Vagus nerve stimulation therapy for treatment-resistant epilepsy: a 15-year experience at a single institution

OBJECTIVE

Treatment-resistant epilepsy (TRE) occurs in 20-30% of patients. The goal of this study is to assess the efficacy and safety of vagus nerve stimulation (VNS) in this group of patients, including adult and pediatric populations and several off-label indications.

METHODS

This is a retrospective review of 59 consecutive patients in whom 60 VNS devices were implanted at a single institution during a 15-year period. Patients were evaluated in the Multidisciplinary Epilepsy Committee and complete presurgical workup was performed. The series included indications not approved by the FDA, such as children under 12 years of age, pregnancy and right-sided VNS. Performing the procedure on an out-patient basis was recently adopted, minimizing hospital length of stay.

RESULTS

There were 42 adults and 17 children (14 under 12 years of age) and the mean age at implantation was 26 years. Duration of VNS therapy ranged from 6 months to 9 years. For the entire cohort, the mean percentage seizure reduction was 31.37%. Twenty patients (34.48%) were considered responders (seizure reduction ≥50%); 7 patients (12.06%) had seizure reduction of ≥75% and 2 patients had seizure control of ≥90% (3.4%). The patient in whom right-sided VNS was implanted achieved the same reduction in seizure burden and the patient who became pregnant could reduce antiepileptic drugs dosage, without complications. Side-effects were mild and there were no permanent nerve injuries. One patient died in the follow-up due to psychiatric disorders previously known.

CONCLUSIONS

VNS is a safe and effective palliative treatment for TRE patients. There are an increasing number of indications and further randomized trials would potentially expand the number of patients who may benefit from it. A multidisciplinary team is crucial for a complete preoperative evaluation and selection of the optimal candidates for the treatment.

Low-pressure hydrocephalus: indication for custom-made catheters? Technical report

BACKGROUND

Low-pressure hydrocephalus (LPH) is characterized by ventriculomegaly with persistent low intracranial pressure (ICP). Sub-zero drainage is needed for its management and multiple solutions have been described. Our aim is to report our experience with custom-made peritoneal catheters with larger inner diameter as an alternative treatment option.

METHODS

We made a retrospective review of all patients diagnosed with LPH and treated with custom-made peritoneal catheters at the Virgen del Rocío Pediatric Neurosurgical Unit. Catheters were coated with antibiotic or silver. The inner diameter of ventricular catheters was 1.4 mm; peritoneal catheters were larger than usual (1.9 mm inner diameter).

RESULTS

We identified four patients in whom five custom-made peritoneal catheters were used over a 3-year period. There were two males and the mean age was 10 years (6 months-17 years). In all patients, placement of an EVD was necessary for sub-zero drainage, with maximum negative pressure of -8 cm H20. The mean time of maintenance of EVD was 102 days (10 days-1 year). Finally, three ventriculoperitoneal (VP) valveless systems, one with antigravitation device, and one Pro-GAV VP shunt were placed, all of them with larger custom-made peritoneal catheters. After a mean follow-up period of 2.3 years (6 months-3 years), two patients are completely recovered, one patient is partially dependent for daily activities with good cognitive status, and the last one is a child who died due to his brain tumor.

CONCLUSION

The custom-made peritoneal catheters with larger inner diameter could be a good option for the management of this complex pathology.

[Adult spontaneous cerebrospinal fluid otorrhea. Report of two cases and review of the literature]

INTRODUCTION

Spontaneous cerebrospinal fluid otorrhea is a relatively rare entity and can be easily missed in adults. Every adult older than 50 years with a negative history of otologic disease who has recurrent serous otitis media should be evaluated for this pathology. Meningitis is the most serious complication, so there is no doubt that the condition needs immediate attention and correction.

OBJECTIVE

We present two patients who were diagnosed with spontaneous CSF otorrhea and make a review of what is reported about this topic.

CONCLUSION

Surgical repair is mandatory to seal these nontraumatic CSF leaks. There are two main surgical approaches, the middle fossa craniotomy and the transmastoid approach. A multilayered closure technique in which autologous and artificial materials are combined is considered to result in the highest rate of success.

A prospective study of a series of 356 patients with supratentorial spontaneous intracerebral haematomas treated in a Neurosurgical Department

BACKGROUND

Spontaneous supratentorial intracerebral haemorrhages (SSIH) carry high morbidity and mortality rates. At present, the proper role of surgery is not clear and data from the International STICH trial have not clarified this challenging question. On the other hand, few prospective studies have measured long term survival regardless of the treatment and clinical condition of the patient.

PATIENTS AND METHODS

We prospectively collected data from all SSIH patients (n = 356) admitted at a tertiary reference hospital over a 40-month time period regardless of their clinical condition and treatment received. Among data investigated were preclinical neurological state, GCS on admission, history of systemic hypertension and treatment (surgical or conservative). Clinical factors influencing mortality at 1-year follow-up were analysed statistically by univariable and multivariable methods.

FINDINGS

We found that patients in the eighth decade were the most frequent. Hypertension was present in 47% of patients. Based on the prehospitalisation modified Rankin Scale, 305 (86%) patients were independent for activities of daily living (ADL). At 12-months follow-up, 91 (46% of alive patients) remained independent for ADL. The surgical rate was 22%. Although it was not a randomised study, we did not find a significantly different mortality rate according to whether the patient was treated surgically or conservatively. Overall, the mortality rate was 44% (157 patients) with a 79% of deaths taking place in the first 30 days after admission.

CONCLUSIONS

This study underscores the high mortality rate of SSIH, especially so in the first month after admission. Among the subgroup of patients clinically independent before the haemorrhagic stroke, only 29.8% remained independent one year after the event. We did not find any statistically significant difference in mortality according to treatment modality received (surgical vs conservative) although treatment assignment was not randomised. Among other clinical factors, pre-ictal functional status, age, level of consciousness on admission and volume of haemorrhage strongly influence mortality as determined at the 1-year follow-up.

Improvement in quality of life in patients with advanced Parkinson's disease following bilateral deep-brain stimulation in subthalamic nucleus

In this article we investigate the changes observed in the scales that quantify the quality of life (PDQ-39) in patients that have already completed 1 and 2 years of bilateral subthalamic stimulation (DBS-STN). Fourteen patients were evaluated 1 year after DBS-STN; the evaluation was repeated on 11 of them, 2 years after surgery. All of them suffered from Parkinson's disease with a 14.3 (+/-5.7) years history of motor complications. Patients were selected according to CAPSIT criteria. All of them were implanted bilateral electrodes in the subthalamic nucleus. The parameters applied were UPDRS II, UPDRS III, PDQ-39, and the scale of quality of life for caregivers (SQLC). Scorings in motor scales (UPDRS III) improved 45% in relation to the first year, and 48% in relation to the second year (P < 0.001). Patient's quality of life (PDQ-39 summary index) improvement was 62% 2 years after surgery (P < 0.001), and caregivers' quality of life improvement was 68% (P = 0.002) by the same time. DBS-STN is a therapy that efficiently improves the quality of life of selected patients with Parkinson's disease. This improvement is still present 2 years after surgery and has a positive impact on caregivers quality of life.

[Tentorial meningiomas. Report of our series]

PURPOSE

The main objectives of this report are to describe the clinical and radiological features, surgical management, complications, and final outcome of patients with a tentorial meningioma.

METHODS

This is a retrospective study of 25 patients operated on for tentorial meningiomas at our department since december 1975 to may 2002. All the patients, except the first, were diagnosed by computed tomography; in 13 of them a magnetic resonance imaging was performed too; in 14 patients, diagnosis was completed with cerebral arteriography. The preoperative clinical condition, the interval between the first symptoms and the date of the operation, the postoperative morbidity and the recurrence are analysed.

RESULTS

There were 20 women and 5 men of ages ranging from 35 to 79 years (average of 54.6). Surgical removal was considered radical (Simpson I-II) in 22 patients. Of them one had a recurrence 25 years after the operation, another had three recurrences, in two years, that were reoperated, and a third one had recurrence at five years who did not require surgery. The postoperative mortality was 8%. The mean follow-up period was of 5.3 years. The final outcome was good recovery in 19 patients, moderate disability in 1 and death in 4.

CONCLUSIONS

Despite the advances in Neuroradiology and Microsurgery, these tumors represent a challenge for the neurosurgeon, due in some cases to a large tumor size and extension to critical areas. A removal as complete as possible allows minimizing the recurrence risk.

Complicaciones intra-abdominales de la cirugía de la hernia discal lumbar

INTRODUCTION

: Removal of a lumbar disc herniation is, at present, the most frequent surgical procedure, related to the spine in Neurosurgical Departments. It carries a very low rates of complications and a short postoperative hospital stay. However, in spite of their rarity, serious adverse intraoperative complications may occur, so we must be aware of its existence in order to make an early diagnosis and treatment to prevent a fatal outcome. It is important to ensure that the patient understand the possible complications and obtaining written consent to avoid later medico-legal problems.

CLINICAL CASES

We report two cases with typical lumbociatic pain secondary to lumbar disc herniation operated at our Department, that resulted in intraoperative complications, due to perforation of intraabdominal structures. Initially, the patients underwent planned flavectomy, followed by simple disc removal. However, symptoms of abdominal pain and systemic hypotension in each case, began some hours later. Early diagnosis was achieved using abdominal-pelvic CT scan, showing an intestinal perforation in one patient and a tear of both iliac artery and vein in the other. In both, an urgent laparotomy was performed by colleagues from the Department of General and Vascular Surgery, with surgical repair. The final outcome was good and both are asymptomatic.

CONCLUSION

Surgical removal of the lumbar disc herniation is a very effective procedure, but is not free from certain severe though rare complications. Intestinal perforation and vascular tears are two possible complications to suspect if abdominal pain or systemic arterial to suspect if abdominal pain or systemic arterial urgent surgical repair of such complications. It is of vital importance that the patient knows the existence of such complications and so obtain a written consent.

[Bilateral subthalamic nucleus deep-brain stimulation (STN-DBS) in Parkinson's disease: initial experience in Cruces Hospital]

INTRODUCTION

Clinical outcomes of Parkinson's disease patients treated for 12 months with STN-DBS were analyzed. PATIENTS ADN METHODS: Twelve patients were selected using the CAPSIT protocol criteria and placement of electrodes in the appropriate target was performed according to results of fusion image techniques and intraoperative microrecording.

RESULTS

A reduction in motor UPDRS (44 %) and activities of daily living (58 %) scores during <<off>> phases were observed. <<On>> time with dyskinesias was reduced (86 %), while severe dyskinesias disappeared. Levodopa dosage was also lowered (44 %). Patients and caregivers showed a clear-cut benefit on quality of life (58 % and 61 % respectively). No cognitive deterioration was observed and morbidity was in the same range as that published by other teams.

CONCLUSION

Bilateral STN-DBS is an effective symptomatic therapy for complicated Parkinsońs disease patients. It improves the quality of life of patients and their caregivers and allows a reduction of levodopa dosage.

Prognostic factors in a series of 185 consecutive spontaneous supratentorial intracerebral haematomas

We report a retrospective observational study of 185 cases with spontaneous supratentorial intracerebral haemorrhage, in which, by univariate and multivariate analysis, the main clinical and CT findings influencing patient outcome were studied. Forty (22%) patients died and 77 (41%) remained in a very disabled state. Using logistic regression analysis we found that the volume of the haematoma, its deep location, surgical treatment and the preictal status in relation to activities of daily living (ADL) were independent factors for patient outcome measured with the Modified Rankin Scale. Similarly, GCS at presentation, preictal status in relation to ADL and age were directly correlated with mortality at 6 months follow-up. We also observed that age, GCS at admission and the volume of the haematoma, were the main factors influencing the neurosurgeon's decision regarding surgical treatment.

Giant pituitary adenomas: clinical characteristics and surgical results

Although most pituitary neoplasms are benign, some grow rapidly, spreading to extrasellar tissues. Definition of these 'giant' pituitary adenomas (PAs) is not clear. In order to clarify this question, we studied all pituitary macroadenomas operated in our hospital during the last 20 years, differentiating those with diameter > or = 3 cm (n = 43) and attempting to identify their typical features and prognosis. The reason for consultation was local in 58.3% of giant PAs, hormonal in 22.9% and tumour recurrence in 16.7%. Surgery was performed via a trans-sphenoidal approach in 92.5% of cases and succeeded in completely removing the tumour in only 27% of cases. In conclusion, we found that giant PAs are not a special type but the extreme case in the gradient of invasiveness of tumours of adenohypophyseal origin. They are characterized by a higher frequency of neuro-ophthalmological symptoms and hormonal deficits, and poorer response to surgical treatment.

[Lumbar root compression secondary to juxtafacet cysts: review of 10 cases]

OBJECT

We report a series of 10 patients with 11 juxtafacet cysts of the lumbar spine treated in our center from 1994 to 2000.

METHODS

The clinical histories, radiographic images, surgical protocols and pathological records of the 10 patients diagnosed of lumbar juxtafacet cyst have been analyzed.

RESULTS

Six patients were women and four were men. The average age of presentation was 54 years. The most frequent clinical presentation was radicular pain, and motor or sensitive deficits were not very common. Computed tomography and magnetic resonance are essential in establishing the diagnosis. The cysts were located at L4-L5 in eight patients, at L2-L3 in one patient, and at L3-L4 in other patient. Eight patients were treated by means of decompressive laminectomy and excision of the cyst, and the remaining two underwent conservative treatment. Degenerative phenomena adjacent to the juxtafacet cysts are easy to evidence. All the patients were improved of their radicular pain.

CONCLUSIONS

Analysing our series, we conclude that the juxtafacet cysts appear more frequently at L4-L5 level in people of advanced age, and produce commonly low back pain and radiculopathy. Although they can be treated initially in a conservative way, in the presence of a progressive sciatic syndrome, surgical management is preferable.

[Our experience with the programmable Codman-Medos valve: review of 125 shunts]

INTRODUCTION

Programmable valves are a possible solution in cases of excessive or insufficient draining.

OBJECTIVE

To report our experience with these shunts and clarify concepts.

PATIENTS AND METHODS

We have implanted 125 Codman-Medos programmable devices in 118 patients. The most frequent indication was secondary hydrocephalus, particularly due to obstruction by a tumour, and primary hydrocephalus. They were also used in cases of benign intracranial hypertension, CSF fistulas and arachnoid cysts. Most valves were inserted frontally, under antibiotic prophylaxis.

RESULTS

Excluding patients with a follow-up of less than three months, the average follow-up was 14.63 +/- 9.07 months, with clinical improvement in 80%. There was 0% mortality in relation to surgery. The initial average pressure was 121.84 +/- 24.74 mmH2O and after 52 reprogrammings done in 36 (30%) of the patients, the final average pressure was 124.96 +/- 30.58 mmH2O. Reprogramming was done for the management of symptoms and to avoid subdural hygromas. We have observed no clinical signs of unprogramming. There were 29 complications which were treated by reprogramming in 7 cases and surgically in the remainder.

CONCLUSIONS

We recommend frontal insertion, with a long peritoneal catheter, mainly in patients with hydrocephalus secondary to stenosis of the aqueduct of Sylvius, benign intracranial hypertension, after head injury and Arnold-Chiari malformation. The initial pressure is difficult to determine but tends to be average or high. Reprogramming is particularly useful in the treatment of subdural hygromas. We have observed no clinical signs of unprogramming. Complications tend to be due to surgical technique rather than the particular shunt used.

[Osteomyelitis of the frontal bone (Pott's puffy tumor). A report of 5 patients]

BACKGROUND

Frontal bone osteomyelitis is considered to be rare but it may develop intracranial complications such as subperiosteal abscess that appears as a painful fluctuated forehead tumor (Pott's puffy tumor).

METHODS

We reviewed retrospectively the clinical history of those patients showing frontal swelling tumour in our Neurosurgery and Infectious Diseases Departments between July 1994 and December 1997 and whose definitive diagnosis was cranial osteomyelitis.

RESULTS

We reported five cases of patients who had been submitted to a neurosurgical operation between 9 months and 27 years ago. The main clinical features were intermittent painful frontal swelling episodes (with or without fever). These episodes were self-limited or limited after short trend of antibiotics. Imaging techniques were necessary for the diagnosis and especially in order to exclude intracranial complications (such as epidural abscess found in two patients). The ascertain diagnosis is made by debriding, histological studies and cultures from the material. Staphylococcus aureus was isolated in three of the patients, Haemophilus influenzae in one patient and Pseudomonas aeruginosa in the other one. All patients were treated with surgery and specific antibiotic therapy during twelve weeks minimum, being definitively cured.

CONCLUSIONS

It is not well know the etiopathogenic mechanism concerning this rare disease. We remark the importance of a prompt diagnosis because of the high frequency of intracranial complications as well as combined treatment: surgery and long term antibiotic therapy (not less than 8 weeks), is necessary to cure the disease.

Postoperative follow-up of pituitary adenomas after trans-sphenoidal resection: MRI and clinical correlation

Our purpose was to correlate the morphological changes seen on MRI studies of the sellar region after trans-sphenoidal resection of pituitary adenomas with clinical and hormonal studies. Between January 1993 and March 1994, 16 patients with a pituitary adenoma (9 macroadenomas and 7 microadenomas) were subjected to trans-sphenoidal resection and included in a prospective study. The protocol consisted of MRI, hormonal and visual studies at the following times: immediately postoperative (1st week), 1st month, 4th month and 1st year after surgery. The evolution of the contents of the sella turcica (tumour remnant, packing material and gland tissue), effects on the infundibulum, optic chiasm, cavernous sinus and sphenoid sinus were correlated with the clinical and hormonal studies. Stabilisation of the postsurgical changes occurred by the 4th month. Tumour remnants were noted in the immediate postoperative period in macroadenomas. Compression of the infundibulum was the only reliable indicator of possible involvement. Optic chiasm compression, defined as close contact between the chiasm and the tumour, was the only morphological finding that indicated visual impairment. There was no standard repneumatisation pattern in the sphenoid sinus, since mucosal changes resembling sinusitis were one of the postsurgical changes. We found MRI not to be useful for follow-up of microadenomas.

Homocysteate-like immunoreactivity in multiform glioblastoma of human brain

Anti-homocysteate antibodies with postembedding immunohistochemistry for light microscopy were used to localize homocysteate-like immunoreactivity in human multiform glioblastoma. The most remarkable stained elements (6.8% of the total tumoral tissue) corresponded to distinct astrocytic cell bodies, intermingled fibrous processes and puncta of diverse size, some of them closely apposed to capillaries. In not affected peritumoral tissue, on the other hand, numerous labelled dots resembling portions of glial processes were observed in the neuropil and around blood vessels (2.7% of the total peritumoral tissue). However, glial and neuronal cell bodies could not be detected. These observations extend to a human brain tumor of glial nature the knowledge on the preferential localization of homocysteate in glia.