vasoespasmo en el grupo 1-3 sobrevivió el 75% a diferencia del 58% del promedio P = o menor de 0.001.
Este análisis arrojó la conveniencia de la cirugía entre los días 10-3°.]]> La muestra observó una mayor prevalencia de CHIP en el sexo masculino (73,5%), con una edad promedio de 6 años 5 meses ±4 años 10 meses (rango 1 día - 15 años). El 53% de las niñas sufrieron CHIP antes de los 3 años, mientras que el 54% de los niños tuvieron 7 o más años (P < 0,05). Los mecanismos originarios del TCE más frecuentesfueron caída (36,3%), accidente con rodados (33,6%) y de causa desconocida (15,9%). Este último, principalmente en niños menores de 3 años (31%). Los síntomas de comienzo más frecuentes fueron: vómitos (58,6%), pérdida del conocimiento (47,1%) y cefaleas (24,1%). El 93,8% presentaron síntomas y signos al momento de ingreso hospitalario, siendo frecuentes la alteración de la conciencia (66%), los vómitos (47,2%) y la cefalea (26,4%).
Las complicaciones hemorrágicas observadas en estos 113 pacientes fueron: 75 hematomas extradurales (66,4%), 35 hematomas subdurales (31,0%), 19 contusiones hemorrágicas (16,8%) y 11 hematomas intraparenquimatosos (9,7%). En 13 pacientes la localización del hematoma fue en fosa posterior (11,5%). Tuvimos pacientes con más de un tipo de complicación hemorrágica (22,1%). La morbilidad fue del 9,7% y la mortalidad del 17,7%.]]> Se presentan 62 pacientes operados de gliomas encefálicos, en el período comprendido entre 1974 y 1991. Las edades oscilaron entre 21 y 75 años, con un pico de incidencia en la sexta década (32%), sin tener prevalencia de sexo.
Los síntomas de comienzo más frecuentes fueron cefaleas, convulsiones, hemiparesia y vómitos.
Se efectúa un análisis de los estudios complementarios de diagnóstico, tanto electrofisiológicos como neurorradiológicos y de los resultados histopatológicos.
El tratamiento fue quirúrgico en todos los casos, de los cuales 2 fueron astrocitomas intrínsecos del tronco cerebral (bulbo raquídeo). Se realizó radioterapia complementaria en 45 pacientes y en sólo 6 se efectuó quimioterapia.
La mortalidad general fue del 80% (50/62) y la mortalidad quirúrgica del 14,5% (9/62).]]> De los catorce procedimientos estereotáxicos, 13 fueron realizados con neuroleptoanalgesia y anestesia local, y 1 con anestesia general.
La localización de las lesiones fueron: múltiples en 5, talámicas en 4, parietal en 1, rolándica en 1, occipital en 1, tronco cerebral en 1 y difuso paraventriclar en 1,
El diagnóstico histológico fue positivo para lesión encefálica en el 100% de los casos, tanto en el examen por citología intraoperatoria con azul de mettleno, como en el de parafina. En dos casos se utilizaron técnicas de trimunohistoquírnica.
No hubo mortalidad en esta serie, y en sólo 1 caso tuvimos morbilidad, que consistió en una hemiparesta leve, que recuperó totalmente a las 24 hs.
Concluimos que la biopsia cerebral estereotáxica es un procedimiento simple que brinda un alto porcentaje de certeza diagnóstica. con muy bajo índice de morbimortalidad.]]> Parte II: Asociación con Disrafismos Abiertos]]> Considerando la probabilidad elevada de deterioro neurológico tardío, progresivo e irreversible se recomienda: a) TC,IRM o ecografía. espinal preoperatoria en pacientes con MC o MMC; b) cuidadosa exploración del canal espinal proximal y distal a la placoda medular durante la cirugía inicial del disrafismo,y: c) control postoperatorio precoz con i.R.M. en pacientes operados de disrafismos espinales abiertos.]]> Parte I: Diagnóstico y Tratamiento]]> La Tomografia Computada y las Imágenes por Resonancia Magnética se complementan para definir las características anatómicas de cada caso. El motivo de este trabajo es analizar la forma de presentación, la información que brindan los métodos diagnósticos y discutir la conducta terapéutica más adecuada para cada caso.
]]> A 50 Años de su Muerte
]]> A propósito de 100 casos consecutivos de etiología no infecciosa]]> ]]> En todos se realizó tracción esquelética con 7-10 Kg de peso. Una vez lograda la esiabiiización, la artrodesis con alambre y metilmetacrilato fue hecha entre el 7° y 10° día de ingreso hospitalario. No hemos registrado complicaciones. Este procedimiento permite movilización temprana del paciente, sin necesidad de soportes externos.]]>