Pérdida de oportunidad en el diagnóstico y tratamiento de un cáncer cerebeloso

La Sección Primera de la Sala de lo Contencioso-Administrativo del Tribunal Superior de Justicia de La Rioja ha estimado parcialmente el recurso interpuesto por un paciente contra la resolución dictada por la Consejería de Salud del Gobierno de la Rioja que desestimó la reclamación de aquel, derivada de la asistencia sanitaria recibida en el diagnóstico y tratamiento de un tumor cerebeloso, solicitando una indemnización por importe de 222.121,43 euros.
El paciente fue valorado en su centro de salud en 10 ocasiones entre el día 06/10/2005 y el 10/07/2007. El día 07/07/2007 sobre las 13:40 horas acudió al servicio de urgencias por un cuadro de vómito acompañado de cefaleas, sudoración, estado presincopal y dolor de cabeza. Refirió antecedentes de cefaleas de repetición. Las exploraciones y pruebas complementarias fueron normales. Se pautó analgesia y se derivó al paciente a control por su médico de cabecera si bien con una recomendación de derivación a consulta de neurología. El paciente acudió de nuevo a urgencias el mismo día 7 de julio sobre las las 23:02 horas con un cuadro de similares características. En este caso se recomendó el mismo tratamiento farmacológico, observación domiciliaria y volver de nuevo al servicio de haber un empeoramiento.
El día 10 acudió al neurólogo. En la anamnesis el paciente refirió que la cefalea episódica había cambiado haciéndose continua y presentando a la exploración física discreta dismetría en la prueba dedo-nariz, que no había sido objetivada en las exploraciones previas realizadas en otros hospitales públicos.
Se practicó una resonancia magnética craneal que informó de tumoración de gran tamaño (45 mm de diámetro) en fosa posterior, en lóbulo izquierdo de cerebelo, introduciéndose en IV ventrículo, produciendo hidrocefalia triventricular. El paciente fue intervenido quirúrgicamente el día 09/08/2007 de un astrocitoma juvenil quístico del cerebelo, siendo derivado a Logroño para continuar seguimiento por los servicios de Rehabilitación, Oncología y Neurología de su zona.
De la prueba practicada la Sala concedió mayor importancia al informe emitido por el perito de la parte demandante, quien consideró que tras diversas asistencias dependientes del Servicio Riojano de Salud no se consideró la posibilidad diagnóstica ni terapéutica adecuada. No se consideró la realización seriada y continua de pruebas complementarias tal y como indican los protocolos de actuación en pacientes con cefaleas y otros síntomas de repetición, ya que con signos y síntomas de alarma, los protocolos y documentos de consenso recomiendan realizar pruebas diagnósticas y de seguimiento de manera protocolizada. Lo cual implica que no se han aportado los medios materiales y humanos disponibles para llegar a un correcto diagnóstico y pronóstico de la patología.
Ello ha determinado un daño desproporcionado, un error (diagnóstico), una falta de estratificación del riesgo y un error / retraso (en el tratamiento), lo que ha conllevado a un periodo en el que el proceso tumoral se encontró más avanzado y el estado clínico del paciente más deteriorado. Ello implica una pérdida de oportunidad de una terapia que hubiese conllevado una posibilidad de curación, de mejorar el cuadro, la evolución y/o la calidad del informado.
La Sala, como decíamos, estimó como más ajustadas a la realidad médica y jurídica, el informe del perito de la parte actora, porque de los datos obrantes en el expediente, se infiere que ante los dolores de cabeza de carácter reiterativo, se tenía que haber enviado al servicio de neurología
En consecuencia, la Sala consideró que se había producido un error médico con la consiguiente pérdida de oportunidad terapéutica, concediendo una indemnización en concepto de daño moral por importe de 40.000  euros.

Update: Choroid plexus cyst of the third ventricle

Choroid plexus cyst of the third ventricle

J.Sales-Llopis
Neurosurgery Department, University General Hospital of Alicante, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Alicante, Spain
Choroid plexus cysts are frequent benign intraventricular lesions that infrequently cause symptoms, usually in the form of obstructive hydrocephalus 1).
Difficult to detect on routine investigations and may lead to the wrong choice of treatment.
These instances are even less common in the adult population.
Although these lesions may float freely within the ventricle leading to intermittent obstruction of the cerebrospinal fluid (CSF) circulation at variable points in a single patient, such a phenomenon has only been documented using cranial ultrasonography and observed intraoperatively by Azab et al. 2).
When warranted, treatment seeks to reestablish cerebrospinal fluid flow and does not necessarily require resection of the cyst itself. Hence, endoscopic exploration of the ventricles with subsequent cyst ablation is the current treatment of choice for these lesions.
The extension of the cyst and whether the hemisphere involved is dominant or not, determines the ideal endoscopic trajectory 3).
Case Reports

1998
In a 6-week-old boy a ventriculoatrial shunt was implanted for correction of an active asymmetrical hydrocephalus of unknown origin. When he was 3 months of age a water-soluble contrast CT ventriculography revealed a noncolloid cyst localised predominantly in the upper portion of the III ventricle. At that time the ventricular catheter obstructed with choroid plexus was removed; new bilateral catheters in a parieto-occipital region were implanted. In the course of the next 4 years, first the atrial catheter had to be extracted and then the peritoneal catheter was changed, in both cases because of obstruction. Periods of normal life alternated with periods of transient and intermittent symptoms of increased intracranial pressure, papilloedema, and myoclonic jerks. Repeated computed tomography (CT) and magnetic resonance imaging (MRI) showed stabilised hydrocephalus with an enlarged left lateral ventricle. When the boy was 16 years old MRI revealed a choroid plexus cyst in the left lateral ventricle 2 cm in diameter, with a ballvalve type of obstruction of the foramen of Monro. CT stereoendoscopic resection of the wall of a large cyst filled with cerebrospinal fluid was performed, and two additional adnexal small cysts were coagulated using the bipolar coagulator, Diomed 25 laser and scissors; the symptoms then regressed, except for superior bilateral altitudinal anopsia. Light and electron microscopy of the cyst wall is reported. The cyst was composed of collagenic connective tissue lined with a basal lamina lacking in epithelial cells. The preoperative and postoperative MRI are presented. According to the literature this case is only the third ever described in a child 4).

2001

A 53-year-old woman with a history of hypertension who sustained a blunt traumatic injury to the occipital region and subsequently developed a progressively worsening right-sided headache. Radiological examinations over the next 2 years revealed an enlarged right lateral ventricle and, ultimately, a choroid plexus cyst in its anterior and middle third, near the foramen of Monro, which is a rare location for these lesions. The cyst was removed en bloc, and follow-up examinations showed a significant improvement in her headache and a minimal differences in size between right and left ventricles 5).

2002

Unusual small choroid plexus cyst obstructing the foramen of monroe 6).

2007

A 2-year-old boy. The patient presented with markedly declining mental status, vomiting, and bradycardia over the course of several hours. Computed tomography scans demonstrated enlarged lateral and third ventricles with sulcal effacement, but no obvious mass lesions or hemorrhage. There was no antecedent illness or trauma. A right frontal external ventricular drain was placed in the patient, resulting in decompression of only the right lateral ventricle. Magnetic resonance (MR) imaging demonstrated a lobulated cyst arising from the choroid plexus of the left lateral ventricle and herniating through the foramen of Monro into the third ventricle, occluding both the foramen of Monro and the cerebral aqueduct. The patient underwent an endoscopic fenestration of the cyst, and histological results confirmed that it was a choroid plexus cyst. Postoperative MR imaging showed a marked reduction in the cyst size. The cyst was no longer in the third ventricle, the foramen of Monro and the aqueduct were patent, and the ventricles were decompressed. The patient was discharged home with no deficits. This case is illustrative because it describes this entity for the first time, and more importantly highlights the need to obtain a diagnosis when a patient presents with acute hydrocephalus without a clear cause 7).

2008

A 3-year-old female child presented with rapid loss of consciousness for the first time. Computed tomography and magnetic resonance imaging scans only showed triventriculomegaly. Endoscopy revealed a cyst of the third ventricle, which was excised, leading to good recovery 8).

2009

11-week-old girl presented to the emergency department with a 1-day history of projectile vomiting, lethargy, and dysconjugate gaze. Hydrocephalus was confirmed on head CT. During hospitalization, the symptoms resolved with a decrease in ventricular size. One week later, the patient again presented with similar symptoms, and MR images with 3D-constructive interference in steady state sequences revealed that a cyst was blocking the third ventricle. The patient subsequently underwent endoscopic fenestration of the cyst with resolution of hydrocephalus and symptoms 9).

2011

A patient was seen in the emergency department with fevers, acute onset of headaches, and lethargy. Computed tomography demonstrated dilated lateral and third ventricles with a relatively normal-sized fourth ventricle. An external ventricular drain was placed. Despite decompression of the lateral ventricles, follow-up magnetic resonance imaging demonstrated a dilated third ventricle with a possible thin-walled mass extending from the foramen of Monro into the posterior portion of the third ventricle. The patient subsequently underwent endoscopic fenestration of the cyst with endoscopic third ventriculostomy. Although two other cases of symptomatic choroid plexus cysts of the third ventricle have been previously reported in children, our paper highlights the possibility of endoscopic cyst fenestration together with a third ventriculostomy as a treatment option in cases where the cyst extends into the posterior third ventricle. Despite adequate decompression, we were concerned that due to CSF pulsations the remnant cyst wall could result in acute aqueduct obstruction and subsequent hydrocephalus 10).

2013

In a case of a 25-year-old female patient with a 3-week history of intermittent headaches, the computerized tomography (CT) of the head detected supratentorial hydrocephalus, with enlargement of the lateral and third ventricles. Magnetic resonance imaging revealed a homogeneous cystic lesion in the third ventricle. A right-sided, pre-coronal burr hole was carried out, followed by endoscopic exploration of the ventricular system. A third-ventriclostomy was performed. With the aid of the 30-degrees endoscope, a cyst arising from the choroid plexus was visualized along the posterior portion of the third ventricle, obstructing the aqueduct opening. The cyst was cauterized until significant reduction of its dimensions was achieved and the aqueduct opening was liberated. Postoperative recovery was without incident and resolution of the hydrocephalus was confirmed by CT imaging. The patient reports complete improvement of her headaches and has been uneventfully followed since surgery. The video can be found in http://youtu.be/XBtj_SqY07Q. (http://thejns.org/doi/abs/10.3171/2013.V1.FOCUS12332). 11).

2015

Azab et al. endoscopically treated a case of third ventricular choroid plexus cyst in a 9-year-old boy who presented with headaches and disturbed conscious level. He underwent a transventricular approach through a single burr hole.
During the procedure, the cyst was noted to intermittently herniate into the lateral ventricle and recede back through the foramen of Monro. Endoscopic ablation of the cyst was achieved and followed by endoscopic third ventriculostomy (ETV). The patient made an excellent recovery after the procedure 12).
1) van Baalen A, Stephani U. Flexible and floating choroid plexus cyst of the third ventricle: an ultrasonographic video documentation. Childs Nerv Syst. 2007 Feb;23(2):259-61. Epub 2006 Nov 15. PubMed PMID: 17106747.
2) , 12) Azab WA, Mijalcic RM, Aboalhasan AA, Khan TA, Abdelnabi EA. Endoscopic management of a choroid plexus cyst of the third ventricle: case report and documentation of dynamic behavior. Childs Nerv Syst. 2015 Feb 26. [Epub ahead of print] PubMed PMID: 25715839.
3) Xi-An Z, Songtao Q, Yuping P. Endoscopic treatment of intraventricular cerebrospinal fluid cysts: 10 consecutive cases. Minim Invasive Neurosurg. 2009 Aug;52(4):158-62. doi: 10.1055/s-0029-1239587. Epub 2009 Oct 16. PubMed PMID: 19838968.
4) Parízek J, Jakubec J, Hobza V, Nemecková J, Cernoch Z, Sercl M, Zizka J, Spacek J, Nemecek S, Suba P. Choroid plexus cyst of the left lateral ventricle with intermittent blockage of the foramen of Monro, and initial invagination into the III ventricle in a child. Childs Nerv Syst. 1998 Dec;14(12):700-8. Review. PubMed PMID: 9881622.
5) Hanbali F, Fuller GN, Leeds NE, Sawaya R. Choroid plexus cyst and chordoid glioma. Report of two cases. Neurosurg Focus. 2001 Jun 15;10(6):E5. PubMed PMID: 16724823.
6) Radaideh MM, Leeds NE, Kumar AJ, Bruner JM, Sawaya R. Unusual small choroid plexus cyst obstructing the foramen of monroe: case report. AJNR Am J Neuroradiol. 2002 May;23(5):841-3. PubMed PMID: 12006289.
7) Nahed BV, Darbar A, Doiron R, Saad A, Robson CD, Smith ER. Acute hydrocephalus secondary to obstruction of the foramen of monro and cerebral aqueduct caused by a choroid plexus cyst in the lateral ventricle. Case report. J Neurosurg. 2007 Sep;107(3 Suppl):236-9. PubMed PMID: 17918533.
8) Kariyattil R, Panikar D. Choroid plexus cyst of the third ventricle presenting as acute triventriculomegaly. Childs Nerv Syst. 2008 Jul;24(7):875-7. doi: 10.1007/s00381-008-0622-8. Epub 2008 Apr 18. PubMed PMID: 18421462.
9) Filardi TZ, Finn L, Gabikian P, Giussani C, Ebenezer S, Avellino AM. Treatment of intermittent obstructive hydrocephalus secondary to a choroid plexus cyst. J Neurosurg Pediatr. 2009 Dec;4(6):571-4. doi: 10.3171/2009.7.PEDS08247. PubMed PMID: 19951046.
10) Eboli P, Danielpour M. Acute obstructive hydrocephalus due to a large posterior third ventricle choroid plexus cyst. Pediatr Neurosurg. 2011;47(4):292-4. doi: 10.1159/000336046. Epub 2012 Feb 22. PubMed PMID: 22378105.
11) de Lara D, Ditzel Filho LF, Muto J, Prevedello DM. Endoscopic treatment of a third ventricle choroid plexus cyst. Neurosurg Focus. 2013 Jan;34(1 Suppl):Video 9. doi: 10.3171/2013.V1.FOCUS12332. PubMed PMID: 23282159.

New Book:Traumatic Brain Injury, Part I, Volume 127: Handbook of Clinical Neurology

Traumatic Brain Injury, Part I, Volume 127: Handbook of Clinical Neurology (Series Editors: Aminoff, Boller and Swaab)Traumatic Brain Injury, Part I, Volume 127: Handbook of Clinical Neurology (Series Editors: Aminoff, Boller and Swaab)

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The Handbook of Clinical Neurology volume on traumatic brain injury (TBI) provides the reader with an updated review of emerging approaches to traumatic brain injury (TBI) research, clinical management and rehabilitation of the traumatic brain injury patient. Chapters in this volume range from epidemiology and pathological mechanisms of injury, and neuroprotection to long-term outcomes with a strong emphasis on current neurobiological approaches to describing the consequences and mechanisms of recovery from TBI. The book presents contemporary investigations on blast injury and chronic traumatic encephalopathy, making this state-of-the-art volume a must have for clinicians and researchers concerned with the clinical management, or investigation, of TBI.

  • Internationally renowned scientists describe cutting edge research on the neurobiological response to traumatic brain injury, including descriptions of potential biomarkers and indicators of potential targets for treatments to reduce the impact of the injury
  • Explores cellular and molecular mechanisms as well as genetic predictors of outcome
  • Offers coverage of various diagnostic tools – CT, MRI, DDTI, fMRI, EEG, resting functional imaging, and more
  • State-of-the-art traumatic brain injury management and treatment principles are presented for both civilian and military care

Product Details

  • Binding: Hardcover
  • 490 pages

Editorial Reviews

About the Author
Jordan Grafman, PhD, is director of Brain Injury Research at the Rehabilitation Institute of Chicago. Before joining RIC, Dr. Grafman was director of the Traumatic Brain Injury Research at Kessler Foundation. His investigation of brain function and behavior contributes to advances in medicine, rehabilitation, and psychology, and informs ethics, law, philosophy, and health policy. His study of the human prefrontal cortex and cognitive neuroplasticity incorporates neuroimaging and genetics, an approach that is expanding our knowledge of the impact of traumatic brain injury, as well as other diseases that impair brain function, such as stroke, multiple sclerosis and degenerative diseases. Dr. Grafman aims to translate his research into more effective, targeted rehabilitation to achieve the best outcomes for people with cognitive disabilities. Dr. Grafman’s background includes 30 years of experience in brain injury research. He has studied brain function in dementia, depression, and degenerative neurological diseases, as well as TBI. He has authored more than 300 research publications, co-editor of the journal Cortex, and provides peer review for numerous specialty journals. At the National Institutes of Health, he served as chief of the Cognitive Neuroscience Section at the National Institute of Neurological Disorders and Stroke. While in the US Air Force, he served at Walter Reed Army Medical Center as neuropsychology chief of the Vietnam Head Injury Project, a long-term study of more than 500 soldiers with serious injuries of the head and brain. He is the leading expert on the long-term effects of penetrating brain injuries in military personnel. His expertise includes the scope of challenges faced during recovery, including behavioral changes like aggression, late sequelae such as seizures, and the impact on TBI on family life and employment, and legal implications. He is an elected fellow of the American Psychological Association and the New York Academy of Sciences. Dr. Grafman is the recipient of many prestigious awards including the Department of Defense Meritorious Service Award, the National Institutes of Health Award of Merit, 2010 National Institutes of Health Director’s Award, and the Humboldt Reserach Award. He is a frequent speaker at national and international conferences. His expert opinion is often sought by national media on issues related to brain function and behavior, cognitive rehabilitation, and policy and legal issues related to brain-behavior research.
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