Transcranial Doppler as a routine in the treatment of vasospasm following subarachanoid hemorrhage (SAH).

BACKGROUND: Vasospasm is an important complication observed after subarachnoid hemorrhage (SAH) and is a frequent cause of mortality and morbidity. We present our routine management of vasospasm after SAH and emphasize the importance of transcranial Doppler (TCD) ultrasonography in this management. METHOD: Historical records and images were sampled from June 2005 to September 2011 for 110 patients with SAH due to ruptured aneurysm in the anterior circulation. All surviving patients were followed after discharge. Vasospasm was defined as mild (Lindegaard index 3-4), moderate (Lindegaard index 4-5), and severe (Lindegaard index greater than 5). We excluded patients treated after 72 h of symptom onset. TCD was performed twice per day. FINDINGS: Ninety-nine patients had surgical clipping of the aneurysm, and 11 had endovascular treatment. Seventy patients treated by clipping and six treated by endovascular procedure had vasospasm. Of the 70 clipped patients with vasospasm, 40 had mild vasospasm, 13 had moderate vasospasm, and 17 had severe vasospasm. All six patients treated by coils had moderate vasospasm. The average duration of vasospasm was 9 days (from 7 to 32 days). CONCLUSIONS: TCD was crucial for monitoring patients with SAH, and to identify which patients will have a higher risk of developing vasospasm.

Removal of clots in subarachnoid space could reduce the vasospasm after subarachnoid hemorrhage.

BACKGROUND: Cerebral vasospasm after subarachnoid hemorrhage (SAH) is a major cause of morbidity and mortality. We studied the effects of clot removal on multiple outcome variables following the clipping of ruptured anterior communicating aneurysms. METHODS: From 2007 to 2011, 30 patients with Fisher grade III aneurysmal SAH underwent clipping of an anterior communicating artery aneurysm before SAH day 3. There were 20 women and 10 men, mean age 53.4, range 28-80 years. Seventeen underwent fenestration of lamina terminalis and cisternal removal of clots (group A), and 13 did not (Group B). We compared clinical grades, presence of hydrocephalus at admission, treatment modality, occurrence of clinical vasospasm, the need for interventional vasospasm therapy, and need for ventriculoperitoneal shunting. FINDINGS: Vasospasm affected 5 of 17 (29%) in group A and 8 of 13 (61.5%) in group B (p < 0.05). Endovascular treatment for vasospasm was required in one patient in group A (5.8% of 17, 20% of 5) and in five from group B (38.4% of 13, 62.5% of 8) (p < 0.05). Mortality was observed in one case in group A (5.8% of 17, 20% of 5) and in two cases in group B (15.3% of 13, 25% of 8) and was related to vasospasm after SAH. Ventriculoperitonal shunt (VPS) was required in one case in group A (5.8%) and in five cases in group B (38.4%). CONCLUSIONS: Fenestration of the lamina terminalis and removal of cisternal clots significantly decreased the incidence of post-SAH hydrocephalus and was associated with better outcomes in our series.

Clinical neurofunctional rehabilitation of a cat with spinal cord injury after hemilaminectomy and autologous stem cell transplantation.

Stem cell-based therapy has been investigated in a number of degenerative and traumatic diseases, including spinal cord injury. In the present study, we investigated the use of autologous mesenchymal stem cells in the functional rehabilitation of a domestic cat presenting a compressive L1-L5 fracture. Bone marrow cells collected by puncture of the iliac crest were cultured to obtain mesenchymal stem cells three weeks before surgery. Hemilaminectomy was performed, followed by injection of the mesenchymal stem cells in the injured area. Clinical evaluation of the animal prior to surgery showed absence of pain, muscular tonus, and panniculi reflexes. Seven days after surgery and cell transplantation the examination revealed a progressive recovery of the panniculus reflexes and of the responses to superficial and deep pain stimuli despite the low proprioceptive and hyperreflexic ataxic hind limbs. Physiotherapy protocols were applied for clinical rehabilitation after surgery. The cat's first steps, three-minute weight-bearing, and intestine and urinary bladder partial reestablishment were observed 75 days post-surgery. Our results indicate the therapeutic potential of mesenchymal stem cells in chronic spinal cord injuries.

Pseudoaneurisma carotídeo secundario a cirugía transesfenoidal tratado exitosamente mediante oclusión carotídea con balón de Fogarty / Carotid pseudoaneurysm artery alter transsphenoidal surgery successfully treated with carotid oclusion with Fogarty balloon

Objetivo. Presentar un caso de pseudoaneurisma de carótida después de una cirugía transesfenoidal. Descripción. Paciente portadora de enfermedad de Cushing, previamente operada en tres oportunidades sin resultados favorables. Cuatro semanas después de la cuarta operación en que se logró finalmente resecar el adenoma, fue internada por presentar una hemorragia cataclísmica. Intervención. Se intentó sin éxito un procedimiento endovascular, por lo que como último recurso, se le insertó un balón Fogarty por arteriotomía cervical ocluyendo el seudoaneurisma en la carótida intracavernosa. La paciente se recuperó sin déficit neurológico. Este caso es el primero en la literatura tratado con balón Fogarty para este propósito. Se discuten las principales complicaciones vasculares de la cirugía transesfenoidal como la hipótesis de la eventual cura de la enfermedad de Cushing en este caso.

The authors presented a case of carotid pseudoaneurysm artery after transsphenoidal surgery in a female patient harboring Cushing disease, previously operated 3 times without endocrinological success. After a severe bleeding she was submittedendovascular procedures without results, and dramatically a Fogarty balloon was inserted by arteriotomy in the neck occluding the segment of pseudoaneurysm in intra-cavernous carotid artery, The patient recovered without neurological deficit. Thisrepresents the first case in literature treated with Fogarty balloon for this purpose. The characteristics of the main vascular complications are discussed as well as the hypothesis for the eventual cure of the Cushing disease in this case with a long term follow up. The association between micro-adenomas mainly Cushing are related to be associated with pseudo-aneurysmof carotid artery after transsphenoidal surgery.

Evaluation of Onyx HD-500 embolic system in the treatment of 84 wide-neck intracranial aneurysms.

OBJECTIVE: We report our results using Onyx HD-500 (Micro Therapeutics, Inc., Irvine, CA) in the endovascular treatment of wide-neck intracranial aneurysms, which have a high rate of incomplete occlusion and recanalization with platinum coils. METHODS: Sixty-nine patients with 84 aneurysms were treated. Most of the aneurysms were located in the anterior circulation (80 of 84 aneurysms), were unruptured (74 of 84 aneurysms), and were incidental. Ten presented with subarachnoid hemorrhage, and 15 were symptomatic. All aneurysms had wide necks (neck >4 mm and/or dome-to-neck ratio <1.5). Fifty aneurysms were small (<12 mm), 30 were large (12 to <25 mm) and 4 were giant. Angiographic follow-up was available for 65 of the 84 aneurysms at 6 months, for 31 of the 84 aneurysms at 18 months, and for 5 of the 84 aneurysms at 36 months. RESULTS: Complete aneurysm occlusion was seen in 65.5% of aneurysms on immediate control, in 84.6% at 6 months, and in 90.3% at 18 months. The rates of complete occlusion were 74%, 95.1%, and 95.2% for small aneurysms and 53.3%, 70%, and 80% for large aneurysms at the same follow-up periods. Progression from incomplete to complete occlusion was seen in 68.2% of all aneurysms, with a higher percentage in small aneurysms (90.9%). Aneurysm recanalization was observed in 3 patients (4.6%), with retreatment in 2 patients (3.3%). Procedural mortality was 2.9%. Overall morbidity was 7.2%. CONCLUSION: Onyx embolization of intracranial wide-neck aneurysms is safe and effective. Morbidity and mortality rates are similar to those of other current endovascular techniques. Larger samples and longer follow-up periods are necessary.

Critérios de malignidade em meningiomas / Malignant meningiomas. Clinical, laboratorial and radiological patterns

Os autores discutem os padrões radiológicos, molecularese clínicos dos meningiomas malignos e suas diferenças emrelação aos meningiomas benignos. É realizada também umarevisão da atual literatura, com maior atenção aos parâmetrosindicativos de malignidade dos meningiomas e sua relaçãocom as taxas de recidiva e prognóstico. Meningiomas malignossão atualmente um tópico controverso pela falta de parâmetroshistológicos aceitos universalmente como critério demalignidade. A ressecção total pode ser curativa, porém nemsempre é possível tal tratamento, seja pela localizaçãoanatômica do tumor, seja pela alta morbidade associada àressecção agressiva, devendo-se considerar, nestes casos, asterapias adjuvantes como a quimioterapia, radioterapia e aradiocirurgia. Em relação à localização anatômica, osmeningiomas malignos ou de alto índice de proliferação debase de crânio têm pior prognóstico e, na maioria das vezes,não são ressecados em sua totalidade.

p53 Protein expression in meningiomas - a clinicopathologic study of 55 patients.

Formalin-fixed, paraffin-embedded surgical specimens from 55 meningiomas were immunostained with monoclonal antibody against p53 (Immunotech, Marseilles, France). There were 38 women and 17 men ranging between 9 and 82 years of age. The patients were divided into two groups: group I (47 patients) - mildly symptomatic and group II (eight patients) - severe initial symptoms. There were 43 WHO grade I, 11 WHO grade II, and one WHO grade III meningiomas according to the 1999 WHO classification of brain tumors. In group A (n=49), the tumors were attached to the dura mater of the skull base, and in group B (n=6) they were not. Tumor volume ranged from 1.23 cm(3) to 303.37 cm(3). Peritumoral edema was classified into three grades: grade 0 (n=28) no or minimum edema, grade I (n=19) edema reaches at least half of one cerebral hemisphere, and grade II (n=8) holohemispheric edema. Immunostaining for p53 was found in the neuronal nuclei of 18 meningiomas. It was not correlated with gender, age, anatomical location, tumor volume, degree of peritumoral edema, or Simpson's resection grade. Labeling for p53 was observed in 9/12 meningiomas of WHO grades II or III and was correlated with severity of symptoms (P=0.033) and histological grade (P=0.0009). Immunolocalization of p53 was not correlated with the degree of malignancy.

Preservation of the olfactory tract in bifrontal craniotomy.

The bifrontal craniotomy approach used to be associated with a high percentage of olfactory tract damage. We present our experience with this technique, that was used with excellent results in a series of 11 patients that underwent the surgical approach described in this paper. We support the idea that bilateral subfrontal craniotomy allows a wide operative exposure as well as the complete anatomic and functional preservation of the olfactory tracts bilaterally.

Preservation of the olfactory tract in bifrontal craniotomy

The bifrontal craniotomy approach used to be associated with a high percentage of olfactory tract damage. We present our experience with this technique, that was used with excellent results in a series of 11 patients that underwent the surgical approach described in this paper. We support the idea that bilateral subfrontal craniotomy allows a wide operative exposure as well as the complete anatomic and functional preservation of the olfactory tracts bilaterally

Abscesso cerebelar por nocardia: relato de caso / Cerebellar abscess by Nocardia: a case report

A nocardiose do sistema nervoso central tem alcançado importante destaque no diagnóstico diferencial de patologias tumorais nos últimos anos pelo aumento da incidência de pacientes imunodeficiêntes (pacientes submetidos a quimioterapia, transplante de órgäos ou com a síndrome de imunodeficiência adquirida - SIDA. Os autores descrevem o caso de um paciente com SIDA que desenvolveu nocardiose cerebelar na sua forma tumoral. O paciente foi submetido a craniectomia de fossa posterior para diagnóstico e tratamento. Os achados de neuroimagem e patológicos bem como a conduta cirúrgica säo discutidos com base em revisäo da literatura

Métodos de estudo do potencial proliferativo das neoplasias primárias do sistema nervoso central: valor prognóstico e implicaçäo terapêutica / Methods of study of the proliferative potencial of primary neoplasms of the central nervous system

Os autores fazem uma revisäo dos conceitos atuais da metodologia empregada na determinaçäo do potencial proliferativo (LI) das neoplasias primárias do sistema nervoso central (SNC). A sua implicaçäo terapêutica e prognóstica é avaliada com base na experiência do serviço e através de revisäo da literatura

Síndrome de Turcot: relato de dois casos / Turcot syndrome: report of 2 cases

Os autores descrevem dois pacientes com associaçäo de polipose intestinal e tumor do sistema nervoso central (síndrome de Turcot), discutindo aspectos clínicos, genéticos e terapêuticos