Brain Tumor Heterogeneity

Tumor heterogeneity is the concept that different tumor cells provide distinct biomorphological lesions, gene expressions, proliferation, microenvironment and graduated capacity of metastatic lesions. Brain tumor heterogeneity has been recently discussed about the interesting interaction of chronic inflammation, microenvironment, epigenetics and glioma steam cells. Brain tumors remain a challenge with regards to medication and disease, due to the lack of treatment options and unsatisfactory results. These results might be the result of the brain tumor heterogeneity and its multiple resistance mechanisms to chemo and radiotherapy.

Spinal fractures in patients with ankylosing spondylitis: A case report and literature review.

BACKGROUND: Severe ankylosing spondylitis (AS) affects the entire spine, increasing the risk of vertebral fractures. There are several fusion procedures used (e.g., anterior, posterior, or combined 360° procedures) to stabilize these fractures. CASE DESCRIPTION: A 45-year-old male with a 33-year diagnosis of AS presented with a progressive quadriparesis of 6 months' duration. Previously, he had surgery on both hips. The medical report documented degenerative spondylolisthesis at the C5-C6 level along with syndesmophytes a herniated disc and stenosis. Following a circumferential decompression/fusion without complications, the patient's symptoms resolved. CONCLUSION: For patients presenting with cervical fractures and AS, circumferential surgical decompression/ fusion may result in good outcomes.

The natural history of patients with acute disc herniation: a series of 150 cases / A história natural de pacientes com herniação discal aguda: uma série de 150 casos / La historia natural de pacientes con herniación discal aguda: una serie de 150 casos

ABSTRACT Objective This study aims to analyze the characteristics of patients with acute lumbar/sciatic disc herniation who underwent conservative, pain block procedures and surgical treatment, in order to better understand the natural history of herniations and their surgical indications, as well as the impact of hernia volume. Methods We analyzed 150 patients with a diagnosis of acute lumbar disc herniation. The treatments considered were: conservative, infiltration/pain block procedures and microdiscectomy. For seven patients who were surgically treated, the lumbar sequestrectomy volume was submitted to pathological analysis. Results Of the 150 patients, 80% were treated conservatively; 15.31% were treated with pain block procedures and 4.66% underwent microdiscectomy. The mean age of the surgical group was 42.5 years, and 57.1% of the patients were men. Most of the hernias were at L5-S1 (55.5%), and 77.7% were on the left side. All patients had presented significant lumbar pain or sciatica for a long period prior to the surgery. The Lasègue sign was present in all patients. Of the total number of patients, 85.7% presented hypoesthesia and 42.8% presented focal motor deficits, among other findings. The mean hernia volume was 9.6 cm3. Conclusions Unresponsiveness to conservative treatment is an important indication for surgery. The clinical manifestations in patients with a lumbar/sciatic hernia can be very diverse, as can the disc herniation volume, so these are not good indicators for surgery. Level of evidence IV; Case series

RESUMO Objetivo O presente estudo tem como objetivo analisar as características dos pacientes com hérnia de disco lombar/ciática aguda que passaram por procedimentos conservadores, procedimentos de bloqueio de dor e tratamento cirúrgico, a fim de melhor entender a história natural das hérnias e suas indicações cirúrgicas, assim como o impacto do volume da hérnia. Métodos Analisamos 150 pacientes diagnosticados com hérnia de disco lombar aguda. Os tratamentos considerados foram: tratamento conservador, procedimentos para bloqueio da dor/infiltração e microdiscectomia. Para sete pacientes tratados cirurgicamente, o volume de sequestrectomia lombar foi enviado para análise patológica. Resultados Dos 150 pacientes analisados, 80% foram tratados de modo conservador, 15,31% com procedimentos de bloqueio da dor e 4,66% com microdiscectomia. A idade média do grupo submetido à cirurgia foi 42,5 anos, sendo que 57,1% dos pacientes eram homens. A maior parte das hérnias estavam localizadas em L5-S1 (55,5%) e 77,7% das hérnias estavam no lado esquerdo. Todos os pacientes apresentaram significativa dor lombar ou ciática por um longo período antes da cirurgia. O sinal de Lasègue estava presente em todos pacientes. Do número total de pacientes, 85,7% apresentaram hipoestesia e 42,8% apresentaram déficits motores focais, entre outros achados. O volume médio das hérnias foi 9,6 cm3. Conclusões A falta de resposta ao tratamento conservador é uma importante indicação para cirurgia. As manifestações clínicas dos pacientes com hérnia lombar/ciática podem ser muito diversas, assim como o volume da hérnia de disco, portanto, esses não são bons indicadores para cirurgia. Nível de evidência IV; Série de casos.

RESUMEN Objetivo El presente estudio tiene como objetivo analizar las características de los pacientes con hernia de disco lumbar/ciática aguda que pasaron por procedimientos conservadores, procedimientos de bloqueo de dolor y tratamiento quirúrgico, a fin de entender mejor la historia natural de las hernias y sus indicaciones quirúrgicas, así como el impacto del volumen de la hernia. Métodos Analizamos a 150 pacientes diagnosticados con hernia de disco lumbar aguda. Los tratamientos considerados fueron: conservador, procedimientos para bloqueo de dolor/infiltraci ón y microdiscectom ía . Para siete pacientes tratados quirúrgicamente, el volumen de secuestrectomía lumbar fue enviado para análisis patológico. Resultados De los 150 pacientes analizados, 80% fue tratado de modo conservador, 15,31% con procedimientos de bloqueo de dolor y 4,66% con microdiscectomía. La edad promedio del grupo sometido a cirugía fue de 42,5 años, siendo que 57,1% de los pacientes eran hombres. La mayor parte de las hernias estaban localizadas en L5-S1 (55,5%) y 77,7% de las hernias estaban en el lado izquierdo. Todos los pacientes presentaron dolor lumbar o ciático significativo por un largo período antes de la cirugía. La señal de Lasègue estaba presente en todos los pacientes. Del número total de pacientes, 85,7% de los pacientes present ó hipostesia y 42,8% present ó déficit s motores focales, entre otros hallazgos. El volumen promedio de las hernias fue de 9,6 cm3. Conclusiones La falta de respuesta al tratamiento conservador es una importante indicación para la cirugía. Las manifestaciones clínicas de los pacientes con hernia lumbar/ciática pueden ser muy diversas, así como el volumen de la hernia de disco, por lo tanto, é stos no son buenos indicadores para cirugía. Nivel de evidencia IV; Serie de casos.

Nonsaccular aneurysms: A wide comparison between the four main types.

BACKGROUND: The present study aims to present the most important considerations when it comes to patients features, clinical presentation, localization, morphology, pathogenesis, and the best treatment for each type of the nonsaccular aneurysms. METHODS: We performed a literature review using PubMed. The search was limited to the studies published in English, from 2010 to 2017. RESULTS: Data about the clinical presentation; the aneurysm pathogenesis, morphology, and localization; the patient features; and about the surgical or endovascular approach were analyzed for the four types of nonsaccular aneurysms presented. CONCLUSION: All types of nonsaccular aneurysms have a higher prevalence in young adults. Men are more affected by fusiform and mycotic aneurysms while women suffer more with blister-like aneurysms (BLAs). The mycotic and the BLAs affect more the anterior circulation while the fusiform affects more the posterior circulation. Mycotic and blister-like has as its major complication and clinical presentation the hemorrhage; however, the fusiform aneurysms usually present ischemia and/or mass effect. The reconstructive endovascular techniques for all types of nonsaccular aneurysms presented as the treatment with the best outcomes. Among this technique, the flow diversion presented good results in all types of aneurysms and it seems to promote the best outcomes.

Microsurgical Management of Trigeminal Schwannoma: Cohort Analysis and Systematic Review.

Background Trigeminal schwannomas are benign tumors with a predilection for women between 40 and 60 years of age and account for less than 0.5% of all intracranial tumors. Clinical presentation depends on size and location, and typical symptoms are ipsilateral hypesthesia, headache, and facial pain. Clinical features and imaging usually make the Diagnosis. Methods A retrospective cohort analysis of 14 patients treated at our institution between January 1999 and October 2016 was performed, with a critical and systematic review of data from the literature, focusing on articles published over the same period. Results Fourteen patients were included in our series comprised of mostly women with a mean age of 40 years. Lesion size ranged from 3 to 6.5 cm (mean 4.6 cm). Clinical status of patients was evaluated and also rated based on the Karnofsky Perfomance Scale with values greater than 90% found in all patients pre and postoperatively. Surgery was our treatment of choice, and gross total resection was achieved in 71% of patients. Associated morbidity was high at 57%, predominantly from cranial nerve palsy, and no deaths were encountered. Conclusions Microsurgery is a suitable treatment for large symptomatic trigeminal schwannomas, achieving good local control rates over the observation period at acceptable morbidity. Therefore, microsurgery appears to a suitable option. During the study period, a significant evolution in the availability of treatment methods occurred. Radiosurgery emerged as an alternative treatment for unresectable lesions. A comprehensive review of the available literature was performed, and results were compared according to treatment modality.

Giant mucopyocele associated with intracranial hypertension: Case report and literature review.

BACKGROUND: Mucoceles are epithelial lined sacs that contain mucous. Eventually, they can be infected and so called mucopyoceles, which are usually slow growing lesions with common bone destruction located in the facial sinus. Mucoceles show multivariate etiology and occur between the fourth and seventh decade of life. CASE DESCRIPTION: Patient, 55-year-old, female, was referred unconscious with Cushing's triad to our department; she had fever since four days. The findings of skull computer tomography highlighted a large bifrontal lesion with an invasion of the rear wall of the frontal sinus, compression of the frontal lobes, and midline deviation. She was taken for an emergency surgery, which showed invasion of the dura and mucous infection. Postoperatively, there was a fast recovery of neurologic level and extubation on the second postoperative day. She took antibiotics for 14 days and was discharged from the hospital without neurologic deficits. CONCLUSIONS: Mucopyoceles are usually slow growing lesions that rarely increases rapidly. Our patient presented signs of intracranial hypertension; therefore, it was necessary to have quick surgical intervention.

Neurosarcoidosis Associated with Psychiatric Symptoms: Case Report

Background Sarcoidosis is a granulomatous disease predominant in women and black men that has inflammatory origin of unknown etiology; neurosarcoidosis is a rare and critical presentation of the disease. Case description A 26-year-old black female presented frontal headache for 1 year, as well as behavioral and mood changes for 15 days. Skull tomography and nuclear magnetic imaging of the skull revealed damaged meninges, a right frontal bone lesion, and an intraparenchymal contrast-enhancing lesion. Screening with computed tomography (CT) scans was performed, and it showed signs of bronchiectasis in the lower third of the right lung, but it was asymptomatic. The biopsy showed signs of reactional lesion with the presence of non-caseating granulomas. After the treatment with corticosteroids, the patient presented progressive improvement. Conclusions Neurosarcoidosis is a rare and critical pathology of sarcoidosis that presents a lytic bone lesion and clinical psychiatric symptoms; neurosarcoidosis is also rare in the literature.

Introdução A sarcoidose é uma doença granulomatosa de origem inflamatória de etiologia desconhecida, predominante em mulheres e negros, sendo a neurosarcoidose uma apresentação da doença rara relacionada a gravidade. Relato de Caso Paciente com 26 anos, negra, apresenta quadro cefaleia frontal ha 1 ano e há 15 dias apresentando sinais de alterações de comportamento e humor. Tomografia de crânio e Ressonância nucelar magnética de crânio que evidenciaram lesão óssea frontal direita, comprometimento meninges e lesão intraparenquimatosa captante de contraste. Realizado screening com tomografias que evidenciaram sinais de bronquiectasia em terço inferior pulmão direito, assintomática. Biopsia indicando sinais de lesão reacional com presenças de granulomas não caseosos, Após a manutenção da corticoterapia, a paciente apresentou melhora progressiva. Conclusões A neurosarcoidose é uma patologia grave e rara da sarcoidose, nesse caso apresenta uma lesão óssea lítica e sintomas psiquiátricos, apresentação rara na literatura.

Neurofibromatosis type 1 and Chiari type 1 malformation: A case report and literature review of a rare association.

BACKGROUND: The association between neurofibromatosis type 1 (NF-I) and Chiari I malformation (CMI) is rare, and not many studies are reported in the literature. Performing magnetic resonance imaging (MRI) in patients with NF-1 is essential because several cases of Chiari type I are completely asymptomatic. We emphasize the need for inclusion of Chiari I as diagnosis in association with NF-1. CASE DESCRIPTION: The patient was a 51-year-old black man who presented with complaints of pain and decreased motion and sensibility of his hands, wrists, and forearms, along with progressive dysarthria. Even though the computed tomography (CT) scan of the skull did not show changes, the MRI showed hydro/syringomyelia in the cervical spine area. Midline suboccipital craniectomy with total laminectomy of c1 and partial laminectomy of c2 was performed; tonsillectomy was also performed for cistern expansion because of intense thickening and obliteration of the obex by the cerebellar tonsils. Following treatment, the patient showed remission of symptoms. CONCLUSION: NF-1 in association with CMI is rare, and early diagnosis and surgical treatment are essential to slow down the myelopathy; although they prevent neurological damages, patients with NF-1 must remain under doctor's attention in case of association with CMI. Our literature review showed that symptoms can vary and include headache, gait disturbance, and sensory/motor diminution, until asymptomatic patients. Moreover, the incidence of NF-1 is considerably higher in CMI patients in comparison to the global incidence (8.6-11.8% and 0.775%, respectively). The surgical technique must be evaluated case by case according to the degree of cerebrospinal fluid obstruction.

McCune-Albright syndrome with craniofacial dysplasia: Clinical review and surgical management.

BACKGROUND: Fibrous dysplasia (FD) is a benign fibro-osseous lesion related to an abnormal bone development and replacement by fibrous tissue. FD has three clinical patterns namely monostotic, polyostotic, and the McCune-Albright syndrome (MAS). MAS is a rare genetic disorder (about 3% of all FD's) that comprises a triad of polyostotic FD, café-au-lait skin macules, and precocious puberty. MAS can involve the orbit region and cause stenosis in the optic canal, leading the patient to a progressive visual loss. METHODS: We reported a case of craniofacial FD in MAS in a 9-year-old male with progressive visual loss, submitted to optic nerve decompression by fronto-orbito-zygomatic approach, with total recovery. A research was made at Bireme, PubMed, Cochrane, LILACS, and MEDLINE with the keywords: FD/craniofacial/McCune-Albright/Optic compression for the clinical review. RESULTS: A clinical review of the disease was made, the multiple, clinical, and surgical management options were presented, and the case report was reported. CONCLUSION: MAS is a rare disease with a progressive polyostotic FD. Whenever it affects the orbit region, the optic canal, and it is associated with a progressive visual loss, the urgent optic nerve decompression is mandatory, either manually or with a rapid drill. It is known that aggressive approach is associated with less recurrence; it is also associated with worsening of the visual loss in optic nerve decompression. In MAS cases, multiple and less aggressive surgeries seem to be more suitable.

Schwannomas of Peripheral Nerves: Unusual Cause of Sciatic and Literature Review / Schwanomas dos nervos periféricos: causa rara de ciatalgia e revisão da literatura

Schwannomas of peripheral nerves are the most common benign tumors in this location; it has specific radiologic and histologic features that enable its fundamental distinction of neurofibromas. Given its importance in neurosurgical practice, known radiologic and histologic criteria must be updated regarding this disease entity, as well as its therapeutic strategy and results obtained with it. This article reviews this subject, followed by a case report considered out of the ordinary, in which the tumor was located in the sciatic nerve in a patient with neurofibromatosis type 1, treated by microsurgical resection, which evolved favorably.

Os schwannomas dos nervos periféricos são os tumores benignos mais comuns nesta localização. Apresentam características radiológicas e histológicas específicas que possibilitam a sua fundamental distinção dos neurofibromas. Dada a sua importância na prática neurocirúrgica, devem ser conhecidos os critérios radiológicos e histológicos atualizados à respeito desta entidade nosológica, bem como sua estratégia terapêutica e o resultado com ela obtido. Neste artigo, é feita uma revisão do tema, seguido do relato de um caso considerado fora do habitual, no qual o tumor localizava-se no nervo ciático, em uma paciente portadora de neurofibromatose tipo 1, tratada por meio de ressecção microcirúrgica, que evoluiu de forma favorável.