Magnesium sulfate: role as possible attenuating factor in vasospasm morbidity.

BACKGROUND: Among the many complications of SAH, one of the most important is vasospasm. Several treatment alternatives have been proposed for this condition, with far-from-ideal results being obtained. Magnesium sulfate recently returned to the scene (with still unproven benefit) as an adjuvant in the treatment of vasospasm. METHODS: Seventy-two patients diagnosed with SAH by aneurysm rupture were submitted to microsurgery craniotomy and subdivided in 2 groups. Group 1, formed by 48 patients, received prophylactic hypervolemic and hemodilution therapy in addition to nimodipine. Group 2, composed of 24 patients, received the same treatment of group 1 with the addition of magnesium sulfate in continuous infusion from 120 to 150 mg a day, keeping serum magnesium levels close to double normal values. RESULTS: Age was 49 +/- 12.6 years. Ratio of female to male was 3.16:1. Most patients were admitted in a Hunt-Hess grade 2 (46.4%) and Fisher grade 3 (52.8%). Anterior communicating artery aneurysms were the most common in location (38.8%). Both groups were compared, and there was no statistical difference related to age, sex, and Glasgow, Fisher, or Hunt-Hess admission grades. No statistical difference in vasospasm incidence was found between the two groups. However, in group 1, vasospasm was correlated with a longer hospitalization time (P = .0003), different from group 2, in which patients with vasospasm receiving magnesium sulfate required less hospitalization time. CONCLUSION: Magnesium did not seem to interfere in vasospasm frequency but apparently acted favorably in decreasing morbidity and length of hospital stay.

Cerebral metastasis of cervical uterine cancer: report of three cases.

Cervical uterine cancer (CUC) spreads locally (pelvis and paraortic lymphnodes) or distantly (lungs, liver and bones). Metastasis to central nervous system (CNS) are rare. There are about 80 cases reported in the literature. Outcome is poor and survival varies from 3 to 6 months. Three cases of CNS metastasis from CUC are reported, one infratentorial and two supratentorials in location. In one patient, the initial manifestation was due to the cerebral lesion, a feature reported for the first time. All cases were treated by surgery, radiotherapy and/or chemotherapy. Clinical findings and treatment options of these rare lesions are reviewed.

Anterior temporal lobectomy versus selective amygdalohippocampectomy in patients with mesial temporal lobe epilepsy.

OBJECTIVE: To contribute our experience with surgical treatment of patients with mesial temporal lobe epilepsy (mTLE) undergoing anterior temporal lobectomy (ATL) or selective amygdalohippocampectomy (SelAH). METHOD: This is a retrospective observational study. The sample included patients with medically refractory mTLE due to unilateral mesial temporal sclerosis who underwent either ATL or SelAH, at Hospital de Clinicas - UFPR, from 2005 to 2012. We report seizure outcomes, using Engel classification, cognitive outcomes, using measurements of verbal and visuospatial memories, as well as operative complications. RESULT: Sixty-seven patients (33 ATL, 34 SelAH) were studied; median follow-up was 64 months. There was no statistically significant difference in seizure or neuropsychological outcomes, although verbal memory was more negatively affected in ATL operations on patients' dominant hemispheres. Higher number of major complications was observed in the ATL group (p = 0.004). CONCLUSION: Seizure and neuropsychological outcomes did not differ. ATL appeared to be associated with higher risk of complications.

Raeder's syndrome after embolization of a giant intracavernous carotid artery aneurysm: pathophysiological considerations.

We present the case of a 47 years old woman submitted to an endovascular trapping of a left cavernous internal carotid artery aneurysm, in which the distal balloon was inflated, as usually done, within the cavernous segment of the internal carotid artery, different from the proximal one which was inflated inside the carotid canal due to technical problems. Consequently, a clinical picture of Raeder's paratrigeminal neuralgia took place. This is the first case report in the literature with theses characteristics. A review of the anatomic pathways and further considerations about the possible pathophysiological mechanisms involved are presented.

Ventral extradural spinal meningeal cyst causing cord compression: neurosurgical treatment.

Spinal extradural meningeal cysts are typically formed by a thin fibrotic membranous capsule, macroscopically similar that of an arachnoid membrane, filled by cerebro spinal fluid and related to a nerve root or to the posterior midline. Ventral location is extremely rare and when it occurs they usually cause spinal cord herniation through the ventral dural gap. A 61 year-old man who began with a two years long history of insidious tetraparesis, spasticity and hyperreflexia in lower extremities, and flaccid atrophy of upper limbs, without sensory manifestations, is presented. Investigation through magnetic resonance imaging demonstrated an extensive spinal ventral extradural cystic collection from C6 to T11. The lesion was approached through a laminectomy and a cyst-peritoneal shunt was introduced. The cyst reduced in size significantly and the patient is asymptomatic over a 48 months follow-up. This is the first reported case of a spontaneous ventral extradural spinal meningeal cyst causing cord compression. Cyst-peritoneal shunt was effective in the treatment of the case and it should be considered in cases in which complete resection of the cyst is made more difficult or risky by the need of more aggressive surgical maneuvers.

Cerebrospinal Fluid Infection with External Ventricular Drainage: Analysis of the Risk Factors in 110 Patients of a Single Institution

Objectives External ventricular drainage (EVD) is extensively used in the neurosurgical practice with the purpose of monitoring the intracranial pressure and draining the cerebrospinal fluid (CSF). Despite its remarkable benefits, the technique is not devoid of risks, notably infections, which have been reported in up to 45% of the cases. Methods A retrospective analysis of the main risk factors for CSF infection in neurosurgical patients submitted to EVD at a single institution. We recorded and submitted to statistical comparison every risk factor for CSF infection present or absent in each of the 110 EVD patients enrolled, 53 males and 57 females, with an average age of 52.9 years, with different underlying neurosurgical conditions. Results Infection of the CSF occurred in 32 patients (29%). The rate of mortality related to CSF infection was of 18.7% (6 of 32). The risk factors that showed statistical significance for CSF infection in this series were: emergency surgery; length of stay at the intensive care unit (UCI); duration of the EVD; parenchymal and/or intraventricular hemorrhage; simultaneous infections; time of bladder catheterization; and the use of non-disposable adhesive drapes as part of the preparation of the wound area. Conclusions Infection of the CSF in patients submitted to EVD is multifactorial and a challenge in terms of prevention. Further studies proposing scores with blended risk factors may be useful to prevent and reduce the morbidity and mortality associated with CSF infection.

Primary pituitary abscess: case report.

Pituitary abscesses are potentially life-threatening lesions if not appropriately diagnosed and treated. The authors have operated on more than five hundred cases of pituitary tumors and only one represented a case of pituitary abscess. A 35-year-old woman was investigated for chronic frontal headache. CT scan showed a cystic sellar lesion with ring enhancement after contrast injection leading to an initial diagnosis of pituitary adenoma. She underwent a sublabial transsphenoidal approach to the pituitary gland. After dural opening, purulent material was obtained and no tumor or other associated lesion was detected. There was no evidence of current or previous septicemic illness, meningitis, cavernous sinus thrombosis or sinus infection. Cultures were negative. She was put on antibiotics and discharged after 4 weeks. Nowadays, 10 years after treatment, she is doing well, with no anterior pituitary hormone deficit. MRI shows a partially empty sella without residual lesion and the pituitary stalck is in the midline. The early diagnosis and adequate treatment of this life-threatening lesion may result in excellent prognosis.

[Prognostic factors in the treatment of intramedullary spinal cord tumors]. / Fatores prognósticos no tratamento dos tumores intramedulares.

Between 1993 and 1999, in the Divisions of Neurosurgery of the Hospital Nossa Senhora das Graças and the Hospital de Clínicas in Curitiba, Paraná, Brazil, 35 patients harboring intramedullary spinal cord tumors who were submitted to microsurgery were analyzed. There were 24 males (68.6%) and average age was 32.9 years. The main location, with 40% of cases, was the thoracic level, followed by cervical and cervico-thoracic levels with 25.7%. Neurological exam, carried out between 6 and 12 months after surgery, showed that 42.9% of patients improved, 34.3% were stable and 22.9% presented neurological worsening. Total resection was obtained in 57.2% of cases and subtotal in 37.1%. In 5.7% of patients a biopsy was the accomplished procedure. Total resection was more often obtained among patients with ependymomas (13 out of 17) than with astrocytomas (5 out of 12). However, degree of resection and tumor histology did not interfere in postoperative morbidity. Factors as sex, age and tumor's size also did not demonstrate significance in predicting prognostic after surgery, whereas tumor in a thoracic level was associated with higher morbidity (p=0.021).

[Central nervous system granulocytic sarcoma after bone marrow transplant: case report]. / Sarcoma granulocítico de sistema nervoso central pós transplante de medula óssea: relato de caso.

Granulocytic sarcoma is a solid tumor, composed by granulocytic precursor cells at various levels of differentiation, located at an extra-medullary site. It is associated with acute myeloid leukemia, and its presence reveals a bad prognostic factor. The treatment usually consists of radiotherapy and chemotherapy. A case of an intracranial granulocytic sarcoma occurring six months after a bone marrow transplant in a patient with acute myeloid leukemia is reported. The patient presented with headache and left hemiplegia caused by a large fronto-parietal lesion with significant mass effect. After a complete surgical resection there was a full recovery of the deficit. The patient completed radiotherapy and chemotherapy with no evidence of disease after three months of follow-up. Surgery is indicated in the presence of progressive neurological deficit. Surgical decompression may provide rapid improvement and therefore, affect quality of survival.

[Magnetic resonance imaging of the intraventricular cavernomas: diagnostic aspects]. / Ressonância magnética dos cavernomas intraventriculares: aspectos diagnósticos.

Cavernomas are vascular malformations that typically affect the white matter of cerebral hemispheres and brain stem. They are angiographically occult lesions that depend on magnetic resonance imaging (MRI) for their diagnosis, presenting a hypointense perilesional ring caused by hemossiderin deposition as seen in T2 sequences. The ventricular location is rare, and image features may differ. We present two cases with diagnosis made only by histopathologic examination, due to a lack of classic image findings. Cavernous hemangiomas must be included in the differential diagnosis of intraventricular tumors, and total surgical resection is the treatment of choice. Perilesional ring as demonstrated by MRI, must not be expected when dealing with such lesions.

[Prognostic factors in the treatment of the intradural extramedullary tumors: a study of 44 cases]. / Fatores prognósticos no tratamento dos tumores intradurais extramedulares: estudo de 44 casos.

Between 1993 and 1999, 44 patients submitted to resection of an expansible intradural extramedullary lesion who filled protocol requirements of appropriate follow up were studied. Patients were constituted by 43.2% female and 56.8% male. The mean age was 32.9 years old. Lesion most common location was at the thoracic spine, with 45.5% of the cases, followed by the lumbar level with 18.2%. Tumor extension varied from 1 to 7 vertebral segments, with an average of 2.5 levels. Schwannoma, with 65,9% of the cases, was the most frequent lesion, followed by meningioma with 20.5%. There were 2 cases of neurofibroma and 1 case of paraganglioma, neuroenteric cyst, metastasis and malignant schwannoma. The evolution was of improvement in 56.8%, stability in 31.8% and of worsening in 11.4%. There was no mortality related to the surgical procedure. All cases of worsening had total resection and they had lesions located in the thoracic segment. Total resection is the ideal modality of surgical treatment. However, at the thoracic level, where the peculiarities of spine irrigation prevail, surgical morbidade may be higher (p=0.014).

Posterior fossa gangliocytoma with facial nerve invasion: case report.

A 5 year-old boy with a cerebellar gangliocytoma with a peripheral right facial paresis and ataxia is presented. His MRI showed a heterogenous, diffuse lesion, isointense on T1 and hyperintense on T2-weigthed sequences, involving the right cerebellar hemisphere with direct extension into the right facial nerve. The present case is the first description of a gangliocytoma with direct facial nerve invasion, as demonstrated for the facial nerve paresis and supported by MRI and surgical inspection.

Gliosarcoma: report of four cases with immunohistochemical findings.

Gliosarcoma (GSa) is a rare primary central nervous system neoplasm (CNS) characterized by biphasic histological pattern with both glial and sarcomatous components. Our objective is to describe the clinical, morphological and immunohistochemical features of four cases of GSa and to discuss its pathogenetic mechanisms. The male:female ratio was 3:1. The mean age was 39 years, ranging from 19 to 48. Headache was the commonest clinical symptom. All patients underwent craniotomy with microsurgery and total resection of the tumor. Diagnosis was suspected due to microscopic architecture and confirmed by detection of reticulin fibers through histochemical techniques. Immunohistochemical analysis was positive for p53 in both glial and sarcomatous cells in all four cases. EGFR was focally positive in glial cells in one case. Our findings support monoclonal origin of GSa involving the TP53 tumor-suppressor gene. However, alternative pathways cannot be ruled out.

Management of primary spinal chondrosarcoma: report of two cases causing cord compression.

Chondrosarcomas are malignant tumors that rarely grow inside the spinal canal. Prognosis depends on histological features, patient's age and surgical margins free from tumor. Response to radio and chemotherapy is poor. Ideal treatment consists of total "en-block" resection, not always achievable due to limitation of location, compromise of stability and risk of inducing neurological deficits. Two cases of spinal chondrosarcoma causing cord compression are reported, located in the cervical and thoracic spine. Microsurgical technique consisted of initial debulking followed by removal of margins until limits free from tumor were obtained. Total resection was accomplished and neurological function improved in both cases. Follow-up has been seven and one year respectively, with no evidence of recurrence and preserved neurological functions. Association between chondrosarcoma and estrogen-dependent tumor has been confirmed in this report. Although "en-block" resection of a chondrosarcoma should be tried whenever possible, tumor fragmentation should be considered in difficult cases, as in the present report, in which a long period free from recurrence with good quality of life can be obtained.

Cerebellar hemorrhage as a complication of temporal lobectomy for refractory medial temporal epilepsy: report of three cases.

Cerebellar hemorrhage is listed among the potential complications following neurosurgical procedures. In this scenario it is usually reported as a rare condition. However, it seems that epilepsy surgery patients are somewhat more prone to this kind of complication, compared to other surgical groups. Head positioning, excessive cerebral spinal fluid draining and the excision of non-expanding encephalic tissue (or combinations among the three) are likely to be cause underlying remote cerebellar hemorrhage. Out of the 118 ATL/AH performed at our institution, between 1996 and 2002, we identified 3 (2.5%) patients presenting with cerebellar hemorrhage. We report on such cases and review the literature on the topic.

33 year-old woman with a large sellar tumor.

The authors describe a case of paraganglioma of the sellar region in a young female patient with loss of vision and headache. She presented with amaurosis, depression, anxiety and amenorrhea. Clinical and radiological impression was that it was a meningioma or pituitary adenoma. She received bromocriptine with no reduction of the lesion. She developed panhypopituitarism, but with normal levels of prolactin. It was resected and histological examination revealed nests of large cells with moderate nuclear pleomorphism, vesicular nuclei with occasional nucleoli. There were rare mitotic figures, but no necrosis. Immunohistochemistry was positive for synaptophysin, chromogranin A, and neuron-specific enolase with a few sustentacular cells positive for S100. The Ki67 proliferation was 1-2%. All pituitary hormonal antibodies were negative as well as GFAP, AE1/AE3, p53 and EMA. Paragangliomas affecting the sellar region are extremely rare and might be due to the presence of remnants of paraganglionic tissue or abnormal migration. The patient's post-operative diabetes insipidus remains under medical control.

Hydroxyapatite granules used in the obliteration of mastoid cavities in rats.

UNLABELLED: Prospective experimental study in which we created a bony defect in the mastoids of rats and filled it up with hydroxyapatite to evaluate bone regeneration, to solve the problems of open cavities after mastoidectomies that frequently present with otorrhea, infection, granulation tissue and hearing loss. OBJECTIVE: The aim was to evaluate bone regeneration in defects created in the mastoids of rats, using hydroxyapatite, to see how much of the cavity we could reduce. MATERIAL AND METHODS: Twelve rats Wistar-Furth were used. A 0.5 x 0.5 cm bone defect was created in both temporal bones of the rats, and filled with 15 micrograms of hydroxyapatite. The left side was used as control. The animals were slaughtered 40 days afterwards and histology analyses were carried out. RESULTS: In the hydroxyapatite group, the new bone growth involved an area of 68.53% of the total; and in the control group it was only of 15.97%. DISCUSSION AND CONCLUSION: It was observed a very good hydroxyapatite integration to the temporal bone in this experimental model. The microscopic results were superior with the use of hydroxyapatite when compared to the control group. It is a safe method and easy to apply to solve the problems of open cavities with chronic discharge and difficult to clean.

Anterior temporal lobectomy versus selective amygdalohippocampectomy in patients with mesial temporal lobe epilepsy / Lobectomia temporal anterior versus amigdalohipocampectomia seletiva para epilepsia de lobo temporal mesial

ABSTRACT Objective To contribute our experience with surgical treatment of patients with mesial temporal lobe epilepsy (mTLE) undergoing anterior temporal lobectomy (ATL) or selective amygdalohippocampectomy (SelAH). Method This is a retrospective observational study. The sample included patients with medically refractory mTLE due to unilateral mesial temporal sclerosis who underwent either ATL or SelAH, at Hospital de Clinicas – UFPR, from 2005 to 2012. We report seizure outcomes, using Engel classification, cognitive outcomes, using measurements of verbal and visuospatial memories, as well as operative complications. Result Sixty-seven patients (33 ATL, 34 SelAH) were studied; median follow-up was 64 months. There was no statistically significant difference in seizure or neuropsychological outcomes, although verbal memory was more negatively affected in ATL operations on patients’ dominant hemispheres. Higher number of major complications was observed in the ATL group (p = 0.004). Conclusion Seizure and neuropsychological outcomes did not differ. ATL appeared to be associated with higher risk of complications.

RESUMO Objetivo Contribuir com nossa experiência para o tratamento cirúrgico de pacientes com epilepsia do lobo temporal mesial submetidos a lobectomia temporal anterior (LTA) ou amigdalohipocampectomia seletiva (AHS). Método Estudo retrospectivo observacional. Foram incluídos pacientes com epilepsia refratária devido a esclerose mesial temporal unilateral, submetidos a LTA ou AHS no Hospital de Clínicas – UFPR, entre 2005-2012. Foram comparados os resultados cognitivos (análises de memórias verbal e visuoespacial), controle de crises (Engel) e complicações cirúrgicas. Resultados Sessenta e sete pacientes (33 LTA, 34 AHS) foram estudados; o período de acompanhamento médio foi de 64 meses. Não houve diferença no controle das crises ou resultado neuropsicológico, mas a memória verbal foi mais negativamente afetada nos pacientes submetidos à LTA no hemisfério dominante. Maior número de complicações graves ocorreu no grupo de LTA (p = 0.004). Conclusão Controle de crises e resultados neuropsicológicos não diferiram. LTA pareceu estar associada a um maior risco cirúrgico.

Surgical management of glomus jugulare tumors: a proposal for approach selection based on tumor relationships with the facial nerve.

OBJECT: The goal of this paper is to analyze the extension and relationships of glomus jugulare tumor with the temporal bone and the results of its surgical treatment aiming at preservation of the facial nerve. Based on the tumor extension and its relationships with the facial nerve, new criteria to be used in the selection of different surgical approaches are proposed. METHODS: Between December 1997 and December 2007, 34 patients (22 female and 12 male) with glomus jugulare tumors were treated. Their mean age was 48 years. The mean follow-up was 52.5 months. Clinical findings included hearing loss in 88%, swallowing disturbance in 50%, and facial nerve palsy in 41%. Magnetic resonance imaging demonstrated a mass in the jugular foramen in all cases, a mass in the middle ear in 97%, a cervical mass in 85%, and an intradural mass in 41%. The tumor was supplied by the external carotid artery in all cases, the internal carotid artery in 44%, and the vertebral artery in 32%. Preoperative embolization was performed in 15 cases. The approach was tailored to each patient, and 4 types of approaches were designed. The infralabyrinthine retrofacial approach (Type A) was used in 32.5%; infralabyrinthine pre- and retrofacial approach without occlusion of the external acoustic meatus (Type B) in 20.5%; infralabyrinthine pre- and retrofacial approach with occlusion of the external acoustic meatus (Type C) in 41%; and the infralabyrinthine approach with transposition of the facial nerve and removal of the middle ear structures (Type D) in 6% of the patients. RESULTS: Radical removal was achieved in 91% of the cases and partial removal in 9%. Among 20 patients without preoperative facial nerve dysfunction, the nerve was kept in anatomical position in 19 (95%), and facial nerve function was normal during the immediate postoperative period in 17 (85%). Six patients (17.6%) had a new lower cranial nerve deficit, but recovery of swallowing function was adequate in all cases. Voice disturbance remained in all 6 cases. Cerebrospinal fluid leakage occurred in 6 patients (17.6%), with no need for reoperation in any of them. One patient died in the postoperative period due to pulmonary complications. The global recovery, based on the Karnofsky Performance Scale (KPS), was 100% in 15% of the patients, 90% in 45%, 80% in 33%, and 70% in 6%. CONCLUSIONS: Radical removal of glomus jugulare tumor can be achieved without anterior transposition of the facial nerve. The extension of dissection, however, should be tailored to each case based on tumor blood supply, preoperative symptoms, and tumor extension. The operative field provided by the retrofacial infralabyrinthine approach, or the pre- and retrofacial approaches, with or without closure of the external acoustic meatus, allows a wide exposure of the jugular foramen area. Global functional recovery based on the KPS is acceptable in 94% of the patients.

Improvement in hippocampal kindling analysis through computational processing data.

The kindling phenomenon is classically investigated in epileptology research. The present study aims to provide further information about hippocampal kindling through computational processing data. Adult Wistar rats were implanted with dorsal hippocampal and frontal neocortical electrodes to perform the experiment. The processing data was obtained using the Spike2 and Matlab softwares. An inverse relationship between the number of 'wet dog shakes' and the Racine's motor stages development was found. Moreover it was observed a significant increase in the afterdischarge (AD) duration and its frequency content. The highest frequencies were, however, only reached at the beginning of behavioral seizures. During the primary AD, fast transients (ripples) were registered in both hippocampi superimposed to slower waves. This experiment highlights the usefulness of computational processing applied to animal models of temporal lobe epilepsy and supports a relevant role of the high frequency discharges in temporal epileptogenesis.