Parallel transverse-sigmoid sinus harboring dural arteriovenous malformation. How to differentiate the pathological and normal sinus in order to treat and preserve patency and function.

An unusual case of dural arteriovenous malformation (DAVM) harboring a parallel transverse-sigmoid sinus (TSS) is presented. The patient had a 2-year history of left-sided pulsatile tinnitus in the left ear refractory to medical management. Angiography demonstrated a DAVM involving the left TSS. Super-selective transvenous dural sinus occlusion of the DAVM situated at the pathological compartment of the TSS provided cure. We were able to spare the normal compartment providing anatomical venous drainage from this system.

Selective hypothermia: an experimental study on traumatic brain injury in rats.

OBJECTIVE: To evaluate the efficiency of selective hypothermia in the treatment of the traumatic brain injury in rats. METHOD: After the trauma produced for the model of cortical impact, a small craniectomy in the right frontoparietal region was carried through; after the procedure the animals had been divided in two groups of 15 each. Group A, without treatment with hypothermia (control group) and group B, treated with selective hypothermia for a period to 5 to 6 hours. After this time all the animals were sacrificed, their brains had been removed and histopathological analysis was carried through. RESULTS: Comparison between both groups was done using the counting of neurons injured for field. Counting in the control group n=15 had an average of 70.80 neurons injured for field against an average of 21.33 neurons injured for field in group B (submitted to the treatment with hypothermia), with n=15 also. The difference was statistically significant. CONCLUSION: Based in the quantification of the neurons injured for field, the effectiveness of the treatment with selective hypothermia was demonstrated.

Comparison between posterior lumbar fusion with pedicle screws and posterior lumbar interbody fusion with pedicle screws in adult spondylolisthesis.

The purpose of this study was to compare patients with lumbar spondylolisthesis submitted to two different surgical approaches, and evaluate the results and outcomes in both groups. In a two-year period, 60 adult patients with lumbar spondylolisthesis, both isthmic and degenerative, were submitted to surgery at the Biocor Institute, Brazil. All patients were operated on by the same surgeon (FLRD) in a single institution, and the results were analyzed prospectively. Group I comprised the first 30 consecutive patients that were submitted to a posterior lumbar spinal fusion with pedicle screws (PLF). Group II comprised the last 30 consecutive patients submitted to a posterior lumbar interbody fusion procedure (PLIF) with pedicle screws. All patients underwent foraminotomy for nerve root decompression. Clinical evaluation was carried out using the Prolo Economic and Functional Scale and the Rolland-Morris and the Oswestry questionnaire. Mean age was 52.4 for Group I (PLF), and 47.6 for Group II (PLIF). The mean follow-up was 3.2 years. Both surgical procedures were effective. The PLIF with pedicle screws group presented better clinical outcomes. Group I presented more complications when compared with Group II. Group II presented better results as indicated in the Prolo Economic and Functional Scale.

[Inhibition of peridural fibrosis after laminectomy using biological sheet in rat model]. / Estudo de membrana biológica em ratos na prevenção de fibrose pós laminectomia.

The prevention of fibrosis after lumbar and thoracic laminectomies by avoiding herniation of muscular tissue was studied using Wistar-EPM rats with a biological membrane made of decorticated bone of bovine material. The rats were sacrificed after eight, sixteen and twenty four weeks and the material was sent to anatomopathological study. This membrane proved to be biocompatible and its efficacy was seen by allowing formation of bone and preventing muscular tissue invasion of the epidural space and avoiding adherences.

Pathophysiology of posttraumatic temporal lobe lesions.

BACKGROUND: Posttraumatic parenchymal lesions in the temporal lobe may cause neurologic deterioration. An analysis was made of the natural evolution of this type of lesion, with emphasis on its 2 components: hemorrhage (hyperdense on computed tomography [CT]), and edema and necrosis (hypodense on CT). The clinical repercussions were studied, and the factors that might influence such evolution were investigated. METHODS: Forty head-injured patients with temporal lobe lesions admitted within 12 hours after the injury were selected in a prospective manner. Computed tomography scans were systematically repeated within the first 36 hours and at 7 and 30 days postinjury. Factors such as interval between injury and the first CT scan, age, velocity of the injury, alcohol consumption, coagulation abnormalities, and the presence of decompressive measures were compared between the patients that had enlargement of the hemorrhage and those who did not. Increase in hypodensity was compared with that in hyperdensity. RESULTS: Fourteen patients showed enlargement of the hemorrhage. In all cases but one, the interval between injury and admission was 3 hours or less. Other factors had no statistical significance as predisposing causes for such enlargement. In approximately half of the cases, the hypodense component increased in the first 36 hours and continued increasing until the end of the first week. Evolution of the hypodense component was not dependent on behavior of the hemorrhage, surgical drainage, or diameter of the hemorrhagic lesion. CONCLUSIONS: The natural evolution of the hyperdense component of temporal lobe lesions was to enlarge within the first few hours after the injury. Edema and necrosis developed more slowly and with no significant clinical manifestations.

[Post-traumatic temporal lobe lesions: surgical decision making based on CT scan findings].

BACKGROUND: The indication for surgical treatment of post-traumatic parenchymal lesions in the temporal lobe remains controversial. OBJECTIVE: We reviewed the tomographic parameters that might be useful in making surgical decisions. METHOD: The tomographic findings of 69 patients were analyzed in a retrospective manner considering: 1) the effects of the lesion (classified into 4 variables: midline shift, status of the cisterns, status of the ventricles, and status of the peripheral sulci); and 2) the characteristics of the lesion: anterior, posterior or anteroposterior location (as defined by a coronal plane tangent to the cerebral peduncles) and its mediolateral diameter. RESULTS: When none or only one of the aforementioned variables was found to be altered, conservative treatment was instituted (22 out of 38 lesions). In two cases, all four variables were altered, and surgery was performed in both. Anterior, anteroposterior and posterior lesions measuring 21, 23 and 28 mm in diameter, respectively, had a 50% chance of surgical removal. CONCLUSION: Amongst the patients who underwent surgical intervention, the more anterior the location of the temporal lobe lesion, the smaller the diameter.

Structural Volume of Hippocampus and Alzheimers Disease

RESUMO Pesquisas recentes demonstram que o hipocampo apresenta uma redução de volume no final da idade adulta, mantendo uma estreita relação com o declínio cognitivo. A aquisição da imagem por diversos métodos de medição de volume nos leva a encontrar na ressonância magnética o método de destaque, pois permite quantificar o volume de determinadas estruturas cerebrais utilizando a reconstrução computadorizada tridimensional das imagens obtidas. OBJETIVOS Confirmar a existência de diferenças entre o volume hipocampal e o declínio cognitivo leve, doença de Alzheimer e cognição normal. MÉTODOS Levantamento bibliográfico de estudos que apresentassem dados referentes aos distúrbios da doença de Alzheimer, alterações macroscópicas cerebrais detectadas com softwares na ressonância magnética e segmentação. Foram adicionados estudos apenas da medição volumétrica do hipocampo, objetivando-se chegar a valores que possam estabelecer uma correlação do menor valor estrutural hipocampal e risco de desenvolvimento da doença. RESULTADOS Um total de 1.070 indivíduos foi analisado em seis estudos clínicos, demonstrando a relação da diminuição do hipocampo na neuroimagem, correlacionado com o comprometimento cognitivo leve e doença de Alzheimer. CONCLUSÕES O desenvolvimento de um valor padrão para esse fim seria bastante útil na coleta de dados, permitindo melhor compreensão de algumas alterações que podem ocorrer na cognição, determinar valores prognósticos e até, em um futuro próximo, fator de risco imagiológico para a doença.

[TSH pituitary adenoma: case report]. / Adenomas produtores de TSH: Relato de caso.

We describe a rare case of thyroid-stimulating hormone-secreting pituitary adenoma in a patient with a clinical picture of hyperthyroidism, that developed bitemporal hemianopsia after four years of a known thyroid dysfunction. CT scan showed a pituitary tumor considered grade 2 and stage C according to Hardy-Vezina and Wilson. Treatment was surgical, initially by a transsphenoidal approach, in which only a biopsy was possible. The patient was then submitted to an orbital-pterional craniotomy with sub-total resection of the tumor. Complementary treatment was indicated with radiotherapy.

[Giant cavernous angioma: report of two cases]. / Cavernoma gigante: relato de dois casos.

Cavernous angiomas or haemangiomas or yet cavernomas are malformations of the central nervous system classified as occult vascular brain lesions. These rare lesions are clinically silent. They are defined by the presence of abnormally large vascular cavities or sinusoids channels of variable size, with sharp walls, located inside but not invading the brain parenchyma. They can occur at any age, including the neonatal period. Most of the small lesions are located inside the brain parenchyma. No abnormal circulation can be demonstrated in angiography and CT scan can be helpful for diagnosis only in rare occasions. Magnetic resonance is the best exam to demonstrate the lesion. Despite the benign character some lesions may cause neurologic dysfunction when their removal may be difficult. Complete extirpation is the best treatment if the lesion is favorable located and is causing neurological dysfunction. Two cases of giant cavernomas with good outcome after total removal are present. Only three cases of giant cavernomas were reported in the literature.

Malignant transformation of pleomorphic xanthoastrocytoma: case report.

We report a case of a pleomorphic xantoastrocytoma which manifested itself as a cystic isodense lesion in the right fronto-temporal lobe in a 26 year-old woman. It appeared as a soft yellow tumor with cystic cavities on surgery. Five months after this surgery, the patient was submitted to a new operation, which revealed a friable tumor, easily differentiated from the normal parenchyma, with cystic components. The histopathological examination demonstrated pleomorphic xanthoastrocytoma with malignant transformation. Histologically, the tumor at first procedure was composed of pleomorphic astrocytes with multinucleated and foamy cells. A rare case of malignant transformation in pleomorphic xanthoastrocytoma is presented, discussed and illustrated in this paper.

[Management of odontoid fractures using anterior screw fixation: analysis of 15 cases]. / Tratamento cirúrgico das fraturas do odontóide tipo II com parafuso anterior: análise de 15 casos.

A retrospective analysis of the results of 15 patients with odontoid fractures type II P and II N, according to Roy-Camille's classification is presented. They were operated on by an anterior approach and direct fixation of the odontoid process through a screw. There were 13 men and 2 women, the age ranging from 14 to 74 years. The follow up period was from 6 to 36 months (mean 20 months). There was only one complication related to the surgical technique: one screw was misplaced and it was necessary another surgery to replace it. There were no deaths in this series. There were no screw breakdown and the fusion rate was 94%. We propose, based on this study, that the classification of Roy-Camille for odontoid fractures should be always used, since it proposes one surgical approach for each type of fracture. The results of this series show that this technique is useful and has advantages over another modalities of treatment. The correct diagnosis of the type of fracture and an appropriate selection of patients are the main elements to achieve good results.

Chordoid meningioma: report of two cases.

We present CT scan, MRI and histopathologic findings of two patients harboring a rare type of meningioma. In the first case, a 52 year-old male patient, a large parasellar mass invading the cavernous sinus, infiltrating the infratemporal fossa and extending as low as C2 was founded. The tumor was isointense on T1, enhanced strongly with gadolinium injection, and was hyperintense on T2. In the second case, a 19-year-old male patient, a large high density temporal right mass was disclosed by CT scan. Both patients were taken to surgery. In the first case, only a partial removal was possible to be accomplished due to a severe intra operative bleeding. In the second case, the tumor was totally removed. Both showed characteristic pathologic findings of a meningioma resembling a chordoma. Meningioma is a relatively common intracranial tumor, occurring most frequently in adults, showing a wide variety of growth patterns. We described a pattern that had a peculiar chordoma-like appearance. The pathological findings and the differential diagnosis from chordoma are discussed.

Prognostic value of intraventricular bleeding in spontaneous intraparenchymal cerebral hemorrhage of small volume: a prospective cohort study.

BACKGROUND: The literature is controversial on whether intraventricular bleeding has a negative impact on the prognosis of spontaneous intracerebral hemorrhage. Nevertheless, an association between intraventricular bleeding and spontaneous intracerebral hemorrhage volumes has been consistently reported. OBJECTIVE: To evaluate the prognostic value of intraventricular bleeding in deep intraparenchymal hypertensive spontaneous hemorrhage with a bleeding volume <30 cm(3). METHODS: Of the 320 patients initially evaluated, 33 met the inclusion criteria and were enrolled in this prospective study. The volume of intraparenchymal hemorrhage was calculated by brain computed tomography (CT) image analysis, and the volume of intraventricular bleeding was calculated by the LeRoux scale. Clinical data, including neurological complications, were collected daily during hospitalization. Neurological outcome was evaluated 30 days after the event by using the Glasgow outcome scale. Patients were assigned to 1 of 3 groups according to intraventricular bleeding: Control, no intraventricular bleeding; LR 1, intraventricular bleeding with LeRoux scale scores of 1 to 8; or LR 2, intraventricular bleeding with LeRoux scale scores >8. RESULTS: There were no significant differences among groups concerning age, mean blood pressure, and time from onset to brain CT scan. Patients with greater intraventricular bleeding presented lower initial Glasgow coma scale scores, increased ventricular index and width of temporal horns, increased number of clinical and neurological complications, and longer hospitalization. Furthermore, their relative risk for unfavorable clinical outcome was 1.9 (95% confidence interval 1.25-2.49). CONCLUSION: Intraventricular bleeding with a LeRoux scale score >8 appears to have a negative effect on deep spontaneous intraparenchymal cerebral hemorrhage of small volume.

Evaluation of arthrodesis and cervical alignment in the surgical results of cervical discectomy using polymethylmetacrylate.

BACKGROUND AND OBJECTIVES: Surgical treatment of cervical radiculopathy with or without myelopathy is a controversy issue, although anterior discectomy is the most common form of treatment. METHOD: We present the evaluation of the arthrodesis' rate and cervical alignment in 48 patients with cervical degenerative disease (CDD) submitted to anterior cervical discectomy with interposition of polymethylmetacrylate (PMMA). Odom and Nürick scales were used to evaluation of functional status before and after surgery. Cervical spine X-rays were used to access arthrodesis and alignment, at least 2 years after the procedure. RESULTS: Excellent and good results (Odom I and II) were obtained in 91% of the patients with radiculopathy and in 69% of those with myelopathy. Using the chi square test of independence (1% of significance), there was no association between excellent and good clinical results with the presence of arthrodesis verified in cervical X-rays. The presence of cervical alignment had association with good results, whereas the misalignment was associated with unfavorable outcomes. Two patients died: one cervical hematoma and other from graft migration with cord compression. CONCLUSIONS: Cervical alignment was more important than fusion to achieve good surgical results in CDD.

Regional cooling for reducing brain temperature and intracranial pressure.

OBJECTIVE: To evaluate the effectiveness of regional cooling for reducing brain temperature (BrTe) and intracranial pressure (ICP) in patients where conventional clinical treatment has failed. METHOD: Regional cooling was carried out using ice bags covering the area of the craniectomy (regional method) in 23 patients. The BrTe and ICP were determined using a fiber optic sensor. Thirteen patients (56.52%) were female. The ages ranged from 16 to 83 years (mean of 48.9). The mean APACHE II score was 25 points (11-35). The patients were submitted, on mean, to 61.7 hours (20-96) of regional cooling. RESULTS: There was a significant reduction in mean BrTe (p<0.0001--from 37.1 degrees C to 35.2 degrees C) and mean ICP (p=0.0001--from 28 mmHg to 13 mmHg). CONCLUSION: Our results suggest that mild brain hypothermia induced by regional cooling was effective in the control of ICP in patients who had previously undergone decompressive craniectomy.

Transitional lumbosacral vertebrae and low back pain: diagnostic pitfalls and management of Bertolotti's syndrome.

OBJECTIVE: Bertolotti's syndrome is a spine disorder characterized by the occurrence of a congenital lumbar transverse mega-apophysis in a transitional vertebral body that usually articulates with the sacrum or the iliac bone. It has been considered a possible cause of low back pain. METHOD: We analyzed the cases of Bertolotti's syndrome that failed clinical treatment and reviewed the literature concerning this subject. RESULTS: Five patients in our series had severe low back pain due to the neo-articulation and two of them were successfully submitted to surgical resection of the transverse mega-apophysis. Taking into account the clinical and surgical experience acquired with these cases, we propose a diagnostic-therapeutic algorithm. CONCLUSION: There is still no consensus about the most appropriate therapy for Bertolotti's syndrome. In patients in whom the mega-apophysis itself may be the source of back pain, surgical resection may be a safe and effective procedure.

Evaluation of arthrodesis and cervical alignment in the surgical results of cervical discectomy using polymethylmetacrylate / Avaliação da artrodese e do alinhamento cervical após discectomia cervical com interposição de polimetilmetacrilato

BACKGROUND AND OBJECTIVES: Surgical treatment of cervical radiculopathy with or without myelopathy is a controversy issue, although anterior discectomy is the most common form of treatment. METHOD: We present the evaluation of the arthrodesis' rate and cervical alignment in 48 patients with cervical degenerative disease (CDD) submitted to anterior cervical discectomy with interposition of polymethylmetacrylate (PMMA). Odom and Nürick scales were used to evaluation of functional status before and after surgery. Cervical spine X-rays were used to access arthrodesis and alignment, at least 2 years after the procedure. RESULTS: Excellent and good results (Odom I and II) were obtained in 91 percent of the patients with radiculopathy and in 69 percent of those with myelopathy. Using the chi square test of independence (1 percent of significance), there was no association between excellent and good clinical results with the presence of arthrodesis verified in cervical X-rays. The presence of cervical alignment had association with good results, whereas the misalignment was associated with unfavorable outcomes. Two patients died: one cervical hematoma and other from graft migration with cord compression. CONCLUSIONS: Cervical alignment was more important than fusion to achieve good surgical results in CDD.

TEMA E OBJETIVO: O tratamento cirúrgico da radiculopatia cervical com ou sem mielopatia é um tema controverso, embora a discectomia por via anterior seja uma das formas mais comuns de tratamento. MÉTODO: Apresentamos a avaliação da artrodese cervical e do alinhamento pós operatório em 48 pacientes com doença degenerativa cervical (DDC) submetidos a discectomia por via anterior seguida da interposição de polimetilmetacrilato (PMMA). As escalas de Odom e de Nurick foram utilizadas para avaliar o status funcional dos pacientes antes e após a cirurgia. Radiografias da coluna cervical foram utilizadas para avaliar a artrodese e o alinhamento cervical, pelo menos 2 anos após o procedimento. RESULTADOS: Excelentes e bons resultados (Odom I e II) foram obtidos em 91 por cento dos casos com radiculopatia e em 69 por cento dos pacientes com mielopatia. Usando o teste do qui-quadrado de independência (1 por cento de significância), não houve associação entre os resultados excelentes e bons e a presença de artrodese. A presença de alinhamento cervical, ao contrário, correlacionou-se com bons resultados. Dois pacientes faleceram devido a hematoma cervical e migração do enxerto. CONCLUSÃO: O alinhamento cervical correlacionou-se com bons resultados cirúrgicos em nossos pacientes, enquanto que a taxa de artrodese não teve relação com o resultado clínico dos pacientes.

Regional cooling for reducing brain temperature and intracranial pressure / Resfriamento cerebral regional para redução da temperatura e pressão intracraniana

OBJECTIVE: To evaluate the effectiveness of regional cooling for reducing brain temperature (BrTe) and intracranial pressure (ICP) in patients where conventional clinical treatment has failed. METHOD: Regional cooling was carried out using ice bags covering the area of the craniectomy (regional method) in 23 patients. The BrTe and ICP were determined using a fiber optic sensor. Thirteen patients (56.52 percent) were female. The ages ranged from 16 to 83 years (mean of 48.9). The mean APACHE II score was 25 points (11-35). The patients were submitted, on mean, to 61.7 hours (20-96) of regional cooling. RESULTS: There was a significant reduction in mean BrTe (p<0.0001-from 37.1ºC to 35.2ºC) and mean ICP (p=0.0001-from 28 mmHg to 13 mmHg). CONCLUSION: Our results suggest that mild brain hypothermia induced by regional cooling was effective in the control of ICP in patients who had previously undergone decompressive craniectomy.

OBJETIVO: Avaliar a eficácia do resfriamento regional na redução da temperatura cerebral (TeCe) e pressão intracraniana (PIC) após falha das medidas clínicas convencionais de tratamento. MÉTODO: O resfriamento cerebral foi realizado com bolsas com gelo, colocadas sobre a área de craniectomia (método regional) em 23 doentes. A TeCe e PIC foram verificadas com sensor de fibra óptica. Treze (56,52 por cento) eram do sexo feminino. A idade variou de 16 a 83 anos (média 48,96). A pontuação média no índice APACHE II foi 25 pontos (11-35). Os doentes foram submetidos, em média, a 61,7 horas (20-96) de resfriamento regional. RESULTADOS: Houve uma redução significativa da TeCe média (p<0,0001-de 37,1ºC para 35,2ºC) e da PIC média (p=0,0001-de 28 mmHg para 13 mmHg). CONCLUSÃO: Nossos resultados sugerem que o resfriamento regional foi eficaz no controle da PIC nos doentes submetidos, previamente, a craniectomia descompressiva.

Transitional lumbosacral vertebrae and low back pain: diagnostic pitfalls and management of Bertolotti's syndrome / Dor lombar associada à vértebra de transição lombossacra: dificuldades no diagnóstico e manejo da síndrome de Bertolotti

OBJECTIVE: Bertolotti's syndrome is a spine disorder characterized by the occurrence of a congenital lumbar transverse mega-apophysis in a transitional vertebral body that usually articulates with the sacrum or the iliac bone. It has been considered a possible cause of low back pain. METHOD: We analyzed the cases of Bertolotti's syndrome that failed clinical treatment and reviewed the literature concerning this subject. RESULTS: Five patients in our series had severe low back pain due to the neo-articulation and two of them were successfully submitted to surgical resection of the transverse mega-apophysis. Taking into account the clinical and surgical experience acquired with these cases, we propose a diagnostic-therapeutic algorithm. CONCLUSION: There is still no consensus about the most appropriate therapy for Bertolotti's syndrome. In patients in whom the mega-apophysis itself may be the source of back pain, surgical resection may be a safe and effective procedure.

OBJETIVO: A síndrome de Bertolotti é uma desordem congênita da coluna vertebral caracterizada pela ocorrência de uma mega-apófise transversa lombar em uma vértebra de aspecto transicional, que geralmente se articula com o sacro ou com o osso ilíaco. Tal síndrome tem sido considerada possível causa de dor lombar. MÉTODO: Análise dos casos de síndrome de Bertolotti que apresentavam dor lombar sem melhora com tratamento conservador e revisão dos artigos publicados. RESULTADOS: Foram revisados cinco pacientes que não apresentaram melhora com o tratamento clínico, sendo que dois foram submetidos à ressecção cirúrgica da mega-apófise transversa. Considerando a experiência adquirida com estes casos, os autores propõem um algoritmo para diagnóstico e tratamento da Síndrome de Bertolotti. CONCLUSÃO: Ainda não há consenso sobre qual é a terapia mais apropriada para a Síndrome de Bertolotti. Em pacientes em que a mega-apófise parece ser a origem da lombalgia, a ressecção cirúrgica parece ser um procedimento seguro e efetivo.