The appearance of brain tumors, as well as tumors of the rest of the body, are due to an alteration in the mechanisms that regulate cell division. In most cases we do not know the factor responsible for this alteration. We can classify brain tumors into two large groups: the so-called primaries whose origin is brain tissue, and the metastatic ones, tumors that originate in another organ and in their process of dissemination through the organism reach the brain tissue. In most cases, the symptoms are insidious (headaches, changes in character, dizziness, etc.). In other cases, he debuted with neurological symptoms (epileptic seizures, difficulty in manipulating objects, difficulty walking, speech). In these cases the course is usually progressive, worsening the clinic from week to week. Types of tumors: Glial, Metastatic, Meningiomas, Pituitary Tumors, Neurinomas, Craniopharyngiomas, Pineal Tumors, Hemangioblastomas, Squamous Tumors, Chordomas and Cysts Colloids. The first diagnostic approach will be clinical: a good clinical history and a complete neurological examination can lead us towards diagnosis. Imaging tests, mainly cranial magnetic resonance, will help us confirm or rule out the diagnosis. In cases in which a metastatic origin is suspected, it will be necessary to carry out a study of the rest of the organism to try to locate the origin of the lesion. In the treatment of brain tumors, we consider three basic pillars: surgery, radiotherapy and chemotherapy. Depending on the type of tumor (histology), location and other factors, the treatment of choice will be one or the other, and should be combined in some cases.
Cerebral Vascular Pathology.
Bleeding at the brain level supposes a neurosurgical emergency. When the blood is out of the blood vessels it displaces the nerve structures causing the pressure inside the skull to increase, which damages the brain, compromising the life of the patient. Brain bleeds can be classified as:
Spontaneous bleeding: there is usually underlying pathology such as high blood pressure, coagulation disorders, tumor processes, etc., which justify such bleeding. In these cases, bleeding often occurs in deep areas of the brain.
Bleeding due to malformations: in this group we include bleeding due to aneurysms, arterial malformations, arteriovenous fistulas and cavernomas. They are more frequent in young people than spontaneous bleeding.
Traumatic bleeding: in this group we include the bruises, contusions and suffusions that occur after a head injury, often in the same patient different types of bleeding coexist.
In the treatment of these pathologies we must differentiate between the treatment of bleeding (which in many cases must be done in an acute way) and the treatment of the causal process in case there is an underlying cause. Subarachnoid hemorrhage (SAH) is found in the brain. It is a hemorrhage that does not produce displacement of cerebral structures, although due to the irritative phenomenon of the blood it can cause the arterial vessels to contract causing vasospasm (decrease in the caliber of the vessel). When the blood accumulates in the same space where the cerebrospinal fluid circulates in its process of resorption, it can cause its obstruction, a phenomenon known as hydrocephalus. Both processes, both vasospasm and hydrocephalus, can seriously compromise the patient's life. This type of bleeding is especially frequent after cranial trauma and after the rupture of an aneurysm. Pathologies: cerebral aneurysms, arteriovenous malformations, cavernomas, and dural fistulas.
Pain is a physiological reaction that aims to alert us to a potentially harmful process for our body. But in certain cases the pain becomes pathological, either due to the mechanism that causes the pain, compression in the trigeminal neuralgia, or due to its disproportionate intensity. We treat different pathologies such as: Trigeminal neuralgia, glossopharyngeal neuralgia, Phantom limb pain, Pain due to spinal pathology. Until a few years ago the procedures for the treatment of chronic pain were based on the injury of the responsible nerve, thus sections of the trigeminal nerve were performed to treat their neuralgia. Subsequently, the treatment was aimed at causing a selective lesion of the part of the nerve responsible for the painful sensation. This injury was produced by compression, by thermal or chemical mechanism. In recent years, stimulators have been implanted for the treatment of pain. The objective is to produce a stimulus that prevents the transmission of the painful sensation without injuring the affected nerve.
Chiari Malformation groups a set of cerebellar malformations. Although four groups are defined, they are not different degrees of the same disease but are probably different entities. The most frequent malformations are type I and II, characterized by a decrease of the cerebellar tonsils in type I and tonsils and IV ventricle in type II. This disease is characterized by having an outbreak course. In cases where the clinic is progressive, the patient adds deficits if an effective treatment is not carried out. The most frequent symptom in these patients is pain either in the head, neck or in the extremities. Equally frequent is the weakness or loss of sensation in the extremities. Through a good clinical history and a neurological examination we can find signs and symptoms that make us suspect the presence of this alteration. The diagnosis is made by means of the brain Magnetic Resonance where we will demonstrate the tonsillar descent. In these patients it is characteristic the existence of a posterior fossa (small bone compartment where the cerebellum is located), which would motivate its compression through the foramen magnum. These patients frequently associate other radiological alterations such as syringomyelia (liquid cavity inside the medulla) or hydrocephalus. All these data must be evaluated when establishing the most appropriate treatment. The treatment of choice will be the decompression of the posterior fossa, which consists in resecting the bone that is compressing the cerebellum while expanding the foramen magnum to avoid compressions at that level. In some selected cases, especially those associated with hydrocephalus, the practice of a premamillary ventriculostomy may be indicated to decrease the pressure that favors herniation of the cerebellum through the foramen magnum.
Hydrocephalus is characterized by a disorder in the circulation of cerebrospinal fluid (CSF). We can differentiate several types of hydrocephalus:
Obstructive: in which there is a difficulty in the circulation of the fluid through the ventricular cavities, they are characterized by having a rapid clinical course.
Areabsortivas: in this case there is a difficulty in the reabsorption of CSF in the arachnoid granulations. Normally, the clinic in these cases is less acute, although there may be cases in which an emergency situation appears in a few hours.
Normotensive: it is due to a mixed mechanism. There is an alteration in the circulation of the CSF inside the ventricular cavities without there being a mechanical obstruction and at the same time some difficulty in the reabsorption of the CSF. In this case, the intracranial pressure of the patient (PIC) is normal most of the time, which makes this disease a differentiated entity within the hydrocephalus.
We must differentiate two large groups within the hydrocephalus:
Acute hydrocephalus (sudden pictures characterized by severe headache, vomiting and finally decreased level of consciousness.) It is a neurosurgical emergency.
Chronic hydrocephalus: its appearance is more larvae, associates headache, poor general condition, visual disorders and sometimes cognitive impairment and gait disorder.
Although there are steriotipated cases of these two entities, in many cases patients are in an intermediate situation between these two tables. The diagnosis will be clinical, although imaging tests will be of great importance when establishing the diagnosis of hydrocephalus when assessing the ventricular size, hydrocephalus should be differentiated from the ventriculomegaly in which there is no disorder in the CSF but the Increased ventricular size is due to the loss of brain tissue.
The treatment of hydrocephalus will be to facilitate CSF drainage either through a ventricular drainage valve (in the case of arreabsorptive hydrocephalus and normotensive hydrocephalus), or through an endoscopic premamilar ventriculostomy in obstructive hydrocephalus.
Under this term we group a set of diseases that are characterized by an alteration in the regulation of movement, either due to an excess or defect in it. The most frequent movement disorder in the general population is essential tremor, although it is not the one that motivates more consultations to the neurosurgeon since its course is generally benign. Among the movement disorders, the one with the highest incidence of neurosurgical activity is Parkinson's disease, given that its course is evolutive and often disabling. The substrate of these clinical pictures lies in an alteration in the mechanisms that regulate movement. These patients present a lesion in the extrapyramidal tract. It is a series of brain nuclei whose function is to coordinate and refine the movement that originates in the cerebral cortex. The alteration in these mechanisms, either by a defect or an excess of inhibition / activation of certain pathways, will be the cause of these movement disorders.
Peripheral nervous system.
The peripheral nervous system is constituted by the set of cranial and spinal nerves and their ganglia. Each nerve is composed of thousands of small wires (axons), which are responsible for transmitting information along the nerve. When a lesion is produced on a peripheral nerve, the damaged part is the axon, which, unlike the neuronal body, does have a certain regenerative capacity. We focus on the nerves that originate from the spinal cord because the pathology that affects the cranial nerves is addressed in other chapters. Among the pathologies that affect the SNP we can differentiate the traumatic, such as the section of a nerve, and the degenerative, such as the compression of the nerves at some point along the way, such as carpal tunnel syndrome.
Neurosurgery has experienced a great advance in recent years, making it possible that procedures that previously involved a very high morbidity and mortality are currently practiced routinely by our neurosurgical team. In this evolution we must differentiate the teams that have allowed the development of minimally invasive surgery, such as the intraoperative microscope, the neuronavigation systems, the cerebral and spinal endoscopy, as well as the equipment that allows us to functionally study the nervous system, either previously to surgery, such as functional magnetic resonances, PET, SPECT, or during the surgical act evoked potentials, brain mapping, electrocorticography, etc.
All these systems allow us a better knowledge of cerebral functionalism, which has led to an improvement in surgical results. The procedures and indications that we describe make reference to standard cases, general situations, and the surgical indication must be adapted to each patient. At Quirónsalud Murcia we perform endoscopic procedures, Neuronavigation, Stereotaxy, Brain Mapping, Intraoperative Registries, Spinal Fixation, Microdiscectomy, Kyphoplasty and Normotensive Hydrocephalus Study.