Overt nickel and cobalt hypersensitivity after pipeline embolization device placement: A case report.

Nickel and cobalt are frequently found in metallic alloys used in the manufacture of aneurysm clips and endovascular prostheses, such as the pipeline embolization device (PED). Nickel hypersensitivity can affect up to 15% of the population, however, it is very rarely overt in patients who undergo endovascular stent placement. Here, we present the case of a 35-year-old woman who developed allergic symptoms after PED placement and was later confirmed to be allergic to both nickel and cobalt by patch testing. Fortunately, she responded well to pharmacologic treatment, rendering surgical intervention unnecessary. To the best of our knowledge, this is the first report of symptomatic nickel hypersensitivity, and the second report of symptomatic cobalt allergy caused by the PED. Despite its low prevalence, we believe that surgeons should actively inquire patients in the postoperative period about allergic symptoms, to facilitate early diagnosis and treatment.

Hydrocephalus Resolution with Third Ventriculostomy with Floor Stenting: Technical Note and Literature Review.

INTRODUCTION: The management of refractory obstructive hydrocephalus is a paramount neurosurgical challenge. The endoscopic third ventriculostomy (ETV) has been accepted as the procedure of choice for obstructive hydrocephalus, depending on the presence of certain risk factors, such as intracranial infections, young age, previous shunt failure and distorted anatomy of the ventricular floor, that predispose occlusion or obstruction of the CSF outflow through the stoma. CASE REPORT: A 20-year-old man with obstructive hydrocephalus due to primary aqueductal stenosis performed several neurosurgical procedures, including two previous ETV, without long term resolution. We performed another ETV, with stent placement at the stoma to prevent occlusion. After 25 months of asymptomatic follow-up, the patient presented with an enlarged fourth ventricle, and a new neuroendoscopic procedure showed a patent stoma and a well-placed stent. DISCUSSION: Stent placement on the third ventricular floor was already reported 19 times in the literature. Its success rate is about 94,7%, and complications happened in 2 cases, with functional impaired in only one of them. CONCLUSION: Third ventriculostomy with floor stenting proved to be an effective procedure in our case of complex hydrocephalus. It is a viable option in cases where there is a greater chance of stoma occlusion.

Bilateral Transverse Sinus Angioplasty for the Treatment of Idiopathic Intracranial Hypertension ­ Case Report and Literature Review

Idiopathic intracranial hypertension (IIH) is a disease characterized by an increase in intracranial pressure, without presence of parenchymal lesions or hydrocephalus that justify it. Over 90% of cases there is association with stenosis of the dural venous sinuses. It is characterized by headache, tinidus, nausea, vomiting and visual disturbances. Initial treatment is clinical and when it fails there is indication of invasive procedures, among them shunts and fenestration of the optic nerve sheath. Angioplasty of dural venous sinuses, when indicated, has shown an alternative with better results and less complications. We report a case of a female patient, with 27 years old, diagnosed with IIH and bilateral transverse sinus stenosis, which was treated by bilateral stenting and total resolution of symptoms. Besides describing the case we review the literature about the subject.

Arterial Embolization in the Treatment of Severe Epistaxis: A Case Report / Embolización Arterial en el Tratamiento de la Epistaxis Severa: Reporte de un Caso

ABSTRACT: Nasal hemorrhage or epistaxis is a common finding in the emergency department. The causes of epistaxis are varied and can be classified as local, systemic or a combination of both. The aim of this study was to report a case of embolization of branches of the maxillary artery for treatment of epistaxis secondary to facial trauma. A 43-year-old man suffered blunt trauma in the frontonasal area as a result of a bicycle accident. It presented with amnesia, severe epistaxis, panfacial edema and nasal deformity. The patient was hypotensive and hypothermic, with evidence of hemorrhagic intracranial. Orotracheal intubation was performed immediately to protect the airways and prevent aspiration of blood to the lower respiratory tract. The occlusion of the artery was successful and was immediately followed by cessation of oronasal bleeding. The patient was discharged after ten days. Arterial embolization should be the gold-standard treatment, which provides a safe and effective alternative for the control of epistaxis.

RESUMEN: La hemorragia nasal o epistaxis es un hallazgo común en el servicio de urgencias. Las causas de la epistaxis son variadas y pueden clasificarse como locales, sistémicas o una combinación. El objetivo de este estudio fuerelatar un caso de embolización de ramas de la arteria maxilar para el tratamiento de epistaxis secundaria a trauma facial. Um hombre de 43 años de edad sufrió traumatismo contuso en la zona frontonasal como consecuencia de un accidente de bicicleta. Se presentaba con amnesia, epistaxis grave, edema panfacial y deformidad nasal. El paciente fue hipotenso y hipotermático, con evidencia de hemorragia intracraneal. La intubación orotraqueal fue realizada inmediatamente para proteger las vías aéreas y evitar la aspiración de sangre para el tracto respiratorio inferior. La oclusión de la arteria fue exitosa y fue seguida inmediatamente por cesación de sangramiento oronasal. El paciente fue dado de alta después de diez días. La embolización arterial debe ser el tratamiento de elección, que proporciona una alternativa segura y eficaz para el control de la epistaxis.

Endovascular Neurosurgery in the Northern Macro-Region of Rio Grande do Sul: Part I

Introduction The city of Passo Fundo, in the north of the Rio Grande do Sul state, has been standing out in the health care field for many years. The state has become a reference in endovascular interventional neuroradiology. We will cover 10 years of experience in this area and divide our observations in 3 parts: cerebral angiograms (part I), carotid angioplasties (part II) and intracranial aneurysms (part III). The goal of part I is to statistically assess the cerebral angiograms, their indications, risks and complications, as well as to do a technical review. Materials and Methods A retrospective study from 2005 to 2015 with a total of 5,567 interventional neuroradiology procedures performed. A total of 4,114 angiograms, 639 embolizations of intracranial aneurysms, 414 carotid angioplasties, 143 embolizations of cerebral arteriovenous malformations, 32 embolizations of dural arteriovenous fistulas, 102 cerebral vasospasm treatments, 21 treatments of epistaxis, 36 embolizations of craniocervical tumor, 25 thrombolysis of ischemic stroke, 18 vertebroplasties and 13 embolizations of arteriovenous malformations of the face. Results A total of 4,084 procedures performed, 21,811 vessels studied, average vase 7.62/2.82 vessel and patient/procedure. Of these, 2,536 were diagnostic procedures and 1,548 angiographic controls. Of the total, 1,188 patients received only an angiogram, 27.14% of which were therapeutic procedures. We obtained a total of 3.89% complications: 2.33% reflection vasovagal, 0.56% allergic skin reaction, anaphylactic shock 0.07%, 0.27% femoral hematoma, 0.26% transient neurological deficit, 0.12% permanent neurological deficit and no case of death. Conclusion Cerebral angiography in adults, children and infants is a safe procedure with low risk of permanent neurological complications.

Cavernous Carotid Artery Giant Aneurysm: Case Report and Literature Review

The giant aneurysm of the cavernous internal carotid artery is an uncommon event. In the case of giant aneurysmal formation, the patient presents with some signs or symptoms, reported or observed on physical examination,which reveal a possiblemass effect with neurovascular compression of the aneurysm, or even a subarachnoid hemorrhage due to the rupture of the aneurysm. We report the case of a 69-year-old patient who was admitted to the emergency department, referred by the basic health unit (BHU) of her locality for neurosurgical evaluation after suffering a mild traumatic brain injury (TBI). The patient, who was asymptomatic, carried with her a tomographic computerized examination of the skull, performed one day after the incident, evidencing left nodular parasellar lesion involving the cavernous sinus, discovered at random. After more specific clinical, laboratory and imaging exams, she was diagnosed with a giant aneurysm of the cavernous segment of the left internal carotid artery (LICA) and was submitted to endovascular embolization for correction.

Spinal Neurocysticercosis: A Rare Variant of a Common Parasitic Infection

Neurocysticercosis is the most common parasitic infection affecting the central nervous system, usually involving the brain parenchyma, intracranial subarachnoid space, or ventricular system. In rare cases, there is involvement of the spine (vertebral, epidural, subdural, arachnoid, or intramedullary). Even in endemic regions, this variant is rare, with an incidence below 5% of all patients. The diagnosis is made based on the symptoms, which can be very unspecific, imaging and CSF analysis, with biopsy as a possibility. Treatment is usually curative, but important deficits can develop, due to compression of the spinal cord or nerve roots, arachnoiditis, or meningitis. We present the case of a patient who developed this entity, with poor clinical scenario, and review the literature on the topic.

Neurocisticercose é a infecção parasitária mais comum afetando o sistema nervoso central, geralmente envolvendo o parênquima cerebral, espaço subaracnóide intracraniano ou sistema ventricular. Em raros casos, há envolvimento da coluna vertebral, espaços epidural e subdural, aracnoide, ou intramedular. Mesmo em áreas endêmicas, esta variante é rara, com incidência abaixo de 5% entre todos os pacientes. O diagnóstico é feito com base nos sintomas, que podem ser bastante inespecíficos, neuroimagem e análise do líquor, sendo a biópsia uma possibilidade. O tratamento geralmente é curativo, porém importantes déficits podem se desenvolver, devido à compressão da medula espinhal ou raízes nervosas, aracnoidite ou meningite. Relatamos o caso de um paciente que desenvolveu esta entidade, com sintomatologia escassa, e revisamos a literatura sobre este tópico.

Number of coils necessary to treat cerebral aneurysms according to each size group: a study based on a series of 952 embolized aneurysms / Quantidade de molas necessárias para o tratamento endovascular dos aneurismas cerebrais de acordo com seu tamanho: estudo baseado em uma série de 952 aneurismas embolizados

OBJECTIVE: The Brazilian public health system determines a quantity of coils allowed to treat a cerebral aneurysm. The goal of this paper was to determine the number of coils necessary to treat an aneurysm based on size. METHODS: All patients harboring an aneurysm treated by endovascular approach between 1999 and 2003 were reviewed. RESULTS: There were 952 aneurysms included. Mean diameter sac was 8.2 mm with 7.9 coils per aneurysm. Out of 462 small aneurysms, mean size was 4.8 mm, with 4.6 coils/aneurysm used. A total of 315 medium aneurysms were treated, mean size was 8.6 mm, with 8.2 coils. Out of 135 large, mean size was 17 mm, with 16.1 coils. Forty giant aneurysms were treated with a mean size of 32 mm and 28.7 coils. CONCLUSIONS: We propose size as a reference to predict the number of coils necessary to treat each aneurysm: one coil for each millimeter of diameter.

OBJETIVO: O sistema público brasileiro determina uma quantidade limitada de molas permitida para o tratamento endovascular dos aneurismas cerebrais. O objetivo deste trabalho foi determinar a quantidade de molas necessária para tratar um aneurisma usando tamanho como referência. MÉTODO: Foram revisados todos os pacientes com aneurismas embolizados entre 1999 e 2003. RESULTADOS: No total, 952 aneurismas foram analisados. O diâmetro médio foi de 8,2 mm, com 7,9 molas usadas por aneurisma. Do total, 462 aneurismas eram pequenos, com tamanho médio de 4,8 mm e 4,6 molas/aneurisma. Foram tratados 315 aneurismas médios, com tamanho médio de 8,6 mm e 8,2 molas/aneurisma. Dentre os 135 aneurismas grandes, o tamanho foi de 17 mm, com 16,1 molas/aneurisma. Foram tratados 40 aneurismas gigantes, com média de 32 mm e 28,7 molas/aneurisma. CONCLUSÃO: Propomos que se utilize o tamanho do aneurisma como referência para prever o número de molas necessário para embolização: uma mola para cada milímetro de tamanho do saco aneurismático.

Ganglioglioma desmoplásico infantil: relato de dois casos / Desmoplastic infantile ganglioglioma: report of two cases

O ganglioglioma desmoplásico infantil (GDI) é um tumor raro, que pertence ao grupo dos tumores mistos neurogliais, descrito pela primeira vez por VandenBerg, em 1987: São tumores supratentoriais, volumosos, apresentando frequentemente envolvimento leptomeníngeo. O exame anatomopatológico evidencia intensa desmoplasia, com diferenciação astrocítica e ganglionar; bem como um teste imunoistoquímico apresenta resultado positivo para "glial fibrillary acidic protein" (GFAP). São relatados dois casos de GDI e discutidos os aspectos clínicos e terapêuticos dos referidos casos.