Pablo M Munarriz | Hospital Universitario 12 Octubre Madrid (original) (raw)

Papers by Pablo M Munarriz

Neurocirugía, May 1, 2023

Neurocirugía, Sep 1, 2020

Results: Our main results were that when we compared patients with controls, patients, regardless... more Results: Our main results were that when we compared patients with controls, patients, regardless of TBI severity, showed significantly reduced mean FA in almost all ROI measured. We found statistically significant correlation between FA metrics and some clinical characteristics. Additionally, the FA values of the three portions of Corpus callosum, Cingulum and cerebral peduncles measured at the early subacute stage were highly associated with outcome assessed at hospital discharge and at 6 and 12 months after TBI. Conclusions: We conclude that DTI is a useful tool to characterize TAI and the detection of FA reduction in the subacute stage after TBI is associated with long-term unfavorable outcome.

Journal of neurosurgery, Dec 1, 2012

The authors describe a patient with delayed thoracic spinal cord compression due to fibrous scar ... more The authors describe a patient with delayed thoracic spinal cord compression due to fibrous scar tissue around an epidural electrode used in spinal cord stimulation (SCS). One year after implantation of the system the stimulation became ineffective, and 1 year later the patient developed progressive paraparesis. There was no evidence of device-related complications on plain radiographs and CT scans, so the system was removed to perform MRI studies. These studies showed a dorsal myelopathy secondary to scar tissue around the electrode. At surgery thick scar tissue was resected, and the patient's neurological symptoms improved. The histological examination confirmed fibrosis, and microbiological studies excluded chronic infection. As far as the authors are aware, this complication has never been reported before at the thoracic level. Scarring around SCS electrodes should be considered as a late complication and as a possible cause of the tolerance phenomenon.

Surgical Neurology International, 2011

Neurocirugía, May 1, 2015

Cranioplasty is carried out for cosmetic reasons and for protection, but it may also lead to some... more Cranioplasty is carried out for cosmetic reasons and for protection, but it may also lead to some neurological improvement after the bone flap placement. Complications of cranioplasty are more frequent than expected for a scheduled neurosurgical procedure. We tried to identify factors associated with both complications and improvement after cranioplasty. We prospectively studied the cranioplasties performed in our hospital from November 2009 to November 2013. Patients whose initial reason for bone removal was tumor infiltration were excluded. Demographic, clinical and radiological data were collected. The NIH Stroke Scale and Barthel Self-Care Index scores were obtained both before and within 72h after cranioplasty. The outcome measures were the occurrences of complications and clinical improvement. Fifty-five cranioplasties were performed. The material used for the cranioplasty was autologous bone in 42 cases, polyetheretherketone (PEEK) in 7 and methacrylate in 6. The average size of the bone defect was 69.5 (19.5-149.5)cm(2). The time elapsed between decompressive craniectomy and cranioplasty was 309 (25-1217) days. There were 10 complications (7 severe and 3 mild), an 18.2% complication rate. Statistically significant risk factors of complications were identified as a Barthel ≤70 (Odds ratio [OR] 22; 2.5-192; P=0.005), age over 45 years (OR 13.5; 1.5-115; P=0.01) and early surgery (≤85 days; OR 8; 1.69-37.03, P=0.004). After multivariate analysis, Barthel ≤70 and age over 45 years remained independent predictors of complications. Twenty-two (40%) of the 55 patients showed objective improvement. Early surgery (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;85 days) increased the likelihood of improvement (OR 4.67; 1.05-20.83; P=0.035). Larger bone defects seemed to be related with improvement, but differences in defect size were not statistically significant (75.3 vs 65.6cm(2); P=0.1). The complication rate of cranioplasty is higher than for other elective neurosurgical procedures. Older age, poorer functional situation (worse Barthel index score) and early surgery (≤85 days) are independent risk factors for complications. However, cranioplasty produces clinical benefits beyond protection and esthetic improvement. Earlier surgery and larger bone defects seem to increase the likelihood of clinical improvement.

Journal of Medical Case Reports, Jul 25, 2023

Background Spinal lipomas not associated with dysraphism are rare and have an unknown natural his... more Background Spinal lipomas not associated with dysraphism are rare and have an unknown natural history. In this report, we describe two cases; they showed recurrence during long-term follow-up, which makes us doubt a benign malformative etiology. Case reports Two patients, a 19-year-old South American woman and a 14-year-old boy with spinal lipomas, underwent surgical resection. The lipomas were not associated with dysraphism and were located in the cervicothoracic and craniocervical junctions. In both cases, we decided to operate due to clinical progression; the former had a progressive natural course, and the latter experienced clinical worsening after recurrence from previous surgeries. The surgery took place with the assistance of neurophysiological monitoring and intraoperative ultrasound; a partial resection and medullary decompression were done, following the more recent recommendations. Discussion The natural history of these lesions is currently unknown due to their rarity and the heterogeneity in the long-term follow-up of previously reported cases. Although previous reports describe good outcomes after surgical resection, long follow-ups, especially in young subjects, may show differences in these outcomes with progression and recurrence. We contribute to this last piece of evidence by describing two more cases of progression and recurrence. Lessons Long-term close follow-up should be done in young subjects with spinal lipomas, as they are more prone to an aggressive course. Metabolism and hormonal changes may be behind this progression. Reoperation must be considered if neurological decline is detected.

Neurocirugía, May 1, 2012

The authors report the case of an 82 year-old woman with a primary malignant melanoma of the caud... more The authors report the case of an 82 year-old woman with a primary malignant melanoma of the cauda equina resembling lumbar schwannoma in the MRI study. Melanocytic neoplasms are very rare but they should be included in the differential diagnosis of lesions involving the spinal nerves. The treatment of choice for these lesions is complete resection followed by radiotherapy. The outcomes reported in the literature are variable and are associated with the age of presentation, histopathological findings, extent of surgical resection and absence of metastatic lesions.

Neurocirugía, Sep 1, 2013

Neurosurgery, Nov 16, 2020

International Journal of Oral and Maxillofacial Surgery, May 1, 2019

Neurosurgery, Dec 1, 2015

BACKGROUND: Quantitative estimation of the hemorrhage volume associated with aneurysm rupture is ... more BACKGROUND: Quantitative estimation of the hemorrhage volume associated with aneurysm rupture is a new tool of assessing prognosis. OBJECTIVE: To determine the prognostic value of the quantitative estimation of the amount of bleeding after aneurysmal subarachnoid hemorrhage, as well the relative importance of this factor related to other prognostic indicators, and to establish a possible cut-off value of volume of bleeding related to poor outcome. METHODS: A prospective cohort of 206 patients consecutively admitted with the diagnosis of aneurysmal subarachnoid hemorrhage to Hospital 12 de Octubre were included in the study. Subarachnoid, intraventricular, intracerebral, and total bleeding volumes were calculated using analytic software. For assessing factors related to prognosis, univariate and multivariate analysis (logistic regression) were performed. The relative importance of factors in determining prognosis was established by calculating their proportion of explained variation. Maximum Youden index was calculated to determine the optimal cut point for subarachnoid and total bleeding volume. RESULTS: Variables independently related to prognosis were clinical grade at admission, age, and the different bleeding volumes. The proportion of variance explained is higher for subarachnoid bleeding. The optimal cut point related to poor prognosis is a volume of 20 mL both for subarachnoid and total bleeding. CONCLUSION: Volumetric measurement of subarachnoid or total bleeding volume are both independent prognostic factors in patients with aneurysmal subarachnoid hemorrhage. A volume of more than 20 mL of blood in the initial noncontrast computed tomography is related to a clear increase in poor outcome risk.

The American Journal of the Medical Sciences, Aug 1, 2013

T he syndrome of pituitary insufficiency secondary to aneurysms of the internal carotid artery is... more T he syndrome of pituitary insufficiency secondary to aneurysms of the internal carotid artery is uncommon, and the prevalence has been estimated in 0.17%. The first description was published by Mitchell in 1889, cited by Dussault et al. A 74-year-old woman presented with a 3-day history of progressive weakness and dizziness, nausea, and increasing confusion. Her medical history was only relevant for systemic hypertension. The examination revealed a conscious patient, disoriented, not obeying commands (Glasgow Coma Scale of 13/15), and having equal pupils, with no cranial nerves or motor limbs deficits. The remainder of the physical examination disclosed no abnormality in an afebrile, well-nourished, and wellhydrated patient. Serum and hematologic analyses showed a sodium level of 131 mmol/L and potassium of 3.7 mmol/L. Lumbar puncture and urinalysis were nonspecific. A brain computed tomography without contrast showed an eroded sella in its left half. Magnetic resonance imaging of the brain revealed an intraand left parasellar lesion, isointense on T1-weighted images and hypointense on T2-weighted images (Figure 1). Magnetic resonance angiography showed a 2.2 3 2.5 cm left cavernous internal carotid artery aneurysm. Cerebral angiography (Figure 2) showed a left carotid cavernous aneurysm with intrasellar extension. Basal endocrine studies showed hyperprolactinemia with decreased levels of thyrotropin, free T4, corticotropin, serum cortisol, insulin-like growth factor 1, follicle stimulating hormone, and luteinizing hormone. She started corticosteroids and levothyroxine. Conservative treatment was decided, and the patient was discharged home with replacement endocrine therapy for life. The pathogenesis of pituitary dysfunction induced by sellar and parasellar aneurysms remains uncertain. Two pathogenetic possibilities are postulated, and often, a combination of them is present. On one hand, compression and destruction of pituitary tissue by an expanding mass lesion might explain itself a decrease in the production of all pituitary hormones, including prolactin. On the other, compression of pituitary stalk or hypothalamic tissue compromising the delivery of hypothalamic factors would also explain hypopituitarism, inducing hyperprolactinemia as in our case and the majority of cases previously published.

Surgical Neurology International, 2012

Background: Ependymomas are the most common intramedullary tumors in adults and are the most comm... more Background: Ependymomas are the most common intramedullary tumors in adults and are the most common in mid-adult years. The presence of synchronous ependymomas in different sites of the spine is not common and it is even more infrequent to find hemorrhage from a spinal ependymoma as a cause of neurological deterioration. Case Description: A 32-year-old man presented with back pain and progressive paraparesia. Magnetic resonance (MR) showed two intradural extramedullary lesions on spinal canal with signs of acute hemorrhage. The patient underwent emergent surgical decompression and resection. Pathology revealed myxopapillary ependymomas. Conclusion: To our knowledge, we report the first case of a patient with acute neurological deterioration as a consequence of synchronous bleeding of two spinal ependymomas located at different levels in the spinal cord. This study illustrates the importance of recognizing the rare, but known occurrence of acute neurological deterioration after spontaneous hemorrhage in spinal ependymomas.

Journal of Neurosurgical Sciences, Feb 1, 2023

BACKGROUND Acute subdural haematomas (ASDH) are found frequently following traumatic brain injury... more BACKGROUND Acute subdural haematomas (ASDH) are found frequently following traumatic brain injury (TBI) and they are considered the most lethal type of mass lesions. The decision to perform a procedure to evacuate ASDH and the approach, either via craniotomy or decompressive craniectomy (DC), remains controversial. METHODS We reviewed a prospectively collected series of 343 moderate to severe TBI patients in whom ASDH was the main lesion (ASDH volumes ≥10cc). Patients with early comfort measures (early mortality prediction >50% and not ICP monitored), bilateral ASDH or the presence of another intracranial haematoma with volumes exceeding two times the volume of the ASDH were excluded. Among them, 112 were managed conservatively, 65 underwent ASDH evacuation by craniotomy and 166 by DC (103 pre-emptive DC, 63 obligatory DC). We calculated the average treatment effect by propensity score (PS) analysis using the following covariates: age, year, hypoxia, shock, pupils, major extracranial injury, motor score, MLS, ASDH volume, swelling, intraventricular and subarachnoid haemorrhage presence. Then, multivariable binary regression and ordinal logistic regression analysis were performed to estimate associations between predictors and mortality and 12 months-GOS respectively. The patients' inverse probability weights were included as an independent variable in both regression models. RESULTS The main variables associated with outcome were year, age, falls from patient´s own height, hypoxia, early deterioration, pupillary abnormalities, basal cistern effacement, compliance to ICP monitoring guidelines and type of surgical approach (craniotomy and preemptive DC). According to sliding dichotomy analysis, we found that patients in the intermediate or worst bands of unfavourable outcome prognosis seemed to achieve better than expected outcome if they underwent pre-emptive DC rather than craniotomy. CONCLUSIONS When differences in patient's baseline characteristics are balanced by PS, the variables associated with long-term outcome are year, age, falls from patient´s own height, hypoxia, early deterioration, pupillary abnormalities, basal cistern effacement, compliance to ICP monitoring guidelines and type of surgical approach (craniotomy and pre-emptive DC are associated with better outcome). Patients with an intermediate or worse risk of unfavourable outcome according to their baseline characteristics might achieve better than expected outcome if they undergo pre-emptive DC.

Neurocirugía, Jul 1, 2013

ABSTRACT Objectives To analyse the clinical, radiological and therapeutic variables of intracrani... more ABSTRACT Objectives To analyse the clinical, radiological and therapeutic variables of intracranial dural arteriovenous fistulae (DAVF) treated at our institution, and to assess the validity of the Borden and Cognard classifications and their correlation with the presenting symptoms. Material and methods The DAVF identified were retrospectively analysed. They were classified according to their location, drainage pattern and the Borden and Cognard classifications. We recorded the different treatments, their complications and efficacy. Results There were 81 DAVF identified between 1975 and 2012. The cavernous sinus (CS) location was the most frequent one. The Borden and Cognard classifications showed an interobserver Kappa index of 0.72 and 0.76 respectively. The odds ratio of aggressive presentation in the presence of cortical venous drainage (CVD) was 19.3 (2.8-132.4). No location, once adjusted by venous drainage pattern, showed significant association with an aggressive presentation. Endovascular transarterial treatment of cavernous sinus DAVF achieved symptomatic improvement of 78%, with a complication rate of 5%. The DAVF of non-CS locations, with CVD, treated surgically were angiographically shown cured in 100% of the cases, with no treatment-related complications. Conclusions The presence of CVD was significantly associated with aggressive presentations. The Borden and Cognard classifications showed little interobserver variability. Endovascular treatment for CS DAVF is safe and relatively effective. Surgical treatment of non-CS DAVF with CVD is safe, effective and the first choice treatment in our environment.

Trauma, 2014

Objetivo: Establecer la relevancia clinica de la presencia de infiltrados de celulas inflamatoria... more Objetivo: Establecer la relevancia clinica de la presencia de infiltrados de celulas inflamatorias evidenciables histologicamente en muestras de hernias de disco lumbares operadas. Material y metodo: Se obtuvieron muestras de discos lumbares de 50 pacientes operados de forma consecutiva durante el ano 2012. Se recogieron los datos clinicos y epidemiologicos de los pacientes antes de la cirugia, el tiempo de evolucion de los sintomas, asi como la presencia de radiculopatia, deficits neurologicos y la exploracion. Se establecio el caracter extruido o contenido de la hernia en RM. Se establecio la presencia y cuantia de celularidad condrocitaria como signo de degeneracion discal. Resultados: Aunque casi todos las muestras reflejaban proliferacion condrocitaria, la presencia de infiltrados inflamatorios o neovascularizacion fue escasa. La presencia de inflamacion se relaciono invariablemente con la formacion de nuevos vasos en el disco, no relacionandose con ninguna variable clinica o r...

Journal of pediatric neurology, Oct 26, 2020

Intracranial ependymal cysts (ECs) are rare benign lesions. They are frequently asymptomatic and ... more Intracranial ependymal cysts (ECs) are rare benign lesions. They are frequently asymptomatic and arise in the supratentorial regions. Retrocerebellar ECs is a rare location. We present a case of 3-months-old infant who developed obstructive hydrocephalus, bulging fontanel, and macrocephaly secondary to a retrocerebellar EC. Magnetic resonance imaging (MRI) showed a large retrocerebellar cyst that compressed the cerebellum and the brainstem, producing fourth ventricle outlet obstruction and supratentorial hydrocephalus. Microsurgical fenestration of the cyst to the obex of the fourth ventricle and a cystic wall biopsy were performed. The procedure improved supratentorial hydrocephalus, as well as the patient&amp;amp;#39;s clinical condition. A histopathological study confirmed the diagnosis of an EC.As far as we know, after a thorough review of the literature, this is the first reported case of retrocerebellar EC. It is a rare cause of hydrocephalus due to outlet obstruction of the fourth ventricle. Treatment of the cause itself has been shown to be effective.

Neurocirugía, Feb 1, 2022