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Introduction: The number of lung metastases (M1) of colorectal carcinoma (CRC) in relation to the findings of computed tomography (CT) is the object of study. Methods: Prospective and multicenter study of the Spanish Group for Surgery of CRC lung metastases (GECMP-CCR). The role of CT in the detection of pulmonary M1 is evaluated in 522 patients who underwent a pulmonary metastasectomy for CRC. We define M1/CT as the ratio between metastatic nodules and those found on preoperative CT. Disease-specific survival (DSS), disease-free survival (DFS), and surgical approach were analyzed using the Kaplan–Meier method. Results: 93 patients were performed by video-assisted surgery (VATS) and 429 by thoracotomy. In 90%, the M1/CT ratio was =1, with no differences between VATS and thoracotomy (94.1% vs 89.7%, p = 0.874). In the remaining 10% there were more M1s than those predicted by CT (M1/CT > 1), with no differences between approaches (8.6% vs 10%, p = 0.874). 51 patients with M1/CT > 1, showed a lower median DSS (35.4 months vs 55.8; p = 0.002) and DFS (14.2 months vs 29.3; p = 0.025) compared to 470 with M1/CT = 1. No differences were observed in DSS and DFS according to VATS or thoracotomy. Conclusions: Our study shows equivalent oncological results in the resection of M1 of CRC using VATS or thoracotomy approach. The group of patients with an M1/CT ratio >1 have a worse DSS and DFS, which may mean a more advanced disease than predicted preoperatively. Introducción El número de metástasis pulmonares (M1) de carcinoma colorrectal (CCR) en relación con los hallazgos de la tomografía computarizada (TC), es objeto de estudio. Métodos Estudio prospectivo y multicéntrico del Grupo Español de Cirugía de las metástasis pulmonares del CCR (GCMP-CCR). Se evalúa el papel de la TC en la detección de M1 pulmonares en 522 pacientes intervenidos de una metastasectomía pulmonar por CCR. Definimos como M1/CT al cociente entre los nódulos metastásicos y los hallados en la TC preoperatoria. Se analizó la supervivencia específica de enfermedad (SEE), la supervivencia libre de enfermedad (SLE) y el abordaje quirúrgico mediante el método de Kaplan-Meier. Resultados En 93 pacientes se utilizó la cirugía videoasistida (VATS) y 429 toracotomías. En un 90% el cociente M1/TC fue =1, sin diferencias entre VATS y toracotomía (94,1 vs. 89,7%; p = 0,874). En el 10% restante existían más M1 que las predichas por la TC (M1/CT > 1), sin diferencias entre abordajes (8,6 vs. 10%; p = 0,874). Cincuenta y un pacientes con M1/CT > 1, mostraron una menor mediana de SEE (35,4 vs. 55,8 meses; p = 0,002) y SLE (14,2 vs. 29,3 meses; p = 0,025) en comparación con 470 con M1/CT = 1. No se observaron diferencias en la SEE y la SLE según VATS o toracotomía. Conclusiones Nuestro estudio muestra unos resultados oncológicos equivalentes en la resección de M1 de CCR mediante abordaje VATS o toracotomía. El grupo de pacientes con un cociente M1/CT > 1 presentan una peor SEE y SLE, pudiendo significar una enfermedad más avanzada de la predicha preoperatoriamente.

Introduction Resection of both liver and lung metastases from colorectal carcinoma (CRC) is a standard of care in selected patients with oligometastatic disease. We present here the analysis of the subgroup of patients undergoing combined surgery from the Spanish Group of Surgery of Pulmonary Metastases (PM) from Colorectal Carcinoma (GECMP-CCR-SEPAR). Methods We analyze characteristics, survival and prognostic factors of patients undergoing combined resection from March-2008 to February-2010 and followed-up during at least 3 years, from the prospective multicenter Spanish Registry. Results A total of 138 patients from a whole series of 543 cases from 32 thoracic surgery units underwent both procedures. Seventy-seven (43.8%) resected liver metastases were synchronic with colorectal tumor. Median disease specific survival (DSS) from first pulmonary metastasectomy was 48.9 months, being three and 5-year DSS 65.1% and 41.7%, respectively. From CRC-surgery median DSS was 97.2 months, with 3 and 5-year DSS rates of 96.7% and 77%, respectively. Five-year DSS from pulmonary metastasectomy was 41.7% for patients with combined resection and 52.4% for those without hepatic involvement (P = .04). Differences disappeared when considering DSS from colorectal surgery. Carcinoembrionary antigen (CEA) before lung surgery over 10 mg/dl and bilateral PM were independent prognostic factors for survival (hazard ratio 2.4 and 2.5, respectively). Conclusions Patients with resection of PM of CRC with history of resected hepatic metastases presented significantly lower disease specific survival rates than those undergoing pulmonary metastasectomy alone. CEA before lung surgery and bilateral PM associated worse prognosis.

Background Although numerous existing studies have analyzed the prognostic factors of patients who have had surgical intervention for lung metastases of colorectal carcinoma (CRC), many of the results obtained until now have been contradictory. As a consequence, there is no established consensus about which group of prognostic factors could have a greater value when considered together. Methods This was a multicenter prospective cohort study that included all patients who underwent a first pulmonary metastasectomy of CRC, with radical intent, during a 2-year period (March 2008 to February 2010). The follow-up continued until March 2013, and an analysis of disease-specific survival (DSS), determined from the first pulmonary metastasectomy, was implemented. The selection of the best submodel was taken based on their coefficient of determination ( R 2 ) and how parsimonious they were depending on the number of variables included. Results The series, consisting of 522 patients, presented the following survival rates: median, 54.9 months; 3-year DSS, 69.4% (95% confidence interval [CI], 65% to 73.8%); and 5-year DSS, 46.1% (95% CI, 38.5% to 53.7%). The resulting survival model consisted of disease-free interval of 12 months or less (hazard ratio [HR], 1.76; 95% CI, 1.21 to 2.54; p = 0.003), carcinoembryonic antigen level exceeding 5 ng/mL (HR, 1.50; 95% CI, 1.04 to 2.17; p = 0.028), bilateral lung disease (HR, 1.81; 95% CI, 1.20 to 2.75; p = 0.005), and thoracic lymph node involvement (HR, 2.71; 95% CI, 1.44 to 5.12; p = 0.002). Conclusions According to these results from the Spanish Group of Lung Metastases of Colo-Rectal Cancer, the combination of these four variables—disease-free interval, carcinoembryonic antigen level, laterality, and thoracic lymph node involvement—constitutes the first-choice survival causal model based on the clinical and pathologic factors most frequently referenced in literature.

BACKGROUND Patients with pulmonary metastases from colorectal cancer (CRC) may benefit from aggressive surgical therapy. The objective of this study was to determine the role of major anatomic resection for pulmonary metastasectomy to improve survival when compared with limited pulmonary resection. PATIENTS AND METHODS Data of 522 patients (64.2% men, mean age 64.5 years) who underwent pulmonary resections with curative intent for CRC metastases over a 2-year period were reviewed. All patients were followed for a minimum of 3 years. Disease-specific survival (DSS) and disease-free survival (DFS) were assessed with the Kaplan-Meier method. Factors associated with DSS and DFS were analyzed using a Cox proportional hazards regression model. RESULTS A total of 394 (75.6%) patients underwent wedge resection, 19 (3.6%) anatomic segmentectomy, 5 (0.9%) lesser resections not described, 100 (19.3%) lobectomy, and 4 (0.8%) pneumonectomy. Accordingly, 104 (19.9%) patients were treated with major anatomic resection and 418 (80.1%) with lesser resection. Operations were carried out with video-assisted thoracoscopic surgery (VATS) in 93 patients. The overall DSS and DFS were 55 and 28.3 months, respectively. Significant differences in DSS and DFS in favor of major resection versus lesser resection (DSS median not reached versus 52.2 months, P = 0.03; DFS median not reached versus 23.9 months, P < 0.001) were found. In the multivariate analysis, major resection appeared to be a protective factor in DSS [hazard ratio (HR) 0.6, 95% confidence interval (CI) 0.41-0.96, P = 0.031] and DFS (HR 0.5, 95% CI 0.36-0.75, P < 0.001). The surgical approach (VATS versus open surgical resection) had no effect on outcome. CONCLUSION Major anatomic resection with lymphadenectomy for pulmonary metastasectomy can be considered in selected CRC patient with sufficient functional reserve to improve the DSS and DFS. Further prospective randomized studies are needed to confirm the present results.

Candidatus Rickettsia amblyommii' is a spotted fever group rickettsia that is not considered pathogenic, although there is serologic evidence of possible infection in animals and humans. The aim of this study was to evaluate the pathogenic potential of a Costa Rican strain of ' Candidatus R. amblyommii' in guinea pigs and determine its capacity to generate protective immunity against a subsequent infection with a local strain of Rickettsia rickettsii isolated from a human case. Six guinea pigs were inoculated with ' Candidatus R. amblyommii' strain 9-CC-3-1 and two controls with cell culture medium. Health status was evaluated, and necropsies were executed at days 2, 4, and 13. Blood and tissues were processed by PCR to detect the gltA gene, and end titers of anti-' Candidatus R. amblyommii' IgG were determined by indirect immunofluorescence. To evaluate protective immunity, another 5 guinea pigs were infected with ' Candidatus R. amblyommii' (IGPs). After 4 weeks, these 5 IGPs and 3 controls (CGPs) were inoculated with pathogenic R. rickettsii. Clinical signs and titers of anti-. Rickettsia IgG were determined. IgG titers reached 1:512 at day 13 post-infection with ' Candidatus R. amblyommii' On day 2 after inoculation, two guinea pigs had enlarged testicles and ' Candidatus R. amblyommii' DNA was detected in testicles. Histopathology confirmed piogranulomatous orchitis with perivascular inflammatory infiltrate in the epididymis. In the protective immunity assay, anti-. Rickettsia IgG end titers after R. rickettsii infection were lower in IGPs than in CGPs. IGPs exhibited only transient fever, while CGP showed signs of severe disease and mortality. R. rickettsii was detected in testicles and blood of CGPs. Results show that the strain 9-CC-3-1 of ' Candidatus R. amblyommii' was able to generate pathology and an antibody response in guinea pigs. Moreover, its capacity to generate protective immunity against R. rickettsii may modulate the epidemiology and severity of Rocky Mountain spotted fever in areas where both species circulate. Candidatus Rickettsia amblyommii' es un grupo de fiebre maculosa rickettsia que no se considera patógena, aunque existen pruebas serológicas de una posible infección en animales y seres humanos. El objetivo de este estudio fue evaluar el potencial patógeno de una cepa costarricense de ' Candidatus R. amblyommii' en conejillos de indias y determinar su capacidad para generar inmunidad protectora contra una infección posterior con una cepa local de Rickettsia rickettsii aislada de un caso humano. Se inocularon seis cobayas con la cepa 9-CC-3-1 de ' Candidatus R. amblyommii' y dos controles con medio de cultivo celular. Se evaluó el estado de salud y se realizaron necropsias en los días 2, 4 y 13. La sangre y los tejidos fueron procesados por PCR para detectar el gen gltA, y los títulos finales de la IgG de ' Candidatus R. amblyommii' fueron determinados por inmunofluorescencia indirecta. Para evaluar la inmunidad protectora, otros 5 conejillos de indias fueron infectados con ' Candidatus R. amblyommii' (IGP). Después de 4 semanas, estos 5 IGP y 3 controles (CGP) fueron inoculados con R. rickettsii patógeno. Los signos clínicos y los títulos de anti. Rickettsia IgG fueron determinados. Los títulos de IgG alcanzaron 1:512 en el día 13 después de la infección con ' Candidatus R. amblyommii' El día 2 después de la inoculación, dos conejillos de indias tenían los testículos agrandados y el ADN de ' Candidatus R. amblyommii' fue detectado en los testículos. La histopatología confirmó la orquitis piogranulomatosa con infiltrado inflamatorio perivascular en el epidídimo. En el ensayo de inmunidad protectora, el anti. Los títulos finales de IgG de Rickettsia después de la infección de R. rickettsii fueron menores en los IGP que en los CGP. Los IGP sólo mostraron fiebre transitoria, mientras que los CGP mostraron signos de enfermedad grave y mortalidad. R. rickettsii se detectó en los testículos y en la sangre de los CGP. Los resultados muestran que la cepa 9-CC-3-1 de ' Candidatus R. amblyommii' fue capaz de generar una patología y una respuesta de anticuerpos en los conejillos de indias. Además, su capacidad de generar inmunidad protectora contra R. rickettsii puede modular la epidemiología y la gravedad de la fiebre maculosa de las Montañas Rocosas en las zonas donde circulan ambas especies. Universidad Nacional, Costa Rica Escuela de Medicina Veterinaria

To evaluate the characteristics of lymph node assessment in the Spanish Colorectal Metastasectomy Registry (GECMP-CCR) and to analyze and compare the survival of patients with pathological absence or presence of lymph node metastases (LNM) with the survival of those with uncertain lymph node status (uLNs). A total of 522 patients with lung metastases from colorectal carcinoma were prospectively registered from 2008 to 2010. To confirm the pathologic absence of LNM, systematic nodal dissection or systematic sampling was required, or the lymph node status was coded as uncertain. Disease-specific survival and disease-free survival were calculated by the Kaplan–Meier method with the log-rank test for comparisons. Lymphadenectomy was performed in 250 (48 %) patients. LNM was found in 25 (10 %) of the patients who had lymph node assessment done. The 3- and 5-year disease-specific survival rates according to lymph node status were 73.5 and 58.3 % in the absence of LNM, 50.5 and 24.8 % when LNM was confirmed, and 69 and 44 % for those with uLNs, respectively (p = 0.006). The presence of LNM and uLNs is associated with an increased risk of death. The association of nodal assessment at the time of metastasectomy to identify LNM helps us to refine the postoperative prognosis; therefore, its impact should be properly studied in a prospective clinical trial.

Hirayama disease, or juvenile amyotrophy of distal upper extremity, is a benign, self-limiting cervical myelopathy consisting of selective unilateral weakness of the hand and forearm. The weakness slowly progresses until spontaneous arrest occurs within 5 years of onset. The condition predominantly affects Asian males and is thought to be secondary to spinal cord compression during neck flexion, because of a forward displacement of the posterior dural sac. The authors present what is to their knowledge the first reported case of a Caucasian male with a severe form of Hirayama disease, suffering from weakness of the leg as well as the forearm. An abnormal range of cervical flexion was observed at the C5–6 level. The patient was successfully treated by anterior cervical discectomy and fusion.

The parasitic tapeworm Echinococcus granulosis causes hydatid disease, which is rarely encountered in nonendemic regions. It is a progressive disease with serious morbidity risks. Rarely, these cysts are found in the spine. They are mainly found epidurally, originating from direct extension from pulmonary, abdominal or pelvic infestation. Nevertheless, the main mechanism for intradural involvement is not yet clear. Antihelminthic treatment should be administered for a long period following early decompressive surgery. We report a case of recurrent hydatid disease that presented unusual intradural dissemination. Prognosis for spinal hydatid disease remains very poor and comparable to that of a malignant neoplasm.

Although compression of the trigeminal nerve by a vascular loop is thought to be the most common cause of trigeminal neuralgia (TN), other aetiologies, such as multiple sclerosis or brainstem infarction may be associated with this disorder. MRI may detect lesions different from vascular loop compression of the trigeminal nerve that may be related to TN. The pre-operative MRIs of 68 patients without the diagnosis of multiple sclerosis who were operated for typical TN between 1998 and 2003 were retrospectively reviewed Four of these showed hyperintense lesions in the pons on T2 MRI sequences. No patient had prior surgery. These four patients underwent different operations for the control of pain but in two of them only ablative procedures were effective Although it is uncertain whether the occurrence of TN in our patients may be attributed to the brainstem abnormalities seen on MRI, the presence of these lesions appears to be the most convincing explanation for the occurrence of pain. We believe that, in the presence of such imaging changes, a destructive procedure should be regarded as the elective surgical treatment in patients presenting with typical TN with or without apparent vascular loop compression of the trigeminal root.

El tratamiento quirúrgico juega un papel fundamental en el manejo de algunos pacientes con hematomas de cerebelo, y sin embargo, no existe una guía de tratamiento universalmente aceptada que permita seleccionar a este subgrupo de pacientes. El objetivo del presente trabajo fue revisar la base sobre la que se fundamentan las indicaciones del tratamiento quirúrgico en esta patología. En ausencia de ensayos clínicos que afronten este problema, las series clínicas muestran que los criterios más consistentes para la decisión terapéutica son el nivel de consciencia, el tamaño del hematoma, la presencia de hidrocefalia y los datos radiológicos de compresión de los espacios continentes de LCR en la fosa posterior. El parámetro mejor estudiado como reflejo de este último aspecto posiblemente sea la deformidad del IV ventrículo. La literatura sugiere que los hematomas de 4 o más cm de diámetro, o que causan una oclusión completa del IV ventrículo o de la cisterna prepontina deben ser intervenidos independientemente del nivel de consciencia, al presentar una compresión significativa del tronco del encéfalo (TDE). Por el contrario, es probable que hematomas de menos de 3 cm y que no deforman el IV ventrículo, no causen una compresión importante en la fosa posterior, y puedan ser manejados de forma conservadora o mediante el drenaje de la hidrocefalia si fuera preciso. Para hematomas de tamaño intermedio la decisión terapéutica está menos clara, pudiendo optarse por observación estricta en los pacientes con GCS 14-15 o con drenaje ventricular externo (DVE) aislado en aquellos con GCS

Resumen El tratamiento quirurgico juega un papel fundamental en el manejo de algunos pacientes con hematomas de cerebelo, y sin embargo, no existe una guia de tratamiento universalmente aceptada que permita seleccionar a este subgrupo de pacientes. El objetivo del presente trabajo fue revisar la base sobre la que se fundamentan las indicaciones del tratamiento quirurgico en esta patologia. En ausencia de ensayos clinicos que afronten este problema, las series clinicas muestran que los criterios mas consistentes para la decision terapeutica son el nivel de consciencia, el tamano del hematoma, la presencia de hidrocefalia y los datos radiologicos de compresion de los espacios continentes de LCR en la fosa posterior. El parametro mejor estudiado como reflejo de este ultimo aspecto posiblemente sea la deformidad del IV ventriculo. La literatura sugiere que los hematomas de 4 o mas cm de diametro, o que causan una oclusion completa del IV ventriculo o de la cisterna prepontina deben ser intervenidos independientemente del nivel de consciencia, al presentar una compresion significativa del tronco del encefalo (TDE). Por el contrario, es probable que hematomas de menos de 3 cm y que no deforman el IV ventriculo, no causen una compresion importante en la fosa posterior, y puedan ser manejados de forma conservadora o mediante el drenaje de la hidrocefalia si fuera preciso. Para hematomas de tamano intermedio la decision terapeutica esta menos clara, pudiendo optarse por observacion estricta en los pacientes con GCS 14-15 o con drenaje ventricular externo (DVE) aislado en aquellos con GCS Finalmente, no parece indicado el tratamiento de pacientes con GCS 3 y ausencia de reflejos de tronco, o aquellos en los que por su edad avanzada o mala calidad de vida previa presenten un pronostico funcional malo. Se ha encontrado ademas que los pacientes en coma y con signos radiologicos de grave compresion del TDE las posibilidades de una buena recuperacion son muy escasas. A pesar de todo el tratamiento ha de ser individualizado en cada caso, ya que no existe la evidencia suficiente que permita elaborar una guia de aplicacion estricta.

Resumen Las colecciones subdurales postraumaticas y postquirurgicas han sido habitualmente denominadas higromas, y corresponden a colecciones de liquido claro, xantocromico o tenido de sangre en el espacio subdural. Actualmente, las colecciones subdurales son denominadas como higromas simples o complejos, efusion subdural o hidrocefalia externa, dependiendo del mecanismo de formacion, la composicion o las caracteristicas que presentan en las modernas pruebas de imagen. Sin embargo, no existe acuerdo en la literatura a la hora de establecer una denominacion homogenea para estas entidades. Se presenta un caso complejo de coleccion subdural postraumatica y posquirurgica y se revisa la literatura, remarcando los aspectos comunes y diferenciales de las variantes mas frecuentes de las colecciones subdurales.

Resumen Introduccion La infeccion es una complicacion habitual de las valvulas de derivacion ventriculoperitoneal, pero la formacion de un absceso cerebral es una complicacion muy rara. Presentamos el caso de una paciente que desarrollo absceso cerebral alrededor del cateter ventricular de una valvula que habia sido retirada por infeccion un ano antes. Caso clinico Mujer de 38 anos, sometida a derivacion ventriculoperitoneal por hidrocefalia secundaria a neurinoma del acustico, que a lo largo de un periodo de trece anos desarrollo dos episodios de meningitis, por lo que se procedio a la retirada del sistema, dejando el cateter ventricular que parecia estar adherido al plexo coroideo. Un ano mas tarde la paciente desarrollo un absceso cerebral alrededor del cateter. Se procedio a evacuar el absceso y a extraer el cateter. El germen cultivado fue un Proteus mirabilis. Discusion El riesgo inherente a la retirada de un cateter ventricular adherido al plexo coroideo debe contrapesarse con el riesgo de infeccion secundario a la permanencia del mismo.

Spontaneous spinal cord herniation through a dural defect is an unusual condition. This entity has been probably underestimated before the introduction of MRI. We report a case of a 49-year-old man with a progressive Brown-Sequard syndrome. MRI and CT myelogram showed a ventrally displaced spinal cord at level T6-T7 and expansion of the posterior subarachnoid space. Through a laminectomy, a spinal cord herniation was identified and reduced. The anterior dural defect was repaired with a patch of lyophilized dura. The patient recovered muscle power but there was no improvement of the sensory disturbance. The diagnosis of spontaneous spinal cord herniation must be considered when progressive myelopathy occurs in middle-aged patients, without signs of spinal cord compression and typical radiological findings. Surgical treatment may halt the progressive deficits and even yield improvement in many cases.

Object. Some authors have questioned the need to perform cerebral angiography in patients presenting with a benign clinical picture and a perimesencephalic pattern of subarachnoid hemorrhage (SAH) on initial computerized tomography (CT) scans, because the low probability of finding an aneurysm does not justify exposing patients to the risks of angiography. It has been stated, however, that ruptured posterior circulation aneurysms may present with a perimesencephalic SAH pattern in up to 10% of cases. The aim of the present study was twofold: to define the frequency of the perimesencephalic SAH pattern in the setting of ruptured posterior fossa aneurysms, and to determine whether this clinical syndrome and pattern of bleeding could be reliably and definitely distinguished from that of aneurysmal SAH. Methods. Twenty-eight patients with ruptured posterior circulation aneurysms and 44 with nonaneurysmal perimesencephalic SAH were selected from a series of 408 consecutive patients with spontaneous SAH admitted to the authors' institution. The admission unenhanced CT scans were evaluated by a neuroradiologist in a blinded fashion and classified as revealing a perimesencephalic SAH or a nonperimesencephalic pattern of bleeding. Of the 28 patients with posterior circulation aneurysms, five whose grade was I according to the World Federation of Neurosurgical Societies scale were classified as having a perimesencephalic SAH pattern on the initial CT scan. The data show that the likelihood of finding an aneurysm on angiographic studies obtained in a patient with a perimesencephalic SAH pattern is 8.9%. Conversely, ruptured aneurysms of the posterior circulation present with an early perimesencephalic SAH pattern in 16.6% of cases. Conclusions. This study supports the impression that there is no completely sensitive and specific CT pattern for a nonaneurysmal SAH. In addition, the authors believe that there is no specific clinical syndrome that can differentiate patients who have a perimesencephalic SAH pattern caused by an aneurysm from those without aneurysms. Digital subtraction angiography continues to be the gold standard for the diagnosis of cerebral aneurysms and should be performed even in patients who have the characteristic perimesencephalic SAH pattern on admission CT scans.

Object. The authors analyzed the clinicoradiological presentation of traumatic basal ganglia hematomas (TBGHs) in severely head injured (SHI) patients. Methods. The records of 37 patients (28 male and nine female patients with a mean age of 28 years) in whom computerized tomography (CT) scans revealed TBGHs 2 ml or more in volume were retrospectively reviewed. These cases represented 2.4% of the total series of 1526 SHI patients admitted to the authors' institution between 1979 and 1998. Thirty-five patients (94%) were involved in traffic accidents and only two exhibited a period of lucidity. Associated extracranial injuries were seen in 21 patients (57%) and coagulation disorders in 32 (86%). Skull fracture was present in 10 (43%) of the 23 patients in whom skull x-ray films were obtained. Computerized tomography findings indicated diffuse axonal injury in 27 patients (73%), intraventricular hemorrhage in 22 patients (59%), and subarachnoid hemorrhage in 16 patients (43%). In all but two patients, the TBGHs were visible on the initial CT scan, and in 28 cases (76%) these hematomas were contralateral to the side of impact. Hematoma enlargement over the first few posttraumatic days was noted in 65% of the patients in whom control CT scans had been obtained (22 of 34 patients). Four patients (11%) underwent surgery to remove their TBGHs. Final outcomes were poor: 22 patients (59%) died, two (5%) became vegetative, seven (19%) experienced severe disabilities, and only six patients (16%) made a favorable recovery. Conclusions. Traumatic basal ganglia hematomas are dynamic lesions that tend to enlarge during the acute posttraumatic period. The overall prognosis in this series was poor. Patients in whom the volume of the hematoma was larger than 25 ml and those in whom hematoma volume enlargement or raised intracranial pressure occurred had the worst outcomes, perhaps indicating the need for a more aggressive surgical treatment.

Idiopathic trigeminal neuropathy is a benign disorder where the main clinical feature is facial numbness limited to the territory of one or more divisions of the trigeminal nerve, persisting for a few weeks to several years and in which no underlying disease can be identified. The case of a 37-year-old man with a brief history of sensory and motor trigeminal symptoms who showed magnetic resonance imaging (MRI) findings consistent with a small trigeminal neurinoma is reported. The patient was operated on but no tumour could be found during surgery and a biopsy was taken from the portio major. Pathological diagnosis was chronic non granulomatous inflammatory reaction with areas of coagulation necrosis. Control MRI showed complete resolution of the trigeminal abnormalities. It is concluded that in patients with MRI findings suggestive of a small trigeminal schwannoma, benign idiopathic trigeminal neuropathy should also be considered in the differential diagnosis. A conservative approach with sequential MRI studies may avoid an unnecessary surgical exploration.

Resumen La pseudoartrosis espinal es una complicacion infrecuente de la espondilitis anquilosante de larga evolucion, si bien es la mas importante desde el punto de vista biomecanico. Generalmente se manifiesta con dolor incapacitante, deformidad y en ocasiones, deficit neurologico. En el diagnostico de estos pacientes influye de manera decisiva la sospecha clinica ya que los hallazgos tanto en radiografia convencional como en resonancia magnetica (R.M.) pueden ser indistinguibles de los de una espondilitis infecciosa. Se presentan dos casos de pseudoartrosis espinal en pacientes con espondilitis anquilosante de larga evolucion que debutaron con clinica de compresion medular. Se discuten los hallazgos radiologicos y la actitud terapeutica.

Resumen Las malformaciones arteriovenosas durales (MAVDs) suponen aproximadamente del 10% al 15% del total de las malformaciones arteriovenosas (MAVs) intracraneales y muchas de ellas son poco sintomaticas o incluso asintomaticas. Las MAVDs que interesan al seno longitudinal superior (SLS) y la dura de la convexidad y hoz cerebrales, son relativamente infrecuentes, representando tan solo entre el 7% Yel 11% de todas las MAVDs intracraneales, pero tienen interes neuroquirurgico ya que sobre todo las dos primeras, muestran una especial tendencia a producir sangrado intracraneal debido a su frecuente asociacion con drenaje venoso cortical. Presentamos tres casos de MAVDs de la region del seno sagital-convexidad dural y dos de la hoz cerebral. Dos pacientes debutaron con hemorragia intracraneal y el resto desarrollo diversos deficits neurologicos. Tres pacientes fueron tratados con embolizacion por via transarterial con diferentes resultados, uno se intervino quirurgicamente y el otro rehuso tratamiento. Se analizan las caracteristicas clinicas, las peculiaridades angiograficas y el manejo terapeutico de las MAVDs de estas localizaciones.

Resumen Objetivo Analizar los resultados obtenidos en una serie de 40 meningiomas espinales. Material y metodos Se estudian retrospectivamente 40 meningiomas espinales intervenidos en nuestro Servicio entre Junio de 1977 y Abril de 1997. Se discuten aspectos clinicos, radiologicos y terapeuticos. Resultados La edad, sexo y localizacion tumoral no difiere de la reportada por otros autores. En nuestra serie la perdida de fuerza destaco como el sintoma predominante, ya que solo dos pacientes presentaban una fuerza muscular normal en el momento del diagnostico. Todos los pacientes fueron intervenidos mediante laminectomia con una tasa de buenos resultados del 90%. Seis pacientes presentaban una paraparesia severa preoperatoriamente (fuerza muscular de 0-1 sobre 5), y de ellos tres pudieron deambular tras la cirugia. Conclusiones : La cirugia de los meningiomas espinales es un procedimiento seguro, que ofrece buenos resultados terapeuticos en la mayoria de los casos. La tendencia a la recurrencia en relacion a los meningiomas de otra localizacion es menor.

Resumen Los paragangliomas son tumores neuroendocrinos que habitualmente se originan en la medula adrenal y sistema paraganglionar. La localizacion en la cauda equina es infrecuente, por lo que habitualmente se confunden con otros tumores observados con mayor frecuencia en esta region como schwannomas y ependimomas. Se presentan dos casos de paragangliomas de la cola de caballo, estudiados con resonancia magnetica (RM), que debutaron clinicamente con dolor lumbar de larga evolucion. Se discuten los hallazgos radiologicos, actitud terapeutica y estudios neuropatologicos realizados.

Only 4 of the 30 previously reported cases of giant sacral schwannomas have been studied with Magnetic Resonance Imaging (MRI). We are reporting 6 more cases, 5 of which had MRI studies. There were 5 women and 1 man (average age 45 years) with long lasting symptoms consisting of lumbosacral and radicular pain accompanied by urinary disturbances and dysaesthetic sensations in the lower limbs. CT clearly defined sacral bone involvement but poorly demonstrated intraspinal tumour extension which was more evident in MRI studies. MRI also clearly showed the intrapelvic extension of the tumour, its relationship with the neighbouring structures and the dumbbell growth pattern due to tumour extension through sacral foramina which are important data for making a pro-operative diagnosis and surgical planning. Surgical treatment consisted of piecemeal tumour resection through a posterior approach in four cases. Two patients underwent operation through an abdominal transperitoneal approach followed by a sacral laminectomy. Total intracapsular resection was apparently achieved in 5 cases. Through an average follow-up period of 9.2 years and despite a rather conservative approach, the recurrence rate has been very low in our series and only one patient had to be re-operated on for tumour recurrence.

OBJECTIVE: Little information is available on postoperative morbidity and mortality after pulmonary metastasectomy. We describe the postoperative morbidity and mortality in a large multicentre series of patients after a first surgical procedure for pulmonary metastases of colorectal carcinoma (CRC) and identify the pre- and intraoperative variables influencing the clinical outcome. METHODS: A prospective, observational and multicentre study was conducted. Data were collected from March 2008 to February 2010. Patients were grouped into Groups A and B according to the presence or absence of postoperative complications. Variables in both groups were compared by univariate and multivariate analyses. P-values of

Objectives To capture an accurate contemporary description of the practice of pulmonary metastasectomy for colorectal carcinoma in one national healthcare system. Design A national registry set up in Spain by Grupo Espanol de Cirugia Metastasis Pulmonares de Carcinoma Colo-Rectal (GECMP-CCR). Setting 32 Spanish thoracic units. Participants All patients with one or more histologically proven lung metastasis removed by surgery between March 2008 and February 2010. Interventions Pulmonary metastasectomy for one or more pulmonary nodules proven to be metastatic colorectal carcinoma. Primary and secondary outcome measures The age and sex of the patients having this surgery were recorded with the number of metastases removed, the interval between the primary colorectal cancer operation and the pulmonary metastasectomy, and the carcinoembryonic antigen level. Also recorded were the practices with respect to mediastinal lymphadenopathy and coexisting liver metastases. Results Data were available on 543 patients from 32 units (6–43/unit). They were aged 32–88 (mean 65) years, and 65% were men. In 55% of patients, there was a solitary metastasis. The median interval between the primary cancer resection and metastasectomy was 28 months and the serum carcinoembryonic antigen was low/normal in the majority. Liver metastatic disease was present in 29% of patients at some point prior to pulmonary metastasectomy. Mediastinal lymphadenectomy varied from 9% to 100% of patients. Conclusions The data represent a prospective comprehensive national data collection on pulmonary metastasectomy. The practice is more conservative than the impression gained when members of the European Society of Thoracic Surgeons were surveyed in 2006/2007 but is more inclusive than would be recommended on the basis of recent outcome analyses. Further analyses on the morbidity associated with this surgery and the correlation between imaging studies and pathological findings are being published separately by GECMP-CCR.

The authors analysed the correlation between different clinical, radiological, and pathological variables and the presence and intensity of brain oedema associated to intracranial meningioma in 400 consecutive patients studied by computerized tomography (CT). The following factors did not show significant correlation with brain oedema development: the age and sex of the patient, the occurrence of focal deficits, the presence of skull changes (endostosis, exostosis, osteolysis), the occurrence of tumour calcification, the density of the tumour on plain CT scan, the presence of a cystic component, the pathological subtype of meningioma (both conventional and non-conventional), and the presence of histological features of tumour aggressiveness, such as an increased vascularization, high cellularity, high mitotic index, pleomorphism, necrosis, and brain infiltration. Factors showing a statistically significant correlation with the presence and intensity of brain oedema at the bivariate analysis were: the presence of symptoms (p < 0.001), the duration of the clinical history (p < 0.05), the location and size of the tumour (p < 0.001), the type (heterogeneous vs homogeneous), and intensity of tumour contrast enhancement (p < 0.001), the presence of irregular tumour margins (p < 0.001), and the existence of focal low density intratumoural areas (p < 0.001). The multivariate analysis using only clinical parameters showed that the group of variables with the highest power for predicting the presence of brain oedema (concordance level of 76.8%) included: the presence of symptoms, the occurrence of seizures (focal or generalized), the presence of an intracranial hypertension syndrome, and the age of the patient. The multivariate analysis using only anatomico-radiological parameters showed that the model which included the size of the tumour, the intensity of contrast enhancement, the tumour margins, and meningioma location, predicted the presence of brain oedema in 80.8% of the cases. Though the results of the present study do not definitively support any of the major physiopathological theories proposed to explain brain oedema formation in patients with intracranial meningioma, some findings could favour the so-called hydrodynamic theory.

Resumen El presente trabajo examina el valor de la resonancia magnetica (RM) sin y con contraste en el estudio preoperatorio de los hemangioblastomas cerebelosos a proposito de cuatro casos seguidos en nuestro servicio, revisandose la literatura al respecto. Se comparan los resultados obtenidos con las tecnicas de neuroimagen convencionales y RM, y se concluye que es este el procedimiento de eleccion, si bien ocasionalmente se requiere la practica de una angiografia vertebral para definir el diagnostico de presuncion.

Resumen Los autores presentan una serie de 29 pacientes con siringomielia tratados quirurgicamente mediante descompresion craneovertebral (DCV) (19 casos), derivacion quistoperitoneal (DQP) (9 casos) y derivacion ventriculoperitoneal (DVP) (1 caso), en la que se comparan los resultados clinicos y de control por resonancia magnetica. La presentacion clinica mas frecuente consistio en alteraciones sensitivas, dolor ocdpitocervical y paraparesia. El tratamiento quirurgico es mas efectivo para resolver el dolor y el defecto motor (50% con DCV y 30% con DQP), que las alteraciones de sensibilidad. La cavidad quistica se resolvio en un 90% de los casos existiendo una disociacion entre los porcentajes de mejoria clinica y los de imagen, especialmente en los sometidos a DQP. La DVP fue efectiva clinica y radiologicamente en el paciente con complejo siringomielia-Chiari-hidrocefalia comunicante. La cirugia DCV puede ser usada como primera eleccion en pacientes con siringomielia, reservando la DQP para los casos en los que no se consigue reducir la cavidad medular.

Resumen Se revisan 11 pacientes con hemorragia subaracnoidea producida por la rotura de un aneurisma del complejo arteria vertebral (AV) - arteria cerebelosa posteroinferior (ACPI). Esta cifra supone el 2,3% del total de aneurismas vistos en nuestro Servicio entre 1974 y 1993. Se analiza la clinica de presentacion, localizacion, presencia de vasoespasmo angiografico, sintomas isquemicos y evolucion final. Se practico tomografia computarizada en 9 casos, discutiendose la localizacion de sangre y los hallazgos patologicos en la TC inicial. Esta serie tiene la particularidad de tener tres casos de malformacion arteriovenosa en la arteria cerebelosa posteroinferior asociada al aneurisma. Se discute la frecuencia de dicha asociacion y su significado patologico.

Resumen Se analiza la presentacion clinica y radiologica en 16 pacientes portadores de cavernomas sintomaticos del tronco cerebral y cerebelo, la mayoria de los cuales fueron estudiados con resonancia magnetica. Un total de 11 pacientes que sufrieron uno o mas episodios hemorragicos fueron intervenidos quirurgicamente. En todos los casos excepto en uno se logro la exeresis total de la lesion, pero dos pacientes tuvieron que ser reintervenidos tras una supuesta extirpacion total inicial. Solo dos pacientes experimentaron incremento definitivo, si bien discreto, de sus sintomas preoperatorios. Cinco pacientes con presentacion clinica benigna estan siendo tratados conservadoramente. Se comenta la indicacion quirurgica en relacion con estas lesiones.

Resumen Se presenta un caso de condrosarcoma cervical en paciente diagnosticado de osteocondromatosis multiple no hereditaria que fue intervenido en dos ocasiones. Esta localizacion es excepcional ya que se trata de un tumor que afecta fundamentalmente a huesos planos de cinturon escapular y pelviano, huesos largos y costillas. En los pocos casos en los que este tumor se localiza en la columna vertebral existe un claro predominio por la region toracica. Se comentan los datos clinicos y radiologicos, se revisa la literatura y se analizan los factores pronosticos asi como el enfoque terapeutico en estos pacientes.

Resumen Se presentan 27 casos de quistes epidermoides y 5 casos de quistes dermoides intracraneales intradurales que fueron intervenidos quirurgicamente en nuestro Servicio durante un periodo de 18 anos. Los pacientes fueron estudiados radiologicamente mediante neumoencefalografia en 5 casos, angiografia cerebral en 16, tomografia computadorizada (T.C.) en 24 casos y resonancia magnetica (R.M.) en 13 (9 preoperatoriamente y 4 postoperatoriamente). Se realizo un seguimiento posquirurgico en 30 pacientes durante un periodo medio de 4 anos. En ambos tipos de quiste la localizacion predominante fue supratentorial (un 59,2 % de los epidermoides y 60 % de los dermoides). Como localizaciones poco frecuentes de quiste epidermoide se presentan 2 intraventriculares (IV ventriculo y region atrial), 2 intradiencefalicas, una paratrigeminal y otra interhemisferica supracallosa. En la mayoria de los quistes la exeresis se practico mediante tecnica microquirurgica. Se considero total en 16 pacientes (50 % de los casos), casi total en 7 (21,8 %) y parcial en 9 (28,1 %). Se consiguio mejoria clinica en 14 pacientes (46,6 %), estabilizacion sintomatica en 11 (36,6 %) y empeoramiento en 5 (16,6 %). Cinco pacientes presentaron recidiva tras un intervalo posquirurgico medio de 7 anos. Cuatro de ellos empeoraron clinicamente y fueron reintervenidos. En nuestra experiencia observamos que la R.M. ofrece mayor informacion diagnostica que la T.C. en la recidiva, especialmente en la secuencia potenciada en densidad protonica. Asimismo hemos comprobado que varios pacientes con imagen radiologica posquirurgica de restos quisticos o recidiva pueden permanecer largo tiempo asintomaticos y nuestra actitud terapeutica en estos casos ha sido expectante.

Summary Five cases of cerebral vasospasm associated with intraventricular or subarachnoid hemorrhage caused by a ruptured intracranial arteriovenous malforma­ tion are reported. In one patient cerebral vasospasm transiently reduced blood flow through the malforma­ tion, preventing angiographic visualization of the ni­ dus and the draining veins. The rarity and possible mechanisms of cerebrovascular spasm following the rupture of AVMs are discussed.

Resumen A pesar de los progresos en la terapia antibiotica y las tecnicas radiologicas, la mortalidad del absceso cerebral es todavia importante, y su incidencia, lejos de disminuir, parece estar aumentando. Analizamos 60 casos de absceso cerebral recogidos en nuestro Servicio entre 1974 y 1990. Las infecciones oticas y pulmonares fueron identificadas como factores predisponentes en el 30% y 12% de los casos, respectivamente. El origen de la infeccion no se encontro en el 35% de los pacientes. La cefalea, la fiebre, el defecto focal y las alteraciones del nivel de conciencia fueron los sintomas de presentacion mas frecuentes. El 75% de los pacientes se trataron despues de la introduccion de la tomografia computadorizada (TC), con un 80% de aciertos en la sospecha diagnostica y dos dias de demora entre ingreso y tratamiento. El 25% restante se manejaron antes de la era Tc, con un 50% de aciertos y ocho dias de demora. Las localizaciones mas frecuentes fueron la temporal y la frontal. En el 10% de los casos los abscesos fueron multiples. Los cultivos del pus obtenido resultaron positivos en un 75% de los casos, y los anaerobios fueron los germenes hallados con mas frecuencia. La mortalidad con la tecnica de puncion-aspiracion, introducida despues de la llegada de la TC, fue del 15%, mientras que con la extirpacion mediante craneotomia, utilizada fundamentalmente antes de la decada de los ochenta, la mortalidad fue del 50%. Los factores pronosticos mas importantes fueron la alteracion del nivel de conciencia previo a la cirugia y el numero de abscesos.

Resumen Se analizan retrospectivamente 412 casos consecutivos de hemorragia subaracnoidea aneurismatica, tratados durante los anos 1974–1991. El 79% de los pacientes ingresaron en los tres primeros dias del sangrado. El 63% de los pacientes ingresaron en buen grado clinico (Botterell I y II). Se aprecio vasoespasmo angiografico en el 38% de los casos. Se intervinieron 336 pacientes (81,6%), la mayoria pasados siete dias. Del total de la serie fallecieron 132 pacientes (32%), 69 de estos (16,7%) despues de haber sido intervenidos. Las complicaciones que mas influyeron en la mortalidad fueron la isquemia cerebral y el resangrado. Apreciamos una estrecha correlacion entre el deposito de sangre cisternal, la aparicion de vasoespasmo angiografico y el desarrollo de isquemia cerebral, lo que apoya la teoria que imputa a la sangre, o a alguno de sus componentes o productos de degradacion un papel fundamental en la produccion de vasoespasmo. Es muy importante reconocer precozmente esta enfermedad con el fin de instaurar lo antes posible el tratamiento adecuado.

Resumen Se analizan retrospectivamente 258 casos consecutivos de hemorragia subaracnoidea idiopatica, tratados durante los anos 1974–1991; estos representan el 34% del total de hemorragias subaracnoideas diagnosticadas en el mismo periodo. Se discuten los datos clinicos y radiologicos de esta en entidad y se comparan con los de la hemorrragia subaracnoidea aneurismatica, comprobandose una menor incidencia de complicaciones neurologicas (isquemia 8% y resangrado 6%) y una mejor evolucion final (90,3% independientes y solo un 5,4% de mortalidad) que en los pacientes con aneurisma. Asimismo, se analiza la distribucion de sangre en las cisternas subaracnoideas, apreciandose una mayor afectacion de las cisternas peritruncales (interpeduncular y ambiens). Se desaconseja repetir el estudio angiografico si este es completo y de buena calidad, pudiendose repetir este si existe resangrado, si el grado clinico inicial es malo, si hubo vasoespasmo en el estudio angiografico, o si la TC al ingreso muestra una extensa distribucion de sangre por cisternas basales.

Introduction. Juvenile amyotrophy of the distal upper extremity (JADUE) is a rare disease afecting young males. Since neck flexion has been thought to be the cause of the spinal cord damage, cervical orthosis, spinal fusion by an anterior or posterior approach and duraplasty in combination with posterior spinal fusion have been proposed as treatment of JADUE. We are presenting the case of a patient with JADUE who was surgically treated with duraplasty without spinal fusion, thus avoiding the compression of the spinal cord without limitation of cervical movement. Case. A previously healthy 19-year-old man presented with insidious onset of weakness in the left forearm and hand for the past year. On MRI, during neck flexion, the posterior dura showed anterior displacement that compressed the cervical spinal cord. The dura was opened linearly from C3 to C6, observing the herniation of the spinal cord through the opening. Duraplasty was performed in order to increase the room of the spinal cord. No spinal fusion was performed. Discussion. The postoperative course was uneventful. Clinical deterioration stopped following operation and two years later unchanged as compared to the preoperative one.

Las fístulas carótido cevernosas (FCC) indirectas o durales son comunicaciones entre el seno cavernoso y ramas extradurales de la arteria carótida interna, la carótida externa o ambas. La mayoría de las FCC indirectas son idiopáticas y aparecen espontáneamente. Los síntomas pueden variar desde una leve inyección conjuntival y escleral hasta la reducción severa de la agudeza visual. En casos poco sintomáticos y sin drenaje leptomeníngeo, el tratamiento conservador estaría indicado inicialmente, pues existe la posibilidad del cierre espontáneo de la fístula. Cuando la sintomatología progresa, requieren algún tipo de tratamiento para cerrarla. Hoy en día, el tratamiento endovascular es el de elección, y la vía transvenosa, con sellado o empaquetado del SC, ha demostrado mayor efectividad que la transarterial. En la mayoría de los casos se puede acceder al SC a través del seno petroso inferior. Sin embargo, en ocasiones no es posible el acceso a la FCC por vía venosa transfemoral, siendo necesario un abordaje directo a la vena oftálmica superior (VOS). Presentamos un caso de FCC indirecta tratada mediante abordaje directo a la VOS y embolización del seno cavernoso.

Resumen Se analiza la presentacion clinico-radiologica de cinco papilomas de plexo coroideo de la fosa posterior en el adulto. Cuatro de estos tumores se localizaban en el cuarto ventriculo y uno ocupaba la region del angulo pontocerebeloso (APC). El diagnostico diferencial de estos tumores se basa actualmente en la tomografia axial computarizada (TAC). Aparte de la calcificacion intratumoral que se observa en el 25% de los casos aproximadamente, pero que no les distingue de otros tumores de la misma localizacion, es caracteristico de los papilomas que presenten densidad elevada en el estudio sin contraste si bien un 20% son isodensos en relacion con el parenquima vecino. Tras la inyeccion de contraste estos tumors captan avida y homogeneamente, a excepcion de aquellos que estan masivamente calcificados. La irregularidad de los bordes tumorales en el estudio con contraste es bastante tipica y ayuda a diferenciarlos del ependimoma, meduloblastoma y astrocitoma. No existe un patron angiografico caracteristico del papiloma de plexo, si bien la angiografia cerebral ayuda en el diagnostico diferencial con el hemangioblastoma. La diferenciacion radiologica del papiloma del APC con otros tumores mas comunes de la region es mas facil. Se comenta la presentacion macroscopica del papiloma durante el acto quirurgico, sus relaciones con las estructuras vecinas y el pronostico operatorio a corto y largo plazo. Finalmente se considera el diagnostico diferencial histologico con otras lesiones de estructura papilar.

Resumen Con el fin de determinar su posible valor localizador se han analizado las respuestas motoras y sensitivas obtenidas mediante la estimulacion electrica monopolar a nivel del cuadrante anterolateral de la medula cervical, el techo mesencefalico, el talamo ventrolateral y el brazo posterior de la capsula interna en 42 pacientes sometidos a lesion antialgica o antitremorica, o bien a estimulacion electrica cronica terapeutica.

Resumen Se describen siete casos de meningioma del ventriculo lateral intervenidos entre 1975 y 1989. Estos siete casos representan el 2,4% del total de 289 meningiomas intracraneales operados durante el mismo periodo. El tumor tenia su origen en el plexo coroideo y ocupaba la region del atrio ventricular en todos los casos, extendiendose hasta el tercer ventriculo a traves del foramen de Monro en uno de ellos. La presentacion clinica resulto atipica en dos pacientes que sufrieron sangrado tumoral. El diagnostico se llevo a cabo con yodoventriculografia (1 caso), arteriografia (5 casos), tomografia computarizada (6 casos) y resonancia magnetica (1 caso). En uno de los pacientes el meningioma se asocio a un astrocitoma de alto grado de malignidad localizado en el mismo hemisferio cerebral. Dos pacientes fallecieron tras la intervencion, uno a causa de dano diencefalico y otro, de edad muy avanzada, por complicaciones medicas extraneurologicas. La paciente con astrocitoma asociado presento recidiva de este tumor no siendo reintervenida.

Most scales used to assess prognosis after subarachnoid haemorrhage (SAH) are based on the level of consciousness of the patient. Based on information from a logistic regression model, Ogilvy et al. developed a new grading scheme (Massachussetts General Hospital (MGH) Scale) which applied a simple scoring method to each prognostic factor considered relevant such as level of consciousness, age, quantity of blood in the first CT scan and size of the aneurysm. The purpose of this study is to introduce a modified version of the MGH scale, built up using factors applicable to every patient suffering SAH, and compare this new scale to the World Federation of Neurological Surgeons scale (WFNS), the Glasgow Coma Scale (GCS) scale for SAH and the MGH scale.A series of 442 patients consecutively admitted to Hospital 12 de Octubre between January 1990 and September 2001 with the diagnosis of spontaneous SAH were retrospectively reviewed. Outcome was assessed by means of the Glasgow Outcome Scale measured six months after hospital discharge. Differences between grades of the WFNS, the GCS scale for SAH, the MGH scale and the new scale were computed by chi2 statistics. ROC curves were plotted for the different scales and their areas compared.Both WFNS and GCS scales fail to present significant differences between most of their grades, while the proposed scale shows a constant inter-grade significant difference in predicting outcome. The proposed scale presents a significantly higher prognostic efficacy in the whole series of patients suffering spontaneous SAH, patients with idiopathic subarachnoid haemorrhage (ISAH) and patients with confirmed aneurysmal SAH. The MGH scale is not applicable to some groups of patients suffering SAH.Grading scales including additional factors to the level of consciousness show higher prognostic efficacy. The proposed modification of the MGH scale makes it applicable to every patient suffering SAH without losing its prediction capability.

Background The accuracy of clinical staging in lung cancer may be evaluated by comparing it against the gold standard of pathologic staging. The objective of this paper is to compare these two staging methods in a series of 2,994 lung cancer cases operated on consecutively in Spain between 1993 and 1997. Methods The raw frequency of agreement was used to compare clinical against pathologic staging and to assess the agreement. Kappa's index was used to determine the random effect of agreement. Results Ninety-three percent of the entire population were men, with a mean age of 64 years (median, 66; SD, 9.6). The majority of cases were classified as squamous tumors (1,774; 59%), with complete resection (2,410; 80%), and with lobectomy or bilobectomy (1,490; 55%). The most frequently found pathologic stage was pIB (997; 37%), followed by pIIIA (524; 19%). Considering the 2,377 cases with clinical and pathologic staging data, a classification coincidence was observed in 1,108 cases (47%; Kappa's index 0.248 for stages IA through IIIB). Considering the pathologic staging as the gold standard, the agreement was 75% for stages IA-IB (Kappa's index 0.56). In general, downstaging is more frequent than upstaging. Conclusions This recent series of lung cancer showed the low diagnostic accuracy of the clinical staging as compared with the pathologic staging. Diagnostic accuracy was found to be much higher in the initial IA-IB stages, as illustrated by Kappa's index.

The purpose of our study was to analyze current indications for surgery in tuberculosis (TB). We present our experience with TB patients presenting with indications for surgery between 1990 and 1998.The indications for surgical intervention included 25 cases of pulmonary aspergilloma, 19 cases of pneumothorax, 16 cases of pulmonary nodes and masses without histological diagnosis, 15 cases of bronchiectasis, 12 cases of massive hemoptysis, 12 cases of pleural empyema, and 33 cases of other complications. No patients with multidrug-resistant tuberculosis required surgical intervention, although 56 were treated during this period.The techniques utilized included lobectomy in 45 cases, pleural drainage in 32 cases, segmented pulmonary resection in 32 cases, surgical procedures on the thoracic wall in 17 cases, pneumonectomy in 10 cases, pleuropulmonary decortication in 8 cases, mediastinoscopy in 6 cases, and thoracoscopy in 5 cases. In 25 cases two or more procedures were performed on the same patient. In 36 cases (27.3%) there were complications, of which persistent air leakage after pulmonary resection was the most frequent (n=10). There was a mortality rate of 5.3% (7In our experience, surgery in the treatment of TB is indicated to resolve sequelae or complications, since cases of simple or multidrug-resistant TB can be managed pharmacologically. The morbidity and mortality rates in our series were acceptable.

Meningiomas are considered to be slow-growing tumors that compress the brain without invading it. The development of metastases is uncommon, with a predilection for the lungs, liver, lymph nodes, and bone. We report the case of a 58-year-old man, diagnosed with a solitary pulmonary nodule in the left lower lobe that was resected through a thoracotomy. The pathology revealed lung metastases of an undiagnosed meningothelial meningioma. The evolution of the patient's case, the second case in the literature of this kind of benign tumor that has developed pleural metastases, was unsatisfactory.

OBJECTIVE: To describe the surgical and ultrastructural findings in the trigeminal root of a patient with trigeminal neuralgia (TN) associated with a cerebellopontine epidermoid tumor, and to relate these to literature reports of patients with vascular compression-related TN. CLINICAL PRESENTATION: A 39-year-old woman presented with right TN. She had a 10-year history of lancinating pain paroxysms in the second and third trigeminal branches. Pain exhibited trigger areas and improved partially with carbamazepine. Cranial magnetic resonance imaging revealed an epidermoid tumor in the right cerebellopontine angle that distorted and compressed the right trigeminal root. TECHNIQUE: The tumor was resected. At operation, the trigeminal root appeared distorted and compressed by the tumor. A small partial rhizotomy was performed, and the biopsy was processed for ultrastructural study. Complete relief of the symptoms was achieved with no deficits after the procedure. Pathologic changes in the biopsy included axonal loss, demyelination, and the presence of abundant collagen infiltrates and myelin debris. No inflammatory cells were present. In some areas, myelin-denuded axons were in close apposition, allowing the presence of axon-to-axon interactions. These findings are similar to others described previously regarding patients with vascular compression-related TN. CONCLUSION: Compression injury to the trigeminal root leading to demyelination is a major determinant in the pathogenesis of TN.

Background . Persistent air leak after operation on the lung is one of the most common problems encountered by thoracic surgeons. We present 6 patients who underwent pleurodesis with autologous blood for persistent air leak after operation. Methods . Between June 1993 and January 1998, pleurodesis with autologous blood was performed in 6 patients who had air leak of more than 10 days' duration after operation for non–small cell lung cancer. A sample of peripheral blood was taken from the patient's arm and immediately introduced into the chest tube with no additives. The chest tube was left unclamped and off suction, connected to the waterseal drainage, and kept 60 cm above the patient's chest. The next day, the waterseal and chest roentgenogram were reviewed before the chest tube was removed. Results . A persistent air leak with a mean duration of 16.7 days was observed after the initial operation. Fifty to 250 mL of blood was introduced one time into the chest tube. No patient experienced pain, respiratory difficulty, fever, or episodes of coughing during the procedure. After 24 hours, no air leak was detected in the waterseal drainage in any patient. Conclusions . On the basis of these preliminary findings, we believe pleurodesis with autologous blood is a safe and effective method for treating persistent air leak after a thoracic surgical procedure.

The authors undertook a follow-up study of 286 patients who underwent surgical treatment for intracranial meningioma between 1973 and 1994, in order to analyse clinical, radiological, topographic, histopathological and therapeutic factors significantly influencing tumour recurrence. All patients were followed by using either computed tomography (CT) or magnetic resonance from 3 months to 17 years since first surgery (mean follow-up: 4.1 years). Forty-four (15.4%) recurrences were detected during this time period. Overall recurrence rates were 14%, 37% and 61% at 5, 10 and 15 years, respectively. Factors significantly associated with tumour relapse in bivariate analysis were: tumour location at petroclival and parasagittal (middle third) regions, incomplete surgical resection (assessed by Simpson's classification), atypical and malignant histological types (WHO classification), presence of nucleolar prominence, presence of more than 2 mitosis per 10 high-power fields, and heterogeneous tumour contrast enhancement on the CT scan. The multivariate analysis using the Cox's proportional hazards model identified the following risk factors for recurrence: incomplete surgical resection (Relative risk: 2.2; 95% Confidence interval: 1.33-3.64), non conventional histological type (RR: 2.13; 95%CI: 1-4.53), heterogeneous contrast enhancement on the CT scan (RR: 2.25; 95%CI: 1.1-4.72) and presence of more than 2 mitosis per 10 high-power fields (RR: 2.28; 95%CI: 0.99-5.27). Patients without any of these features showed low recurrence rates (4% and 18% at 5 and 10 years), and thus, they need less clinical and radiological controls through the follow-up than patients with some of these risk factors.