Pearls & Oy-sters: A Challenging Optic Neuropathy-What Not to Miss in Optic Nerve Sheath Enhancement.

Optic neuropathies include a wide range of disorders from ischemic, toxic, demyelinating, or inflammatory processes with acute/subacute onset to more gradual compressive or genetic etiologies. Accurate clinical history and multimodality optic nerve imaging including MRI and optical coherence tomography have greatly improved the diagnosis of patients with optic neuropathies. We report a case of a woman with severe monocular visual acuity deficit. Optic nerve sheath enhancement seen on MRI led to a broad differential diagnosis including demyelinating causes, optic nerve sheath meningioma (ONSM), tuberculosis, and sarcoid optic neuropathy. Lack of response to treatment with steroids or plasmapheresis led to biopsy, which confirmed the diagnosis of ONSM.

Multidisciplinary Approach to Spinal Metastases and Metastatic Spinal Cord Compression-A New Integrative Flowchart for Patient Management.

Metastatic spine disease (MSD) and metastatic spinal cord compression (MSCC) are major causes of permanent neurological damage and long-term disability for cancer patients. The development of MSD is pathophysiologically framed by a cooperative interaction between general mechanisms of bone growth and specific mechanisms of spinal metastases (SM) expansion. SM most commonly affects the thoracic spine, even though multiple segments may be affected concomitantly. The great majority of SM are extradural, while intradural-extramedullary and intramedullary metastases are less frequently seen. The management of patients with SM is particularly complex and challenging, with multiple factors-such as the spinal stability status, primary tumor radio and chemosensitivity, cancer biological burden, patient performance status and comorbidities, and patient's oncological prognosis-influencing the clinical decision-making process. Different frameworks were developed in order to systematize and support this process. A multidisciplinary, personalized approach, enriched by the expertise of each involved specialty, is crucial. We reviewed the most recent evidence and proposed an updated algorithmic approach to patients with MSD according to the clinical scenario of each patient. A flowchart-based approach offers an evidence-based management of MSD, providing a valuable clinical decision tool in a context of high uncertainty and quick-acting need.

Extradural thoracic nerve root hemangioblastoma approached by a combined posterior thoracic spine and video-assisted thoracoscopic surgery: A case report.

BACKGROUND: Hemangioblastomas commonly occur in the posterior fossa and are typically attributed to sporadic or familial Von Hippel-Lindau disease. Spinal hemangioblastomas, found in 7-10% of patients, are usually located within the cord (i.e., intramedullary). Here, a 58-year-old male presented with a purely extradural hemangioblastoma involving a spinal root that was surgically excised. CASE DESCRIPTION: A 58-year-old male was admitted with a progressive paraparesis and incomplete sensory deficit. The magnetic resonance imaging documented a solid dumbbell-shaped lesion that extended through the left T3-T4 foramen resulting in nerve root and spinal cord compression. Following arterial embolization and lesion excision by both neurosurgeons and thoracic surgeons, the patient's deficits improved. The postoperative computed tomography scan documented complete tumor removal, and the neuropathology revealed a hemangioblastoma. CONCLUSION: Here, we describe a 58-year-old male with a purely extradural thoracic foraminal T3-T4 dumbbell-shaped hemangioblastoma successfully treated by both embolization and surgical excision.

HIPTCN: Prospective Observational Study of Hypocoagulated Head Trauma Patients with Normal Admission Computed Tomography Scan.

INTRODUCTION: Our national protocol for traumatic brain injury dictates that hypocoagulated patients with mild trauma and initial tomography scan with no intracranial traumatic changes must be hospitalized for 24 hours and do a post-surveillance tomography scan. The main goal of this study was to evaluate the clinical relevance of these measures. MATERIAL AND METHODS: A prospective observational study was undertaken in four hospitals. Adult hypocoagulated traumatic brain injury patients with a normal tomography scan were included. The main outcomes evaluated were rate of delayed intracranial hemorrhage, rate of admission in a neurosurgical department, rate of complications related with surveillance and rate of prolonged hospitalization due to complications. An analysis combining data from a previously published report was also done. RESULTS: A total of 178 patients were included. Four patients (2.3%) had a delayed hemorrhage and three (1.7%) were hospitalized in a neurosurgery ward. No cases of symptomatic hemorrhage were identified. No surgery was needed, and all patients had their anticoagulation stopped. Complications during surveillance were reported in seven patients (3.9%), of which two required prolonged hospitalization. DISCUSSION: The rate of complications related with surveillance was higher than the rate of delayed hemorrhages. The initial period of in-hospital surveillance did not convey any advantage since the management of patients was never dictated by neurological changes. Post-surveillance tomography played a role in deciding about anticoagulation suspension and prolongation of hospitalization. CONCLUSION: Delayed hemorrhage is a rare event and the need for surgery even rarer. The need for in-hospital surveillance should be reassessed.

Introdução: O nosso protocolo nacional para traumatismos cranioencefálicos recomenda que doentes hipocoagulados com trauma craniano ligeiro e tomografia inicial sem alterações traumáticas intracranianas sejam hospitalizados 24 horas e façam uma tomografia computorizada pós-vigilância. O principal objetivo deste estudo foi avaliar a relevância clínica dessas medidas. Material e Métodos: Foi realizado em quatro hospitais um estudo prospetivo e observacional. Foram incluídos adultos hipocoagulados com trauma craniano e tomografia normal. Os principais outcomes avaliados foram: taxa de hemorragia intracraniana tardia, taxa de internamento numa enfermaria de neurocirurgia, taxa de complicações relacionadas com a vigilância e taxa de hospitalização prolongada por complicações. Resultados: Foram incluídos um total de 178 doentes. Quatro doentes (2,3%) apresentaram hemorragia tardia e três (1,7%) foram mantidos hospitalizados numa enfermaria de Neurocirurgia. Não foram documentados casos de hemorragia tardia sintomática. Nenhuma cirurgia foi necessária e em todos estes doentes a anticoagulação foi interrompida. Durante a vigilância, foram relatadas complicações em sete doentes (3,9%), dos quais dois exigiram hospitalização prolongada. Discussão: A taxa de complicações relacionadas com a vigilância foi maior do que a taxa de hemorragia tardia. O período inicial de vigilância intra-hospitalar não trouxe qualquer vantagem, já que o manejo dos doentes nunca foi ditado por alterações neurológicas. A tomografia pós-vigilância desempenhou um papel importante na decisão sobre a suspensão da anticoagulação e o prolongamento da hospitalização. Conclusão: A hemorragia tardia é um evento raro e a necessidade de cirurgia ainda mais. Deve ser reavaliada a necessidade de vigilância intra-hospitalar.

Acute Subdural Hematoma Evacuation: Predictive Factors of Outcome.

BACKGROUND: Acute subdural hematoma (aSDH) is a major cause of admission at Neurosurgical Emergency Department. Nevertheless, concerns regarding surgical indication in patients with multiple comorbidities, poor neurological status, antithrombotic therapy, and older age still persist. Therefore, a correct recognition of predictive outcome factors at hospital discharge is crucial to an appropriate neurosurgical treatment. METHODS: Eighty-nine medical records of consecutive patients with age ≥18 years old who were submitted to aSDH evacuation between January 2008 and May 2012 were reviewed. Demographic characteristics, neurological status on admission, anticoagulant or antiplatelet therapy, and outcome on discharge were collected. Patients with insufficient data concerning these variables were excluded from the study. RESULTS: Sixty-nine patients were included; 52% were male; 74% were older than 65 years; 41% were under oral antithrombotic therapy (OAT); at admission, 54% presented with Glasgow coma scale (GCS) ≤8; 23% were submitted to a craniectomy instead of a craniotomy; 26% of the patients died, 32% were dependent, and 42% were independent on discharge. Crude analysis revealed craniectomy, A/A pupils, GCS ≤8 at admission statistically significant related with the worst outcome (P < 0.05). In the adjusted evaluation only A/A pupils (P = 0.04) was associated to poor outcome (spontaneous etiology P = 0.052). Considering daily living independency at hospital discharge, either male gender (P = 0.044) and A/A pupils (P = 0.030) were related to the worst outcome. No effect of age in outcome was observed. CONCLUSIONS: Male gender and A/A pupils are associated with lower probability of achieving independency living at hospital discharge. A/A pupils, low GCS at admission, spontaneous etiology, and craniectomy were associated with the worst outcome. Age and OAT were not predictive factors in this series. Caution should be taken when considering these factors in the surgical decision.

[Intratechal Chemotherapy Treatment Through an Ommaya Reservoir Catheter for Meningeal Carcinomatosis: A Single-Centre Experience]. / Tratamento de Carcinomatose Meníngea por Quimioterapia Intratecal Através de Catéter Reservatório de Ommaya: Experiência de um Centro Neurocirúrgico.

INTRODUCTION: Meningeal carcinomatosis is defined as tumour cells infiltration of leptomeninges and subarachnoid space. It is normally related with poor survival (2 - 5 months). The best multidisciplinary treatment for this condition is a matter of discussion. Patient's condition and the natural history of the disease should be considered in the decision making process. MATERIAL AND METHODS: Retrospective cohort analysis of patients submitted to Ommaya Reservoir placement due to systemic solid tumour meningeal carcinomatosis between 2006 and 2014. RESULTS: Twenty three patients were included (19 females, four males) with median age of 56.1 ± 2.2 years. The primary tumour was: breast - 16 patients, lung - four patients, stomach, bladder and cervix - one patient each. No complications were seen (infection, intracranial haematoma or CSF fistula). The median survival was 26.4 ± 7.7 weeks, range between nine days and 118 weeks (21/23 patients). Male gender was related to poor prognosis in crude analysis (p value = 0.0032). Breast adenocarcinoma was related with better prognosis in adjust analysis (p value = 0.036, HR: 4.36 ± 3.06; 95% IC: 1.10 - 17.25). Longer time between initial tumour and meningeal carcinomatosis diagnosis was related to a better outcome but without statistical significance. DISCUSSION: Despite the low complication rate of Ommaya reservoir placement, the poor response to chemotherapy and the disease prognosis should be considered in patients with poor functional status. The relationship observed between the primary tumour and the overall survival supports that meningeal carcinomatosis should not be considered a disease by itself but always in the context of a systemic disease. The low incidence of breast cancer in male population might be related with it poorer prognosis. CONCLUSION: Meningeal carcinomatosis has a poor prognosis. Breast adenocarcinoma, longer time between initial tumour and meningeal carcinomatosis diagnosis, and age < 60 years were related with longer survival.

Introdução: A carcinomatose meníngea consiste na infiltração de células tumorais ao longo das leptomeninges e espaço subaracnoideu, encontrando-se associada a uma sobrevida média de 2 - 5 meses. As indicações sobre a modalidade mais adequada de tratamento permanecem tema de discussão, sendo fundamental um correto conhecimento da história natural da doença e da dualidade risco-benefício para uma decisão terapêutica interdisciplinar.Material e Métodos: Análise retrospectiva dos doentes com diagnóstico de carcinomatose meníngea com origem em tumores sólidos submetidos a colocação de catéter reservatório de Ommaya no período entre 2006 a 2014 no Serviço de Neurocirurgia do Hospital Santa Maria.Resultados: Foram operados 23 doentes com carcinomatose meníngea (19 mulheres, quatro homens) com idade média de 56,1 ± 2,2 anos. A origem do tumor primário foi: mama ­ 16 doentes, pulmão ­ quatro doentes, estômago, bexiga e colo do útero ­ um doente cada. Não se verificaram complicações tais como infecção, hematomas intracranianos ou fístula de líquor. A sobrevida média dos 21 doentes falecidos à data foi de 26,4 ± 7,7 semanas (mínimo nove dias, máximo 118 semanas). A análise estatística não ajustada revelou que o sexo masculino esteve associado a pior prognóstico (p value = 0,0032), enquanto a análise ajustada mostrou que a origem na mama esteve associada a melhor prognóstico (p value = 0,036) quando comparada com as outras etiologias (HR: 4,36 ± 3,06; 95% IC: 1,10 - 17,25). Um maior tempo de evolução de doença primária até ao diagnóstico esteve associado a melhor prognóstico, apesar de não ter atingido significado estatístico.Discussão: Apesar da colocação de catéter reservatório de Ommaya ser um procedimento com baixo risco de complicações, a resposta à quimioterapia intratecal é limitada e o prognóstico da doença poderá não justificar um procedimento cirúrgico num doente com mau estado funcional. A relação da sobrevida global com a origem do tumor primário sugere que o prognóstico da carcinomatose meníngea deve ser considerado no contexto da doença sistémica e não como uma doença isolada. O pior prognóstico do sexo masculino pode justificar-se pela menor incidência do tumor da mama neste género.Conclusão: A carcinomatose meníngea está associada a um mau prognóstico. Origem primária na mama, maior tempo de evolução de doença primária e idade < 60 anos estiveram associados a sobrevida mais longa.

Orbital lymphangiomas: surgical treatment and clinical outcomes.

BACKGROUND: Orbital lymphangiomas (OL) are rare benign lesions that represent less than 4% of all space-occupying orbital lesions. Total surgical resection is usually difficult because of its infiltrative nature. Our objective was to analyze the indications for surgical treatment, the selection of surgical approach, and the clinical outcome after surgical treatment of OL. METHODS: Five patients with OL who were surgically treated between January 2003 and December 2009 were included. Clinical, surgical, and follow-up data were retrospectively analyzed. RESULTS: Mean age was 32 years, with two patients treated when they were adults. Proptosis was present in all patients, and the mean duration of symptoms was 9.4 years. Two patients had clinically relevant hemorrhagic episodes. Three patients presenting with large retrobulbar tumors were submitted to the pterional approach with superolateral orbitotomy; in one patient, a lateral approach was used and in another an anterior superomedial approach was used. In all cases a subtotal removal was achieved. There was no permanent morbidity. With a mean follow-up of 3.2 years, no patient presented new hemorrhagic episodes or tumor recurrence. CONCLUSION: Subtotal resection of OL is an effective and safe treatment option, may prevent new hemorrhagic episodes, and is not associated with a high recurrence rate after a relatively short-term follow-up. Progressive proptosis, visual or oculomotor impairment, and repeated symptomatic hemorrhagic episodes are considered indications for surgery. Transcranial access should be performed in large tumors extending posteriorly.

Sphenoid Wing en plaque meningiomas: Surgical results and recurrence rates.

BACKGROUND: Sphenoid wing en plaque meningiomas are a subgroup of meningiomas defined by its particular sheet-like dural involvement and its disproportionately large bone hyperostosis. En plaque meningiomas represent 2-9% of all meningiomas and they are mainly located in the sphenoid wing. Total surgical resection is difficult and therefore these tumors have high recurrence rates. METHODS: Eighteen patients with sphenoid wing en plaque meningiomas surgically treated between January 1998 and December 2008 were included. Clinical, surgical, and follow-up data were retrospectively analyzed. RESULTS: Mean age was 52.2 years and 83% were female. Five patients presented extension of dural component into the orbit and six patients presented cavernous sinus infiltration. Adjuvant radiation therapy was performed in three patients. After a mean follow-up of 4.6 years, five patients developed tumor recurrence - two patients were submitted to surgical treatment and the other three were submitted to radiation therapy. No patient presented recurrence after radiation therapy, whether performed immediately in the postoperative period or performed after recurrence. Patients without tumor extension to cavernous sinus or orbital cavity have the best prognosis treated with surgery alone. When tumor extension involves these locations the recurrence rate is high, especially in cases not submitted to adjuvant radiation therapy. CONCLUSION: Cavernous sinus and superior orbital fissure involvement are frequent and should be considered surgical limits. Postoperative radiation therapy is indicated in cases with residual tumor in these locations.