New perspectives on assessment and understanding of the patient with cranial bone defect: a morphometric and cerebral radiodensity assessment.

Background: Skull defects after decompressive craniectomy (DC) cause physiological changes in brain function and patients can have neurologic symptoms after the surgery. The objective of this study is to evaluate whether there are morphometric changes in the cortical surface and radiodensity of brain tissue in patients undergoing cranioplasty and whether those variables are correlated with neurological prognosis. Methods: This is a prospective cohort with 30 patients who were submitted to cranioplasty and followed for 6 months. Patients underwent simple head CT before and after cranioplasty for morphometric and cerebral radiodensity assessment. A complete neurological exam with Mini-Mental State Examination (MMSE), modified Rankin Scale, and the Barthel Index was performed to assess neurological prognosis. Results: There was an improvement in all symptoms of the syndrome of the trephined, specifically for headache (p = 0.004) and intolerance changing head position (p = 0.016). Muscle strength contralateral to bone defect side also improved (p = 0.02). Midline shift of intracranial structures decreased after surgery (p = 0.004). The Anterior Distance Difference (ADif) and Posterior Distance Difference (PDif) were used to assess morphometric changes and varied significantly after surgery. PDif was weakly correlated with MMSE (p = 0.03; r = -0.4) and Barthel index (p = 0.035; r = -0.39). The ratio between the radiodensities of gray matter and white matter (GWR) was used to assess cerebral radiodensity and was also correlated with MMSE (p = 0.041; r = -0.37). Conclusion: Morphological anatomy and radiodensity of the cerebral cortex can be used as a tool to assess neurological prognosis after DC.

Tranexamic acid in bleeding reduction and operative time of nasal surgeries: systematic review and meta-analysis.

PURPOSE: Our study goal is to review the efficacy of tranexamic acid in reducing blood loss and operative time in nasal surgeries. METHODS: We included randomized clinical trials using oral or intravenous tranexamic acid, excluded non-randomized studies, topic administration, coagulopathy, and using other drugs interfering in the coagulation cascade. Online databases, National Library of Medicine (MEDLINE-PubMED), Latin American and Caribbean Literature on Health Sciences (Lilacs), Cochrane Library, Embase and Google Scholar were used to perform the search. The review was registered in PROSPERO by no CRD42022310977. Two authors, independently, selected the articles meeting the inclusion criteria. They extracted the data and used RevMan 5 software to perform the meta-analysis. RESULTS: Our search resulted in 16 RCTs that were included in the meta-analysis totalizing 1108 patients. Studies were evaluated resulting in a low risk of bias for the five domains. The use of tranexamic acid resulted in significant reduction in duration of surgery (DOS) and intraoperative blood loss (IBL) had significant reduction. The level of evidence according to GRADE System was high in all studies and variables. CONCLUSION: Tranexamic acid has an important role in reducing intraoperative blood loss and duration of surgery. Our study has some limitations due to the low number of RCTs available in the literature.

Measuring pituitary tumor volume: a comparison of the simplified and non-simplified ellipsoid equation with the 3D planimetric volume assessment.

PURPOSE: The ellipsoid equation came in an attempt to facilitate the estimation of tumor volume, by measuring the height, width, and anteroposterior length of the lesion. The estimated tumor volume can sometimes be different between methods, thus, it is of extreme interest to evaluate if the methods are significantly different, as well as to discuss the main limitations of each one. METHODS: This is an observational, analytical, cross-sectional study. A systematic review of the literature was also performed in order to discuss the results observed in the present study. RESULTS: A total of 82 patients (43 males and 39 females) ranging in age from 15 to 78 years (mean 47.95 ± 14.76) were included in the study. Seven patients were classified as Knosp grade 0 (8.5%), 36 Knosp grade 1 (44%), 14 Knosp grade 2 (17%), 20 Knosp grade 3 (24.4%), 5 Knosp grade 4 (6.1%). The tumor volume estimated by 3D planimetric assessment, non-simplified ellipsoid equation, and simplified ellipsoid formula averaged 10.68 cm³, 10.36 cm³, and 9.9 cm³ respectively. CONCLUSION: A simplified form of the ellipsoid equation increases the divergence between the measurement obtained in planimetry, and should be discouraged, in view of the new automated methods of performing quick calculations using periodic digits. The non-simplified form underestimated the tumor volume by 2.9% on average but did so regularly. In clinical practice, measurement should be accompanied by an evaluation of tumor morphology.

Improvement in neurological outcome and brain hemodynamics after late cranioplasty.

BACKGROUND: Early cranioplasty has been encouraged after decompressive craniectomy (DC), aiming to reduce consequences of atmospheric pressure over the opened skull. However, this practice may not be often available in low-middle-income countries (LMICs). We evaluated clinical improvement, hemodynamic changes in each hemisphere, and the hemodynamic balance between hemispheres after late cranioplasty in a LMIC, as the institution's routine resources allowed. METHODS: Prospective cohort study included patients with bone defects after DC evaluated with perfusion tomography (PCT) and transcranial Doppler (TCD) and performed neurological examinations with prognostic scales (mRS, MMSE, and Barthel Index) before and 6 months after surgery. RESULTS: A final sample of 26 patients was analyzed. Satisfactory improvement of neurological outcome was observed, as well as significant improvement in the mRS (p = 0.005), MMSE (p < 0.001), and Barthel Index (p = 0.002). Outpatient waiting time for cranioplasty was 15.23 (SD 17.66) months. PCT showed a significant decrease in the mean transit time (MTT) and cerebral blood volume (CBV) only on the operated side. Although most previous studies have shown an increase in cerebral blood flow (CBF), we noticed a slight and nonsignificant decrease, despite a significant increase in the middle cerebral artery flow velocity in both hemispheres on TCD. There was a moderate correlation between the MTT and contralateral muscle strength (r = - 0.4; p = 0.034), as well as between TCD and neurological outcomes ipsilateral (MMSE; r = 0.54, p = 0.03) and contralateral (MRS; p = 0.031, r = - 0.48) to the operated side. CONCLUSION: Even 1 year after DC, cranioplasty may improve cerebral perfusion and neurological outcomes and should be encouraged.

Primary central nervous system tumors in Sergipe, Brazil: descriptive epidemiology between 2010 and 2018.

BACKGROUND: Central nervous system (CNS) tumors are a heterogeneous group with high morbidity and mortality. OBJECTIVES: To describe the epidemiology of primary CNS tumors diagnosed in the state of Sergipe from 2010 to 2018. METHODS: We evaluated histopathological and immunohistochemical reports on primary CNS tumors diagnosed in Sergipe, Brazil, between 2010 and 2018 and collected data regarding age, sex, location, World Health Organization (WHO) classification and histology. RESULTS: Altogether, 861 primary CNS tumors were found. Tumors in brain locations occurred most frequently (50.8%; n=437). The neoplasms observed were most prevalent in the age range 45‒54 years (20.4%; n=176). Grade I tumors occurred most frequently, corresponding to 38.8% of the cases (n=38) in the age group of 0‒14 years, and 44.6% (n=340) in the population ≥15 years old. Between 0 and 14 years of age, other astrocytic tumors were the most prevalent (29.6%; n=29). In the age group between 15 and 34, gliomas were the most frequent (32.7%; n=54). Meningiomas predominated in the age group of 35 years and above, comprising 47.5% of cases (n=206) in the 35‒74 age group; and 61.2% (n=30) among patients over 75 years old. CONCLUSION: The epidemiology of primary CNS tumors in Sergipe between 2010 and 2018 is consistent with data in other current studies on the subject. Studies on the epidemiological evolution of these entities in Sergipe are needed.

Primary central nervous system tumors in Sergipe, Brazil: descriptive epidemiology between 2010 and 2018 / Tumores primários do sistema nervoso central em Sergipe, Brasil: epidemiologia descritiva entre 2010 e 2018

ABSTRACT Background: Central nervous system (CNS) tumors are a heterogeneous group with high morbidity and mortality. Objectives: To describe the epidemiology of primary CNS tumors diagnosed in the state of Sergipe from 2010 to 2018. Methods: We evaluated histopathological and immunohistochemical reports on primary CNS tumors diagnosed in Sergipe, Brazil, between 2010 and 2018 and collected data regarding age, sex, location, World Health Organization (WHO) classification and histology. Results: Altogether, 861 primary CNS tumors were found. Tumors in brain locations occurred most frequently (50.8%; n=437). The neoplasms observed were most prevalent in the age range 45‒54 years (20.4%; n=176). Grade I tumors occurred most frequently, corresponding to 38.8% of the cases (n=38) in the age group of 0‒14 years, and 44.6% (n=340) in the population ≥15 years old. Between 0 and 14 years of age, other astrocytic tumors were the most prevalent (29.6%; n=29). In the age group between 15 and 34, gliomas were the most frequent (32.7%; n=54). Meningiomas predominated in the age group of 35 years and above, comprising 47.5% of cases (n=206) in the 35‒74 age group; and 61.2% (n=30) among patients over 75 years old. Conclusion: The epidemiology of primary CNS tumors in Sergipe between 2010 and 2018 is consistent with data in other current studies on the subject. Studies on the epidemiological evolution of these entities in Sergipe are needed.

RESUMO Introdução: Os tumores do sistema nervoso central (SNC) são um grupo heterogêneo de entidades que apresenta significativa morbimortalidade. Objetivos: O presente estudo visa à descrição epidemiológica dos tumores primários do SNC com diagnóstico histopatológico no estado de Sergipe, Brasil, entre 2010 e 2018. Métodos: Foram avaliados laudos histopatológicos e imuno-histoquímicos de tumores primários do SNC, diagnosticados entre 2010 e 2018, no estado de Sergipe. Os dados coletados foram descritos de acordo com as variáveis de idade, sexo, localização, classificação da Organização Mundial da Saúde (OMS) e tipo histológico. Resultados: Foram encontrados 861 tumores primários do SNC. A localização cerebral foi a mais frequente (50,8%; n=437). As neoplasias observadas prevaleceram na faixa etária de 45 a 54 anos (20,4%; n=176). Os tumores grau I foram os mais frequentes, correspondendo a 38,8% dos casos (n=38) na faixa etária de 0‒14 anos e 44,6% (n=340) na população a partir de 15 anos de idade. Na faixa etária entre 0‒14 anos, o grupo histológico dos outros tumores astrocíticos foi o mais prevalente (29,6%; n=29). Na população entre 15‒34 anos, os gliomas foram os mais frequentes (32,7%; n=54). Os meningiomas predominaram nas faixas etárias a partir de 35 anos, com 47,5% dos casos (n=206) entre 35‒74 anos; e 61,2% (n=30) nos pacientes acima de 75 anos de idade. Conclusão: A descrição epidemiológica dos tumores primários do SNC em Sergipe, entre 2010 e 2018, é condizente com outros trabalhos atuais sobre o tema. Estudos voltados à evolução epidemiológica dessas entidades em Sergipe são necessários.

Ventricular-Peritoneal Shunt in Newborns in a High-Risk Maternity Unit: Case Series

Objective To identify factors related to ventricular-peritoneal shunt (VPS) complications in pediatric patients at a high-risk maternity hospital. Methods Prospective study, conducted between September/2018 and June/2019, with selected newborns without previous ventricular bypass who underwent neurosurgery for VPS placement in a high-risk maternity hospital in the state of Sergipe, Brazil. Diagnosis of hydrocephalus occurred by transfontanelle ultrasound. The variables were analyzed by Student t-test, adopting p < 0.05 as statistical significance. Results Seven newborns participated in the study, 3 male and 4 female. Folic acid supplementation during pregnancy was considered a positive influencing factor in the 1st minute Apgar.Hydrocephalus secondary to premature hemorrhagewas present inmost newborns. Prematurity, 1st minute Apgar score < 7, and birth weight< 2,500 g did not represent a significant negative risk factor for prolonged hospitalization after neurosurgery. One newborn had cerebrospinal fluid infection and was the only one with heart disease. Conclusion This is the first scientific research that associates the benefits of maternal use of folic acid during pregnancy to better newborn Apgar scores. Only one newborn developed complications after neurosurgery, the only one with an associated comorbidity. Further studies are needed to provide more evidence on risk factors related to complications of VPS implantation in newborns. This neurosurgical procedure in a highrisk maternity contributed to the early management of hydrocephalus.

Efeitos da cranioplastia em doentes submetidos à craniectomia descompressiva: avaliação anatômica, neurológica e da hemodinâmica encefálica / Cranioplasty effects on patients submitted to decompressive craniectomy: anatomical, neurological and hemodynamic assessment

Introdução e Objetivos: Falha óssea craniana após craniectomia descompressiva (CD) causa alterações neurológicas que podem estar associadas a modificações da anatomia cortical e hemodinâmica encefálica. Nosso objetivo foi avaliar se essas alterações ocorrem e se estão associadas ao prognóstico neurológico. Métodos: Avaliamos prospectivamente doentes com falha craniana após CD pelo método de Tomografia com estudo de perfusão (TCP) e Doppler Transcraniano (DTC) antes e entre 15 e 30 dias após a cranioplastia. O exame neurológico sistematizado e avaliação de escalas prognósticas (mRs, MEEM, índice de Barthel) foi realizado antes e seis meses após a operação. Resultados: Nós avaliamos 30 doentes, 15 (50%) com CD relacionada a traumatismo cranioencefálico (TCE) e 15 (50%) devido a doença cerebrovascular (DCV). Observamos que houve melhora satisfatória de queixas neurológicas, além de melhora significativa da mRs (p=0,003), MEEM (p < 0,001) e índice de Barthel (p=0,002). Houve reestruturação significativa da superfície cortical, tanto anterior (p < 0,001) quanto posterior (p=0,045). A diferença cortical posterior mostrou correlação com melhora do MEEM (p=0,03; r=-0,4) e índice de Barthel (p=0,035; r=-0,39). As alterações da anatomia encefálica foram mais evidentes em doentes com antecedente de DCV do que TCE. A relação entre a radiodensidade da substância cinzenta (SC) e branca (SB) apresentou elevação (p=0,007), sem correlação com prognóstico. A TCP demonstrou redução da duração média de trânsito (DMT) de 8,23 ± 1,30 segundos(s) para 7,50 ± 1,21 s (p=0,02) e do volume sanguíneo cerebral de 2,29 ± 0,58 ml/100g para 2,00±0,59 ml/100g (p=0,037) apenas no lado operado. O fluxo sanguíneo cerebral (FSC) não demonstrou alterações significativas em nenhum dos lados. Observamos correlação moderada entre DMT (diferença entre lado operado e não operado) com força muscular contralateral (r=-0,4, p =0,034). Na divisão entre grupos, a redução da DMT ocorreu no TCE e DCV mas,...

Introduction and Objectives: Cranial vault defects after decompressive craniectomy (DC) causes neurological disorders that may be associated with changes in brain anatomy and hemodynamics. Our objective was to evaluate whether these changes occur and if they were associated with neurological prognosis. Methods: We prospectively evaluated patients with bone defect after DC with computed tomography perfusion (CTP) and transcranial Doppler Sonography (TCD) before and between 15 and 30 days after cranioplasty . We performed neurological examination and prognostic scales (mRs, MMSE and Barthel index) before and after six months. Results: We studied 30 patients, 15 (50%) had DC related to traumatic brain injury (TBI) and 15 (50%) due to cerebrovascular disease (CVD). We observed a satisfactory improvement of neurological complaints, as well as significant improvement in mRs (p= 0.003), MMSE (p < 0.001) and Barthel index (p=0.002). Significant anatomical expansion of both cerebral hemispheres, including anterior (p < 0.001), posterior (p=0.045), and cortical surface. The posterior measurements was correlated with improvement in the MMSE (p=0.03; r=-0.4) and Barthel index (p=0.035; r=-0.39). Brain anatomy changes were more evident in patients with history of CVD than TBI. Increase in radiodensity relationship between gray and white matter by CT scan (p=0.007) were observed without correlation with prognosis. TCP showed mean transit time (MTT) decrease from 8.23 ± 1.30 seconds (s) to 7.50 ± 1.21 s (p=0.02) and cerebral blood volume (CBV) from 2.29 ± 0.58 ml/100g to 2.00 ± 0.59 ml/100g (p=0.037) both in operated side. Cerebral blood flow (CBF) did not show significant changes in either side. We verified moderate correlation between MTT and contralateral muscle strength (r=-0.4; p=0.034). In the sub groups analysis, MTT decrease in TBI and CVD but was significant only in TBI patients. TCD showed a significant increase in middle cerebral artery flow...

Perioperative care in brain arteriovenous malformations / Cuidados perioperatórios em malformações arteriovenosas encefálicas

The authors provide a review of brain arteriovenous malformations, initially reviewing epidemiological and etiological aspects in addition to the pathophysiology and risk factors associated with bleeding. The emphasis of this review is directed to the clinical and care should be taken since the diagnosis of this pathology, intraoperative management on the viewpoint of the anesthesiologist to the potential complications that occur after resection of the lesion.

Os autores realizam uma revisão sobre malformações arteriovenosas encefálicas, revisando inicialmente aspectos etiológicos e epidemiológicos, além da fisiopatologia e de fatores relacionados com risco de sangramento. A maior ênfase dessa revisão é direcionada para o quadro clínico e para os cuidados que devem ser tomados desde o diagnóstico dessa patologia, o manejo intraoperatório sob o ponto de vista do anestesista, até as possíveis complicações que ocorrem após a ressecção da lesão.

Fisher revised scale for assessment of prognosis in patients with subarachnoid hemorrhage / Avaliação prognóstica com escala de Fisher modificada em pacientes com hemorragia subaracnóidea

The Fisher revised scale (FRS) presents an alternative for evaluating patients with subarachnoid hemorrhage (SAH). In this study, we compared the prognosis of patients with SAH and vasospasms (VSP). METHOD: This was a prospective study on patients with a diagnosis of aneurysmal SAH, 72 hours after the initial event. Sequential neurological examinations and Hunt and Hess (HaH) score were performed on the 1st, 7th and 14th days. Transcranial Doppler was used to assess vasospasms. RESULTS: Out of the 24 patients studied, ten (41.66 percent) presented a delayed neurological deficit, such as diminished consciousness, decreased HaH score or death. The single patient classified as FS-1 did not have any delayed neurological deficit, while such deficits evolved in one patient out of five with FS-2 (20 percent); two out of seven with FS-3 (28.57 percent) and seven out of 11 with FS-4 (63.63 percent). CONCLUSION: Level three of the FS and FRS seemed to be compatible with regard to predicting the likelihood of progression to severe VSP.

A escala revisada de Fisher (FRS) representa uma alternativa para avaliação de pacientes com hemorragia subaracnóidea (HSA). Neste estudo comparamos a evolução prognóstica referente ao vasoespasmo (VSP) nos pacientes com HSA. MÉTODO: Estudo prospectivo em pacientes com diagnóstico de HSA, com 72 horas após o evento inicial. Escala de Hunt e Hess (HeH) foi realizada no 1º, 7º, 14º dia. Utilizamos Doppler transcraniano para avaliação de VSP. RESULTADOS: Dos 24 pacientes estudados dez (41,66 por cento) tiveram déficit neurológico tardio (DNT), como diminuição da consciência, grau de HeH ou morte. Um paciente de cinco classificados como FS-2 (20 por cento), dois de sete pacientes com FS-3 (28,57 por cento) e sete de 11 pacientes com FS-4 (63,63 por cento) evoluíram com DNT. Para o FRS não encontramos piora neurológica precoce no paciente com FRS-0. CONCLUSÃO: O nível três da FS e FRS parecem ser comparáveis, quando se trata de predizer a probabilidade de progressão para VSP grave.

Cognitive rehabilitation following traumatic brain injury / Reabilitação cognitiva após traumatismo crânio encefálico

Abstract Annually, some 500,000 people are hospitalized with brain lesions acquired after traumatic brain injury (TBI) in Brazil. Between 75,000 and 100,000 individuals die within hours of the event and 70,000 to 90,000 evolve to irreversible loss of some neurological function. The principal causes of TBI include motor vehicle accidents (50%), falls (21%), assaults and robberies (12%) and accidents during leisure activities (10%). Within this context, cognitive rehabilitation, a clinical area encompassing interdisciplinary action aimed at recovery as well as compensation of cognitive functions altered as a result of cerebral injury, is extremely important for these individuals. Therefore, the aim of this study was to review the basic concepts related to TBI, including mechanisms of injury, severity levels of TBI, the most common findings in moderate and severe TBI survivors, and the most frequent cognitive impairments following TBI, and also to discuss the strategies used to handle patients post-TBI. The study results yielded relevant information on a structured cognitive rehabilitation service, representing an alternative for patients and families afflicted by TBI, enabling the generation of multiple research protocols.

Resumo Anualmente, 500 mil pessoas são hospitalizadas com lesão cerebral adquirida após traumatismo crânio-encefálico (TCE) no Brasil. Setenta e cinco a cem mil pessoas morrem poucas horas após o evento e 70 a 90 mil evoluem para perda irreversível de alguma função neurológica. Entre as principais causas de TCE estão os acidentes automobilísticos (50%), quedas (21%), assaltos e roubos (12%) e atividades de lazer (10%). Dentro deste contexto, a reabilitação cognitiva, uma área clínica de atuação interdisciplinar em busca de recuperação, tanto quanto a compensação de alterações das funções cognitivas resultantes de lesão cerebral, é extremamente importante para estes indivíduos. Portanto, neste estudo, foram revisados os conceitos básicos relacionados ao TCE, tais como os mecanismos de lesão, os níveis graves de TCE, os achados mais comuns em sobreviventes de TCE moderado e grave e as deficiências cognitivas mais comuns após TCE e discutidas as estratégias utilizadas para lidar com pacientes pós-TCE. Como resultado, nosso estudo irá fornecer informações relevantes relacionadas com um serviço de reabilitação cognitiva estruturada e, certamente, irá oferecer uma alternativa para pacientes e famílias vítimas de TCE e, portanto, gerar múltiplos protocolos de pesquisa.

Reabilitação cognitiva após traumatismo crânio encefálico: [revisão] / Cognitive rehabilitation followingtraumatic brain injury: [review]

Annually, some 500,000 people are hospitalized with brain lesions acquired after traumatic brain injury (TBI) in Brazil. Between 75,000 and 100,000 individuals die within hours of the event and 70,000 to 90,000 evolve to irreversible loss of some neurological function. The principal causes of TBI include motor vehicle accidents (50%), falls (21%), assaults and robberies (12%) and accidents during leisure activities (10%). Within this context, cognitive rehabilitation, a clinical area encompassing interdisciplinary action aimed at recovery as well as compensation of cognitive functions altered as a result of cerebral injury, is extremely important for these individuals. Therefore, the aim of this study was to review the basic concepts related to TBI, including mechanisms of injury, severity levels of TBI, the most common findings in moderate and severe TBI survivors, and the most frequent cognitive impairments following TBI, and also to discuss the strategies used to handle patients post-TBI. The study results yielded relevant information on a structured cognitive rehabilitation service, representing an alternative for patients and families afflicted by TBI, enabling the generation of multiple research protocols.

Anualmente, 500 mil pessoas são hospitalizadas com lesão cerebral adquirida após traumatismo crânio-encefálico (TCE) no Brasil. Setenta e cinco a cem mil pessoas morrem poucas horas após o evento e 70 a 90 mil evoluem para perda irreversível de alguma função neurológica. Entre as principais causas de TCE estão os acidentes automobilísticos (50%), quedas (21%), assaltos e roubos (12%) e atividades de lazer (10%). Dentro deste contexto, a reabilitação cognitiva, uma área clínica de atuação interdisciplinar em busca de recuperação, tanto quanto a compensação de alterações das funções cognitivas resultantes de lesão cerebral, é extremamente importante para estes indivíduos. Portanto, neste estudo, foram revisados os conceitos básicos relacionados ao TCE, tais como os mecanismos de lesão, os níveis graves de TCE, os achados mais comuns em sobreviventes de TCE moderado e grave e as deficiências cognitivas mais comuns após TCE e discutidas as estratégias utilizadas para lidar com pacientes pós-TCE. Como resultado, nosso estudo irá fornecer informações relevantes relacionadas com um serviço de reabilitação cognitiva estruturada e, certamente, irá oferecer uma alternativa para pacientes e famílias vítimas de TCE e, portanto, gerar múltiplos protocolos de pesquisa.

The puzzling olfactory groove schwannoma: a systematic review.

We systematically reviewed the literature concerning the anterior cranial fossa schwannomas to understand their pathogenesis, determine their origin, and standardize the terminology. We performed a MEDLINE, EMBASE, and Science Citation Index Expanded search of the literature; age, gender, clinical presentation, presence or absence of hyposmia, radiological features, and apparent origin were analyzed and tabulated. Cases in a context of neurofibromatosis and nasal schwannomas with intracranial extension were not included. Age varied between 14 and 63 years (mean = 30.9). There were 22 male and 11 female patients. The clinical presentation included seizures (n = 15), headache (n = 16), visual deficits (n = 7), cognitive disturbances (n = 3), and rhinorrhea (n = 1). Hyposmia was present in 14 cases, absent in 13 cases (39.3%), and unreported in five. Homogeneous and heterogeneous contrast enhancement was observed in 14 and 15 cases, respectively. The region of the olfactory groove was the probable site in 96.5%. Olfactory tract could be identified in 39.3%. The most probable origin is the meningeal branches of trigeminal nerve or anterior ethmoidal nerves. Thus, olfactory groove schwannoma would better describe its origin and pathogenesis and should be the term preferentially used to name it.

Fisher revised scale for assessment of prognosis in patients with subarachnoid hemorrhage.

UNLABELLED: The Fisher revised scale (FRS) presents an alternative for evaluating patients with subarachnoid hemorrhage (SAH). In this study, we compared the prognosis of patients with SAH and vasospasms (VSP). METHOD: This was a prospective study on patients with a diagnosis of aneurysmal SAH, 72 hours after the initial event. Sequential neurological examinations and Hunt and Hess (HaH) score were performed on the 1(st), 7(th) and 14(th) days. Transcranial Doppler was used to assess vasospasms. RESULTS: Out of the 24 patients studied, ten (41.66%) presented a delayed neurological deficit, such as diminished consciousness, decreased HaH score or death. The single patient classified as FS-1 did not have any delayed neurological deficit, while such deficits evolved in one patient out of five with FS-2 (20%); two out of seven with FS-3 (28.57%) and seven out of 11 with FS-4 (63.63%). CONCLUSION: Level three of the FS and FRS seemed to be compatible with regard to predicting the likelihood of progression to severe VSP.

Cognitive rehabilitation following traumatic brain injury.

Annually, some 500,000 people are hospitalized with brain lesions acquired after traumatic brain injury (TBI) in Brazil. Between 75,000 and 100,000 individuals die within hours of the event and 70,000 to 90,000 evolve to irreversible loss of some neurological function. The principal causes of TBI include motor vehicle accidents (50%), falls (21%), assaults and robberies (12%) and accidents during leisure activities (10%). Within this context, cognitive rehabilitation, a clinical area encompassing interdisciplinary action aimed at recovery as well as compensation of cognitive functions altered as a result of cerebral injury, is extremely important for these individuals. Therefore, the aim of this study was to review the basic concepts related to TBI, including mechanisms of injury, severity levels of TBI, the most common findings in moderate and severe TBI survivors, and the most frequent cognitive impairments following TBI, and also to discuss the strategies used to handle patients post-TBI. The study results yielded relevant information on a structured cognitive rehabilitation service, representing an alternative for patients and families afflicted by TBI, enabling the generation of multiple research protocols.

Anualmente, 500 mil pessoas são hospitalizadas com lesão cerebral adquirida após traumatismo crânio-encefálico (TCE) no Brasil. Setenta e cinco a cem mil pessoas morrem poucas horas após o evento e 70 a 90 mil evoluem para perda irreversível de alguma função neurológica. Entre as principais causas de TCE estão os acidentes automobilísticos (50%), quedas (21%), assaltos e roubos (12%) e atividades de lazer (10%). Dentro deste contexto, a reabilitação cognitiva, uma área clínica de atuação interdisciplinar em busca de recuperação, tanto quanto a compensação de alterações das funções cognitivas resultantes de lesão cerebral, é extremamente importante para estes indivíduos. Portanto, neste estudo, foram revisados os conceitos básicos relacionados ao TCE, tais como os mecanismos de lesão, os níveis graves de TCE, os achados mais comuns em sobreviventes de TCE moderado e grave e as deficiências cognitivas mais comuns após TCE e discutidas as estratégias utilizadas para lidar com pacientes pós-TCE. Como resultado, nosso estudo irá fornecer informações relevantes relacionadas com um serviço de reabilitação cognitiva estruturada e, certamente, irá oferecer uma alternativa para pacientes e famílias vítimas de TCE e, portanto, gerar múltiplos protocolos de pesquisa.

Perspective of the frontolateral craniotomies.

The pterional craniotomy is one of the most frequently surgical approaches used in neurosurgery and currently it has become a mainsteam. It allows excellent microsurgical exposure of anterior and posterior regions of the arterial circle of Willis, supra and paraselar regions, the superior orbital fissure of sphenoid bone, cavernous sinus, orbit, temporal lobe, midbrain and the frontal lobe. Like others techniques, the pterional craniotomy presented disadvantages related to dissection of the temporal muscle. From the first fronto lateral craniotomy described by Dandy to expose the optic chiasm and the pituitary we pass through the Yasargil's classical description of craniotomy centered in fronto-temporal sylvian fissure until reaching the recent"minipterional craniotomy", modifications of the pterional craniotomy were proposed to reduce the extra cranial tissue trauma and reduce the area of craniotomy without affecting the exposure of surgical targets, thus improving their aesthetic and functional results. An historical analysis of the frontolateral approaches has demonstrated that they have evolved from larger craniotomies to smaller ones, however only the minipterional craniotomy is able to offer similar surgical exposure.

Remote postoperative epidural hematoma after subdural hygroma drainage.

Objective. Subdural hygroma is reported to occur in 5%-20% of all patients with closed head trauma, the treatment is controversial and in symptomatic cases surgical drainage is need. We report on a new case with remote acute epidural hematoma (AEH) after subdural hygroma drainage. Case Presentation. A 38-year-old man suffered blunt head trauma and had diffuse axonal injury grade III in CT scan. A CT scan that was late performed showed an increasing subdural fluid collection with mild mass effect and some effacement of the left lateral ventricle. We perform a trepanation with drainage of a hypertensive subdural collection with citrine aspect. Postoperative tomography demonstrated a large left AEH. Craniotomy and evacuation of the hematoma were performed. Conclusion. The mechanism of remote postoperative AEH formation is unclear. Complete reliance on neurologic monitoring, trust in an early CT scan, and a relative complacency after an apparently successful initial surgery for hygroma drainage may delay the diagnosis of this postoperative AEH.

Perspective of the frontolateral craniotomies / Perspectivas das craniotomias frontolaterais

The pterional craniotomy is one of the most frequently surgical approaches used in neurosurgery and currently it has become a mainsteam. It allows excellent microsurgical exposure of anterior and posterior regions of the arterial circle of Willis, supra and paraselar regions, the superior orbital fissure of sphenoid bone, cavernous sinus, orbit, temporal lobe, midbrain and the frontal lobe. Like others techniques, the pterional craniotomy presented disadvantages related to dissection of the temporal muscle. From the first fronto lateral craniotomy described by Dandy to expose the optic chiasm and the pituitary we pass through the Yasargil's classical description of craniotomy centered in fronto-temporal sylvian fissure until reaching the recent"minipterional craniotomy", modifications of the pterional craniotomy were proposed to reduce the extra cranial tissue trauma and reduce the area of craniotomy without affecting the exposure of surgical targets, thus improving their aesthetic and functional results. An historical analysis of the frontolateral approaches has demonstrated that they have evolved from larger craniotomies to smaller ones, however only the minipterional craniotomy is able to offer similar surgical exposure.

A craniotomia pterional é um dos acessos cirúrgicos mais freqüentemente utilizados. Esta técnica permite excelente exposição microcirúrgica das regiões anterior e posterior do polígono de Willis, regiões supra-selar, fissura orbital superior do osso esfenóide, seio cavernoso, órbita, lobo temporal, mesencéfalo e lobo frontal. Como outras técnicas, a craniotomia pterional tem desvantagens relacionadas à manipulação do músculo temporal. Desde a primeira craniotomia fronto lateral descrita por Dandy para expor o quiasma óptico e a hipófise, passando pela descrição clássica de Yasrgil para craniotomia centrada na fissura silviana, até chegar em craniotomias recentes como a"minipterional", modificações da craniotomia pterional foram propostas para reduzir o trauma do tecido extra craniano e reduzir a área da craniotomia sem afetar a exposição dos alvos cirúrgicos e melhorar seus resultados estéticos e funcionais. Uma análise histórica das abordagens frontolaterais demonstrou que elas evoluíram a partir de craniotomias maiores para menores, contudo somente a craniotomia minipterional oferece exposição cirúrgica similar à craniotomia pterional clássica.