Optimizing resources: financial evaluation of flow diverters versus stent assisted coiling in large and giant cerebral aneurysm management in Brazil public health system.

BACKGROUND: Cerebral aneurysms, especially large and giant aneurysms, pose challenges in neurointerventional surgery. Treatment choices involve clinical presentation, aneurysm details, and global resource variations. Neurointerventional methods, while innovative, may be cost restrictive in certain regions. In public healthcare, cost is crucial, notably in countries like Brazil. This study examines the device specific cost estimation of flow diverters (FD) and traditional stent assisted coiling (SAC) for large and giant cerebral aneurysms, providing insights into optimizing neurosurgical interventions within the Brazilian public health system's unique challenges. METHODS: A comprehensive retrospective analysis was conducted at our medical center of cases of large and giant aneurysms treated between 2013 and 2023. Determination of the estimated number of coils for aneurysms previously treated with FDs at our center was made, with the cost of each case, and the difference between both treatments was calculated. RESULTS: We investigated the profiles of 77 patients: 40 had large aneurysms (51.9%) and 37 had giant aneurysms (48.1%). Large aneurysms had a mean cost difference of US$274 (standard deviation (SD) $2071), underscoring the device specific cost estimation of FDs over SAC in their treatment. For giant aneurysms, the mean cost difference increased to $6396 (SD $2694), indicating FDs as the more economically sound choice. CONCLUSION: Our study indicated that, for the treatment of giant aneurysms and some large aneurysms, the FD intervention was more economical than SAC.

Evaluating the efficacy of stent retriever and catheter aspiration combination in refractory cerebral venous sinus Thrombosis: A comprehensive Meta-Analysis.

BACKGROUND: Cerebral Venous Sinus Thrombosis (CVST) is a rare but potentially life-threatening condition, often associated with specific risk factors. The primary treatment for CVST is anticoagulation, but some cases progress to Refractory CVST (rCVST), requiring endovascular treatment. A combination of stent retriever and catheter aspiration is emerging as a promising technique to enhance treatment effectiveness. We conducted a systematic review and meta-analysis to assess the safety and efficacy of this approach, aiming to improve recanalization success and neurological outcomes while reducing complications in rCVST patients. METHODS: A search following PRISMA guidelines was conducted across Pubmed, Embase, Web of Science, and Cochrane databases to identify studies on the use of stent retrievers and catheter aspiration for rCVST. Pooled analysis with 95 % confidence intervals was used to assess the effects. Heterogeneity was evaluated using I2 statistics and a random-effects model was used. Complete recanalization. good clinical outcomes (mRS ≤ 2), hemorrhagic, neurological, ischemic, and total complications, poor clinical outcomes (mRS > 2), and mortality were assessed. RESULTS: A meta-analysis of five retrospective studies involving 55 patients examined outcomes in CVST. The median mean age was 40 years. Complete recanalization rate: 36 % (95 % CI: 9 % to 62 %, I2 = 90 %). Good clinical outcomes: 72 % (95 % CI: 50 % to 94 %, I2 = 76 %). Hemorrhagic complications: 2 % (95 % CI: 0 % to 8 %, I2 = 15 %). Ischemic complications: 0 % (95 % CI: 0 % to 6 %, I2 = 0 %). Neurological complications: 7 % (95 % CI: 0 % to 14 %, I2 = 0 %). Poor clinical outcomes: 26 % (95 % CI: 6 % to 46 %, I2 = 70 %). Total complications: 6 % (95 % CI: 0 % to 15 %, I2 = 10 %). Mortality rate: 5 % (95 % CI: 0 % to 13 %, I2 = 19 %). CONCLUSION: This systematic review and meta-analysis scrutinized the efficacy of combining Stent Retriever and Catheter Aspiration for rCVST. Findings highlighted varied outcomes, including recanalization rates, complications, and mortality. The dichotomy between good and poor outcomes underscores the necessity for personalized therapeutic decisions. While offering a comprehensive overview, the study emphasizes literature heterogeneity, suggesting a need for more rigorous and standardized research to optimize therapeutic strategies in clinical practice.

Eosinophils induces glioblastoma cell suppression and apoptosis - Roles of GM-CSF and cysteinyl-leukotrienes.

BACKGROUND: Glioblastoma is the most common and lethal primary brain tumor in adults. Despite the available cancer treatments, the recurrence of the tumor is high, and the survival rate is low. New approaches to antitumor therapies are needed. Eosinophils are prominent in allergic diseases and accumulate in several human brain tumors. Recently, the antitumor role of eosinophils has been targeted as eosinophils release several cytotoxic factors that induce cell impairment and death. OBJECTIVE: Here we aim to evaluate the interaction of the eosinophil and glioblastoma cells, the mechanism involved in the potential killing of the glioblastoma cells by the eosinophils, and how allergy/asthma could confer a better glioblastoma prognosis. METHODS: Eosinophils and serum from asthmatic and non-asthmatic donors were cultivated with different glioblastoma cell lines. RESULTS: Glioblastoma cells recruit eosinophils via GM-CSF signaling, activating and increasing eosinophil survivability and function on a GM-CSF-dependent manner. Eosinophils reduce glioblastoma cells metabolism, proliferation, and migration, via Fas/FasL. Cysteinyl-leukotrienes are accounted for the asthmatic serum enhancement of the glioblastoma cell migration and proliferation. Cysteinyl-leukotrienes enhance glioblastoma cell proliferation and migration, albeit activate eosinophils that suppress glioblastoma cells. CONCLUSION: Eosinophils have the potential to be key cells on glioblastoma therapeutics, as allergy and eosinophilia are correlated with a better glioblastoma prognosis. Eosinophils are elicited and attach to glioblastoma cells, where, by its cytotoxic function, via Fas/FasL, hind glioblastoma cell metabolism, proliferation, migration, and induce cell death.

Recent advances in the use of liquid biopsy to fight central nervous system tumors.

Brain tumors are considered one of the deadliest types of cancer, being challenging to treat, especially due to the blood-brain barrier, which has been linked to treatment resistance. The genomic classification of brain tumors has been helping in the diagnostic precision, however tumor heterogeneity in addition to the difficulties to obtain tissue biopsies, represent a challenge. The biopsies are usually obtained either via neurosurgical removal or stereotactic tissue biopsy, which can be risky procedures for the patient. To overcome these challenges, liquid biopsy has become an interesting option by constituting a safer procedure than conventional biopsy, which may offer valuable cellular and molecular information representative of the whole organism. Besides, it is relatively easy to obtain such as in the case of blood (venipuncture) and urine sample collection. In the present comprehensive review, we discuss the newest information regarding liquid biopsy in the brain tumors' field, methods employed, the different sources of bio-fluids and their potential circulating targets.

The Use of Liquid Biopsy in the Molecular Analysis of Plasma Compared to the Tumour Tissue from a Patient with Brain Metastasis: A Case Report.

Different cancers have multiple genetic mutations, which vary depending on the affected tumour tissue. Small biopsies may not always represent all the genetic landscape of the tumour. To improve the chances of identifying mutations at different disease stages (early, during the disease course, and refractory stage), liquid biopsies offer an advantage to traditional tissue biopsy. In addition, it is possible to detect mutations related to metastatic events depending on the cancer types analysed as will be discussed in this case report, which describes a patient with brain metastasis and lung cancer that harboured K-RAS mutations both in the brain tumour and in the ctDNA present in the bloodstream.

Freehand Ventriculoperitoneal Shunt for Idiopathic Intracranial Hypertension: Technical Note for Slit-Like Ventricle Puncture.

Idiopathic intracranial hypertension (IIH) is a syndrome characterized by elevated intracranial pressure, headache, and papilledema. It is frequently associated with obese women and can result in irreversible vision loss. The ventriculoperitoneal (VP) shunt has been proven to be superior to the lumboperitoneal (LP) shunt in IIH patients, with better clinical outcomes. It has been reported that the accurate placement of the ventricular catheter is highly important for shunt survival. However, a slit-like ventricle pattern, typically seen in the disease, has been considered a great concern and challenge for ventricular catheter placement, primarily for freehand technique. Frameless stereotaxy, ultrasound, and endoscopy have been described to improve the accuracy of catheter insertion. However, intraoperative image guidance is not widely accessible, especially in lower-resource countries, due to the high costs associated with its use. Techniques to improve the accuracy of the freehand VP shunt in IIH are scarce in the literature, and any effort to contribute to its development is valuable and helpful.

Liquid biopsy evaluation of circulating tumor DNA, miRNAs, and cytokines in meningioma patients.

Introduction: Liquid biopsy is a non-invasive method used to detect cancer and monitor treatment responses by analyzing blood or other bodily fluids for cancer biomarkers. Meningiomas are the most common primary central nervous system tumors, and biomarkers play a crucial role in their diagnosis, prognosis, and treatment monitoring. The World Health Organization (WHO) classifies meningiomas based on tumor grades and molecular alterations in genes such as in NF2, AKT1, TRAF7, SMO, PIK3CA, KLF4, SMARCE1, BAP1, H3K27me3, TERT promoter, and CDKN2A/B. Liquid biopsy, specifically cell-free DNA (cfDNA) analysis, has shown potential for monitoring meningiomas as it can detect ctDNA release in the blood, unaffected by the blood-brain barrier. MicroRNAs (miRNAs) have also been found to be deregulated in various cancers, including meningiomas, presenting potential as diagnostic biomarkers. Additionally, studying cytokines in the tumor microenvironment may aid in establishing prognostic or diagnostic panels for meningiomas. Methods: In the present study we analyzed the DNA coming from both the plasma and tumor samples, in addition to analyze miRNA-21 and cytokines in the plasma of 28 meningioma patients. Discussion and Conclusion: Our findings indicate that the detection of ctDNA in the plasma of meningioma patients is feasible. However, it's important to note that certain challenges persist when comparing plasma DNA analysis to that of tumor tissues. In our study, we observed a paired identification of mutations in only one patient, highlighting the complexities involved. Furthermore, we successfully identified miR-21 and cytokines in the plasma samples. Notably, our analysis of Interleukin 6 (IL-6) unveiled higher expression in the clear cell subtype compared to the other types. Despite the ongoing research, the clinical implementation of liquid biopsy in meningiomas remains somewhat limited. Nevertheless, our promising results underscore the need for further investigation.

P-glycoprotein and cancer: what do we currently know?

Acquired resistance during cancer treatment is unfortunately a frequent event. There are several reasons for this, including the ability of the ATP-binding cassette transporters (ABC transporters), which are integral membrane proteins, to export chemotherapeutic molecules from the interior of the tumor cells. One important member of this family is the protein known as Permeability Glycoprotein (P-Glycoprotein, P-gp or ABCB1). Its clinical relevance relies mainly on the fact that the inhibition of P-gp and other ABC transporters could result in the reversal of the multidrug resistance (MDR) phenotype in some patients. Recently, other roles apart from being a key player in MDR, have emerged for P-gp. Therefore, this review discusses the relationship between P-gp and MDR, in addition to the possible role of this protein as a biomarker in cancer.

Determinants of success in treating acute ischemic cerebral and ocular ischemia through carotid revascularization. An observational study of a case series.

OBJECTIVE: stroke etiology is ischemia in 85%, and in circa 25% of these, the source is the extracranial carotid. Recurrence is frequent and usually more severe. Carotid revascularization prevents new ischemic strokes. The sooner the treatment is undertaken, complete recovery chances are greater with less recurrences. But, historically, intervention in the acute setting was catastrophic. Objective: Identify determinants of success when carotid revascularization after a recent cerebral ischemic event is performed. MATERIALS AND METHODS: A cohort of 50 subjects underwent carotid revascularization after ischemic symptoms, within a period of 71 months. The currently diagnostic tools were used, and the symptoms stratified by the Rankin scale. The extension of the cerebral lesion and the source location the source of the event was analyzed. RESULTS: indications were based on the Rankin Scale (R0: 35.4%; R1: 45.8%; R2:18.8% and R3: zero), on the location of the source and the absence of ischemic areas greater than 15mm. An early surgical approach was adopted in all patients. Extreme care was applied to control arterial pressure. At discharge, no additional deficits were observed. CONCLUSIONS: carotid revascularization after ischemic events can be achieved without additional morbidity and no recurrences, using the most appropriate therapy in the shortest time, in patients with Rankin Scale up to 2, absence of intracranial hemorrhage and single or multiple ischemic intracerebral areas, with 15mm or less in their greater dimension.

Determinants of success in treating acute ischemic cerebral and ocular ischemia through carotid revascularization. An observational study of a case series / Determinantes do sucesso no tratamento da isquemia cerebral e ocular aguda por meio da revascularização carotídea. Um estudo observacional de uma série de casos

ABSTRACT Objective: stroke etiology is ischemia in 85%, and in circa 25% of these, the source is the extracranial carotid. Recurrence is frequent and usually more severe. Carotid revascularization prevents new ischemic strokes. The sooner the treatment is undertaken, complete recovery chances are greater with less recurrences. But, historically, intervention in the acute setting was catastrophic. Objective: Identify determinants of success when carotid revascularization after a recent cerebral ischemic event is performed. Materials and Methods: A cohort of 50 subjects underwent carotid revascularization after ischemic symptoms, within a period of 71 months. The currently diagnostic tools were used, and the symptoms stratified by the Rankin scale. The extension of the cerebral lesion and the source location the source of the event was analyzed. Results: indications were based on the Rankin Scale (R0: 35.4%; R1: 45.8%; R2:18.8% and R3: zero), on the location of the source and the absence of ischemic areas greater than 15mm. An early surgical approach was adopted in all patients. Extreme care was applied to control arterial pressure. At discharge, no additional deficits were observed. Conclusions: carotid revascularization after ischemic events can be achieved without additional morbidity and no recurrences, using the most appropriate therapy in the shortest time, in patients with Rankin Scale up to 2, absence of intracranial hemorrhage and single or multiple ischemic intracerebral areas, with 15mm or less in their greater dimension.

RESUMO Introdução: isquemia é a etiologia do acidente vascular cerebral em 85% dos casos e em cerca de 25% destes, a fonte é a carótida extracraniana. Recorrência é frequente e usualmente mais grave que a inicial. A revascularização carotídea previne novos acidentes. Quanto mais cedo for realizado o tratamento, maiores as chances de recuperação e menor o risco de recorrência. Mas, historicamente, os resultados das intervenções precoces eram catastróficos. Objetivos: identificar determinantes de sucesso da revascularização carotídea após um evento isquêmico cerebral recente. Materiais e Métodos: uma coorte de 50 pacientes foi submetida à revascularização carotídea após sintomas isquêmicos, em um período de 71 meses. Foram empregados os métodos de investigação atuais e os sintomas estratificados pela Escala de Rankin. A extensão das lesões cerebrais e a fonte do evento foram estudados e analisados. Resultados: as indicações foram baseadas na escala de Rankin (R0: 35.4%; R1: 45.8%; R2: 18.8% e R3: zero), na localização da fonte e na ausência de áreas isquêmicas com menos de 15mm. Uma abordagem cirúrgica precoce foi empregada em todos os pacientes. Cuidados extremos com a pressão arterial foram aplicados. Na alta hospitalar, nenhum déficit adicional foi observado. Conclusões: a revascularização carotídea após eventos isquêmicos pode ser realizada sem morbidade adicional ou recorrências, empregando a terapêutica mais apropriada no período de tempo mais curto, em pacientes classificados como Rankin até 2, na ausência de hemorragia intracraniana e com áreas isquêmicas intracerebrais únicas ou múltiplas, com menos de 15mm em sua maior dimensão.

Deep Vein Thrombosis in the Setting of Neurofibromatosis Type 1: Case Report

Neurofibromatosis type 1 (NF1) is a genetic syndrome which typically presents with neurological manifestations. Some of the patients may also present with vasculopathies, among which arterial aneurysms and stenosis are the most common. Deep vein thrombosis (DVT) has rarely been described, and, to the best of our knowledge, the present is the first report of DVT due to venous compression by a neurofibroma in the setting of NF1. This is the case of a 23-year-old male with NF1 who experienced DVT due to compression of the left posterior tibial veins by a large tumor arising from the tibial nerve. The DVT was acutely treated with enoxaparin and then with rivaroxaban. Two months after the diagnosis, Doppler ultrasonography showed partial recanalization and persistence of the DVT. The patient was then referred to neurosurgery for surgical resection of the tumor. There were no complications during the procedure, and the patient did not present postoperative neurological deficits. The final histopathological diagnosis was of a benign neurofibroma. After one year of follow-up with vascular surgery, the patient presented no more episodes of DVT. In case there is a tumor compressing the deep vessels of the leg and promoting DVT, surgical resection with microsurgical techniques may be curative.

Therapeutic anticoagulation for venous thromboembolism after recent brain surgery: Evaluating the risk of intracranial hemorrhage.

OBJECTIVE: Venous thromboembolism (VTE) is particularly prevalent in neurosurgical patients. A major dilemma arises when a patient needs to be treated with therapeutic anticoagulation during the early days after brain surgery due to the concern of intracranial hemorrhage (ICH). There is still a lack of studies regarding the optimal time to start therapeutic anticoagulation and risk assessment of ICH in this setting. This study aims to assess the risk of ICH for patients with venous thromboembolism treated with therapeutic anticoagulation started within the first 30 days after intracranial neurosurgical procedure. PATIENTS AND METHODS: This study was an analytical observational research based on a retrospective record review of VTE patients submitted to therapeutic anticoagulation started within the first 30 days after intracranial neurosurgical procedure at Paulo Niemeyer State Brain Institute, from September 2013 to February 2020. Patients' clinical and surgical data, anticoagulation drug therapy, time interval between surgery and start of therapeutic anticoagulation, bleeding complications and hemorrhage-related deaths were some of variables evaluated. A p value < 0.05 was considered statistically significant. RESULTS: A series of 53 consecutive patients and 54 intracranial neurosurgical procedures met the criteria. Twenty-nine (53.7 %) patients were treated with warfarin, 21 (38.9 %) with new oral anticoagulant (NOAC) and 4 (7.4 %) only with enoxaparin. VTE diagnosis between the postoperative days 0 and 4 was statistically associated with a delay in starting therapeutic anticoagulation of more than two days (p < 0.001). The frequency of bleeding complication was statistically significant higher in patients treated with warfarin (p = 0.03). Although with no statistical significance, there were a higher rate of ICH in patients receiving warfarin (13.8 % vs. 0% in NOAC group, p = 0.13). There was no statistical difference about ICH incidence between the postoperative intervals from 2nd to 7th, 8th to 14th, 15th to 21 st and 22th to 29th days (p = 0.35). Hemorrhage-related mortality rate was 3.7 %. CONCLUSION: ICH was not statistically associated with the timing of therapeutic anticoagulation after brain surgery between the 2nd and 29th postoperative days, which may encourage the strategy of early treatment considering the life-threatening potential of VTE. However, the risk of ICH should not be ignored in the setting of warfarin use, which had a remarkable incidence of 13.8 %. Warfarin must be used cautiously, especially in high-grade gliomas.

Using the Lateral Pontine Safe Entry Zone for Resection of Deep-Seated Cavernous Malformations in the Lateral Pons: 2-Dimensional Operative Video.

The retrosigmoid approach is one of the main approaches used in the surgical management of pontine cavernous malformations. It definitely provides a lateral route to large central lesions but also makes possible resection of some ventral lesions as an alternative to the petrosal approaches. However, when these vascular malformations do not emerge on surface, one of the safe corridors delimited by the origin of the trigeminal nerve and the seventh-eight cranial nerve complex can be used.1-5 Baghai et al2 described the lateral pontine safe entry zone in 1982, as an alternative to approaches through the floor of the fourth ventricle when performing tumor biopsies. They advocated a small neurotomy performed right between the emergence of the trigeminal nerve and the facial-vestibulocochlear cranial nerves complex. Accurate image guidance, intraoperative cranial nerve monitoring, and comprehensive anatomical knowledge are critical for this approach.4,5 Knowing the natural history of a brainstem cavernous malformation after bleeding,6 we sought to demonstrate in this video: (1) the use of the retrosigmoid craniotomy in lateral decubitus for resection of deep-seated pontine cavernous malformations; (2) the wide opening of arachnoid membranes and dissection of the superior petrosal vein complex to improve surgical freedom and prevent use of fixed cerebellar retraction; and (3) the opening of the petrosal fissure and exposure of the lateral pontine zone for gross total resection of a cavernous malformation in a 19-yr-old female with a classical crossed brainstem syndrome. She had full neurological recovery after 3 mo of follow-up. The patient consented in full to the surgical procedure and publication of the video and manuscript.

The First Two Years of Instituto Estadual do Cérebro Paulo Niemeyer: Initial Results of a Brazilian Public Hospital Dedicated to Neurosurgery

The dissemination of specialty hospitals throughout the urban centers has revolutionized the full spectrum of care for cardiology, oncology and orthopedics during the last decades. To centralize care, from translational and basic research to clinicians and surgeons, in the same dedicated institution leads to a decrease in complications rates, mortality and possible reductions in the length of hospital stays. Moreover, there has been a significant impact on hospital costs and on the quality of care. The Insituto Estadual do Cérebro Paulo Niemeyer (IECPN, in the Portuguese acronym) was opened in June 2013 in Rio de Janeiro, Brazil. It is the very first high-volume neurosurgical institution in the country. The core foundation of this institution is that the anesthesiologists, intensive care practitioners, nurses, pathologists, radiologists and rehabilitation staffs are trained and live the full management of neurosurgical lesions at the same facility on a daily basis. The present paper seeks to analyze the circumstances in which the institution was planned and opened as well as its complexity, infrastructure and initial results following its first 24 months of operation.

Unilateral thalamic and pallidal deep brain stimulation for idiopathic hemidystonia: results of individual and combined stimulations. Case report.

Pallidal stimulation has been the usual surgical treatment for dystonia in the last decades. The continuous investigation of the physiopathology and the motor pathways involved leads to the search for complementary targets to improve results. The authors present the case of a 37-year-old woman who had suffered from idiopathic hemidystonia with hyperkinetic and hypokinetic movements for 11 years, and who was treated with deep brain stimulation. A brief literature review is also provided. The globus pallidus internus and the ventral intermediate/ventral oral posterior complex of the thalamus were stimulated separately and simultaneously for 3 months and compared using the Burke-Fahn-Marsden Dystonia Rating Scale and the Global Dystonia Severity Rating Scale, with a 3.5-year follow-up. The synergism of multiple-target stimulation resulted in a complete improvement of the mixed dystonic symptoms.

Engaging in a Keyhole Concept for the Management of Ruptured and Unruptured Aneurysms.

OBJECTIVE: Many new endovascular devices have been used under the guidance of the International Subarachnoid Aneurysm Trial. Clipping still offers higher occlusion rates, and its technique continues to evolve, resulting in smaller exposures and reduced manipulation to brain tissue. We sought to evaluate the routine use of the minisphenoidal approach to manage intracranial aneurysms in a high-volume institution. METHODS: We retrospectively reviewed our database of patients with aneurysm from October 2013 to May 2016. Data were originally collected prospectively. The minisphenoidal approach has been progressively replacing the pterional approach for managing aneurysms in our department. Occlusion rates for ruptured and unruptured aneurysms were analyzed using late follow-up angiograms. Functional outcome assessment and the impact on quality of life were also measured. RESULTS: We performed 124 minisphenoidal craniotomies in 117 patients to clip 147 aneurysms. Patient mean age was 53.9 years. Seventy patients (59.8%) presented with subarachnoid hemorrhage. Middle cerebral artery aneurysms represented 48% of the total number of aneurysms; posterior communicating artery aneurysms represented 24%. The minisphenoidal craniotomy was helpful in managing superior cerebellar artery aneurysms and 1 ruptured orbitofrontal artery aneurysm. We achieved an occlusion rate of 97.8%, with a mean follow-up of 13.2 months. Favorable outcomes were achieved for 79% of patients with subarachnoid hemorrhage and for 98% of unruptured patients. CONCLUSIONS: Evolution of endovascular techniques has paved the way for minimizing surgical exposures. Routine use of the minisphenoidal approach for managing ruptured, unruptured, and previously coiled aneurysms is safe and provides adequate exposure with robust occlusion rates.

Temporal muscle haematoma as a cause of suboptimal haemicraniectomy: case report.

OBJECTIVE: To call attention to an unusual complication of decompressive haemicraniectomy in the treatment of malignant haemispheric infarction. METHOD: We describe a case in which partial decompression occurred despite large craniectomy. Complete decompression followed resection of the temporal muscle. Pertinent literature is briefly reviewed. CASE DESCRIPTION: A 55-year old woman developed massive right middle cerebral artery infarction evolving to cerebral haerniation in 40 hours. Decompressive haemicraniectomy without cortical excision was unable to revert coma and decerebrate posturing because of a massive temporal muscle haemorrhage with persistent contralateral deviation of midline structures. Muscle resection was followed by adequate external haerniation of the affected haemisphere and fast recovery. Cranioplasty was succesfully performed 22 days later, following gradual regression of cerebral oedema. CONCLUSION: There is an increasing perception of the need to operate patients with massive middle cerebral or internal carotid artery territory infarctions before the development of coma and cerebral haerniation. The most common factor leading to inadequate surgical decompression is small size craniectomy. The case reported calls attention to temporal muscle bleeding as an additional complication of craniectomy.

Temporal muscle haematoma as a cause of suboptimal haemicraniectomy: case report

OBJECTIVE: To call attention to an unusual complication of decompressive haemicraniectomy in the treatment of malignant haemispheric infarction. METHOD: We describe a case in which partial decompression occurred despite large craniectomy. Complete decompression followed resection of the temporal muscle. Pertinent literature is briefly reviewed. CASE DESCRIPTION: A 55-year old woman developed massive right middle cerebral artery infarction evolving to cerebral haerniation in 40 hours. Decompressive haemicraniectomy without cortical excision was unable to revert coma and decerebrate posturing because of a massive temporal muscle haemorrhage with persistent contralateral deviation of midline structures. Muscle resection was followed by adequate external haerniation of the affected haemisphere and fast recovery. Cranioplasty was succesfully performed 22 days later, following gradual regression of cerebral oedema. CONCLUSION: There is an increasing perception of the need to operate patients with massive middle cerebral or internal carotid artery territory infarctions before the development of coma and cerebral haerniation. The most common factor leading to inadequate surgical decompression is small size craniectomy. The case reported calls attention to temporal muscle bleeding as an additional complication of craniectomy

Esclerose múltipla, ependimoma medular e meningioma intracraniano: relato de caso / Multiple sclerosis, spinal cord ependymoma and intracranial meningioma: case report

Relatamos a associaçäo impar entre esclerose múltipla (EM), tumor medular e tumor intracraniano em uma paciente de 63 anos de idade e com EM há dez anos com evoluçäo em surtos de remissäo e exacerbaçäo. Havia melhora dos sintomas com o uso de corticosteráides. Em 1997 apresentou paraparesia crural e do membro superior direito, de instalaçäo progressiva e que näo respondeu à corticoterapia. A ressonância magnética da coluna cervical evidenciou tumor intramedular, que se revelou um ependimoma, e a do crânio, a presença de meningioma parietal à esquerda. Ressaltamos a associaçäo incomum entre tumores do sistema nervoso central e EM e enfatizamos a necessidade de investigaçäo clínica e por imagem diante de uma manifestaçäo ou evoluçäo clínica incomum no curso da doença

Pseudotumor hipofisário secundário e hipotireoidismo primário / Primary hypothyroidism presenting with pituitary enlargement

Apresentamos o caso de uma menina de 15 anos que foi enviada inicialmente ao Serviço de Neurocirurgia com diagnóstico de macroadenoma hipofisário näo funcionante, por apresentar lesäo expansiva em regiäo selar à RNM e näo ter qualquer sintoma ou sinal de hipersecreçäo hormonal. Feito o diagnóstico de hipotireoidismo e iniciada reposiçäo de L-tiroxina (na dose diária de até 150 mcg) com normalizaçäo da funçäo tireoidiana, nova RNM mostrou regressäo da imagem hipofisária. Este caso demonstra que em qualquer lesäo suspeita da regiäo hipotálamo-hipofisária deve ser realizada avaliaçäo hormonal completa antes do envio à cirurgia.