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BACKGROUND: Facial paralysis secondary to a complete and irreversible anatomic or functional lesion of the facial nerve (FN) causes severe functional and psychological disorders for the patient. A large number of surgical techniques have therefore been developed for FN repair. Our objective was to propose a surgical FN reanimation protocol for patients with irreversible anatomic or functional postsurgical injury of the FN in the cerebellopontine angle after vestibular schwannoma resection. METHODS: The clinical study included a total of 16 patients undergoing side-to-end hypoglossal-facial neurorrhaphy (SEHFN) since 2010, in which the FN injury was always secondary to vestibular schwannoma surgery in the cerebellopontine angle using a retrosigmoid approach. All patients had complete clinical facial paralysis at the time of the SEHFN. The anatomic study was conducted using 3 heads and necks (6 SEHFN). RESULTS: Twelve months after surgery, FN function assessment with the House and Brackmann scale showed 2 patients with grade II, 13 patients with grade III, and only 1 patient with grade IV, and after 2 years, 4 patients had grade II, 11 patients had grade III, and 1 patient had grade IV. The average length of the anastomotic translocation portion of the FN in the anatomic study was 34.76 mm. CONCLUSIONS: Side-to-end epineural suture of the FN, mobilizing its mastoid segment on the hypoglossal nerve with partial section of the dorsal aspect of the hypoglossal nerve, is a safe anatomic surgical technique for FN reanimation with outstanding clinical results.

Objectives The main objective of this article is to describe a simple and safe protocol for the microsurgical management of ventrally located intrinsic pontomedullary lesions based on the retrosigmoid approach, cortectomy performed utilizing safe entry zones of the pons and medulla, and a delicate microsurgical resection. The intraoperative protocol includes redundant procedures that provide security in decision-making during surgery. Design A prospective series of 11 cases is presented. All patients were studied following the same clinical and imaging workup. A regular retrosigmoid craniotomy surgical approach was utilized. The peritrigeminal area in the pons and the olivary area in the medulla were considered as the safe entry zones. Neuronavigation of the white fiber tracts and electrophysiological monitoring were used as intraoperative aids to locate the lesions, the safe entry zones, and the placement of the cortectomy. Results Six lesions were pontine, two medullary, and the remaining six pontomedullary. Eight lesions were cavernomas, while the remaining three tumors. Overall, we obtained a postoperative functional improvement in the affected cranial nerves in 90.1% of the patients and a total or partial recovery of long ascending or descending pathway symptoms in 72.3% of the patients. All the patients were satisfied with the procedure and the results. Conclusions Radical resection of ventral intrinsic pontomedullary lesions displays a high degree of intraoperative reliability, and a good clinical result is possible using simple surgical procedures. The anatomical references are the first element in the decision-making process during surgery.

Introducción: La dilatación infundibular (DI) de la arteria comunicante posterior (AComP) se define como la dilatación cónica, triangular o en forma de embudo, menor de 3 mm, en el origen de la AComP de la arteria carótida interna. El propósito del presente trabajo es presentar la experiencia propia en el tratamiento microquirúrgico de la DI de la AComP, revisar la bibliografía y proponer algoritmos para optimizar su manejo clínico y microquirúrgico. Material y métodos: Se han estudiado nueve casos de DI intervenidos a través de un abordaje pterional. En cuatro pacientes con hemorragia subaracnoidea (HSA) la DI se consideró la única causa del sangrado; en otros cuatro pacientes la DI se intervino tras una HSA por ruptura de otra lesión aneurismática; finalmente, en un paciente con pseudoxantoma elástico la DI se intervino de forma preventiva. Resultados: En ocho casos se procedió al clipaje de la DI y cierre de la AComP y en uno al reforzamiento de la DI al tratarse de una AComP del tipo fetal. No aparecieron complicaciones salvo una paresia transitoria del III par. El Glasgow Outcome Scale al alta y al año fue de 5 en todos los casos. Conclusiones: La DI de la AComP es una lesión de significado no aclarado, pero que plantea la necesidad de considerar su tratamiento en algunas ocasiones: 1. En pacientes con aneurismas rotos sometidos a cirugía y DI homolateral se recomienda explorar y tratar la lesión; 2. En pacientes con aneurismas rotos tratados con embolización con DI no tratada y en aquellos tratados con microcirugía con una DI contralateral, se considerarán en cada caso los factores de riesgo para indicar un tratamiento microquirúrgico; 3. En los pacientes con DI como única lesión vascular asociada a una HSA debe repetirse la angiografía y, en ausencia de otra explicación del sangrado, considerar el tratamiento microquirúrgico; 4. El hallazgo de una DI en pacientes sin sangrado es una indicación de observación con neuroimagen y control de los factores generales de riesgo vascular, en ausencia de sustanciales factores de riesgo. Introduction: The infundibular dilatation (ID) of the posterior communicating (PCom) artery is defined as the conic, triangular or infundibular shaped, less than 3mm wide, origin of the PCom artery from the internal carotid artery. The purpose of this paper is to present the personal experience in the microsurgical management of the ID, to review the literature and to propose some algorithms to improve its clinical and microsurgical management. Material and methods: Nine cases of ID have been operated on through a pterional approach. In four patients with subarachnoid hemorrhage (SAH) the ID was considered as the potential source of the bleeding; in four cases the ID was treated after a SAH due to the rupture of an aneurysm; finally, an ID was treated in patient with diagnosis of pseudoxantoma elasticum. Results: In eight cases the ID was clipped and the Pcom artery subsequently occluded and in the remaining case the ID was associated with a fetal PComA and the ID was reinforced. There were no complications excepting a transitory third cranial nerve paresis. The Glasgow Outcome Scale was 5 in all cases at discharge and one year later. Conclusions: The true significance of the ID remains unknown, but in some instances it is necessary to consider its management: 1. In patients with ruptured aneurysms submited to microsurgical clipping and with an ipsilateral ID, the lesion must be explored and treated; 2. In patients with ruptured aneurysms treated with endovascular procedures or harbouring an ID contralateral to a microsurgically treated aneurysm, the microsurgical indication will be done after considering all risk factors; 3. In patients with SAH and an ID as the only potential source of the bleeding there would be an indication for microsurgical exploration; 4. The incidental finding of an ID should be indication for observation in absence of major risk factors.

El dolor central y el dolor periférico por desaferentización son de difícil tratamiento incluso con fármacos de última generación. La estimulación eléctrica sobre diversas estructuras ha demostrado en general ser poco efectiva. La estimulación sobre la corteza motora es una técnica relativamente nueva que parece ofrecer resultados prometedores en estos cuadros. Aunque desde el punto de vista quirúrgico es una técnica sencilla, no lo es tanto la localización adecuada de la corteza motora, lo cual es una condición importante para su efectividad. En este trabajo ofrecemos una revisión bibliográfica sobre ella. Sus indicaciones fundamentales actualmente son el dolor central fundamentalmente talámico, y el dolor trigeminal por desaferentización. La respuesta a barbitúricos sin respuesta a opioides, la conservación relativa de las vías motoras y sensitivas, y la respuesta a la estimulación magnética transcraneal predicen un buen resultado. Diversos métodos son utilizados para determinar la zona a estimular: PESS, estimulación intraoperatoria, neuronavegación, RNM funcional. Los parámetros de estimulación recomendados varían de unos autores a otros. Su mecanismo de actuación no es en la actualidad bien conocido aunque las teorías más aceptadas son la activación de zonas que modulan el dolor y la inhibición de la transmisión de los estímulos nociceptivos a nivel medular. Central pain and peripheral pain caused by desafferentation are difficult to treat even with last generation drugs. Electric stimulation of several structures has shown to be scarcely effective in general. Stimulation of motor cortex is a relatively new technique that seems to offer promising results in these disorders. While it is a simple technique from the surgical point of view, the adequate location of the motor cortex is not so easy, this being a significant condition for its effectiveness. In this paper we review the literature that has been published on the matter. Currently, its major indications are central pain, mainly thalamic, and trigeminal pain caused by desafferentation. The response to barbiturates without response to opiates, the relative preservation of motor and sensitive pathways and the response to transcranial magnetic stimulation predict a good result. Several methods are used to determine the area that has to be stimulated: SSEP, intraoperatory stimulation, neuronavegation, functional MRI. The stimulation parameters recommended vary according to the author. Its mechanism of action is still not well understood, but the most accepted theories are the activation of areas that modulate pain and the inhibition of the transmission of nociceptive stimuli at the medullar level.

The objective of this study was to compare the clinical and analytical repercussion of a new type of intestinal valve -which can be used in both massive resections and right hemicolectomies requiring the elimination of the ileocecal valve- on two historical series of patients: one group with ileocolic resections and end-to-end anastomoses (EE), and one group with Ricotta valves. We compared 23 patients with ileocolic resection and end-to-end anastomosis, 15 with Ricotta's valve, and 20 patients with a new valve made with a small intestinal invagination. There were no statistically significant differences in baseline characteristics among patients. Patients with the new valve showed less relevant weight loss and fewer stools at 3 months and one year when compared to patients with Ricotta's valve, and particularly those with ileocolic resection. Moreover, with the new valve technique there was neither colonization of the ileal mucosa nor bacterial overgrowth. In conclusion, in massive intestinal resections and right hemicolectomies, including the ileocecal valve, the new valve technique would be of choice. El objetivo del estudio ha sido comparar la repercusión clínica y analítica de un nuevo tipo de válvula intestinal, aplicable tanto en las resecciones masivas intestinales como en las hemicolectomías derechas que requieren la eliminación de la válvula ileocecal, con dos series históricas: una con la técnica de resección ileocólica con anastomosis término-terminal (TT) y otra con la técnica válvular de Ricotta. Se han comparado 23 pacientes en los que se aplicó la resección ileocólica TT, en 15 pacientes la formación de la válvula de Ricotta y en 20 pacientes a los que se aplicó la neoválula formada con la invaginación del intestino delgado en el colon. No hubo diferencias estadísticamente significativas en el peso inicial de los pacientes. Los pacientes con la neovávula presentaron una menor pérdida de peso y menor número de deposiciones a los 3 meses y al año comparados con las técnicas de Ricotta y especialmente con la resección ileocólica TT. Además con la neoválvula no hubo colonización de la mucosa ileal ni sobrecrecimiento bacteriano. En conclusión ante las resecciones masivas intestinales y las hemicolectomías derechas que incluyan la válvula ileocecal, la técnica de elección sería la neoválvula.

Word-finding difficulties observed in some patients with anomia have been attributed to an insufficient activation of phonology by semantics. There are, however, few direct tests of this hypothesis. This paper reports the case of FR, who presented with anomic aphasia following temporal lobe epilepsy and a cavernoma in the left superior temporal lobe. His anomic deficit was characterized by: (1) no apparent associated semantic impairment; (2) item consistency for accuracy and errors across different administrations; (3) accuracy strongly correlated with word frequency; and (4) a partial, albeit weak, knowledge of the gender of unnamed items. We conducted a naming experiment in which target pictures were implicitly primed by briefly presented masked words. Results showed that the prior presentation of the written target name improved accuracy. When compared with unprimed trials, the presence of the primes also increased phonological errors and decreased semantic errors. We argue that automatic phonological activation derived directly from the implicit written primes interacted with the remaining phonological input from the picture's semantic representation leading to increased accuracy and a change in the balance of error types. Copyright 2001 Academic Press.