Tumor cerebral no conocido que se presenta con compresión del tronco cerebral tras punción dural accidental

A 36-year old primigravid of 41 weeks gestation was admitted to the labour ward. Her past medical history included hyperemesis gravidarum and migraine. An accidental dural puncture occurred during labour epidural analgesia. In the postpartum period she presented with continuous headache, and was treated with oral analgesics, oral caffeine, fluid therapy, and tetracosactide. She refused an epidural blood patch. On the seventh day postpartum, the patient was re-admitted to the Emergency Department with decreased level of consciousness and signs of brainstem compression. Cranial computed tomography and magnetic resonance imaging showed a posterior fossa tumour. An emergency craniotomy was performed with complete neurological recovery.This case emphasises the need to consider the differential diagnoses of post-dural puncture headache and to highlight the warning signs in patients who do not respond despite treatment with conventional therapy.     

Influencia del inicio precoz del tratamiento conservador en la evolución del paciente pediátrico con vejiga neuropática

BackgroundClean intermittent catheterization (CIC) and anticholinergic drugs are the mainstay treatment for neuropathic bladder (NB). However, there is not consensus about the time therapy should be started in pediatric patients.AimTo analyze the impact of early start (first year of life) of CIC and anticholinergic treatment on long-term renal and bladder function. Our hypothesis is that those children who start conservative treatment in the first year of life have better outcome in terms of bladder and renal function and less need of surgical procedures, compared to those who started treatment later in life.Patients and methodRetrospective study of pediatric patients with NB treated in our hospital (1995-2005) dividing them for comparison in two groups: group 1 started treatment in the first year of life and group 2 between 1 and 5 years old. Collected data included: date of CIC and anticholinergic initiation, presence of VUR or UHN, renal function, UTIs, renal scars, bladder behavior, surgery and urinary continence.ResultsSixty-one patients were included, 25 in group 1 and 36 in group 2. Initially vesico-ureteral reflux (VUR) and overactive bladders were more frequent in group 2. In group 1 one overactive bladder changed to low compliant and in group 2, one normal bladder and 4 overactive bladders changed. At the end of follow-up there were 11 low compliant bladders in group 1 and 17 in group 2. However, in group 1, only 2 patients required bladder augmentation (BA) while in group 2, 12 patients needed it. At the end of the study only 2 patients in group 2 had slight renal insufficiency.ConclusionsPatients who started conservative treatment in the first year of life have better long-term outcome in terms of UTI, renal scars and surgical procedures. Even if they initially had low compliant bladders, these patients require less BA.     

Hipertensión intracraneal idiopática: cesárea con anestesia epidural tras normalización de la presión del líquido cefalorraquídeo

Idiopathic intracranial hypertension is diagnosed by exclusion. Because of its uncertain physiopathology and infrequent occurrence, its anaesthetic management is not well defined.The patient in this case is a pregnant woman with this disease with no lumbar-peritoneal shunt who was referred for non-urgent caesarean section, consisting of CSF drainage and pressure normalisation before the administration of epidural anaesthesia.We believe this technique can de effective to achieve adequate blockage and increased patient comfort, as well as improving postoperative recovery.     

Factores pronósticos del tratamiento endoscópico del reflujo vesicoureteral en pacientes con lesión medular

IntroductionVesicoureteral reflux (VUR) is an important complication in patients with spinal cord injury due to its frequency and morbidity. One of the most extended therapeutic options is endoscopic injection of obliteration substances in the urethral meatus.ObjectiveTo analyze the prognostic factors of VUR treatment using obliterative substances in patients with spinal cord injury.Material and methodsA prospective study was performed in a cohort of 76 patients (age 48.9 ± 14.4 years), of both genders, with spinal cord injuries, who underwent endoscopic treatment of the VUR during the years 2008 to 2011. In all the patients, a clinical history was obtained and a pre-operative videourodynamic study was performed. Another study was carried out at 7.32 months (standard deviation: 6.28 months) of the intervention. Treatment consisted in endoscopic injection of dextranomer/hyaluronic acid copolymer (62 cases) and polydimethylsiloxane (14). The statistical tests applied were the Fisher's exact test and the Student's T test comparing the means. Bilateral significance level was established at 95%.ResultsResolution of VUR was achieved in 46 cases (61%). The statistically significant prognostic factors were age (younger aging cured patients), bilaterality and reflects great (greater grade in bilaterality in the cases with persistence of reflux) and presence of neurogenic detrusor overactivity (greater percentage in the cases of reflux persistence). Stress urinary incontinence (greater percentage in cured patients), contractile potency (lower percentage in cured patients) and urethral resistance (greater percentage in cured patients) were also statistically significant prognostic factors.ConclusionsAmong the prognostic factors that affected the endoscopic treatment results of the VUR in patients with neurogenic lower urinary tract dysfunction (NLUTD), anatomical as well as functional factors were found.     

Resección hepática con trombectomía en el tratamiento del carcinoma hepatocelular con invasión vascular macroscópica

IntroductionMacrovascular invasion (MVI) in patients with hepatocellular carcinoma (HCC) is a very poor prognostic factor. Treatment in such cases is still a matter of debate. The goal of this study is to assess short- and long-term results of liver resection and thrombectomy in a series of patients with HCC and MVI.MethodsRetrospective cohort study of patients who underwent liver resection for HCC in the period 2007-2015 (n = 120). Of all the patients, 108 did not have MVI, while 12 presented with MVI: 1 patient in the common portal vein (Vp4), 8 patients in first-order portal branches (Vp3), 1 patient in a sectorial branch (Vp2), 1 patient in a segmental branch (Vp1); another patient presented with tumor thrombus in a main hepatic venous branch in the confluence with the vena cava (Vv2).ResultsPatients with MVI needed major hepatic resection more frequently than patients without MVI (83.3% vs 25.9%, P < .0001), with no differences in postoperative mortality or severe morbidity. Patients with MVI required a longer operative time and developed more frequently postoperative ascites (33.3% vs 9.3%, P = .034).Global survival at 1, 3 and 5 years was 66.7%, 33.3% and 22.2% in patients with IMV, and 90.7%, 72.4% and 52.2% in patients without IMV (P = .009), respectively.ConclusionsHepatectomy associated with thrombectomy might be justified in a selected group of patients with HCC and MVI, offering a potential benefit in survival with acceptable morbidity.     

Manejo conservador de los traumatismos renales por arma blanca. Presentación de dos nuevos casos y revisión de la literatura

IntroductionStab wounds of the kidney have traditionally been managed by open surgery. Nowadays the conservative management of stab wounds injuries is extended in order to avoid unnecessaries nephrectomies and laparotomies without increasing morbidity and mortality. Although there is no a strong evidence to recommend when to operate or what sort of follow up we must do.Material and methodsWe present two new cases of stab wounds injuries managed conservatively. We performed a systematic review of the literature.ResultsBoth patients evolved favorably although one of them presented hematuria 7 days after the traumatism and we performed an embolization of an arteriovenous fistula. Most of the articles are based on series of cases or retrosprospective studies.ConclusionsThe diagnosis and staging of stab wounds of the kidney must be done with clinic and CT scan. Conservative management is required when the patient is not hemodinamically unstable and injuries do not require inmediate repair. These patients require a long term follow up to prevent the appearance of complications. Randomized prospective multicenter trials are needed to support the optimum management for each kidney injury degree.