Intramedullary spinal cord paracoccidioidomycosis. Report of two cases.

Two cases of intramedullary paracoccidioidomycosis are reported. Paracoccidioidomycosis is a systemic disease that involves the buccopharyngeal mucosa, lungs lymph nodes and viscera and infrequently the central nervous system. Localization in the spinal cord is rare. Case 1: a 55-year old male admitted with crural pararesis, tactile/painful hypesthesia and sphincter disturbances of 15 days duration. Cutaneous-pulmonary blastomycosis was diagnosed 17 years ago. Myelotomography showed a blockade of T3-T4 (intramedullary lesion). The lesion surgically removed was a Paracoccidioides brasiliensis granuloma. Treatment with sulfadiazine was started after the surgery. Follow-up of 15 month showed an improvement of the clinical signs. Case 2: a 57-year old male was admitted elsewhere 6 months ago and, with a radiologic diagnosis of pulmonary paracoccidioidomycosis, was treated with amphotericin B. He progressively developer paresthesia and tactile/pain anaesthesia on the left side, sphincter disturbances and tetraparesis with bilateral extensor plantar response and clonus of the feet. Myelotomography showed a blockade of C4-C6 (intramedullary lesion). The lesion was not found during surgical exploration and the patient deteriorated and died. Post-mortem examination revealed an intramedullary tumor above the site of the mielotomy (Paracoccidioides brasiliensis granuloma). The preoperative diagnosis of intramedullary paracoccidioidomycotic granulomas is difficult because the clinical and radiologic manifestations are uncharacteristic. Clinical suspicion was possible in our cases based on the history of previous systemic disease. Contrary to intracranial localizations, paracoccidioidomycotic granulomas causing progressive spinal cord compression may require early surgery because response to clinical treatment is slow and the reversibility of neurological deficits depends on the promptness of the decompression.

Cysticercosis of the central nervous system. I. Surgical treatment of cerebral cysticercosis: a 23 years experience in the Hospital das Clínicas of Ribeirão Preto Medical School.

Cysticercosis is the most frequent parasitosis of the nervous system and nowadays it is widespread through the world. Despite the development of anticysticercal drugs (praziquantel and albendazole), their efficacy is more marked in cases with parenchymal active cysts and they do not prevent complications such as hydrocephalus. Thus, many patients with neurocysticercosis require surgical intervention, generally of palliative nature, but that may occasionally produce a cure. The clinical outcome of 180 patients with cerebral cysticercosis who underwent surgical treatment form 1970 to 1993 was analyzed. Surgical treatment was performed to control increased ICP in 177 patients and due to local compression of cranial nerves or brainstem in five. Some patients had more than one surgical procedure, totalizing 287 interventions. Increased intracranial pressure (ICP) was caused by hydrocephalus in 91%, by intracranial mass lesion (tumoral form) in 6.2% and by pseudotumor cerebri (pseudotumoral form) in 2.8% of the case. Based on the pathophysiological mechanisms of intracranial hypertension identified through conventional CT-scan, ventriculography, cysternotomography, ventriculotomography and MRI, different surgical approaches were indicated. Patients with tumoral form were submitted to direct approach and cyst removal and generally they had benefits from this procedure. Patients with pseudotumoral form whose clinical treatment failure underwent decompressive craniectomies and had a poor outcome (40% of good results). Direct removal of ventricular/cisternal cysts and/or ventriculoatrial/peritoneal shunting (VA/VPS) was performed in patients with hydrocephalus. Removal of free ventricular cysts in patients who had no ependimitis/arachnoiditis generally allowed a good outcome. Patients with adherent cysts and inflammatory process needed a VA/VPS posteriorly and the outcome was not so good. One hundred thirty-two patients were submitted to VA/VPS (109 as the first procedure and 23 after another surgical treatment). The VA/VPS was effective to control increased ICP, despite many complications observed mainly during the two first postoperative years. After this period the surviving patients generally had a better outcome. The patients submitted to cyst removal due to local compression of cranial nerves/brainstem generally had good results. Based on the experience acquired with the management of these patients we present our recent policy for the treatment of patients with neurocisticercosis.

Cysticercosis of the central nervous system. II. Spinal cysticercosis.

The compromising of the spinal canal by cysticercus is considered infrequent, varying from 16 to 20% in relation to the brain involvement. In the spinal canal the cysticercus predominantly places in the subarachnoid space. Clinical signs in spinal cysticercosis can be caused by direct compression of the spinal cord/roots by cysticerci and by local or at distance inflammatory reactions (arachnoiditis). Another mechanism of lesion is degeneration of the spinal cord due to pachymeningitis or circulatory insufficiency. The most frequent clinical features are signs of spinal cord and/or cauda equina compression. The diagnosis of spinal cysticercosis is based on evidence of cerebral cysticercosis and on neuroradiological examinations (myelography and myelo-CT) that show signs of arachnoiditis and images of cysts in the subarachnoid space and sometimes, signs of intramedullary lesions, but the confirmation can only be made through immunological reactions in the CSF or during surgery. The clinical course of 10 patients with diagnosis of spinal cysticercosis observed among 182 patients submitted to surgical treatment due to this disease are analyzed. The clinical pictures in all cases were signs of spinal cord or roots compression. All but two presented previously signs of brain cysticercosis. Neuroradiological examinations showed signs of arachnoiditis in 4 patients, images of cysts in the subarachnoid space in 5, and signs of arachnoiditis and images of cysts in one. The 6 patients that presented intraspinal cysts were submitted to exeresis of the cysts and 2 patients with total blockage of the spinal canal underwent surgery for diagnosis. The 2 remaining patients with arachnoiditis and blockage of the spinal canal were clinically treated. All of the six patients submitted to cyst exeresis had initial improvement but 4 of them later developed arachnoiditis and recurrence of the clinical signs and only 2 remained well for long-term. The 2 non operated patients had no improvement of their clinical signs. Two patients died later due to complications of cerebral cysticercosis. Based on the experience acquired in the management of these patients we indicate surgical treatment for patients that present free cyst in subarachnoid space. For those who present arachnoiditis, surgery is indicated only when there is doubt in the diagnosis. Intramedullary cysts should also be surgically treated.

Isolated fourth ventricle in neurocysticercosis: pathophysiology, diagnosis, and treatment.

Four cases of isolated fourth ventricle in neurocysticerocosis are reported (three after ventriculoperitoneal shunting, and one after hydrocephalus without shunting). Diagnosis was made based on computed tomography (CT) and/or CT cisternogram/ventriculogram. Three patients underwent fourth ventricle drainage (two died and the third remains well). The fourth patient refused surgical treatment and continues to have severe ataxia. Diagnosis, pathophysiology, and treatment of this entity in neurocysticercosis are discussed.

[Surgical treatment of intracranial aneurysms: comparison between early and late surgery]. / Tratamento cirúrgico dos aneurismas intracranianos. Comparação entre cirurgias precoce e tardia.

The clinical course of patients with subarachnoid hemorrhage (SAH) due to rupture of cerebral aneurysm admitted during the last five years is analysed: 157 patients were treated by direct surgical approach of the aneurysm, 58 localized in the anterior communicating artery (ACoA), 48 in the internal carotid artery (ICA), 43 in the middle cerebral artery (MCA), and 8 in the posterior circulation. Fourty-four patients were operated on during the first 72 hours (early surgery), 40 during the 4th and 7th days, 16 during the 8th and the 10th, and 57 after the 10th (late surgery). According to main localizations, the outcome of patients with aneurysms in the ACoA was good in 79.1%, in the ICA in 69.7%, and in the MCA in 69.7%. Patients treated in Hunt & Hess grade I and II had both good results in 77.5%, grade III patients had good results in 71.3%, and grade IV in 56.2%. According to timing of surgery good results were observed in 61.4% for patients submitted to early surgery, in 80% for patients treated during the 4th and 7th days, in 81.2% for patients treated during the 8th and the 10th days, and in 70.2% for that submitted to late surgery. The overall mortality was 14.6%. For grade I patients mortality was 6.4%, for grade II was 12.2%, for grade III was 15.2%, for grade IV was 25%, and all patients operated on in grade V died.(ABSTRACT TRUNCATED AT 250 WORDS)

Infantile hydrocephalus: brain sonography as an effective tool for diagnosis and follow-up.

Infantile hydrocephalus is a common disease. In most affected children the process starts before the age of 2 when the bregmatic fontanel is still open. Brain sonography has emerged as an effective tool in diagnosing progressive ventricle dilation and may be used for continuous follow-up. It gives such important information as: (a) cortical thickness, an expression of proper shunt function and of prognostic value concerning neuropsychological development; (b) position of the tip of the catheter, which is considered by some to be a predictive factor of shunt failure; (c) other complications such as subdural collections, isolated IV ventricle, and slit ventricles. This methodology permits frequent examinations and allows better comprehension of the pathological process by the parents and medical staff.

[Infantile hydrocephalus: long-term results in 102 patients and the importance of neurosonography]. / Hidrocefalia infantil: resultados tardios em 102 pacientes e importância da neuro-sonografia.

A personal series (in 94% of the cases) of 102 children who underwent 170 procedures (1.66 procedures/patient) for hydrocephalus has been followed for 5 1/2 years (Jan-83 to June-88). Most of the children were under two years of age (80%) and in these cases brain sonography was the examination of choice for both diagnosis and follow-up (307 examinations, 4.4 per patient). Only occasionally was computed tomography necessary for better study in these cases. Our results suggest that there was no significant difference between our cases and those published in the literature concerning the number or procedures/patient (1.66)., infection rate (5.2%), mortality rate (6.8%) and intellectual performance. We recommend the use of brain sonography both in diagnosis and follow-up studies for hydrocephalic children since this examination is innocuous, inexpensive and easy to perform by neurosurgeons. Also it provides a good interaction between the examiner, the child and the parents, which is of utmost importance for the comprehension of the disease by the parents and early diagnosis of complications by the neurosurgeon.

Surgical treatment of multiple intracranial aneurysms.

A retrospective study was conducted on 42 patients with multiple aneurysms surgically treated from 1975 to 1986. Thirty one of them had 2 aneurysms 6 had 3, 3 had 4 and 2 had 5 (62 in the internal carotid, 27 in the middle cerebral artery, 11 in the anterior cerebral and 3 in the basilar artery). All patients had subarachnoid hemorrhage and were classified as follows upon admission: 11, grade I; 12, grade II; 15, grade III, and 4, grade IV, and most of them improved before surgery (29, grade I, 7, grade II, and 6, grade III). In most cases, surgery was delayed and the 42 patients needed 57 craniotomies for clipping the aneurysms. Of the 24 patients with bilateral aneurysms, 15 were operated on both sides (11 are asymptomatic, 1 has hemiparesis, and 3 died later). Of the 9 patients submitted to unilateral craniotomy, 4 died and 5 are alive and well. Of the 18 patients with unilateral aneurysms, 11 are asymptomatic, 2 have hemiparesis, 1 has diplegia and behavioral disorders, and 4 died. Overall mortality was 26.1%, intraoperative mortality was 11.9%, and no mortality occurred among the patients operated over the last 5 years. The management of these patients is discussed.

Cerebromeningeal hemorrhage. Analysis of autopsies performed over a 10-year period.

A study was conducted on the medical records of 353 patients who died of a subarachnoid hemorrhage (SAH) and who were submitted to autopsy over the last 10 years. SAH was associated with arterial hypertension in 180 (51%) cases, with ruptured aneurysms in 102 (28.9%), and with other pathologies in 71 (20.1%). The patients with hemorrhage associated with arterial hypertension were mostly males, and those with hemorrhage due to aneurysms were mostly females. Of the patients with aneurysms, 36 (35.3%) had aneurysms in the anterior communicating artery, 30 (29.4%) in the internal carotid artery, and 23 (22.6%) in the middle cerebral artery. Among the patients with aneurysms who suffered rebleeding and vasospasm, 59.1% and 61.5%, respectively, were classified as grade I and II upon admission, and all evolved toward grade IV after these complications. Vasospasm predominated from the 3rd to the 10th day after hemorrhage, and rebleeding from the 9 to 16th day and both were most frequent among patients with aneurysms of the anterior communicant artery. Sixty eight percent of the patients with aneurysms died during the first 9 days after hemorrhage. Because of our conduct was to operate systematically late, a considerable number of patients lost the opportunity to be treated surgically with possible favorable evolution due to vasospasm or rebleeding.

[Multiple non-neoplastic lesions in computerized cranial tomography]. / Lesões múltiplas não neoplásicas na tomografia computadorizada do crânio.

Multiple intracranial lesions observed in the computerized tomography ever cause worry due to the possibility of neoplastic etiology, although granulomatous diseases (parasitic or not) and vascular diseases can produce this type of lesions. Five patients with clinical picture that suggested expansive intracranial masses and that had multiple lesions in the computerized tomography that suggested neoplastic diseases are presented. In all patients the clinical evolution and/or other complementary diagnostic tests showed the non neoplastic etiology of the lesions. In three patients the lesions were due to parasitic diseases (intracranial tuberculomas in one case and neurocysticercosis in two cases) and in the other two cases the lesions were due to vascular disturbs (cerebral infarcts). The knowledge of the several diseases that can cause multiple intracranial lesions as seen in the computerized tomography allows to direct the etiologic diagnostic that is essential to introduce the correct treatment avoiding irradiation of non neoplastic lesions and unnecessary surgical procedures. In our country, granulomatous parasitic diseases, mainly neurocysticercosis, tuberculosis and fungal diseases must be considered in the differential diagnosis of multiple intracranial lesions observed in the computerized tomography, together with cerebral infarcts and neoplasms.

[Tumor form of neurocysticercosis: surgical removal of a cysticercus measuring 70X77 mm and treatment with praziquantel]. / Forma tumoral da neurocisticercose: exérese de cisticerco de 70X77 mm e tratamento com praziquantel: relato de caso.

The authors report a case of a female patient, age 22, who presented episodes of focal seizures, right hemiparesis and dysphasia of five months duration. The neurologic exam revealed bilateral papilledema and computarized tomography of the head showed a cystic lesion (70X77 mm) in the left fronto-temporo-parietal area, midline shift and similar lesions scattered in the brain parenchyma. She was submitted to a left craniotomy with the diagnosis of cerebral cysticercosis and the major cyst (Cysticercus racemosus) and a small cortical cyst (10X10 mm) were removed to aliviate the increased intracraneal pressure and for histopathological examination. Thirteen days after surgery she was discharged without neurological deficits, except mild papilledema. One month later she was treated with praziquantel (50 mg/kg/day) during 21 days. The CSF examination was normal before the treatment started and showed a transient eosinophilic cellular reaction with positivation of the complement fixation test for cysticercosis while on treatment. The CT-Scan performed before the medical treatment revealed ventricular dilatation and several low density areas (10 to 40 mm) scattered in the cerebral parenchyma, including the operative site. CT-Scan performed three months later showed small low density areas only in the left cerebral hemisphere, including the operative site, calcification in the parenchyma, and slight dilatation of the left lateral ventricle. The clinical evolution was uneventful and the neurologic examination was normal three months later.

[Computerized tomography in patients with neurocysticercosis with intracranial hypertension due to obstructive hydrocephalus: comparison with Dimer-X ventriculography]. / Tomografia computadorizada em pacientes portadores de neurocisticercose com hipertensão intracraniana por hidrocefalia obstrutiva: comparação com ventriculografia com Dimer-X.

The authors reviewed the alterations observed on computerized tomography (CT) examinations of 16 patients with increased intracranial pressure and obstructive hydrocephalus due to cerebral cysticercosis. Plain radiograms of the skull were available in all cases and Dimer-X ventriculography in 12 cases. In 7 cases there were radiologic signs of increased intracranial pressure. CT scan showed normal cerebral parenchyma in 9 cases and low density areas, with various size, with or without surround contrast enhancement, and/or small calcifications in the parenchyma. Hydrocephalus was the only alteration observed in the ventricular system in the case that the examination was done before ventricular drainage. Ventriculography was analyzed in other paper and permitted to situate the obstruction, determine its morphological characteristics and identify occuping space lesions within the ventricles. Comparison between ventriculography and CT scan made in the same period evidence that the former gives best information about the ventricular system and that tomography gives additional information about the cerebral parenchyma. In conclusion, CT scan and ventriculography are investigations that complete each the other for evaluation and diagnosis of cerebral cysticercosis.

Erosao da base do cranio em pacientes portadores de neurocisticercose com fistula liquorica e pneumencefalo espontaneo. Relato de 2 casos. / Skull basis erosion in patients with neurocysticercosis with cerebrospinal fluid fistula and spontaneuous pneumoencephalus. Report of 2 cases

Os autores relatam os casos de 2 pacientes portadores de hidrocefalia por neurocisticercose, submetidos a derivacoes ventriculo-peritoneais e postoriormente tratados com praziquantel (50 mg/kg/dia durante 21 dias), e que apresentaram surtos de ativacao da doenca apos este tratamento. Ambos, um deles 3 meses e outro 1 anos e 3 meses apos a derivacao, apresentaram fistulas liquoricas nasais e as radiografias e tomografia computadorizada do cranio mostraram erosao da fossa craniana anterior e pneumencefalo espontaneo.Concomitantemente os pacientes apresentaram piora do nivel de consciencia, apatia e confusao mental.As derivacoes foram revisadas mas nao houve resolucao das fistulas liquoricas. Ambos foram submetidos a correcao das fistulas por abordagem subfrontal (intra e extradural). Um deles foi reoperado por recidiva da fistula. Os 2 pacientes desenvolveram complicacoes infecciosos pos-operatorias ventriculite, meningite e pneumonia) e faleceram em virtude destas, 2 e 3 meses apos a correcao da fistula. A erosao ossea na neurocisticercose e rara e a fistula liquorica e o pneumencefalo consequentes nao foram relatados na literatura consultada. Os possiveis mecanismos das lesoes sao discutidos

Aumento de tamanho de um pequeno aneurisma documentado por angiografia e autopsia. (Relato de caso). / Enlargement of a \"Minute Aneurysm\" documented by angiography and autopsy.(Case report)

Os autores relatam o caso de uma paciente de 25 anos que foi acometida por 2 episodios de hemorragia subaracnoidea por ruptura de 2 aneurismas, tendo sido o crescimento de 1 deles documentado angiograficamente e confirmado na autopsia. Sao feitos comentarios sobre a conduta seguida quando existem pequenos aneurismas assintomaticos

Ventriculografia com Dimer-X em pacientes portadores de neurocisticercose com hipertensao intracraniana por hidrocefalia obstrutiva. Consideracoes sobre tratamento cirurgico. / Dimer-X ventriculography in patients with neurocysticercosis presenting intracranial hypertension due to obstructive hydrocephalus. Considerations on surgical treatment

Os autores estudaram as ventriculografias (realizadas com Dimer-X) de 18 pacientes portadores de neurocisticercose com hipertensao intracraniana por hidrocefalia obstrutiva. O sistema ventricular encontrava-se bloqueado parcial ou completamente em todos os casos, no IVo. ventriculo ou aqueduto cerebral. Os pacientes foram subdivididos em 3 grupos, de acordo com as caracteristicas da obstrucao. 1 - Obstrucao do forame de Magendie com os recessos laterais, fastigio e porcao inferior do ventriculo ora bem delimitados, ora nao contrastados ou irregulares, sem evidencia de processo expansivo (obstrucao inflamatoria). 2 - Obstrucao inflamatoria do Magendie com a presenca de processos arredondados, regulares e livres no interior do ventriculo. 3 - Obstrucao por processo arredondado bem delimitado e com contorno regular, as vezes movel, que ocupa o ventriculo parcial ou totalmente. Associadas as obstrucoes, foram observadas em varios casos falhas de enchimento regulares, arrendondadas, moveis ou nao, no interior dos ventriculos laterais, IIIo. ventriculo e aqueduto cerebral e/ou irregularidades nas paredes destes ventriculos. Os autores discutem a importancia do estudo completo das cavidades ventriculares nestes pacientes e a conduta terapeutica adotada (exereses de cisticercos ou derivados liquoricas), baseada nos achados ventriculograficos

Fistula liquorica pela cicatriz umbilical como complicacao de derivacao ventriculo-peritoneal. Relato de 2 casos. / Cerebraspinal fluid fistula through umbilical cicatrix as a complication of ventriculoperitoneal shunt. Report of 2 cases

Os autores relatam 2 casos de criancas hidrocefalicas tratadas com derivacao ventriculo-peritoneal, que apresentaram fistula liquorica pela cicatriz umbilical, que surgiram, 14 e 10 meses apos a instalacao do sistema de derivacao. Em 1 caso houve extrusao do cateter pela cicatriz umbilical. As condutas terapeuticas pertinentes sao discutidas em comparacao com a literatura

[Cerebral ultrasonography in children during the 1st year of life. A method for diagnosis and follow-up of ventricular dilatation]. / Ultra-sonografia cerebral em crianças no primeiro ano de vida. Método para o diagnóstico e acompanhamento das dilatações ventriculares.

The ultrasonography (Mode B--Real Time) experience was analyzed to evaluate neurological diseases in children during their first year of life. Forty-two examination were accomplished in twenty-eight children with the following diagnosis: hydrocephalus (22), normal (15), subdural hygroma (3), intracranial cyst and hydrocephalus (1), giant encephalocele (1). The technique consists of positioning the transducer in the coronal, sagital and axial direction and selecting dynamically the images to be photographed. In the coronal position, the height of the lateral ventricle and the width of the third ventricule were obtained. In the axial position, the ventricular ratio-lateral ventricle width cerebral hemisphere width was obtained. Although it was a small group of patients, those indexes can objectify the ventricular size variation in children with well or poor functioning shunts. The importance of this method was the possibility to follow the development of hydrocephalus in cases of myelomeningocele and to analyze the etiology and features of hydrocephalus with or without shunts. In conclusion, this test is very usefull, mainly because it is very brief (about 20 minutes), the patient does not need sedation, it is innocuous, very precise even when compared with computerized tomography and for its low cost.

Ultra-sonografia cerebral em criancas no primeiro ano de vida:metodo para o diagnostico e acompanhamento das dilatacoes ventriculares. / Cerebral ultrasonography in children in the first year of life: a method for diagnosis and follow-up of ventricular dilation

Os autores expoem a experiencia adquirida com a utilizacao da ultra-sonografia (Modo-B e real-time) na avaliacao de criancas com afeccoes neurologicas durante o primeiro ano de vida. A rapidez com que o exame e realizado (20 minutos), seu baixo custo, a desnecessidade de sedacao e ausencia de irradiacao e o fato de ser um exame dinamico tornam esta tecnica util, mesmo quando comparado com a tomografia computadorizada. Seu valor maior esta na analise, diagnostico e acompanhamento dos hidrocefalos, embora sua utilizacao se estenda a outros diagnosticos dentro da faixa etaria estabelecida