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A 55-year-old woman with a unique form of chronic hypertrophic pachymeningitis involving the posterior fossa and upper cervical spine is reported. Unlike other cases previously described, the clinical picture was dominated by signs of increased intracranial pressure, lower cranial nerve disorders, and a progressive cervical radiculomyelopathy. The diagnosis was made by means of a contrast-enhanced magnetic resonance imaging scan and confirmed by histological examination of the excised dura. Surgical treatment with removal of the hypertrophic dura provided temporary relief, although the natural history of the disease was not modified. Exhaustive bacteriological and histopathological studies failed to identify a specific cause for this diffuse hypertrophy of the cranial and cervical dura. The literature is reviewed, and other histologically documented cases are discussed.

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INTRODUCTION Laparoscopic cholecystectomy may not be suited in elderly patients with comorbidities. Our objective is to evaluate whether our indication for cholecystostomy is in accordance with the 2018 Tokio Guidelines and to determine the clinical-epidemiological and analytical characteristics as well as the clinical results depending on the treatment (surgical, conservative or cholecystostomy). MATERIAL AND METHODS Retrospective observational study with patients diagnosed with acute cholecystitis between the 25/01/2019 and the 13/03/2020. RESULTS Out of 145 patients, 87 (60%) underwent cholecystectomy (average age 63 years), 47 (32,4%) treated conservatively (74,8) and 11 (7,6%) by cholecystostomy (85,8). The multivariate analysis showed that suffering from cardio and cerebrovascular diseases, CKD, taking anticoagulants and altered levels of creatinine, Quick or CRP, multiplies by 5.2, 6.4, 10.9, 4.6, 1.2 and 1.1 the probability of cholecystostomy versus cholecystectomy (p < 0,005). Both the time of admission and of antibiotic treatment was longer in the cholecystostomy group (15.2 and 11.5 days) compared to conservative (7 and 9) and surgical (5.3 and 5.8) (p = 0,000 and p = 0,011). Only one patient in the cholecystostomy group underwent subsequent surgery compared to 50% in the conservative group. The mortality rate did no differ. Out of 11 cholecystostomies, 6 met the Tokio Guidelines criteria. CONCLUSIONS 1. Patients undergoing cholecystostomy are older, multipathological and present greater systemic involvement (KD, coagulopathy and elevated APR). They require a longer hospital stay and duration of antibiotic treatment. 2. 54,54% of the cholecystostomies performed were adapted to the 2018 Tokio Guidelines. 3. Conservative treatment means higher long-term complication rates.