Challenges in radiological evaluation of brain metastases, beyond progression.

MRI is the cornerstone in the evaluation of brain metastases. The clinical challenges lie in discriminating metastases from mimickers such as infections or primary tumors and in evaluating the response to treatment. The latter sometimes leads to growth, which must be framed as pseudo-progression or radionecrosis, both inflammatory phenomena attributable to treatment, or be considered as recurrence. To meet these needs, imaging techniques are the subject of constant research. However, an exponential growth after radiotherapy must be interpreted with caution, even in the presence of results suspicious of tumor progression by advanced techniques, because it may be due to inflammatory changes. The aim of this paper is to familiarize the reader with inflammatory phenomena of brain metastases treated with radiotherapy and to describe two related radiological signs: "the inflammatory cloud" and "incomplete ring enhancement", in order to adopt a conservative management with close follow-up.

Update on meningioma: Clinical-radiological and radio-pathological correlation.

Meningiomas are tumors that originate in the arachnoid villi and are the most common non-glial neoplasm in the central nervous system. The clinical manifestations associated with meningioma depend, fundamentally, on its location. The location in the cerebral convexity is the most frequent, especially in the frontal lobes, manifesting with headache, motor disturbances, seizures and even neurocognitive disorders. There are 15 histologic subtypes of meningioma and three histologic grades. Within these, grades two and three have a worse prognosis and a higher rate of recurrence, as well as a radiological behavior that is generally more aggressive. Although there are some imaging features that can suggest a specific subtype, the definitive diagnosis will always require histological/molecular confirmation.

Brain teratoma in a free-ranging mallard (Anas platyrhynchos) - case report / [Teratoma cerebral em um pato-real (Anas platyrhynchos) de vida livre - relato de caso]

Teratoma is a rare neoplasia with differentiation in two or three germ cell lines. Intracranial teratoma in birds has rarely been reported, especially affecting the brain. This is the first report of a brain teratoma in a mallard with neurological clinical signs. The neoplasm was characterized as a mature brain teratoma, extending from the cerebellum to the brainstem, and with one nodule in the cortex.(AU)

O teratoma é uma neoplasia rara, com diferenciação em duas ou três linhagens de células germinativas. Teratomas intracranianos, em aves, são raramente relatados, principalmente, com localização cerebral. Este é o primeiro relato de teratoma cerebral em um pato-real com sinais clínicos neurológicos. A neoplasia foi caracterizada como um teratoma cerebral maduro, estendendo do cerebelo ao tronco encefálico e com um nódulo no córtex.(AU)

Profile of Patients with Intracranial Tumors Undergoing Surgical Resection at a Neuro-oncology Referral Hospital

Objectives To analyze the epidemiological aspects of primary and metastatic tumors of the central nervous system (CNS) among patients operated on by a single surgeon dedicated to neuro-oncology at Hospital Regional do Oeste, in Chapecó (Santa Catarina, Brazil), between 2013 and 2016. Methods Cross-sectional, retrospective, and observational analysis of 347 patients undergoing surgery due to intracranial tumors. The patients' data were obtained from the hospital registry, medical records, and pathology reports. Results Primary CNS tumors comprised 72.1% of the sample. There was a predominance of females (52.7%), and the mean age was 49.3 years, with a peak of incidence between the ages of 25 and 64 years. Gliomas were the most common primary brain tumors (23.7%), followed by meningiomas (17.0%). Lung cancer (15.3%), breast cancer (4.9%), and melanoma (3.5%) were, in descending order, the most frequent primary sites of metastases, which were recorded in 97 cases (27.9%). Conclusion The lack of standardization in the process of notification of tumor diseases imposes challenges in the establishment of estimates close to the real ones, preventing improvement of public health care policies to protect patients with neuro-oncological conditions. Based on the current model, regionalization of the data seems to be the best option in the management of this subgroup of patients.

Objetivos Analisar aspectos epidemiológicos dos tumores cerebrais primários e metastáticos entre os pacientes operados por um único cirurgião dedicado à neurooncologia no Hospital Regional do Oeste, em Chapecó, SC, Brasil, durante os anos de 2013 a 2016. Métodos Estudo transversal, retrospectivo, do tipo observacional, com análise de 347 casos de neoplasias intracranianas de acordo com os dados obtidos no setor de registro hospitalar, nos prontuários da instituição e registros anatomopatológicos dos pacientes tratados cirurgicamente. Resultados Tumores cerebrais primários corresponderam a 72.1% da amostra. Houve predomínio do sexo feminino (52,7%) e a média de idade foi de 49,3 anos, com pico de incidência na faixa etária de 25 a 64 anos. Gliomas foram os tumores cerebrais primários mais encontrados (23.7%), seguidos por meningiomas (17,0%). Cânceres de pulmão (15,3%), mama (4,9%) e melanoma (3,5%) foram, em ordem decrescente, as localizações primárias mais frequentes das metástases registradas em 97 casos (27.9%). Conclusão A dificuldade em se estabelecer uma estimativa mais próxima da realidade devido à falta de padronização na notificação de agravos tumorais impede uma melhor condução de políticas públicas de amparo ao paciente neuro-oncológico. Assim, nos moldes atuais, a regionalização dos dados parece a melhor opção na administração desse subgrupo de pacientes.

Vasculitis primaria del sistema nervioso central, un reto diagnóstico. Reporte de caso / Primary vasculitis of the central nervous system, a diagnostic challenge. Case report

RESUMEN La angeítis primaria del sistema es una rara entidad, en la cual hay destrucción y compromiso inflamatorio de los vasos del sistema nervioso central. Con frecuencia, es subdiagnosticada por sus múltiples formas de presentación clínica y por los hallazgos en neuroimágenes que pueden simular otras patologías, lo que retrasa el diagnóstico y el manejo oportuno. Este tipo de vasculitis es muy poco comprendida y no existen suficientes estudios en la actualidad respecto a su fisiopatología y manejo. Los marcadores inflamatorios suelen ser normales, con alteración del LCR en un 80-90 % de los casos y la arteriografía cerebral puede mostrar un patrón típico descrito como áreas alternantes de dilatación y estenosis; sin embargo, con muy baja sensibilidad. Ante una alta sospecha clínica y ausencia de pruebas diagnósticas no invasivas, el diagnóstico se realiza a través de biopsia de las lesiones cerebrales y meninges. Finalmente, el tratamiento se basa en combinación de corticoides y ciclofosfamida, aunque se carece de estudios controlados que lo soporten.

SUMMARY Primary angiitis of the central nervous system is a rare condition in which there is destruction and inflammatory involvement of the vessels of the central nervous system. It is often underdiagnosed given its multiple forms of clinical presentation and neuroimaging findings that can mimic other pathologies delaying diagnosis and management. This type of vasculitis is very poorly understood and there are not enough studies at present regarding the pathophysiology and management. Inflammatory markers are usually normal with abnormal CSF in 80-90 %% of cases and cerebral arteriography may show a typical pattern described as in "Rosario" however with very low sensitivity. Given the persistence of high clinical and absence of non-invasive diagnostic tests suspect the final diagnosis is made by biopsy of brain lesions and meninges. Finally, treatment is based on a combination of corticosteroids and cyclophosphamide however has not controlled studies support it.

Quiste epidermoide frontotemporal en un hombre de 78 años: reporte de un caso y revision de la literatura / Cyst epidermoid cyst in a 78-year-old man: case report and literature review

Introducción: Los quistes epidermoides cerebrales son tumores de origen embrionario presentes desde la formación del tubo neural. Caso clínico: Hombre de 78 años con focalización en hemicuerpoizquierdo TAC cerebral reportó masa frontotemporal que se extirpó quirúrgicamente y el estudio histopatológico confirma diagnóstico de quiste epidermoide. Discusión: Los quistes epidermoides son tumores poco frecuentes y representan menos del 2% de los tumores intracraneales, el angulo cerebelopontino es la ubicación más frecuente y la resección completa junto con toda la cápsula es el único tratamiento efectivo.

Introduction: Epidermoid cysts are tumors of embryonic origin present since the formation of the neural tube. Case report: A 78-year-old male with a left hemisphere, brain CT scan reported frontotemporal mass that was surgically removed and the histopathological study confirmed a diagnosis of epidermoid cyst. Discussion: Epidermoid cysts are rare tumors and account for less than 2% of intracranial tumors, cerebellar angle is the most frequent site, and complete resection with the entire capsule is the only effective treatment.

Intracranial Mature Teratoma: A Case Report

Teratomas are the most common type of Germ Cell Tumors (GCTs). GCTs are classified as extragonadal, if there is no evidence of a primary tumor in neither the testicles, nor in the ovaries. Intracranial Mature Teratomas are tumors with a very low incidence, and clear male predominance. We present the case of a 21 year-old female patient, with a history of two seizures 15 days prior to admission, without any abnormalities upon physical examination. The Magnetic Resonance Imaging (MRI) performed at the admission evidenced an expansive, heterogeneous lesion in the frontal lobe, hypointense on T1-weighted images, hyperintense on T2-weighted images, and restriction on the diffusion imaging and ADC-mapping. The patient underwent microsurgical resection, and it was possible to achieve a near-total resection. During surgery, a welldefined capsule was identified, which was removed after adequate debulking. Tissues resembling hair were taken from inside the lesion. The patient recovered well, without any neurological deficits, and no further intervention was necessary. The authors aim to describe this rare pathology and their option for a surgical approach.

Os teratomas são o tipo mais comum de Tumores de Células Germinativas (TCG). TGC são classificados como extragonadais, quando não há evidências de um tumor primário em nos testículos, ou nos ovários. Os Teratomas Maduros Intracranianas são tumores com uma incidência muito baixa, e com uma predileção pelo sexo masculino. Nós apresentamos o caso de uma paciente, feminina, 21 anos de idade, com história de dois episódios de convulsões tônico-clônicas generalizadas, 15 dias antes da admissão, sem nenhum déficit focal ao exame físico. A Ressonância Magnética realizada na chegada mostrou uma lesão sólida, expansiva, grande e heterogênea, hipointensa em T1, e hiperintensa em T2, com restrição a difusão e ADC-mapping. Foi realizado uma cirurgia, e foi possível obter uma ressecção quase total. Havia uma cápsula bem definida, a qual foi removida após adequada redução do volume tumoral. Dentro da lesão foi encontrado tecido semelhante a cabelo. A paciente se recuperou bem, e foi dado alta sem novos déficits neurológicos, não foi realizado mais nenhuma intervenção, e ela está sendo acompanhada regularmente. Os autores visam descrever essa patologia rara e sua opção por uma abordagem cirúrgica.

Moderada concordancia espectroscópica e histopatológica en pacientes con lesiones cerebrales no traumáticas, Hospital Escuela Universitario, 2012-2015 / Spectroscopic and histopathologic moderate concordance in patients with non-traumatic brain injuries, Hospital Escuela Universitario, 2012 - 2015

Antecedentes:La comparación entre diagnóstico espectroscópico e histopatológico se fundamenta en variaciones de los metabolitos encontrados en las lesiones cerebrales. En Honduras no se cuenta con datos de correlación diagnostica entre estos métodos. Objetivo: Determinar la concordancia diagnóstica entre espectroscopía por resonancia magnética e histopatología en pacientes con lesiones cerebrales no traumáticas, Sala de Neurocirugía de Adultos, Hospital Escuela Universitario, Tegucigalpa, 2012-2015. Metodología: Estudio de valoración de concordancia entre pruebas diagnósticas en pacientes mayores de 18 años, con lesión cerebral no traumática. Se registró información sociodemográfica, antecedentes, presentación clínica y resultados diagnósticos. Los datos fueron procesados en programa SPSS Statistics versión 22. La concordancia se estableció estimando índice Kappa. Resultados: De 150 casos registrados, se evaluaron 42 pacientes con criterios de inclusión; 57.1% (24) hombres, edad promedio 44.8 años (18­79), 17 (40.5%) procedentes de Francisco Morazán. Al ingreso presentaron hipertensión endocraneana 38.1% (16), hemiparesia 33.3% (14) y parálisis facial periférica 4.8% (2). Los metabolitos Colina y N-Acetil Aspartato presentaron elevación 76.2% (32) y disminución 71.4% (30), respectivamente. Astrocitomas de bajo grado 9 (21.4%) y de alto grado 8 (19.0%) fueron los diagnósticos espectroscópicos más frecuentes. Astrocitomas de bajo grado y de alto grado, 10 (23.8%) cada uno, fueron los diagnósticos histopatológicos más frecuentes. Se estimó Índice diagnósticos espectroscópicos e histopatológicos sugiere que la combinación de ambos mejora la precisión del diagnóstico pero no la diferenciación entre tipos de lesiones...(AU)

The Role of the IntraoperativeAuxiliaryMethods in the Resection of Motor Area Lesions / O papel dos métodos auxiliares intraoperatórios na ressecção de lesões em área motora

Objective In recent years, technologies have advanced considerably in improving surgical outcome following treatment of lesions in eloquent brain areas. The aimof this study is to explore which method is best in the resection of motor area lesions. Methods Prospective, non-randomized study Evaluate on 74 patients who underwent surgery to remove lesions around the motor area. Results Total lesion removal was achieved in 68 patients (93.1%). Fifty-four patients (73.9%) presented normal motor function in the preoperative period; of these, 20 (37.3%) developed transitory deficits. Nevertheless, 85% of these patients later experienced a complete recovery. Nineteen patients presented with motor deficits preoperatively; of these, five presented deteriorating motor abilities. Intraoperative stimulation methods were used in 65% of the patients, primarily in cases of glioma. Conclusions The morbidity in patients submitted to resections of motor area lesions is acceptable and justify the surgical indication with the purpose of maximal resection. Intraoperative stimulation is an important tool that guides glioma resection in many cases.

Objetivo Nos últimos anos, consideráveis avanços tecnológicos têm surgido no sentido de melhorar os resultados cirúrgicos no tratamento de lesões em áreas eloquentes do cérebro. O objetivo deste estudo é investigar qual o melhor método para ressecção de lesões em área motora. Método Estudo prospectivo não aleatório que avaliou os resultados pós-operatórios em 74 pacientes submetidos à ressecção de lesões em área motora ou adjacente. Resultados A ressecção cirúrgica foi considerada total em 68 (93,1%) pacientes. 54 pacientes (73,9%) apresentavam força muscular normal no pré-operatório. Destes, 20 (37,3%) apresentaram déficit no pós-operatório imediato, sendo que 17 (85%) recuperaram completamente o déficit. 19 pacientes apresentavam déficit no préoperatório, sendo que 05 apresentaram piora do déficit no pós-operatório imediato. A estimulação intraoperatória foi utilizada em 65% dos casos, principalmente nos gliomas. Conclusão Amorbidade empacientes operados de lesões emáreamotora é bastante aceitável e justifica a indicação cirúrgica com objetivo de ressecção máxima. A estimulação intraoperatória é uma ferramenta importante para guiar a resseção dos gliomas em muitos casos.

Angiolipoma intracraniano adjacente a aneurisma sacular cerebral: relato de caso e revisão da literatura / Intracranial Angiolipoma Associated with Cerebral Saccular Aneurysm: Case Report and Review of Literature

Angiolipomas são neoplasias benignas compostas por adipócitos maduros e proliferação vascular angiomatosa de rara ocorrência no Sistema Nervoso Central. É relatado o caso de angiolipoma em cisterna silviana adjacente a aneurisma sacular de artéria cerebral média. São discutidas as características imagenológicas do tumor e a possibilidade de uma origem comum com lesões vasculares intracranianas. Este é o primeiro caso relatado de angiolipoma intracraniano associado a aneurisma de artéria cerebral média.

Angiolipomas are benign neoplasms composed of mature fat cells and vascular angiomatous proliferation of rare incidence in Central Nervous System.It's related a case of angiolipoma in Sylvian fissure associated with cerebral saccular aneurysm of medial cerebral artery. Imagenologic characteristics of the tumor and a possible common origin with intracranial vascular lesions are discussed. This is the first reported case of intracranial angiolipoma involving medial cerebral artery aneurysm.

Costos económicos en craneotomía vigíl para la resección de tumores intracerebrales / Economic costs in a craniotomy monitor for the resection of intracerebral tumors

INTRODUCCIÓN: la técnica de craneotomía vigíl (CV) ha facilitado la extracción de lesiones intracerebrales cercanas a áreas elocuentes debido a la información inmediata que se puede obtener por vía de cortico-estimulación. OBJETIVO: describir los costos económicos comparativos entre CV y anestesia general (CAG). MÉTODO: se estudiaron los casos operados bajo CV, desde noviembre del 2007 a octubre del 2012, en el Hospital de Diagnóstico de El Salvador. Se operaron 63 pacientes bajo CV, de estos, 45 con patología oncológica fueron comparados contra 45 pacientes operados bajo CAG. Se analizan costos de CV versus CAG, los cuales se desglosan en: procedimiento, días de estancia intrahospitalaria y unidades intermedias. RESULTADOS: el costo promedio de CV fue de 6,540 USD (6,300 ­ 6,900) versus 8,550 USD (8,000 - 9,000) de CAG (p.0003). El tiempo en quirófano fue de 257.49 minutos en CV y de 247.51 minutos para CAG (p.0.63). El tiempo promedio hospitalización en CV fue de 2.1 días (1-4) y en CAG de 2.9 días (2-5) (p0.004). Tres (6.6%) pacientes de CV pasaron a unidad de cuidados intermedios (UCIM), de CAG 6 (13.3%) pacientes pasaron a UCIM (p.0.04). La tasa de resección volumétrica según RM control fue de 92% (40-100) en CV versus 95% (62-100) en CAG (p.0.5). CONCLUSIONES: la CV mostró ser más económica que la clásica CCAG e incurre en menor tiempo de hospitalización. Las series no fueron comparables en cuanto a cercanía de las lesiones a áreas elocuentes y a la existencia de complicaciones, ya que la mayoría de casos en dichas áreas fueron operados por CV

INTRODUCTION: awake craniotomy (CV) technique made easier the resection of intracerebral lesions near eloquent cortex due to the immediate information that can be obtained via cortico-stimulation. OBJECTIVE: to investigate comparative costs at our center between CV and general anesthesia (CAG). METHOD: we analyzed the cases that were operated under CV from November 2007 to October 2012 at the Hospital de Diagnóstico de El Salvador. During this period 63 patients were operated using CV. 45 patients with oncological pathology were chosen that could be compared to 45 patients that were operated by the same team but under CAG. Comparative costs were studied and broken down in the direct cost of procedure, hospital stay in regular and intermediate care units. A brief description of the techniques used is provided and clinical results with regards to volumetric resection and neurologicalcomplications. RESULTS: the average cost of CV was 6,540 USD (6,300 ­ 6,900) versus 8,550 USD (8,000 - 9,000) of CAG (p.0003). Operating room time was 257.49 minutes in CV and 247.51 minutes for CAG p.0.63. The average hospitalization time was in CV 2.1 days (1-4) and 2.9 days in CAG (2-5) (p.0.004). Three (6.6%) patients of CV needed Intermediate Care (UCIM), in CAG 6 (13.3%) patients needed (UCIM p.0.04). The proportion of lesions next to or in eloquent cortex was CV (36) versus CAG (15) 2.4:1 (p.0.0031). Volumetric resection according MRI was 92% (40-100) in CV versus 95% (62-100) in CAG, (p.0.5). CONCLUSIONS: awake craniotomy showed to be less expensive than CAG and had less hospital stay. Both series were not comparable with regards to tumor resection in eloquent or near eloquent cortex and complications due to the fact that most of the complex cases were operated under CV

Stereotactic biopsies of brain lesions / Biópsia estereotáxica de lesões encefálicas

OBJECTIVE: In the majority of cases, the correct treatment of brain lesions is possible only when the histopathological diagnosis is made. Several deep-seated lesions near eloquent areas are not safely approached by the classical neurosurgical procedures. These patients can get benefit by a minimally invasive procedure. METHOD: We present a series of 176 consecutive patients submitted to stereotactic biopsies due to a great variety of brain lesions. RESULTS: Histological diagnosis found in this series: glioma in 40.1 percent of the patients, other neoplasms in 12.2 percent and infectious or inflammatory diseases in 29.1 percent. The result was inconclusive in 5.2 percent of the procedures. One patient died (0.6 percent) and two (1.2 percent) presented operative complications. The criteria, advantages and risks of the stereotactic biopsies are discussed. CONCLUSION: The efficacy of the method is adequate and morbid-mortality rates were low.

OBJETIVO: O diagnóstico anatomopatológico das lesões encefálicas é muitas vezes necessário para a instituição do tratamento adequado. Entretanto, muitas lesões localizadas profundamente no encéfalo ou em centros nervosos de grande importância funcional não podem ser acessadas sem riscos, com a aplicação dos procedimentos neurocirúrgicos habituais. MÉTODO: Apresentamos uma série de 176 doentes submetidos a biópsias estereotáxicas de lesões encefálicas. RESULTADOS: Em 40,1 por cento dos casos, o diagnóstico foi de glioma, em 12,2 por cento de outras neoplasias e em 29,1 por cento, de doenças infecciosas ou inflamatórias. O resultado foi inconclusivo em 5,2 por cento dos doentes. Um (0,6 por cento) doente faleceu e dois (1,2 por cento) apresentaram graves complicações operatórias. Os critérios de seleção, as vantagens e os riscos da biópsia estereotáxica são discutidos. CONCLUSÃO: A eficácia do método é boa e a morbimortalidade das biópsias estereotáxicas é baixa.

Frecuencia de tumores cerebrales en pacientes epilepticos. / Frequency of brain tumors in epileptic patients

Con objeto de precisar la frecuencia en que se presentan tumores cerebrales en pacientes epilepticos, estudiamos con ayuda de la tomografia axial computarizada (TAC) en un grupo consecutivo y no seleccionado de 200 enfermos epilepticos la posibilidad de padecer tumor cerebral como causa etiologica de epilepsia. La frecuencia encontrada fue de 2%. Se discuten las caracteristicas de estos pacientes y la importancia de la TAC en el estudio integral del enfermo epileptico