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Resumen Introduccion La migracion posterior epidural de un fragmento de hernia discal lumbar es una presentacion clinica infrecuente. Caso clinico Presentamos el caso de un paciente varon de 76 anos, que acude por dolor lumbar y paraparesia progresiva en extremidades inferiores, con la aparicion a los 4 dias del ingreso de un sindrome de cauda equina. La resonancia magnetica muestra espondilosis lumbar y una masa intrarraquidea bien delimitada en el espacio epidural posterior. Se realiza una exeresis quirurgica de la masa epidural. El estudio anatomopatologico informo de fragmento de disco intervertebral, por lo que se trataba de una migracion completa de una hernia discal lumbar. Tras la intervencion quirurgica y un tratamiento rehabilitador especifico remitio la clinica del paciente. Conclusiones Los pacientes con migracion posterior de un fragmento de disco presentan graves deficits neurologicos como el sindrome de cauda equina. Debido a que las imagenes radiologicas de los fragmentos del disco son similares a los de otras lesiones como metastasis, quiste sinovial, absceso dural o hematoma, el diagnostico definitivo se realiza mediante exeresis y estudio anatomopatologico. El tratamiento quirurgico urgente es necesario para evitar deficits neurologicos severos.

Introduction The posterior epidural migration of a fragment of lumbar disc herniation is a rare clinical presentation. Case report We report the case of a 76-year-old male patient with back pain and progressive paraparesis in the lower limbs, with the emergence of a cauda equina syndrome 4 days after admission. MRI showed lumbar spondylosis and a well-defined intra-spinal mass in the posterior epidural space. Surgical resection of the epidural mass was performed. The pathological study revealed an intervertebral disc fragment; thus, it was a complete migration of a herniated lumbar disc. The patient was healed after surgery and specific rehabilitation treatment. Conclusions Patients with posterior migration of disc fragment may present with severe neurological deficits, such as cauda equina syndrome. Because the radiological images of disc fragments are similar to those of other lesions, such as metastasis, synovial cyst, dural abscess or haematoma, definitive diagnosis is made by excision and pathological study. Emergency surgery is required to prevent severe neurological deficits.

Background.Nocardiosis is a rare disease that mainly affects severely immunocompromised patients. Symptoms are nonspecific and microbiological isolation is difficult, hiding the diagnosis. Treatment should be guided by species and susceptibility testing.Findings.We report a clinical case of a disseminated nocardiosis in a patient with HIV and HVB infections.Interpretation.Diagnosis should be presumed early and microbiological conditions should be optimized, in order to identify the species and achieve antibiotic susceptibility testing. This is a very important step to choose an effective therapeutic regimen or alternative options.

Resumen Diversas lesiones tumorales pueden estar en rela-cion con el sistema ventricular ocasionando con fre-cuencia hidrocefalia obstructiva. El objetivo de este trabajo es evaluar la utilidad de la neuroendoscopia en el manejo de las lesiones tumorales ventriculares tanto en su vertiente diagnostica corno terapeutica. Presentamos una serie de 19 pacientes con lesiones tumorales ventriculares, biopsiadas endoscopicamente entre los annos 1992–95. Ambos tipos de endoscopio, rigido y flexible, fueron utilizados. En 8 casos se realizo una ventriculostomia adicional para resolver un cuadro de hidrocefalia. La efectividad diagnostica alcanzada fue del 73,6% (9 gliomas, 2 craneofaringiomas, 1 linfoma, 1 germinoma y 1 pineoblastoma). Se discute la morbilidad de esta tecnica y se comparan sus resultados con los de procedimientos estereotaxicos.

The posterior epidural migration of a fragment of lumbar disc herniation is a rare clinical presentation.We report the case of a 76-year-old with back pain and progressive paraparesis in the lower limbs, with the emergence of a cauda equina syndrome 4 days after admission. MRI showed lumbar spondylosis and a well-defined intra-spinal mass in the posterior epidural space. Surgical resection of the epidural mass was performed. The pathological study revealed an intervertebral disc fragment; thus it was a complete migration of a herniated lumbar disc. The patient was healed after surgery and specific rehabilitation treatment.Patients with posterior migration of disc fragment may present with severe neurological deficits, such as cauda equina syndrome. Because the radiological images of disc fragments are similar to those of other lesions, such as metastasis, synovial cyst, dural abscess or haematoma, definitive diagnosis is made by excision and pathological study. Emergency surgery is required to prevent severe neurological deficits.

Resumen La neuroendoscopia es una tecnica que permite un tratamiento alternativo en pacientes afectos de hidrocefalia obstructiva. Se realizaron fenestraciones neuroendoscopicas en siete pacientes: 3 afectos de estenosis de acueducto, 2 hidrocefalias tabicadas y 2 quistes paraventriculares. En 6 pacientes se obtuvo un resultado satisfactorio sin complicaciones importantes. Se discuten las indicaciones, metodos y ventajas de esta tecnica.

Resumen El hallazgo de una calcificacion intracerebral de forma aislada, no es un fenomeno excepcional y su aparicion puede ser dcbida a alguna manifestacion fisiologica o patologica; sin embargo en la practica clinica diaria, no es habitual encontrar calcificaciones multiples, y en el caso de haberlas, suelen ser el reflejo de una entidad patologica. Se presenta el caso clinico de un paciente recien nacido, afecto de gran calcificacion cerebral por afectacion congenita de citomegalovirus. Se revisan la etiologia y las alternativas terapeuticas.

INTRODUCCIÓN: El glioblastoma multiforme (GBM) es el más frecuente y maligno de los tumores cerebrales. Su presentación en cerebelo es excepcional. CASO CLÍNICO: Paciente de 42 años con historia breve de trastorno de la marcha y cefalea. La resonancia magnética cerebral mostró una lesión de unos 4 cm de diámetro sólida y quística, con edema, en hemisferio cerebeloso dcho. Se extirpó un Glioblastoma multiforme con p53 positiva. CONCLUSIONES: La edad y la p53 hacen pensar que se trate de una forma secundaria de GBM. La bibliografía revisada constata que se trata de una localización infrecuente. El tratamiento inicial es quirúrgico pero las supervivencias son cortas a pesar de la radioterapia y del uso de nuevos quimioterápicos como la Temozolomida.

CT-scan allows emergency surgical evaluation of head injury lesions, but does not offer a comprehensive diagnosis of the resulting brain injuries. Magnetic Resonance Imaging (MRI) can complete the evaluation of head injury, particularly in the brain stem. We attempted to estimate the frequency of traumatic primary brain stem injuriesThirty patients with moderate or severe head injury (GCSor = 13) underwent a MRI study during the first two weeks after trauma. In order to exclude old patients with previous ischemic lesions unrelated to the head trauma, only young patients (16-40 years-old) were included. Patients with cranial surgery were also eliminated from the study. Based on previous studies, the FLAIR (8000/120/T. Inversion 2200mseg) sequence was selected.Brain stem injuries were detected in 26.6% of the patients; this was confirmed by two independent radiologists. Six patients had hyperintense lesions compatible with diffuse axonal damage, and two others showed hemorrhagic lesions. These findings were directly related to a specific neurological deficit in four patients; while in the remaining, unspecific consciousness disturbances were noted.We believe that the FLAIR sequence demonstrate a type of traumatic brain stem injury (probably corresponding to diffuse axonal injury) that is more frequent and less severe in terms of prognosis than those classically described in previous CT scan studies.

Introducción y Objetivos. La TAC craneal permite la evaluación quirúrgica urgente de un TCE, pero no supone una evaluación completa de las lesiones encefálicas producidas. La resonancia magnética (RM) puede complementar la evaluación del TCE, especialmente a nivel de tronco cerebral. Utilizando la secuencia FLAIR pretendemos obtener una estimación de la frecuencia de lesión primaria traumática de tronco cerebral. Material y métodos. Se presenta una serie prospectiva de 30 casos con TCE moderado o grave (GCS ≤13) a los que se les realizó RM en un intervalo menor a dos semanas tras el traumatismo. En la serie se incluyeron exclusivamente pacientes jóvenes (entre 16 y 40 años), con objeto de excluir lesiones previas de tipo isquémico no relacionadas con el traumatismo. Quedaron fuera los pacientes con cirugía craneal para excluir lesiones yatrogénicas. En base a estudios previos, se utilizó la secuencia FLAIR (Fluid Attenuated Inversion Recovery 8000/ 120/ T. Inversion 2200mseg) para la detección óptima de lesiones de tronco cerebral. Resultados. En un 26,6% de los casos se apreciaron lesiones en tronco cerebral confirmadas por dos radiólogos independientes. De ellas, seis casos correspondían a lesiones hiperintensas compatibles con lesión axonal difusa y dos casos a lesión hemorrágica. La supervivencia de la serie fue del 100%, si bien este dato está sesgado por la selección exclusiva de pacientes que en un plazo inferior a dos semanas habían salido de cuidados intensivos. En cuatro casos pudo establecerse una relación directa entre lesión y focalidad neurológica. En el resto, la lesión fue relacionada con trastornos inespecíficos del nivel de consciencia. Conclusiones. Consideramos que la RM en secuencia FLAIR nos permite visualizar un tipo de lesión traumática de tronco cerebral (posiblemente lesión axonal) que presenta mayor frecuencia y menor gravedad pronóstica que aquellas otras descritas clásicamente en estudios realizados mediante TAC. Introduction and Objectives. CT-scan allows emergency surgical evaluation of head injury lesions, but does not offer a comprehensive diagnosis of the resulting brain injuries. Magnetic Resonance Imaging (MRI) can complete the evaluation of head injury, particularly in the brain stem. We attempted to estimate the frequency of traumatic primary brain stem injuries by using the FLAIR (Fluid Attenuated Inversion Recovery) sequence. Material and Methods. Thirty patients with moderate or severe head injury (GCS ≤ 13) underwent a MRI study during the first two weeks after trauma. In order to exclude old patients with previous ischemic lesions unrelated to the head trauma, only young patients (16-40 years-old) were included. Patients with cranial surgery were also eliminated from the study. Based on previous studies, the FLAIR (8000/120/T. Inversion 2200mseg) sequence was selected. Results. Brain stem injuries were detected in 26.6% of the patients; this was confirmed by two independent radiologists. Six patients had hyperintense lesions compatible with diffuse axonal damage, and two others showed hemorrhagic lesions. These findings were directly related to a specific neurological deficit in four patients; while in the remaining, unspecific consciousness disturbances were noted. Conclusions. We believe that the FLAIR sequence demonstrate a type of traumatic brain stem injury (probably corresponding to diffuse axonal injury) that is more frequent and less severe in terms of prognosis than those classically described in previous CT scan studies.

Non-communicating hydrocephalus is defined as a blockade of the physiological cerebrospinal fluid (CSF) flow from the choroid plexus to the subarachnoid space. Usually, a ventricle peritoneal shunt with a valve is employed as treatment but this does not provide a physiological restoration on the CSF flow.The aim of the study is to introduce a more physiological solution by means of endoscopic technique. We also pretend to find out some prognostical factors related to successful treatment.We present a prospective non-randomized series of 32 endoscopic III ventriculostomies performed in patients with non-communicating hydrocephalus. When the blockade was due to a tumor, an endoscopic biopsy was performed at the same surgical time. In the same way, if the cause was a ventricular hematoma, an endoscopic aspiration was performed. The patients follow-up was two years.The procedure was considered successful (83.8% of the cases) when the clinical symptoms resolved without ventricle-peritoneal shunt. We study the relationship of the blockade level and the highest value of intracranial pressure during endoscopy with the results of the procedure in terms of success and morbidity. We have found significant relation between high pressure during endoscopy and the practice of a complementary biopsy or hematoma evacuation.Endoscopic third ventriculostomy provides an effective and physiological solution to non communicating hydrocephalus. Complementary endoscopic procedures can be associated at the same surgical time, however this association can be related to increased values of intracranial pressure during surgical performance.

There are some controversial items concerning normal pressure hydrocephalus (NPH). The incidence of NPH is unknown since there is not agreement concerning diagnostic criteria. The choice of shunt location and valve type may be difficult if we consider the wide range of options available. We present a descriptive multicentric study which pretends evaluate the consensus between different centers.We have requested 19 neurosurgical departments about diagnostic criteria, shunt location, valve type, cases number per year and therapeutic results.The study shows the lack of agreement in our sample. We observed some kind of relationship between the number of cases/year and the use of more complex and invasive diagnostic procedures. The most frequently shunt location was ventricleperitoneal. Concerning type valve, most of departments use to have a predilection for a certain type and model which was ever used. However, the model was frequently different on each department. Anyway, differential pressure valve was the more frequent choice. The average therapeutic result of the sample was 77.6%.In our opinion, is advisable to define a common diagnostic criteria for NPH in order to establish the real incidence of this entity.

Arachnoid cysts are space-occupying lesions filled with CSF-like content and surrounded by a membrane resembling arachnoid matter. They are regarded as a development abnormality of the arachnoid, originating from a splitting or duplication of this membrane. However, precise etiology and natural history remain controversial. Different hypotheses have been developed including agenesis of brain structures, arachnoiditis, active fluid secretion, and pulsatile pump. We present a review of the literature concerning these items and report one case of a suprasellar arachnoid cyst in which a slit-valve mechanism was observed by means of cine-mode MRI preoperatively and confirmed during the endoscopic intervention.

The term "cephalhematoma" is applied to a collection of blood under the periosteum of a skull bone. It most frequently occurs in the neonatal period and is rare at other times of life.We report on a 15-year-old boy with a subperiosteal hematoma involving the whole cranial surface. Surgical drainage was performed. In the immediate postoperative course, the patient developed a progressive decrease in the right eye visual acuity. An orbital computed tomographic scan revealed the retro-orbital subperiosteal extension of the hematoma. A second surgical procedure was necessary to obtain visual recovery.The occurrence of cephalhematoma in adults is exceptional. However, it may lead to serious complications. Surgical treatment should be aimed to avoid retro-orbital extension of the hematoma.