Multiple primary brain tumors may occur in the setting of neurofibromatosis but the simultaneous occurrence of two neoplasms, without predisposing factors, is much less frequent. We present eight patients studied at our Service between 1976 to 1998, who had such dual tumoral association. We emphasize the diagnostic difficulties found in the cases admitted before the advent of Computerized Tomography and Magnetic Resonance. Even with the new neuroimaging studies, discrepancies between clinico-radiologic, intraoperative and postoperative findings should led to the suspicion of tumor association. Tumoral associations reported in the literature are commented.

La presencia de formaciones tumorales múltiples de la misma histogénesis en el interior de la cavidad craneal (TMI) es una situación bien conocida desde los puntos de vista neurorradiológico, neuroquirúrgico y neuropatológico. Mucho menos frecuentes son las asociaciones tumorales intracraneales (ATI), es decir, los cuadros constituidos por dos o más tumores de distinta histogénesis en la cavidad craneal; aproximadamente, el 50% de las ATI consisten en la asociación sincrónica o diacrónica de un meningioma y un glioblastoma multiforme. Una forma especial de ATI es la que se ha denominado en la literatura tumor en colisión (ATI-C), consistente en la presencia de dos tumores de distinta histogénesis topográficamente yuxtapuestos.

Se analizan retrospectivamente 258 casos consecutivos de hemorragia subaracnoidea idiopática, tratados durante los años 1974–1991; éstos representan el 34% del total de hemorragias subaracnoideas diagnosticadas en el mismo período. Se discuten los datos clínicos y radiológicos de ésta en entidad y se comparan con los de la hemorrragia subaracnoidea aneurismática, comprobándose una menor incidencia de complicaciones neurológicas (isquemia 8% y resangrado 6%) y una mejor evolución final (90,3% independientes y sólo un 5,4% de mortalidad) que en los pacientes con aneurisma. Asimismo, se analiza la distribución de sangre en las cisternas subaracnoideas, apreciándose una mayor afectación de las cisternas peritruncales (interpeduncular y ambiens). Se desaconseja repetir el estudio angiográfico si éste es completo y de buena calidad, pudiéndose repetir éste si existe resangrado, si el grado clínico inicial es malo, si hubo vasoespasmo en el estudio angiográfico, o si la TC al ingreso muestra una extensa distribución de sangre por cisternas basales.

Se analizan retrospectivamente 412 casos consecutivos de hemorragia subaracnoidea aneurismática, tratados durante los años 1974–1991. El 79% de los pacientes ingresaron en los tres primeros días del sangrado. El 63% de los pacientes ingresaron en buen grado clínico (Botterell I y II). Se apreció vasoespasmo angiográfico en el 38% de los casos. Se intervinieron 336 pacientes (81,6%), la mayoría pasados siete días. Del total de la serie fallecieron 132 pacientes (32%), 69 de éstos (16,7%) después de haber sido intervenidos. Las complicaciones que más influyeron en la mortalidad fueron la isquemia cerebral y el resangrado. Apreciamos una estrecha correlación entre el depósito de sangre cisternal, la aparición de vasoespasmo angiográfico y el desarrollo de isquemia cerebral, lo que apoya la teoría que imputa a la sangre, o a alguno de sus componentes o productos de degradación un papel fundamental en la producción de vasoespasmo. Es muy importante reconocer precozmente esta enfermedad con el fin de instaurar lo antes posible el tratamiento adecuado.

Se analiza la presentación clínico-radiológica de cinco papilomas de plexo coroideo de la fosa posterior en el adulto. Cuatro de estos tumores se localizaban en el cuarto ventrículo y uno ocupaba la región del ángulo pontocerebeloso (APC). El diagnóstico diferencial de estos tumores se basa actualmente en la tomografía axial computarizada (TAC). Aparte de la calcificación intratumoral que se observa en el 25% de los casos aproximadamente, pero que no les distingue de otros tumores de la misma localización, es característico de los papilomas que presenten densidad elevada en el estudio sin contraste si bien un 20% son isodensos en relación con el parénquima vecino. Tras la inyección de contraste estos tumors captan ávida y homogéneamente, a excepción de aquellos que están masivamente calcificados. La irregularidad de los bordes tumorales en el estudio con contraste es bastante típica y ayuda a diferenciarlos del ependimoma, meduloblastoma y astrocitoma. No existe un patrón angiográfico característico del papiloma de plexo, si bien la angiografía cerebral ayuda en el diagnóstico diferencial con el hemangioblastoma. La diferenciación radiológica del papiloma del APC con otros tumores más comunes de la región es más fácil. Se comenta la presentación macroscópica del papiloma durante el acto quirúrgico, sus relaciones con las estructuras vecinas y el pronóstico operatorio a corto y largo plazo. Finalmente se considera el diagnóstico diferencial histológico con otras lesiones de estructura papilar. The authors analyze the clinicoradiological presentation of choroid plexus papilloma of the posterior fossa in five adult patients. The tumor located into the fourth ventricle in four cases and in the cerebellopontine angle (CPA) in one. Differential diagnosis of choroid plexus papilloma is currently based on computerized tomography (CT). Apart from intratumoral calcifications, which occur in nearly 25% of the cases, papillomas usualy show an increased density in the CT study. Following contrast injection tumor enhancement is marked and homogeneous. Irregularity of the tumoral borders is a most characteristic finding which helps in the differential diagnosis with other tumors of the región. Differential diagnosis,of CPA papilloma is easy. There is not a characteristic angiographic pattern of choroid plexus papilloma but cerebral angiography may aid to distinguish this tumor from solid hemangioblastoma. The surgical findings, technical problems and the immediate and long term prognosis with posterior fossa papillomas are considered.

The authors have analyzed the clinical course and intracranial pressure (ICP) changes in 55 severely head-injured patients presenting with bulk enlargement of one cerebral hemisphere within a few hours after trauma. These patients represent 10.5% of a series of 520 patients with severe head injury studied with computerized tomography (CT). Cerebral hemispheric swelling has the highest mortality rate and the shortest survival period after trauma in all series of severe head injury. In this series, it was associated with an ipsilateral subdural hematoma of variable size in 47 patients (85%) or with a large epidural hematoma in five patients (9%); in three patients (5.4%) it occurred as an isolated lesion. Evacuation of an associated extracerebral hematoma, which was performed within 4 hours after injury in only 20% of cases, scarcely changed the patients' preoperative neurological status. The high incidence of arterial hypotension and/or hypoxemia at admission (47% of cases) and the severity of the clinical presentation (82% of patients scored 5 points or less on the Glasgow Coma Scale, 74% had unilateral or bilateral mydriasis, and 80% had an initial ICP above normal) correlated with a very poor final outcome (87% mortality). Only one of the 11 patients with normal initial ICP continued to have normal pressure throughout the course. High-dose thiopental failed to control severe intracranial hypertension in 24 patients (51%) who had a fulminant, malignant course. A transient decrease in ICP elevation was achieved in 15 patients (31.4%) and definitive control in eight patients (17%), among whom were the seven survivors in this series. In the authors' experience, once ICP is controlled, barbiturate administration should not be discontinued until a control CT scan shows complete disappearance of the mass effect.

Mortality due to epidural hematoma is virtually restricted to patients who undergo surgery for that condition while in coma. The authors have analyzed the factors influencing the outcome of 64 patients who underwent epidural hematoma evacuation while in coma. These patients represented 41% of the 156 patients operated on for epidural hematoma at their centers after the introduction of computerized tomography (CT). Eighteen patients (28.1%) died, two (3.1%) became severely disabled, and 44 (68.8%) made a functional recovery. The mortality rate for the entire series was 12%, significantly lower than the 30% rate observed when only angiographic studies were available. A significant correlation was found between the final result and the mechanism of injury, the interval between trauma and surgery, the motor score at operation, the hematoma CT density (homogeneous vs. heterogeneous), and the hematoma volume. The patient's age, the course of consciousness before operation (whether there was a lucid interval), and the clot location did not correlate with the final outcome. The mortality rate was significantly higher in patients operated on within 6 hours or between 6 and 12 hours after injury than in those undergoing surgery 12 to 48 hours after injury. Compared with the patients operated on later, the patients undergoing surgery in the early period were, on the average, older and had more rapidly developing symptoms, more pupillary changes, lower motor scores at surgery, larger hematomas, a higher incidence of mixed CT density clots, more severe associated intracranial lesions, and higher postoperative intracranial pressure (ICP). The mechanism of trauma seems to influence the course of consciousness before and after surgery. Passengers injured in traffic accidents had a lower incidence of a lucid interval and longer postoperative coma than patients with low-speed trauma, suggesting more frequent association of diffuse white matter-shearing injury. The duration of postoperative coma correlated with the morbidity rate in survivors. Forty-eight patients (75%) had one or more associated intracranial lesions, and 70% of these required treatment for elevation of ICP after hematoma evacuation. An ICP of over 35 mm Hg strongly correlated with poor outcome; administration of high-dose barbiturates was the only effective means for lowering ICP in nine of 15 patients who developed severe intracranial hypertension after surgery. This study attempts to identify patients at greater risk for presenting postoperative complications and to define a strategy for control CT scanning and ICP monitoring.

A group of 78 severe head injury patients showing computerized tomography (CT) findings of the so-called "diffuse axonal injury" is analyzed. These patients represent 20% of the authors' series of severe head injury. Twenty-three patients showed small intraparenchymal haemorrhages in the CT scan study, 15 intraventricular haemorrhage and 40 patients had both intraparenchymal and intraventricular haemorrhages. Signs of brainstem haemorrhagic contusion were seen in 29 (38%) patients. Generalized brain swelling superimposed on the above findings was present in 75% of the cases. Raised intracranial pressure, which was found in 50% of the patients, correlated with the presence of ventriculocisternal collapse in the CT scan and an unfavourable outcome. Only 4 patients in this series made a good recovery, 13 developed a moderate disability, 11 a severe disability, 12 became vegetative and 38 (49%) died. The prognosis with this post-traumatic lesion is the worst in the authors' severe head injury series after excluding cases with subdural haematoma.

The authors analyze the clinical course of 46 severely head-injured patients who had completely normal computerized tomography (CT) scans through the immediate posttraumatic period (1 to 7 days after trauma). These patients represent 10.2% of a consecutive series of 448 cases of severe head injuries and two-thirds of the cases showing a normal CT scan on admission (the other one-third of the cases developed new pathology). The usual course in these 46 patients after the initial coma was toward progressive neurological improvement, and 35 patients (76%) achieved a functional level of survival. Nine patients (19.5%) remained comatose for several weeks and developed severe disability. There were two fatalities due to medical complications. The final outcome was more closely related to the duration of coma (the longer the duration the worse the result) than to the initial Glasgow Coma Scale (GCS) score. In fact, 26% of the patients in the lower GCS score ranges (3 to 4 points) made a good recovery and 46% developed moderate disability only. These findings indicate that the grim prognostic significance of deep posttraumatic coma is tempered in the presence of a normal scan. However, the absence of CT abnormalities in severely head-injured patients cannot be equated with a good prognosis because in one-fifth of the cases serious permanent disability develops. Sustained elevation of the intracranial pressure (ICP) was not seen in these patients, indicating that ICP monitoring may be omitted in cases with a normal scan. However, since one-third of the patients with a normal admission scan developed new pathology within the first few days of injury, a strategy for control scanning is recommended. Control CT scans performed more than 6 months after injury showed a significantly higher incidence of brain atrophy in patients developing permanent disability than in those who made a good recovery.

We present a series of 56 children who suffered severe head injuries, with a Glasgow Coma Score (GCS) of less than 8. The cases were classified according to the type of morphologic lesion on computed tomography (CT) scan. Intracranial pressure (ICP) was monitored in all children in this series. A protocol that included artificial ventilation and other measures of treatment for intracranial hypertension was applied. Results were analyzed according to age, type of lesion, and ICP. The usefulness of the ICP recording and of obtaining a correct classification of lesions using the CT scan is emphasized.

The authors surveyed 31 surgical and radiotherapy series comprising over 2300 patients with spinal metastases to determine the influence of factors such as tumor biology and topography, pretreatment neurological status, the presence of a myelographic block, the progression rate of symptoms, and the general medical condition of the patient on both the functional prognosis and the choice of treatment. Both life expectancy and the functional results after therapy are mainly dependent on tumor biology, which in turn determines radiosensitivity. The remaining factors seem to have only complementary predictive power. Because radiotherapy has been found to be as effective as operation plus radiotherapy in the management of the majority of patients with spinal metastases, it is very important to improve the selection of surgical candidates (less than 42% of the total cases) to prevent unnecessary surgery-related morbidity and mortality. Factors considered important in the selection of therapy are the location of the tumor within the spinal canal, the neurological status at the time of treatment, and the systemic condition of the patient.

A series of 30 patients suffering posttraumatic intraventricular hemorrhage (IVH) after closed head injury is reviewed. Clotted blood and a mixture of blood and cerebrospinal fluid could be distinguished by computerized tomography (CT). Posttraumatic IVH was associated with diffuse brain lesions in most cases; intracerebral lesions with contusion, and subdural hematomas coexisted with posttraumatic IVH in eight and four instances, respectively. In two more cases, no CT abnormality other than IVH was noted. All patients in this series were in deep coma at the time of CT examination, and only seven survived. The early clinical findings, the site of ventricular hematoma, and the final outcome are analyzed.

The influence of the type of intracranial lesion on the final outcome in a consecutive series of 277 severely head-injured patients was analyzed. Patients were studied with computerized tomography (CT) and underwent continuous measurement of intracranial pressure. They received identical treatment according to a standardized protocol. Outcome of patients with either epidural hematoma (38 cases), subdural hematoma (56 cases), brain contusion (87 cases), or diffuse brain damage (96 cases) was rather heterogeneous, and serial CT scanning allowed the authors to outline eight consistent anatomical patterns in the whole series which have stronger prognostic significance than the four major lesion categories mentioned above. Patients with pure extracerebral hematoma (19 cases), single brain contusion (45 cases), general brain swelling (41 cases), and normal CT scans (28 cases) had a significantly better outcome than patients developing acute hemispheric swelling after operation for a large extracerebral hematoma (27 cases), patients with multiple brain contusion, either unilateral or bilateral (74 cases), and patients with diffuse axonal injury (43 cases). These anatomical patterns are interesting because, in addition to having clinical and physiopathological significance, they provide useful prognostic information and facilitate improved therapeutic decision-making in severely head-injured patients.

Favorable results have been reported with the use of barbiturate induced coma in patients suffering from intracranial hypertension of various origins (Rockoff et al. 1979). However it is still doubtful whether high dose barbiturates greatly influence the outcome of head injury patients presenting severe intracranial hypertension (SIH), (Miller 1979). Because of the difficulties and the high risks of this type of treatment we limited its use to patients in a very poor neurological State in whom raised ICP could not be controlled by conventional means.

Since Computed Tomography (CT) has been available in common neurosurgical practice, the term diffuse brain injury has been used to define a lesion which excludes both gross contusive lesions and intra- or extracerebral hematomas (Becker et al. 1977, Snoek et al. 1979, Papo et al. 1980, Gennarelli et al. 1982). The clinical findings, the intracranial pressure (ICP) and the CT images have been weltdocumented in patients with diffuse cerebral swelling (Sweet et al. 1978, Bruce et al. 1981). A good correlation has been demonstrated between CT examinations and gross autopsy findings in the so-called diffuse shearing injury of the white matter (Zimmermann et al. 1978).

The case of a neonate with an extradural hemorrhage in the left posterior fossa, the result of trauma at birth, is reported. The routine axial transverse CT scan did not detect the exact preoperative location of the clots in the extradural space of the posterior fossa. Good recovery was achieved following the operation.

The case of a woman with a large, mixed, cerebral arteriovenous malformation mainly involving the posterior fossa and producing a noncommunicating hypertensive hydrocephalus is reported. Relief of ventricular enlargement by means of a cerebrospinal fluid shunt unexpectedly resulted in stupor and Parinaud's syndrome. These complications were completely relieved by ligating the shunt. The vascular and mechanical factors involved in the production of hydrocephalus in this patient are discussed.

The cases of 11 patients with hydrocephalus secondary to cerebral cysticercosis are analyzed. Most of the patients had suffered from epilepsy before they developed hydrocephalic symptoms, and computerized tomography showed that infestation of the parenchyma coexisted with ventricular or cisternal colonization. In four cases, the parasitic vesicles compromised cerebrospinal fluid (CSF) flow in the ventricular system, resulting in internal hydrocephalus. Communicating hydrocephalus, caused by the presence of Cysticercus larvae in the basal cisterns (Cysticercus racemosus), or by the occurrence of a chronic basal meningitis, or both, developed in seven more patients. Changes in CSF pressure were related to the number and location of the cysts and to the leptomeningeal inflammatory reactions evoked by them. The majority of patients presented with a chronic and relatively normotensive hydrocephalus. All patients except one had identifiable ventricular or cisternal Cysticercus larvae; these patients were treated with open removal of the cysts, and did well. However, most of them had impairment of CSF flow through the basal cisterns and required permanent CSF shunting. Communicating hydrocephalus due to leptomeningeal scarring was also successfully managed with extracranial shunting. Epilepsy was controlled with anticonvulsant therapy. Although good lasting results may be obtained with aggressive treatment of neurocysticercosis, patients are liable to relapse because surgery is only palliative in most instances.

Cordobes, F.; Lobato, R. D.; Rivas, J. J.; Munoz, M. J.; Chillon, D.; Portillo, J. M.; Lamas, E.; Dubois, Philip J. Author Information

✓ A consecutive, unselected series of 82 patients with epidural hematoma treated between 1973 and 1980 is presented. Forty-one patients were managed before the advent of computerized tomography (CT) and the other 41 after this neuroradiological method was available. Mortality and disability rates which were 29.2% and 31.7% during the pre-CT period decreased to 12.1% and 19.5%, respectively, with the aid of CT scanning. This technique allowed a more rapid and accurate diagnosis of the hematomas than angiography, and defined better the presence and the evolutional changes of the associated cerebral lesions. As a consequence, surgery has been more effectively planned and executed during the CT era.