Neurosurgical Management of Nonmissile Penetrating Cranial Lesions.

OBJECTIVE: The objective of this study is to present a case series of nonmissile penetrating (NMP) injuries and to establish a workflow for an uncommon mechanism of traumatic head injury through the analysis of each case, classification of the type of lesion, management, and outcome score at follow-up. METHODS: From January 1991 to December 2008, 36,000 patients presenting with traumatic brain injury (TBI) were admitted in the Department of Neurosurgery, Hospital Antônio Targino, Campina Grande-PB, Brazil. From these patients, 11 presenting with lesions caused by NMP objects were selected. RESULTS: Among the 11 patients, 9 were men and 2 were women. Their ages ranged from 7 to 74 years old (mean age ± SD, 29.1 ± 22.99 years). All patients underwent neuroradiologic evaluation. The entry point was classified as natural (orbit) or artificial (skull transfixation), and we also divided the patients presenting with secondary parenchymal or vascular damage from those presenting with only lesions caused by the primary penetration into the cranium and meninges. All patients were neurosurgically treated with removal of the foreign body through craniotomy, except the patient whose object (pen) was removed without craniotomy with local anesthesia. Glasgow Coma Scale (GCS) score on admission was a statistically significant factor on prognosis, and any patient who presented with a GCS score of 15 evolved satisfactorily, and there were no deaths in this group of patients (P = 0.04). CONCLUSIONS: TBIs caused by NMP objects are unusual and caused by aggression, self-inflicted harm (in the case of psychiatric patients), and accident. The foreign body may enter into the skull through a natural hole (orbit, nose, mouth, or ear) or crosses the skull, causing a fracture and creating an artificial hole. Preoperative neuroradiologic assessment is paramount for the correct neurosurgical approach. The main prognostic factor for these patients is the GCS score at admission.

Paraplegia espástica causada por cisticercose intramedular: apresentação de caso e breve revisão bibliográfica / Spastic paraplegia due to spinal cord cisticercosis: case report

Relato de cisticercose intramedular em homem de 42 anos que há seis anos sentia parestesias em ambas as pernas, que evoluíram para ausência de sensação dolorosa, por fim paraparesia espástica dos membros inferiores. Ao exame físico, verificaram-se sinal de Babinski bilateral, espasticidade dos membros inferiores e déficit de sensibilidade abaixo de T7. Ressonância nuclear magnética mostrou uma lesão expansiva ao nível de T5. Durante a exérese do processo, constatou-se que se tratava de cisticercose, em sua forma tumoral intramedular. Após a retirada, o mesmo evoluiu de maneira satisfatória, porém sem regressões dos sintomas.

A case of spinal cord cysticercosis in a 42 year-old man is reported. He presented a six years history of paresthesia in both legs, which progressed to lack of feeling pain, spastic paraparesis of the lower limbs. On physical examination there was bilateral Babinski sign, spasticity of the lower limbs, and lack of sensitivity below T7. The magnetic resonance imaging showed an expansive lesion at the level of T5. Patient was referred for excision of the process, and while it was withdrawn, it was found that to be a cysticercosis in a shape of spinal cord tumor. There was no postoperative complication but the symptoms did not improve.

Manobra de Valsalva como preditor do resultado da cirurgia de hérnia discal lombar / Valsalva maneuver as a predictor of herniated lumbar disc surgical treatment results

Objetivo: Demonstrar o valor da resposta dolorosa à realização da manobra de Valsalva na escolhado tratamento adequado da hérnia discal lombar. Casuística e método: Estudo prospectivo de 2.200pacientes de ambos os gêneros, de diversas faixas etárias, atendidos e acompanhados no HospitalAntônio Targino e na Clínica de Neurologia e Neurocirurgia Domício Holanda, na cidade de CampinaGrande, PB, com diagnóstico de hérnia discal, no período de janeiro de 1993 a outubro de 2008. Ospacientes foram divididos em dois grupos: um grupo de 2.000 pacientes com lombociatalgia decorrentesde hérnias lombares que apresentavam dor durante a manobra de Valsalva e outro grupo de 200 pacientes que tinham as mesmas características clínicas do primeiro grupo, porém não apresentavam exacerbação da dor durante manobra de Valsalva. Resultado: Os 2.000 pacientes que apresentaram dor com a execução da manobra e foram submetidos à cirurgia tiveram boa resposta, enquanto os outros200 pacientes que não referiram a mesma dor e que foram seguidos de maneira ambulatorial tiveramuma diminuição dessa dor, porém não precisaram de tratamento cirúrgico. Conclusão: A dor provocada pela manobra de Valsalva é sinal extremamente útil no que se refere à triagem desses pacientes.

Valsalva maneuver as a predictor of herniated lumbar disc surgical treatment resultsObjective: Demonstrate the value of pain response to the Valsalva maneuver in choosing the appropriate treatment of lumbar disc herniation. Patients and methods: Prospective study of 2,200 patients of both genders in various age groups, treated and followed at Hospital Antônio Targino and Clínica de Neurologia e Neurocirurgia Domício Holanda, Campina Grande, PB, Brazil with disc herniation in theperiod from January 1993 to and in October 2008. Patients were divided into two groups: one group of2,000 patients with herniated lumbar disc with radicular pain that presented pain to maneuver Valsalvaand another group of 200 patients who had similar clinical characteristics of the first group, but showed no exacerbation of pain during maneuver of Valsalva. Results: The 2,000 patients from the first group (Valsalva-positive) underwent surgery and had a good response, while the other 200 Valsalva-negativepatients were followed in outpatient settings, had the pain decreased but did not require surgical treatment. Conclusion: The pain caused by the Valsalva maneuver is extremely useful signal with regard to triage these patients.

Técnica de microincisão na cirurgia do túnel do carpo / Micro-incision for the surgery of carpal tunnel syndrome

Contexto: O tratamento proposto para síndrome do túnel do carpo é dividido em conservador e cirúrgico. O tratamento conservador versa em fisioterapia e uso de medicamentos. A cirurgia para liberação do túnel do carpo é um assunto corrente na literatura, motivo de diversas publicações, principalmente a partir dos anos 1950. Na liberação tradicional, o cirurgião faz uma incisão de 5 cm a 6 cm, estendida longitudinalmente em relação à prega formada pelo punho, e realiza a liberação do ligamento transverso do carpo sob visualização direta. Objetivo: Apresentar a técnica cirúrgica desenvolvida por nós, que consiste em uma microincisão de 1 cm na linha média da prega do punho e recortar os bordos do retináculo dos flexores, e demonstrar as vantagens dessa técnica, perante a vigente. Casuística: A técnica foi utilizada em 40 pacientes de ambos os gêneros, das mais variadas faixas etárias, atendidos e acompanhados no Hospital Antônio Targino e na Clínica de Neurologia e Neurocirurgia Domício Holanda, (ambos situados na cidade de Campina Grande, PB) com síndrome do túnel do carpo no período de janeiro de 1993 a dezembro de 2008. Resultados: Verificou-se que houve diminuição da dor, a técnica proporcionou melhor efeito estético, uma vez que, pela microincisão na linha da prega palmar, pouco tempo após o procedimento a cicatriz perdia-se entre as pregas palmares; em nenhum dos pacientes acompanhados após a cirurgia houve recidiva, constituindo uma vantagem sobre a técnica vigente; quanto à cicatrização, não houve formação de queloides em nenhum dos pacientes, ratificando-se melhor reposta cicatrizante; melhor exequibilidade ao cirurgião e menor tempo cirúrgico. Conclusão: A técnica apresentada oferece resultados extraordinários, diminuindo a chance de recidivas, trazendo melhor exequibilidade ao cirurgião e levando maior satisfação aos pacientes.

Background: The proposed treatment for carpal tunnel syndrome is divided into conservative and surgical. Conservative treatment consists in physiotherapy and medication. Surgery to release the carpal tunnel is a current topic in the literature, subject to various publications, mostly from the 50s. In the traditional release, the surgeon makes an incision from 5 cm to 6 cm long, extended longitudinally in relation to the fold formed by the handle, and holds the release of the transverse carpal ligament under direct visualization. Objective: To present the surgical technique developed by us, which is a micro-incision 1 cm long in the midline of the wrist crease and cut the edges of the flexor retinaculum and demonstrate the advantages of this technique. Methods: The technique was used in forty patients presenting carpal tunnel syndrome, of both genders in a wide range of age groups from January 1993 to December 2008. Results: We found in all the cases that the pain was relieved, a better cosmetic result, the surgical scar was imperceptible shortly after the procedure lost in the palmar crease, there was no recurrence, providing an advantage over the usual techniques as for healing, no keloid formation confirming that there was better healing response, best feasibility for the surgeon and a shorter duration of surgery. Conclusion: The technique presented provides extraordinary results, reducing the chance of recurrence, easier feasibility to the surgeon and more patient?s satisfaction.

Hematoma intradural espontâneodo canal espinal / Spontaneous intradural spinal hematoma

Um caso de hematoma na intradural espinal espontâneo ao nível de T11-12, simulando um quadro de tumor, é relatado. O diagnóstico de processo expansivo intradural extramedular foi feito por meio de ressonância magnética. O exame histopatológico confirmou tratar-se de hematoma organizado. Hematomas espinais espontâneos são raros, e os casos descritos referem-se a hematomas extradurais. Não encontramos na literatura pesquisada hematoma intradural espinal espontâneo.

A case of intradural spontaneous hematoma in the thoracic spine (T11-12), simulating a tumor is presented. The mass lesion was detected by nuclear magnetic resonance imaging, in a patient presenting paraplegia. The diagnosis of organized hematoma was coinfirmed by histopathology. Spinal spontaneous hematomas are very rare and the reports refer to extradural hematomas. Descrition of spontaneous subdural spinal hematoma was not found in the literature searched.

Lombociatalgia decorrente de hidrocefalia: relato de caso / Low back and sciatic pain caused by hydrocephalus

Relata-se o caso de um paciente com quadro de lombocialtalgia decorrente de uma causa atípica: hidrocefalia comunicante. Foi, inicialmente, submetido a exame complementar de imagem da região lombar que não demonstrou anormalidades. Submetido ao tratamento conservador, houve persistência da dor. Na reavaliação, relatou episódios de cefaléia, razão pela qual foi realizada tomografia cerebral que revelou dilatação ventriculoperitoneal. Esse relato sugere a hidrocefalia comunicante como possível etiologia de lombociatalgia.

Epidural hematoma after ventriculoperitoneal shunt surgery: report of 2 cases

Ventriculoperitoneal shunt operations represent the most used choice for treating hydrocephalus, although some related complications have been reported. Due to its rarity, potential dangers, and mortality rate, we present two cases of epidural hematoma following ventriculoperitoneal shunt, discussing its pathophysiology and prophylaxis.