"Subclinical atherosclerosis in acromegaly: Possible association with cardiovascular risk factors rather than disease activity".

OBJECTIVE: Cardiovascular (CV) disease is still a major cause of excessive morbidity and mortality in patients with active acromegaly, which may be attributed to a high prevalence of associated pro-atherosclerotic risk factors. However, a direct effect of GH/IGF-1 excess on the vasculature has been previously suggested, warranting further investigation. The present study was designed to investigate whether chronic GH/IGF-1 excess is associated with an increased prevalence of subclinical atherosclerosis in patients with acromegaly. DESIGN: We measured carotid intima-media thickness (cIMT) and assessed carotid plaques by ultrasonography along with classical CV risk factors in 54 acromegaly patients (34 females, 50 ± 12 years and compared those with 62 (42 females, 53 ± 13 years) age-, sex- and CV risk factors- matched controls. In order to compare cIMT measurements between patients and controls we analyzed common carotid artery far wall data as well as a combined measurement result, which consisted of the mean value of the six different measurements, three at each side. RESULTS: mean ± SD serum GH and IGF-1 levels were 2.76 ± 4.65 ng/mL and 1.7 ± 1.25 x ULN, respectively, in all acromegaly patients. Age, body mass index, blood pressure, lipid levels, fasting glucose and Framingham's global cardiovascular risk score classification were similar comparing patients and controls. Combined median [IQR] cIMT measurements were similar in acromegaly patients and matched controls (0.59 [0.52-0.66] mm vs. 0.59 [0.52-0.69] mm; P = 0.872) as well as in acromegaly patients with active and controlled disease (0.59 [0.51-0.68] mm vs. 0.60 [0.54-0.68] mm; P = 0.385). No significant correlations were observed between cIMT measurements and GH (Spearman r = 0.1, P = 0.49) or IGF-1 (Spearman r = 0.13, P = 0.37) levels in patients with acromegaly. Carotid atherosclerotic plaques prevalence was similar in patients and controls (26% vs. 32%; P = 0.54) as well as in patients with active and controlled acromegaly (22% vs. 30%; P = 0.537). CONCLUSIONS: Our data suggest that GH/IGF-1 excess itself is not one of the main drivers of subclinical morphological atherosclerosis changes in patients with acromegaly and that optimal control of acromegaly-associated CV risk factors may preserve vasculature structure even when strict biochemical control is not achieved.

Endovascular treatment of residual or recurrent intracranial aneurysms after surgical clipping.

OBJECTIVE: Total aneurysm occlusion is crucial for the prevention of rebleeding of a ruptured aneurysm or to avoid rupture of an unruptured lesion. Both surgical and endovascular embolization fail to achieve complete aneurysm occlusion in all the cases. The objective of the study was to establish the safety and efficacy of endovascular treatment for previously clipped residual or recurrent aneurysms. METHODS: This was an observational, retrospective study of patients harboring incompletely occluded intracranial aneurysms after clipping who underwent endovascular treatment. Patients were treated using 4 different techniques: (1) simple coiling, (2) balloon remodeling, (3) stent-assisted coiling, and (4) flow diversion. Analyses were performed to identify predictors of total aneurysm occlusion, recanalization and complications. RESULTS: Between May 2010 and September 2018, 70 patients harboring incompletely occluded intracranial aneurysms after clipping met the inclusion criteria in 5 centers. The mean residual aneurysm size was 7.5 mm. Fifty-nine aneurysms were unruptured. Total aneurysm occlusion was achieved in 75.3% of the aneurysms after 1 year. All aneurysms treated with flow diversion revealed complete occlusion according to control angiography. Recanalization was observed in 14.5%. Permanent morbidity and mortality occurred in 2.9% and 1.4% of the patients, respectively. CONCLUSIONS: Endovascular treatment of recurrent or residual aneurysms after surgical clipping was safe and efficacious. Flow diversion seems to be associated with better anatomical results. A more rigid study, a larger group of patients, and longterm follow-up are required to provide stronger conclusions about the best approach for residual clipped aneurysms.

Comparative study of complications after primary and revision transsphenoidal endoscopic surgeries.

A preferred treatment for residual/recurrent pituitary adenomas has not been established. The existence of higher complication rates for revision surgeries remains under debate. This study aimed to compare complication rates of primary and revision transsphenoidal endoscopic surgeries and to identify risk factors for complications. Data from 144 primary and 39 revision surgeries were analysed. The surgical complications evaluated were intraoperative and postoperative cerebrospinal fluid (CSF) leaks; meningitis; permanent diabetes insipidus (DI) and hypopituitarism; worsening visual acuity; ophthalmoplegias; visual field defects; otorhinolaryngological, systemic and vascular complications; and death. The variables that were potentially associated with surgical complications were gender, age, comorbidities, lumbar drain use, duration of lumbar drain use, invasion of the sphenoid and cavernous sinuses, presence and degree of suprasellar expansion, preoperative identification of the pituitary, CSF leaks and intraoperative pituitary identification. Intraoperative CSF leaks, visual field losses and worsening visual acuity were more common for revision surgeries. There were no between-group differences in the occurrence of postoperative CSF leaks; systemic, vascular and otorhinolaryngological complications; meningitis; DI and hypopituitarism; ophthalmoplegias; or death. Intraoperative identification of the pituitary was associated with lower rates of permanent DI and hypopituitarism, systemic complications, intraoperative CSF leaks and worsening visual acuity. Suprasellar expansion increased the risk of intraoperative CSF leaks but not endocrinological deficits or visual impairment. Intraoperative CSF leaks were associated with postoperative CSF leaks, meningitis, anterior hypopituitarism, DI and worsening visual acuity. Intraoperative CSF leaks, worsening visual acuity and visual field losses were more common in reoperated patients.

Proposed radiological score for the evaluation of isolated fourth ventricle treated by endoscopic aqueductoplasty.

PURPOSE: Evidence supporting the effectiveness of endoscopic aqueductoplasty (EA) for the treatment of isolated fourth ventricle (IFV) is limited to small surgical series of cases. Additionally, studies adopted different radiological outcome criteria, which makes it difficult to compare outcomes accurately. Thus, we aimed to develop a radiological score (RS) as an alternative assessment method for EA. METHODS: The cases of 20 consecutive pediatric patients harboring IFV and treated by EA were retrospectively reviewed. Clinical data and pre- and 1-year postoperative brain images were analyzed. The RS was based on the enlargement of the fourth ventricle and deformation of the cerebellum and brainstem. After randomization, three experts, blinded to patient outcomes, analyzed the brain images and established a consensus for the values of the score. Outcomes were validated by comparing the maximum anteroposterior distance of the fourth ventricle using the RS, pediatric functional status score, and clinical symptoms. RESULTS: The RS was strongly correlated with the anteroposterior distance of the fourth ventricle (Pearson's coefficient = 0.78), and the mean RS dropped from 6.15 to 3.90 (p < 0.001) 1 year after EA. Upward extension (p = 0.021) and brainstem deformation (p = 0.010) were the most significant improved features. There was agreement among RS and symptom improvement in 16 children (80%) and the pediatric functional status score in 14 children (70%). CONCLUSION: In this study, the proposed radiological score proved to be an accurate tool for the evaluation of IFV treatment with EA.

Minimally Invasive Approaches to the Lateral Cavernous Sinus and Meckel's Cave: Comparison of Transorbital and Subtemporal Endoscopic Techniques.

BACKGROUND: Transorbital and subtemporal keyhole approaches have recently been proposed to approach lesions in the lateral wall of the cavernous sinus (CS) and Meckel's cave (MC). Our goal was to compare these approaches and suggest indications for each of them. METHODS: Five cadaver heads (10 sides, 40 procedures) were used. The lateral transorbital approaches were carried out without and with the removal of the lateral orbital rim, herein referred to as the lateral transorbital approach (LTOA) and the lateral orbital wall approach (LOWA). The subtemporal approaches were performed without and with the removal of the zygomatic arch, referred to as the subtemporal approach (STA) and the subtemporozygomatic approach (STZA). Five targets were chosen and 2 triangles were created representing the lateral wall of the CS and MC. Stereotactic measurements were quantified to calculate angles of attack, surgical freedom, and temporal lobe retraction for each approach. RESULTS: LTOA presented the smaller horizontal angles of attack. LOWA increased the angles to the same level of STA and STZA. STA and STZA presented larger vertical angles of attack. The surgical freedom presented gradual increase from LTOA to LOWA, STA, and STZA. STA and STZA needed greater temporal lobe retraction for most targets. CONCLUSIONS: LTOA is a good option to biopsy a lesion in the lateral wall of the CS and LOWA increased the surgical corridor to work with microsurgical techniques. STA and STZA could be better options when wide exposure is necessary, but temporal lobe retraction should be taken into consideration.

Microgliosis is associated with visual memory decline in patients with temporal lobe epilepsy and hippocampal sclerosis: A clinicopathologic study.

Hippocampal sclerosis (HS) is characterized by neuronal loss and gliosis. The intensity and distribution of these histopathological findings over the Cornu Ammonis (CA) subfields are important for the classification of HS and prognostication of patients with temporal lobe epilepsy (TLE). Several studies have associated the neuronal density reduction in the hippocampus with cognitive decline in patients with TLE. The current study aimed at investigating whether the expression of glial proteins in sclerotic hippocampi is associated with presurgical memory performance of patients with TLE. Before amygdalohippocampectomy, patients were submitted to memory tests. Immunohistochemical and morphometric analyses with glial fibrillary acidic protein (GFAP) for astrogliosis and human leucocyte antigen DR (HLA-DR) for microgliosis were performed in paraffin-embedded HS and control hippocampi. Sclerotic hippocampi exhibited increased gliosis in comparison with controls. In patients with TLE, the area and intensity of staining for HLA-DR were associated with worse performance in the memory tests. Glial fibrillary acidic protein was neither associated nor correlated with memory test performance. Our data suggest association between microgliosis, but not astrogliosis, with visual memory decline in patients with TLE.

Circulating levels of adipokines are altered in patients with temporal lobe epilepsy.

OBJECTIVE: A persistent low-grade inflammatory state has been described in patients with temporal lobe epilepsy (TLE) in the interictal period. Adipokines are cytokines produced by the adipose tissue that can influence inflammatory response. The purpose of this study was to evaluate the plasma levels of adipokines in patients with TLE in comparison with controls. In addition, we sought to investigate whether the levels of adipokines were associated with clinical parameters in TLE. METHODS: Forty patients with TLE and 40 controls were enrolled in this study. All participants were subjected to clinical assessment that included the Mini International Neuropsychiatric Interview (MINI) and the Hamilton Depression Rating Scale (HAM-D). Peripheral blood was drawn, and plasma levels of adipokines (adiponectin, leptin, and resistin) were measured by enzyme-linked immunoassay (ELISA). RESULTS: People with TLE presented higher leptin and lower adiponectin and resistin levels in comparison with controls. The levels of these adipokines correlated negatively with illness length but not with other clinical parameters. In a binary logistic regression model, higher leptin and lower adiponectin levels remained as significant predictors of TLE diagnosis. CONCLUSIONS: These results corroborate the view that TLE is a multisystemic condition associated with low-grade inflammation.

A novel complex neurological phenotype due to a homozygous mutation in FDX2.

Defects in iron-sulphur [Fe-S] cluster biogenesis are increasingly recognized as causing neurological disease. Mutations in a number of genes that encode proteins involved in mitochondrial [Fe-S] protein assembly lead to complex neurological phenotypes. One class of proteins essential in the early cluster assembly are ferredoxins. FDX2 is ubiquitously expressed and is essential in the de novo formation of [2Fe-2S] clusters in humans. We describe and genetically define a novel complex neurological syndrome identified in two Brazilian families, with a novel homozygous mutation in FDX2. Patients were clinically evaluated, underwent MRI, nerve conduction studies, EMG and muscle biopsy. To define the genetic aetiology, a combination of homozygosity mapping and whole exome sequencing was performed. We identified six patients from two apparently unrelated families with autosomal recessive inheritance of a complex neurological phenotype involving optic atrophy and nystagmus developing by age 3, followed by myopathy and recurrent episodes of cramps, myalgia and muscle weakness in the first or second decade of life. Sensory-motor axonal neuropathy led to progressive distal weakness. MRI disclosed a reversible or partially reversible leukoencephalopathy. Muscle biopsy demonstrated an unusual pattern of regional succinate dehydrogenase and cytochrome c oxidase deficiency with iron accumulation. The phenotype was mapped in both families to the same homozygous missense mutation in FDX2 (c.431C > T, p.P144L). The deleterious effect of the mutation was validated by real-time reverse transcription polymerase chain reaction and western blot analysis, which demonstrated normal expression of FDX2 mRNA but severely reduced expression of FDX2 protein in muscle tissue. This study describes a novel complex neurological phenotype with unusual MRI and muscle biopsy features, conclusively mapped to a mutation in FDX2, which encodes a ubiquitously expressed mitochondrial ferredoxin essential for early [Fe-S] cluster biogenesis.

Choroid plexus cauterization on treatment of hydranencephaly and maximal hydrocephalus.

INTRODUCTION: The standard treatment for hydranencephaly and maximal hydrocephalus consists of inserting shunts, although complications frequently occur. Choroid plexus cauterization (CPC) is an alternative, but its long-term efficacy and the factors associated with the success and failure of controlling head circumference (HC) are not well defined. OBJECTIVE: This study aims to evaluate the long-term efficacy and factors related to the success rate of CPC in the treatment of hydranencephaly and maximal hydrocephalus. METHOD: Forty-two children with maximal hydrocephalus and hydranencephaly underwent CPC from 2006 to 2014 and were retrospectively evaluated. Children with less than 3 months of follow-up were excluded. The long-term efficacy and success rate of possible variables (i.e., sex, type of malformation, type of surgery performed, treatment hospital, age, and HC at the time of surgery and birth) were evaluated. RESULTS: Thirty-four children were considered for the effectiveness analysis. Treatment was successful in 24 children (70.6%), and failure occurred in 10 children (29.4%). Failure was detected soon after the endoscopic procedure (average 116 days). There was no difference in effectiveness when comparing the age at the moment of surgery (p = 0.473), type of malformation (p = 1), HC at birth (0.699), and HC at the time of surgery (p = 0.648). The surgical death rate was 7.14%. CONCLUSION: Endoscopic CPC was a valid procedure used to treat hydranencephaly and maximal hydrocephaly, and it was effective in 70.6% of cases, with an average follow-up period of 32 months. When failures occurred, they occurred early. None of the analyzed variables interfered with the success of the treatment.

Does the Simultaneous Use of a Neuroendoscope Influence the Incidence of Ventriculoperitoneal Shunt Infection?

BACKGROUND: The relationship between the use of an endoscope during ventriculoperitoneal shunt (VPS) procedures and infection remains poorly defined. In this study, we sought to analyze whether the simultaneous use of an endoscope could in fact increase the infection rate associated with VPS procedures. METHODS: This study included 438 VPS procedures, 49 in which an endoscope was used (11.2%) and 389 in which an endoscope was not used (88.8%). The infection rates in these 2 main groups were calculated and compared. Subsequently, 4 new groups were created, composed of patients with a shunt inserted for the first time (groups 1A and 1B) and patients with a shunt reviewed or inserted for a second time (groups 2A and 2B). Groups 1A and 2A comprised patients in whom an endoscope was used simultaneously with VPS surgery, and groups 1B and 2B comprised patients in whom an endoscope was not used. These groups were compared to determine the infection rate. RESULTS: The overall infection rate was 18.5%, including 22.4% in the groups in which an endoscope was used and 18% in those in which an endoscope was not used (P = 0.449). Groups 1A and 1B and groups 2A and 2B were matched for possible intervening risk factors. The infection rate was 28.6% in group 1A and 16.2% in group 1B (P = 0.27), and 20% in group 2A and 19.8% in group 2B (P = 0.977). CONCLUSIONS: In the present study, the use of an endoscope during VPS procedures did not increase the risk of surgical infection.

Transsphenoidal Approach to Pituitary Adenomas: from the Microscope to the Endoscope

Objective Report the transitioning from the usage of microscope to endoscope in the transsphenoidal approach to pituitary adenomas with a main focus on technical nuances and incorporation of new surgical instruments throughout several years. Methods Between 1993 and 2015, the Skull Base team of Hospital das Clínicas of UFMG operated on 225 pituitary adenomas through a transsphenoidal approach. The study was divided into 3 groups: the first group (from 1993 to 2001) used the microscope only; the second group (from 2002 to 2004) used both the microscope and endoscope simultaneously, and the third group (from 2005 to 2015) used the endoscope only. Results There were 120 functional adenomas and 98 non-functional pituitary tumors; 7 cases could not be classified. The first two groups consisted of 50 cases, as 175 cases were operated with the endoscope only. As the transseptal moved to the endonasal route, it allowed the procedure to be performed by three or four hands, better visualization of the lateral sella, approach to the cavernous sinus and treatment of CSF leaks with a vascularized graft from the septal mucosa. The surgical instruments were adapted as the microscopic approach was switched to the endoscopic technique. Conclusion Despite the lack of literature data showing superior magnification or lighting when comparing the endoscope to the microscope, we believe the former provides greater comfort and safety in the transsphenoidal approach for the treatment of pituitary adenomas.

Objetivo Relatar a transição do microscópio ao endoscópio no acesso transesfenoidal aos adenomas hipofisários, com ênfase nas nuances técnicas, conceitos e incorporações de instrumentos cirúrgicos ao longo dos anos. Método No período de 1993 a 2015, foram operados 225 adenomas hipofisários por via transesfenoidal pelo grupo de cirurgia de base do crânio do Hospital das Clínicas da UFMG. O estudo foi dividido em três etapas, de acordo com o dispositivo usado para iluminação e magnificação do campo operatório: primeira etapa (1993 a 2001), uso do microscópio; segunda etapa (2002 a 2004), uso simultâneo do microscópio e do endoscópio; terceira etapa (2005 a 2015), uso exclusivo do endoscópio. Resultados Adenomas funcionantes corresponderam a 120 casos, e os não funcionantes, a 98. Sete casos não puderam ser classificados. Cinquenta cirurgias corresponderam às duas primeiras etapas, e 175 foram realizadas exclusivamente com o endoscópio. O acesso migrou do transeptal para o endonasal, o que permitiu a cirurgia a três ou quatro mãos, melhor visualização das porções laterais da sela e abordagem do seio cavernoso, além de tratamento de fístulas com retalho pediculado de mucosa do septo. Os instrumentos cirúrgicos foram adaptados à medida que se trocou o microscópio pelo endoscópio. Conclusão Apesar de a literatura não demonstrar que um tipo de equipamento de iluminação e magnificação seja superior ao outro, acreditamos que o endoscópio nos propiciou maior conforto e segurança no tratamento dos adenomas hipofisários por via transesfenoidal.

Bladder perforation by ventriculoperitoneal shunt.

BACKGROUND: Bladder perforation by ventriculoperitoneal shunt is a rare complication that has been describe in 19 cases in prior literature. CASE DESCRIPTION: This work describes the case of a 4-month-old baby who presented with extrusion of the distal catheter through the urethra. The patient underwent a laparotomy; the catheter was cut close to the bladder wall and repositioned into the peritoneal cavity. The bladder wall was sutured, and the remaining distal portion of the catheter was removed through the urethra. DISCUSSION AND CONCLUSION: Based on this single experience and a literature review, the authors classified the clinical signs and symptoms of bladder perforation by the ventriculoperitoneal shunt catheter. Finally, the authors propose a more conservative approach for this rare complication.

Chemical and cytological analysis of cerebral spinal fluid after intrathecal injection of hypodense fluorescein / Análise química e citológica do líquor após injeção intratecal de solução hipodensa de fluoresceína

ABSTRACT INTRODUCTION: Intrathecal fluorescein has been effective for topographic diagnosis of rhinoliquorrhea. Nonetheless, there are no reports on the study of cerebral spinal fluid (CSF) after use of intrathecal fluorescein. OBJECTIVE: A prospective study attempting to evaluate CSF through chemical and cytological analysis, after injection of fluorescein. METHODS: Prospective analysis of 24 samples of CSF after intrathecal injection of fluorescein for topographic diagnosis of CSF fistulae, collected at the time of puncture and after 24 and 48 h, divided by cellularity: Group 1, up to five cells, and Group 2, with more than five cells. RESULTS: The yellow-greenish color of CSF remained after 48 h in 36%, evidencing permanence of fluorescein. No changes in protein and glucose levels were observed between 0-24 h and 0-48 h. In group 2, an increase in cell count was observed between 24 h and 48 h (p = 0.019). In both groups, there was an increase of neutrophils between 0 and 48 h (p = 0.048) and a decrease between 24 and 48 h (p = 0.05). CONCLUSION: Intrathecal fluorescein provoked discreet meningeal reactions, such as an increase of cells between 24 and 48 h and an increase of neutrophils at 24 h, with a subsequent decrease at 48 h with no correlation with symptomatology.

RESUMO Introdução: A fluoresceína intratecal tem sido efetiva no diagnóstico topográfico da rinoliquorréia. Entretanto, não há estudos no líquor após o uso de fluoresceína intratecal. Objetivo: Estudo prospectivo visando avaliar o líquor, através de análise química e citológica, após injeção de fluoresceína. Método: Análise prospectiva de 24 punções após injeção intratecal de fluoresceína para diagnóstico topográfico de fístula liquórica, coletado no momento da punção, 24 e 48 horas, divididos pela celularidade: grupo 1, com até 5 células e grupo 2 com mais de 5 células. Resultado: A coloração amarelo-esverdeada do líquor permaneceu após 48 horas em 36%, evidenciando permanência de fluoresceína. Observou-se ausência de mudanças no nível de proteína e glicose entre 0-24 horas e 0-48 horas. No grupo 2, um aumento na contagem celular foi observado entre 24 e 48 horas (p = 0,019). No dois grupos juntos, observou-se um aumento de neutrófilos entre 0 e 48 horas (p = 0,048) e uma diminuição entre 24 e 28 horas (p = 0,05). Conclusão: Fluoresceína intratecal provocou discretas reações meníngeas, como o aumento de células entre 24 e 48 horas e aumento dos dos neutrófilos em 24 horas com uma subsequente dimi nuição em 48 horas sem correlação com sintomas.

Chemical and cytological analysis of cerebral spinal fluid after intrathecal injection of hypodense fluorescein.

INTRODUCTION: Intrathecal fluorescein has been effective for topographic diagnosis of rhinoliquorrhea. Nonetheless, there are no reports on the study of cerebral spinal fluid (CSF) after use of intrathecal fluorescein. OBJECTIVE: A prospective study attempting to evaluate CSF through chemical and cytological analysis, after injection of fluorescein. METHODS: Prospective analysis of 24 samples of CSF after intrathecal injection of fluorescein for topographic diagnosis of CSF fistulae, collected at the time of puncture and after 24 and 48h, divided by cellularity: Group 1, up to five cells, and Group 2, with more than five cells. RESULTS: The yellow-greenish color of CSF remained after 48h in 36%, evidencing permanence of fluorescein. No changes in protein and glucose levels were observed between 0-24h and 0-48h. In group 2, an increase in cell count was observed between 24h and 48h (p=0.019). In both groups, there was an increase of neutrophils between 0 and 48h (p=0.048) and a decrease between 24 and 48h (p=0.05). CONCLUSION: Intrathecal fluorescein provoked discreet meningeal reactions, such as an increase of cells between 24 and 48h and an increase of neutrophils at 24h, with a subsequent decrease at 48h with no correlation with symptomatology.

Pure Neuroendoscopic Resection of Cystic Cerebellar Tumors.

BACKGROUND: We describe the resection of cerebellar cystic tumors using pure neuroendoscopy. This technique consists of performing all of the procedures under an endoscopic view, with the instruments introduced into the operative field coaxially to the endoscope through a trocar. CASE DESCRIPTION: Three cases of cerebellar cystic lesions (two pilocytic astrocytomas and one hemangioblastoma) were approached using the pure neuroendoscopic technique. Under general anesthesia and prone positioning, a suboccipital burr hole was created. The endoscope was introduced into the tumor cavity, and a reddish nodule was identified. The monopolar electrode was used to coagulate and dissect the surrounding nodular tissue. Grasping forceps were used to remove the nodule. There were no complications related to tumor removal, and the patients recovered from their symptoms. The follow-up images showed reduction of the cavity with no contrast enhancement. CONCLUSION: The pure neuroendoscopic technique was shown to be minimally invasive and a successful and secure method to treat cystic cerebellar tumors.

Risk Factors for Graft Infection After Cranioplasty in Patients with Large Hemicranial Bony Defects.

OBJECTIVE: To identify infection incidence and related risk factors in patients who underwent cranioplasty (CP) after unilateral decompressive craniectomy (DC). METHODS: CP after DC was performed in 45 patients from April 2011 through January 2012. The covariates studied were compared with occurrence versus nonoccurrence of infection. Univariate analysis was performed, followed by a multivariate analysis and development of independent logistic regression models with significance of 5%. RESULTS: Wound infections were observed in 24% of cases. Patients treated with polymethyl methacrylate flaps had a 31% rate of infection compared with 12% in patients treated with autologous flaps, but the difference was not statistically significant (P = 0.279). Increased risk of infection was associated with performing CP during the same period of hospitalization as DC (45% vs. 8%; P = 0.006), recent systemic infection (53% vs. 10%; P = 0.003), a Glasgow Outcome Scale score lower than 4 (48% vs. none; P < 0.001), motor deficit (42% vs. 5%; P = 0.011), and lower levels of hemoglobin (P < 0.001). Another risk factor for infection was an interval between DC and CP of 29-84 days compared with >168 days (P = 0.007). CONCLUSIONS: The incidence of wound infection was high. Risk factors included motor deficits, Glasgow Outcome Scale score <4, lower hemoglobin levels, recent systemic infections, interval between DC and CP of 29-84 days, and DC and CP performed during the same hospitalization. Performing CP during a different hospitalization may reduce the risk of graft infection because the hemoglobin level would be higher, and patients would be less dependent and free of recent infection.

Neuroendoscopic biopsy of brain lesions: accuracy and complications.

OBJECT: The authors conducted a study to analyze the accuracy of neuroendoscopic biopsies of ventricular and periventricular lesions and record any difficulties or complications of the neuroendoscopic biopsy procedure. METHODS: A total of 50 patients with different diseases consecutively underwent endoscopic biopsy procedures. The biopsy result was considered diagnostic if the pathologist reported any specific finding on which clinicians could base decisions about treatment or observation. The biopsy result was referred to as accurate if the results matched results of a sample obtained later or if the treatment response and disease evolution were compatible with the diagnosis. The biopsy result was considered inaccurate if results showed any relevant differences from those of the later sample or if the patient's disease did not evolve as expected. Complications were recorded and compared with those found in a literature review. RESULTS: For 2 patients, the procedure had to be terminated. The biopsy diagnostic rate was 89.6%, and the accuracy rate was 86%. Complications associated with the procedure were 3 hemorrhages (6%), 2 infections (4%), and 1 death (2%); no reoperations were needed. CONCLUSIONS: Endoscopic biopsy seems to be an accurate procedure with acceptable morbidity and mortality rates.

Clinical and molecular characterization of McArdle's disease in Brazilian patients.

McArdle's disease, a glycogen storage disease type V, is caused by a deficiency of the enzyme myophosphorylase, encoded by the PYGM gene. Worldwide distribution of mutations has revealed interesting data about the prevalence of mutations and population migrations. Currently, more than 100 mutations in the PYGM gene have been described, with some recurrent mutations in the different populations. However, no molecular studies of McArdle's disease were reported in Brazilian patients. Here, we describe the clinical phenotype and genotype of 10 patients from 8 unrelated Brazilian families. Among the 10 patients (3 females, 7 males), eight presented with the typical phenotype, with exercise intolerance, cramps, and myalgia; one patient showed permanent muscle weakness; and one patient showed a mild phenotype. Molecular analysis identified 5 different mutations in the 8 families, both in homozygosis or compound heterozygosis state. Four of them had already been described (p.R50X, p.T692kfs30, p.K609K, and p.G455R), and one, pI513V, is a novel heterozygous mutation. The common nonsense p.R50X mutation was found in 6 of the 8 families, being therefore the commonest mutation in the Brazilian population as well. Other mutations previously reported in European patients were also found in the patients in this study, which was expected considering the European ancestry of the Brazilian population.

Purely neuroendoscopic resection of an intraventricular cavernous angioma: case report.

BACKGROUND: Intraventricular cavernomas are rare and generally treated by microsurgical approach. With the advances in neuroendoscopy, intraventricular lesions have been managed by this technique. However, tumor size and vascular nature are considered restrictive factors. As far as we are concerned, there are two cases in the literature of intraventricular cavernoma resection done by neuroendoscopy. CASE: We describe a case of a man who presented with hydrocephalus secondary to a mesencephalic cavernoma and a second cavernous angioma located at the dorsum thalamus. This second lesion was successfully removed using a pure neuroendoscopic technique at the same time as a third ventriculostomy was performed. CONCLUSION: As neuroendoscopy evolves, we see that lesions considered impossible to be managed by neuroendoscopy before today are being treated with the advantages that the minimally invasive surgery offers.

A tomographic study of the skull base in primary spontaneous cerebrospinal fluid leaks.

INTRODUCTION: This study aims to evaluate the existence of anatomic abnormalities in the skull base that could contribute to the origin of primary spontaneous cerebrospinal fluid leaks (PSL). METHODS: Twenty PSL patients were compared with 20 healthy individuals. The following features were measured through an analysis of computed tomography scans: the angles of the petrosal bones and skull base in both the sagittal and coronal planes; the anteroposterior and mediolateral diameters of the anterior skull base, sella, and sphenoid sinus; the depth of the olfactory fossa; the pneumatization of the sphenoid sinus; the position of the crista galli; and the state of the dorsum sellae. Body mass index (BMI) was compared. RESULTS: There were no differences between the two groups with respect to the angles and diameters of the anterior cranial fossa and the sphenoid sinus or the depth of the olfactory fossa. Pneumatization of the lateral recess of the sphenoid sinus was more frequent in the PSL group (55%) than in the control group (25%, p = 0.053). The dorsum sellae were eroded in 30% of the PSL patients but intact in all healthy subjects. PSL subjects showed higher sellae (1.0 versus 0.8 cm, p = 0.002). The average BMI of PSL patients was higher than that of the control group. CONCLUSION: Global alterations in the skull base of PSL patients were not found. The increase in the height of sellae and the erosion of its dorsum suggest intracranial hypertension. The higher BMI in the case group confirms the relation between obesity and PSL.