Background: The natural history of cavernous malformations (CMs) has remained unclear. This lack of knowledge has made treatment decisions difficult. Indeed, the use of stereotactic radiosurgery is nowadays controversial. The purpose of this paper is to throw light on the effectiveness of Gamma Knife radiosurgery (GKRS) therapy. Methods: The authors reviewed data collected from a prospectively maintained database. A total of 95 patients (57 female and 38 male) underwent GKRS for high-surgical-risk CMs. A total of 76 cavernomas were deeply located (64 lesions in the brainstem and 12 lesions in the thalamus). All of them were located in eloquent regions. The median malformation volume was 1,570 mm3. The median tumor margin dose was 11.87 Gy, and the mean tumor maximum dose was 19.56 Gy. Results: Ninety-five cavernous CMs were managed from 1994 to 2014. All patients had experienced at least 1 symptomatic bleeding incident before treatment (only 1 hemorrhage event in 81%). The median length of follow-up review was 78 months. The pretreatment annual hemorrhage rate was 3.06% compared with 1.4% during the first 3-year latency interval, and 0.16% thereafter (p = 0.004). Four patients developed new location-dependent neurological deficits, and 3 patients had edema-related headache after radiosurgery. All of them presented full recovery. Conclusions: The best dosage range for preventing bleeding was identified as between 11 and 12 Gy in our series. Although the efficacy of radiosurgery in CMs remains impossible to quantify, a very significant reduction in the bleeding rate occurs after a 3-year latency interval. No permanent neurological morbidity is reported in our series. These results defend the safety of GKRS in surgical high-risk CM from the first bleeding event.
332 Neurocirugía 2011; 22: 332-336 Resumen Introducción. En la literatura se recogen alrededor de 600 casos de hematomas epidurales espinales. En varios estudios, se afirma que la incidencia de paraparesia secundaria a anestesia epidural oscila entre 0,0005-0,02%. Se han descrito numerosas etiologías, incluyendo cirugía, traumatismos, anticoagulación, malformaciones arteriovenosas, embarazo, procesos hematológicos y punción lumbar. Los procedimientos anestésicos raquídeos y epidurales representan la décima causa más frecuente. Pero en combinación con el tratamiento anticoagulante, dichos procedimientos aumentan su incidencia hasta alcanzar la quinta causa. Publicamos un caso clínico de hematoma epidural cervical yatrogénico en el adulto y el buen resultado obtenido con tratamiento conservador.Caso clínico. Paciente varón de 80 años, que a las 2 horas de tratamiento analgésico de cervicoartrosis mediante infiltración epidural cervical desarrolla intensa cervicalgia y pérdida de fuerza en extremidades inferiores, mostrando paraplejia completa con arreflexia. En RM cervical se evidencia hematoma epidural entre los niveles C4 y T1. Es trasladado a nuestro centro para cirugía pero ante la rápida recuperación se decide tratamiento médico conservador. Al mes de seguimiento, la situación clínica es similar a la previa, sin secuelas con completa reabsorción del hematoma en RM control.Conclusión. Actualmente, la tendencia general es realizar cirugía en pacientes con hematoma espinal y empeoramiento neurológico importante durante las primeras horas. Sin embargo, se pueden obtener buenos resultados neurológicos con tratamiento conservador, en pacientes bien seleccionados con déficit parcial, incompleto y no progresivo. En el presente, no estamos en condiciones de decir qué tratamiento es el mejor para cada caso concreto.
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