Quality of life long after temporal lobe epilepsy surgery.

OBJECTIVES: To identify variables independently associated with a meaningful improvement in QOL long after surgical treatment of drug-resistant MTLE-HS patients. MATERIAL & METHODS: We prospectively evaluated 72 consecutive MTLE-HS surgically treated patients and analyzed pre and post-surgical variables independently associated with a meaningful improvement in QOL evaluated by the Quality of Life in Epilepsy-31 (QOLIE-31) overall score, and its domain scores determined at follow-up after 36 to 131 months (mean 93 months) after surgery. RESULTS: The mean overall QOLIE-31 score and its subdomain scores improved significantly after surgery (p < 0.01), and 55 patients (76.4%) had a meaningful QOL improvement. Being seizure-free (Engel IA) after surgery showed a non-significant association (OR 2.63, CI 95% 0.53 to 13.05, p = 0.23) and lower depressive symptoms a significant association (OR 4.15, CI 95% 1.19 to 14.53, p = 0.03) with meaningful improvement of QOL. CONCLUSIONS: Patients with MTLE-HS who underwent epilepsy surgery show a sustained, meaningful improvement in their QOL. Pre-surgical variables do not predict long-term QOL improvement after surgery. Lower levels of depressive symptoms at postoperative evaluation are associated with meaningful QOL improvement.

Predictors of meaningful improvement in quality of life after temporal lobe epilepsy surgery: A prospective study.

OBJECTIVES: To investigate prospectively the independent predictors of a minimum clinically important change (MCIC) in quality of life (QOL) after anterior temporal lobectomy (ATL) for drug-resistant mesial temporal lobe epilepsy related to hippocampal sclerosis (MTLE-HS) in Brazilian patients. METHODS: Multiple binary logistic regression analysis was performed to identify the clinical, demographic, radiologic, and electrophysiologic variables independently associated with MCIC in the Quality of Life in Epilepsy-31 Inventory (QOLIE-31) overall score 1 year after ATL in 77 consecutive patients with unilateral MTLE-HS. RESULTS: The overall QOLIE-31 score and all its subscale scores increased significantly (p < 0.0001) 1 year after ATL. In the final logistic regression model, absence of presurgical diagnosis of depression (adjusted odds ratio [OR] 4.4, 95% confidence interval [CI] 1.1-16.1, p = 0.02) and a complete postoperative seizure control (adjusted OR 4.1, 95% CI 1.2-14.5, p = 0.03) were independently associated with improvement equal to or greater than the MCIC in QOL after ATL. The overall model accuracy for MCIC improvement in the QOL was 85.6%, with a 95.2% of sensitivity and 46.7% of specificity. SIGNIFICANCE: These results in Brazilian patients reinforce the external validation of previous findings in Canadian patients showing that presurgical depression and complete seizure control after surgery are independent predictors for meaningful improvement in QOL after ATL, and have implications for the surgical management of MTLE patients.

Mitochondrial Respiration Chain Enzymatic Activities in the Human Brain: Methodological Implications for Tissue Sampling and Storage.

Mitochondrial respiratory chain complexes enzymatic (MRCCE) activities were successfully evaluated in frozen brain samples. Epilepsy surgery offers an ethical opportunity to study human brain tissue surgically removed to treat drug resistant epilepsies. Epilepsy surgeries are done with hemodynamic and laboratory parameters to maintain physiology, but there are no studies analyzing the association among these parameters and MRCCE activities in the human brain tissue. We determined the intra-operative parameters independently associated with MRCCE activities in middle temporal neocortex (Cx), amygdala (AMY) and head of hippocampus (HIP) samples of patients (n = 23) who underwent temporal lobectomy using multiple linear regressions. MRCCE activities in Cx, AMY and HIP are differentially associated to trans-operative mean arterial blood pressure, O2 saturation, hemoglobin, and anesthesia duration to time of tissue sampling. The time-course between the last seizure occurrence and tissue sampling as well as the sample storage to biochemical assessments were also associated with enzyme activities. Linear regression models including these variables explain 13-17 % of MRCCE activities and show a moderate to strong effect (r = 0.37-0.82). Intraoperative hemodynamic and laboratory parameters as well as the time from last seizure to tissue sampling and storage time are associated with MRCCE activities in human samples from the Cx, AMYG and HIP. Careful control of these parameters is required to minimize confounding biases in studies using human brain samples collected from elective neurosurgery.

Complications of post-operative seizure prophylaxis in patients submitted to cranial irradiation

The clinical status of patients with malignant intracranial tumors, such as high-grade gliomas, is often aggravated by seizure activity. Phenytoin is typically employed as prophylactic anticonvulsant in this setting. In such patients, severe systemic drug reactions such as erythema multiforme (EM) may occur. However, in a subgroup of patients with brain radiation therapy, EM-like lesions appear to develop in an increased ratio. The acronym ‘EMPACT’ (E: erythema; M: multiform; associated with P: phenytoin; A: and; C: cranial, radiation; T: therapy) has been suggested to best describes this syndrome. In this article, the authors present a case report of a patient treated with phenytoin for seizure prophylaxis, during the post-operative period following resection of a malignant glioma, and who presented a severe cutaneous rash, evolving with serious consequences due to abrupt change of seizure medications. Because of these predictable complications we abandoned our routine institutional protocol which employed phenytoin for seizure prophylaxis for patients in the post-operative period following malignant tumor resection and which expect to be irradiated in the near future. Once both carbamazepine and barbiturates show cross-sensitivity with phenytoin and may interfere with serum levels of chemotherapy drugs, we now advocate, as other worldwide renown neuro-oncological centers, the use of valproate gabapentin, or alternatively, as recent literature guidelines suggests levetiracetam (keppra), for seizure prophylaxis in this select subset of patients.

El estado clínico de los pacientes con tumores malignos intracraneales, como los gliomas de alto grado, es a menudo agravado por la actividad convulsiva. La fenitoína es normalmente empleadaa como anticonvulsivante profiláctico en esto contexto. En estos pacientes, graves reacciones sistémicas, como eritema multiforme (EM) puedem ocurrir. Sin embargo, en un subgrupo de pacientes con terapia de radiación en el cerebro, lesiones de EM, parece que se desarrollan en una proporción mayor. ‘EMPACT’ La sigla (E: eritema, M: multiforme; asociados con P: fenitoína; A: y C: la radiación craneal, T: La terapia) Se ha sugerido que mejor describe este síndrome. En esto artículo, los autores presentan un caso clínico de un paciente tratado con fenitoína para la profilaxia de convulsiones, durante el período post-operatorio después de la resección de un glioma maligno, y que presenta una erupción cutánea grave, que evoluciona con consecuencias graves debido al cambio brusco de medicamentos anticonvulsivos. Debido a estas complicaciones predecibles, que abandonamos nuestro protocolo institucional de rutina que la fenitoína empleadas para la profilaxia de convulsiones en los pacientes en el período post-operatorio después de la resección del tumor maligno y que esperan ser irradiado en un futuro próximo. Una vez que ambos carbamazepina y los barbitúricos mostran sensibilidad cruzada con fenitoína y puede interferir con los niveles séricos de drogas de la quimioterapia, ahora defendemos, como otros centros de renombre mundial neuro-oncológico, el uso de gabapentina valproato, o bien, como orientación la literatura reciente sugiere levetiracetam (keppra), para la profilaxia de las convulsiones en este subgrupo seleccionado de pacientes.

The usefulness of neuronavigation in functional hemispherectomy / Aplicabilidade da neuronavegação em hemisferectomia funcional

Catastrophic epileptic encephalopathies in children comprise devastating conditions that features cerebral dysfunction in association with refractory epileptic seizures. The diagnosis is based on the clinical findings, on magnetic resonance imaging (MRI) of the brain and on electroencephalographic findings. For these conditions, surgery remains essential for attaining seizure control. We report two cases of 5-year-old girls. The first one had a diagnosis of Rasmussen’s syndrome. The second one had a large porencephalic cyst secondary to perinatal cerebral ischemia. Despite trials of anticonvulsants, both patients deteriorated, and a functional hemispherectomy guided by neuronavigation was indicated and performed, with low morbidity and excellent seizure control. The neuronavigation proved to be a valuable guidance tool in performing the functional hemispherectomy, making the disconnections more accurate, and thus decreasing the surgical time and blood loss.

Aplicabilidade da neuronavegação em hemisferectomia funcional As encefalopatias epilépticas catastróficas da infância compreendem condições graves que associam disfunção cerebral e crises epilépticas refratárias. Seu diagnóstico é firmado com base nos dados clínicos e nos achados de ressonância magnética e eletrencefalográficos. Para algumas destas condições o tratamento cirúrgico continua sendo essencial para o controle das crises. Relatamos dois casos de pacientes de 5 anos. A primeira teve diagnóstico de síndrome de Rasmussen. A segunda tinha antecedentes de encefalopatia hipóxico-isquêmica perinatal. Ambas apresentaram epilepsia parcial refratária em associação com rápida deterioração neurológica, e foram submetidas à hemisferectomia funcional com auxílio da neuronavegação, com baixa morbidade e excelente controle das crises. A neuronavegação se mostrou como uma valiosa ferramenta na realização da hemisferectomia funcional, possibilitando desconexões mais precisas, menor tempo de cirurgia e menor perda sanguínea.

Experience with the Strata valve in the management of shunt overdrainage.

OBJECT: The overdrainage of cerebrospinal fluid (CSF) in children with shunt-treated hydrocephalus may cause chronic disabling symptoms and require repeated surgery. Externally adjustable valves offer a noninvasive way of altering the valve opening pressure. The authors report on their experience with using the Strata valve in the management of symptomatic CSF overdrainage. METHODS: The authors treated 24 patients with symptomatic CSF overdrainage by inserting a Strata valve. The severity of symptoms was graded, and the frequency of hospital visits and shunt operations was recorded before and after insertion of the valve. Additionally, results of brain imaging and intracranial pressure monitoring were reviewed. Nineteen patients (79.2%) had severe symptoms at the time of the insertion; 1 year after Strata valve insertion only one patient (4.17%) still suffered severe symptoms. The number of hospital admissions was 3.38/patient/year before placement and 1.21 for the 1st year, 1 for the 2nd, and 0.4 for the 3rd postoperative year. The number of operations was 3.42/patient/year during the year before placement of the valve, and then 0.71 for the 1st, 0.56 for the 2nd, and 0.25 for the 3rd postoperative years. During the 1st year after placement of the Strata valve, the settings were changed 2.79 times/patient/year, 1.29 for the 2nd, and 1.33 times/patient/year for the 3rd year. CONCLUSIONS: The Strata valve was effective in improving the symptoms of overdrainage in the majority of patients in this series. The number of hospital admissions and operations for valve malfunction was reduced.

Chiari-like tonsillar herniation associated with intracranial hypotension in Marfan syndrome. Case report.

The authors describe the case of a 12-year-old girl with Marfan syndrome, sacral dural ectasia, and tonsillar herniation, who presented with headache. Initially, it was hypothesized that the headaches were secondary to the tonsillar herniation, and the patient consequently underwent surgical decompression of the foramen magnum. Postoperatively, the patient's condition did not improve, and additional magnetic resonance (MR) imaging demonstrated evidence of a cerebrospinal fluid (CSF) leak at the level of the dural ectasia. It was surmised that the girl's symptoms were due to spontaneous intracranial hypotension (SIH) and that the tonsillar herniation was caused by the leakage. The patient responded well to application of a blood patch at the level of the demonstrated leak, and her headache resolved. This appears to be the first reported case of a patient with Marfan syndrome presenting with a symptomatic spontaneous CSF leak complicated by tonsillar herniation. In this rare association of SIH and connective tissue disorders, recognition of the clinical signs and typical MR imaging features of SIH may lead to more appropriate and less invasive treatment, potentially avoiding surgery.

Intracranial midline dermoid and epidermoid cysts in children.

OBJECT: Dermoid and epidermoid cysts are rare space-occupying lesions of the central nervous system. Although characterized by a slow growth rate, they are often associated with serious complications. Surgery is the only effective treatment, and radical resection of the entire cyst, whenever possible, generally succeeds in achieving a cure. Authors of large series have only occasionally reported on pediatric cases, and these reports often lack a specific analysis of those cerebral midline lesions. METHODS: The authors report on the treatment of 19 patients (16 with intracranial intradural dermoid and three with epidermoid cysts located along the cerebral midline). All patients underwent surgery at the Catholic University Medical School in Rome. The patients ranged in age from 3 months to 16 years. Nine cysts were located in the posterior cranial fossa, six in the frontobasal subarachnoid spaces, two in the third ventricle, and two in the quadrigeminal plate cistern. In the cases presenting with dermal sinus tracts, attempts at resecting the dermoid cyst and the associated dermal sinus were made in a single stage to achieve an en bloc removal. In the cases without dermal sinus tracts, and in the three with epidermoid cysts, a standard craniotomy was performed to reach the lesion. There were no surgery-related deaths, and the morbidity rate was low. Total and subtotal resections were achieved in 15 and four cases, respectively; however, regrowth of the residual tumor was observed only in two of them. After repeated resection, tumor progression has not been observed. At a mean follow-up period of 92.7 months, excellent clinical results were achieved in 18 patients. CONCLUSIONS: Because surgery is the only effective treatment modality for these lesions, radical resection should be performed in all cases to avoid tumor recurrence; however, because the cyst capsule can adhere firmly to vital structures and attempts at its radical removal can be dangerous, subtotal resection may be a wise option in selected cases.

Aseptic meningitis in a large MMR vaccine campaign (590,609 people) in Curitiba, Paraná, Brazil, 1998

The aseptic meningitis after Measles-Mumps-Rubella vaccine (MMR) is a well recognized complication, and different incidences have been observed in several studies. We retrospectively analyzed forty cases of aseptic meningitis, during a large public immunization campaign (1998) in Curitiba, Southern Brazil (590,609 people), admitted in our Service. The vaccine utilized was Leningrad-3-Zagreb mumps strain, Edmonston-Zagreb measles strain, and RA 27#3 rubella strain. In all county, a total number of 87 cases were reported, resulting in a incidence of 1.7 cases per 10,000 given doses . The mean age was 23.7 ± 12.8 years. The female:male ratio was 1.35:1. Severe headache with meningismus (92.5 percent), fever (87.5 percent), nausea/vomiting (82.5 percent) were the most common clinical findings. Three cases (7.5 percent) developed mild mumps. All patients underwent cerebrospinal fluid (CSF) tap with the following findings: mononuclear pleocytosis from 100 to 500 cells/mm³ in 17 cases (42.5 percent; 257.5 260.6 cells/mm³); increased protein 28 cases (67.5 percent; 92.1 76.9 mg/dL); glucose was normal in all cases (56.8 11.2 mg/dL) except in 4 (10 percent) cases, which presented less than 44 mg/dL. All serological tests (latex to bacterial meningitis, Cryptococcus, cysticercosis, VDRL) and bacteriological cultures were negative. Virus identification were also negative in 8 samples. None of the patients had neurological deficits or related symptoms after one year of onset. We believe the benefit of vaccination clearly outweights the incidence of benign vaccine-associated meningitis

Cirurgia estereotáxica guiada para angiomas cavernosos / Stereotactic-guided surgery for cavernous angioma

Os angiomas cavernosos intracerebrais são lesões que podem causar hemorragias, crises convulsivas e déficits neurológicos. Essa patologia passou a ter diagnóstico mais precoce com o advento da ressonância magnética. A remoção radical por cirurgia é o melhor método de tratamento. Devido a frequente localização subcortical ou profunda, a utilização de métodos de localização por imagem como a estereotaxia apresentam várias vantagens como: menor incisão de pele, craniotomia e manipulação do tecido cerebral, consequentemente com menor morbidade. Apresentamos uma série de nove angiomas cavernosos tratados por ressecção cirúrgica radical guiada por estereotaxia. Em todos os casos o diagnóstico foi realizado por ressonância magnética e houve confirmação anátomo-patológica. A média de idade dos pacientes foi 30 anos, variando entre 20 e 54 anos. Como morbidade transitória, um paciente teve uma crise convulsiva no 3§ dia pós-operatório e uma paciente apresentou disfasia e hemiparesia no 2§ dia pós-operatório, com recuperação total na evolução. No total, a remoção foi radical em todos os casos e os pacientes permanecem sem nenhum déficit neurológico relacionado à cirurgia.

Estudo da cicatrizaçäo colônica em cólon preparado e näo preparado de ratos através do azul de Evans / Study of colonic cicratization in prepaired and not prepaired colon of rats through Evans blue

A diminuiçäo de mortalidade e morbidade nas cirurgias colônicas se devem sobretudo a limpeza mecânica do cólon e a antibioticoterapia profilática. Caracterizando a fase inflamatória da cicatrizaçäo, observamos um afluxo maior de células e plasma à ferida, além de um aumento da vascularizaçäo às custas da angiogênese. Estes fenômenos podem ser analisados com o uso de um corante vital, o Azul de Evans. Para isso utilizamos 72 ratos, da cepa Wistar divididos em 6 grupos: A1, A2, A3, B1, B2 e B3. Em 50 por cento dos animais foi realizado prepraro do cólon (grupos A1, A2 e A3) e nos restantes nada foi feito como preparo pré-operatório (grupos B1, B2 e B3). Os grupos A1 e B1 constituíram os grupos controle, onde foram retiradas amostras de cólon normal com e sem preparo respectivamente. Nos grupos A2, A3, B2 e B3 foi realizada anastomose em cólon terminal. Foi retirada amostras no terceiro dia dos grupos A2 E B2 e no sétimo dia dos grupos A3 e B3. Foi realizado estudo da cicatrizaçäo colônica determinando-se a força de explosäo e a dosagem tissular de azul de Evans oito horas após sua administraçäo parenteral. Os valores da concentraçäo tissular do corante no grupo A1 foi de 42,72ug/mg, no grupo B1 de 39,04ug/mg, näo havendo diferença estatística. No grupo A2 observamos um concentraçäo média significativamente maior do corante no local da anastomose, 41,36ug/mg, em relaçäo ao grupo B2 no qual obtivemos 34,53ug/mg. Nos grupos A3 e B3 näo houve diferença estatística na concentraçäo de corante na anastomose com valores de 29,87ug/mg e 31,21ug/mg respectivamente. O grupo A2 apresentou um resistência significativamente maior a força de explosäo com 106,25mmHg em relaçäo ao grupo B2 com 40mmHg (p<0,05); entre os grupos A3 e B3 näo houve diferença estatística com166,67mmHg e 137,77mmHg, respectivamente (p>0,05). Concluímos que a falta de preparo do cólon parece indicar que a presença de um meio mais contaminado interfere na fase vascular da cicatrizaçäo e na resistência das anastomoses colônicas no que diz respeito ao 3 dia de pós-operatório