Gamma Knife Radiosurgery for Cerebral Cavernous Malformations: Meta-analysis of Reconstructed Time-to-Event Data.

INTRODUCTION: Cavernomas are vascular lesions with a genetic heritage that can be spotted on the central nervous system. Whenever these lesions are localized in eloquent regions, surgical resection is not recommended. In this type of situation, Gamma Knife stereotactic radiosurgery (GKRS) could be a feasible option for treating patients. Thus, we aim to explore the outcomes associated with this procedure. METHODS: We performed a systematic review and meta-analysis of reconstructed time-to-event data based on Kaplan-Meier curves. A thorough search was conducted on PubMed, Cochrane, Web of Science and Embase databases targeting papers that provided information regarding hemorrhagic outcomes associated with GKRS through Kaplan-Meier curves. RESULTS: After a systematic search in the specific databases, seven studies were included in this review. Notably, a total of 1071 patients had 1104 cavernomas treated by GKRS. Assessment of short-term and long-term post-procedure outcomes was performed, with the estimated overall events-free rate at 2 years being 89.8% (95% CI 87.7 - 91.5), whilst, at ten years, the estimated overall events-free rate was 71.3% (95% CI 67.2 - 75.1). CONCLUSION: GKRS seems to be a good alternative for control of symptomatic events in early and long-term follow-up, despite the need of further investigation provided by future studies.

Cerebral Cavernous Malformations: Patient-Reported Outcome Validates Conservative Management.

BACKGROUND: Cerebral cavernous malformations (CCM) are clusters of dilated sinusoidal channels lined by a single layer of endothelium. In contradistinction to arteriovenous malformations, these lesions do not have smooth muscle or elastin in their lining and they are angiographically occult, and the MRI is the most sensitive test for CCM detection. CCM are one of the most prevalent vascular malformations of the central nervous system, affecting about 0.4-0.6% of the general population. The main complication of this malformation is the risk of bleeding, which may cause neurological deficits that affect the quality of life (QoL) in patients. When symtomatic, they may be surgically treated for relieving the mass effect and seizures refractory to drug uses, hemorrhage and drug-refractory epilepsy. Patient-reported outcome (PRO) may be a strategy that can be used to evaluate QoL of CCM population and was used in a sample of non-operated patients. METHODS: An observational, cross-sectional analysis to evaluate the PRO using the SF-36 and EuroQol 5 dimensions (EQ-5D) questionnaires of QoL added to functional metrics using the Karnofsky Performance Status (KPS) in 49 patients not submitted to intervention and with long-term follow-up. RESULTS: During the 364 person-years of follow-up, there was an average of individual follow-up of 7.42 years. The mean age was 46.8 years (18-84) - 57% of them were female, 71% had superficial lesions, and 65% had the familial form. Comparisons of SF-36 dimensions with KPS graded <100 had a worse score only in terms of the pain (p = 0.04), vitality (p = 0.001), and general state of health (p = 0.03) domains. The domain mental health was worse in patients without surgical indication (p = 0.032). The functional capacity domain had the highest overall grading in the group. The EQ-5D dimensions of mobility (p = 0.03) and pain/discomfort (p = 0.001) were the ones with lower score compared to KPS <100. CONCLUSION: The study is the first to evaluate, with validated tools, the PRO of non-operated CCM patients and has demonstrated in a selected group of patients that it was possible to achieve long-term clinical stability, thereby maintaining QoL and functional neurological outcome.

Neurocysticercosis, familial cerebral cavernomas and intracranial calcifications: differential diagnosis for adequate management.

Neurocysticercosis (NCC) is an endemic disease and important public health problem in some areas of the World and epilepsy is the most common neurological manifestation. Multiple intracranial lesions, commonly calcified, are seen on cranial computed tomography (CT) in the chronic phase of the disease and considered one of the diagnostic criteria of the diagnosis. Magnetic resonance imaging (MRI) is the test that better depicts the different stages of the intracranial cysts but does not show clearly calcified lesions. Cerebral cavernous malformations (CCM), also known as cerebral cavernomas, are frequent vascular malformations of the brain, better demonstrated by MRI and have also epilepsy as the main form of clinical presentation. When occurring in the familial form, cerebral cavernomas typically present with multiple lesions throughout the brain and, very often, with foci of calcifications in the lesions when submitted to the CT imaging. In the countries, and geographic areas, where NCC is established as an endemic health problem and neuroimaging screening is done by CT scan, it will be important to consider the differential diagnosis between the two diseases due to the differences in adequate management.

Neurocysticercosis, familial cerebral cavernomas and intracranial calcifications: differential diagnosis for adequate management / Neurocisticose, cavernoma cerebral familiar e calcificações intracranianas: diagnóstico diferencial e acompanhamento adequado

ABSTRACT Neurocysticercosis (NCC) is an endemic disease and important public health problem in some areas of the World and epilepsy is the most common neurological manifestation. Multiple intracranial lesions, commonly calcified, are seen on cranial computed tomography (CT) in the chronic phase of the disease and considered one of the diagnostic criteria of the diagnosis. Magnetic resonance imaging (MRI) is the test that better depicts the different stages of the intracranial cysts but does not show clearly calcified lesions. Cerebral cavernous malformations (CCM), also known as cerebral cavernomas, are frequent vascular malformations of the brain, better demonstrated by MRI and have also epilepsy as the main form of clinical presentation. When occurring in the familial form, cerebral cavernomas typically present with multiple lesions throughout the brain and, very often, with foci of calcifications in the lesions when submitted to the CT imaging. In the countries, and geographic areas, where NCC is established as an endemic health problem and neuroimaging screening is done by CT scan, it will be important to consider the differential diagnosis between the two diseases due to the differences in adequate management.

RESUMO A neurocisticercose (NCC) é um importante problema endêmico de saúde pública em algumas áreas do mundo, sendo epilepsia sua manifestação clínica mais comum. Múltiplas lesões intracranianas, geralmente com calcificações visualizadas em tomografia computorizada de crânio, são interpretadas como um dos critérios diagnósticos na fase crônica da doença. A ressonância magnética é o melhor teste de imagem para identificar a doença em diferentes estágios de sua forma cística mas apresenta limitações para demonstrar lesões calcificadas. Malformações cavernosas cerebrais, ou cavernomas, são malformações vasculares comuns ao sistema nervoso e epilepsia é também a sua forma mais frequente de apresentação. Na sua forma familiar cavernomas apresentam-se tipicamente com múltiplas lesões encefálicas e, frequentemente, com focos de calcificações na TC. Em alguns países, e determinadas regiões geográficas, onde neurocisticercose é endêmica, a neuroimagem mais usada para diagnóstico é a TC de crânio. Nesse contexto torna-se importante estabelecer bases para o diagnóstico diferencial entre as duas doenças, devido às diferentes formas de acompanhamento e tratamento adequado.

Cavernous Malformation in the Trigeminal Distribution: A Case Report of Aggressive Presentation and Management.

BACKGROUND: Cavernous malformation (CM) is a vascular malformation found in the encephalic parenchyma, spinal cord, nerve roots, and extraneural tissue. CM in the trigeminal distribution is exquisitely uncommon and its biological behavior not completely understood. The clinical picture might be diverse, depending on the affected sector of the trigeminal architecture, and literature debating its pathobiology is scarce. CASE DESCRIPTION: We describe a case of 56-year-old woman who presented with left trigeminal neuralgia and a rapidly growing cavernous malformation of the entire distribution of the fifth nerve. The clinical picture evolved to a progressive gait ataxia and follow-up neuroimaging showed a large intracranial mass leading to a brainstem compression. After microsurgical resection, the mass proved to be a typical CM of the trigeminal root. CONCLUSION: We present an uncommonly aggressive progression of a CM of the trigeminal root, Gasserian ganglion, and cavernous sinus evolving to severe brainstem compression. The documentation of this unique case as well as its management is presented is discussed.

Familial cerebral cavernous malformations: Rio de Janeiro study and review of the recommendations for management.

OBJECTIVE: Multiple cerebral cavernous malformation (CCM) is the hallmark of familial presentation of cavernous malformation in the brain. We describe an ongoing Familial Cerebral Cavernous Malformation Project in the Rio de Janeiro state showing genetic profile and the pattern of emergent neuroimaging findings of this particular population besides a review of the updated recommendations for management of familial CCM versus patients harboring sporadic lesions. METHOD: Four families of our cohort of 9 families were genetically mapped showing mutational profile linked to CCM1. The neuroimaging paradigm was shifted from T2*gradient-echo (GRE) sequence to susceptibility weighting MR phase imaging (SWI). RESULTS: Only two index cases were subjected to surgery. There was no surgical intervention in any of the kindreds of our entire cohort of 9 families of our Neurovascular Program within seven years of follow-up. The genetic sequencing for mutational profile in four of these families has demonstrated only CCM1 gene affected. Our management of the familial CCM is according to the review of the literature recommendations. CONCLUSIONS: The Project of Familial Cerebral Cavernous Malformations of Rio de Janeiro detected mutations of the gene CCM1 in the first four families studied. Familial cavernous malformation are to be settled apart from the more common sporadic lesion. A set of recommendations was searched for in the literature in order to deal with these specific patients and kindreds.

Familial cerebral cavernous malformations: Rio de Janeiro study and review of the recommendations for management / Malformação cavernosa cerebral familiar: um estudo no Rio de Janeiro e revisão das recomendações para tratamento

OBJECTIVE: Multiple cerebral cavernous malformation (CCM) is the hallmark of familial presentation of cavernous malformation in the brain. We describe an ongoing Familial Cerebral Cavernous Malformation Project in the Rio de Janeiro state showing genetic profile and the pattern of emergent neuroimaging findings of this particular population besides a review of the updated recommendations for management of familial CCM versus patients harboring sporadic lesions. METHOD: Four families of our cohort of 9 families were genetically mapped showing mutational profile linked to CCM1. The neuroimaging paradigm was shifted from T2*gradient-echo (GRE) sequence to susceptibility weighting MR phase imaging (SWI). RESULTS: Only two index cases were subjected to surgery. There was no surgical intervention in any of the kindreds of our entire cohort of 9 families of our Neurovascular Program within seven years of follow-up. The genetic sequencing for mutacional profile in four of these families has demonstrated only CCM1 gene affected. Our management of the familial CCM is according to the review of the literature recommendations. CONCLUSIONS: The Project of Familial Cerebral Cavernous Malformations of Rio de Janeiro detected mutations of the gene CCM1 in the first four families studied. Familial cavernous malformation are to be settled apart from the more common sporadic lesion. A set of recommendations was searched for in the literature in order to deal with these specific patients and kindreds.

OBJETIVOS: A apresentação de malformação cavernosa cerebral (CCM) através de múltiplas lesões cerebrais é a marca da forma familiar da doença. Os autores descrevem o Projeto Malformação Cavernosa Cerebral Familiar, em andamento no Rio de Janeiro, demonstrando o perfil genético e o padrão atual de achados neurorradiológicos dessa população específica e uma revisão das recomendações atuais para o manuseio e tratamento dos portadores dessa forma da doença versus os pacientes com malformação cavernosa cerebral esporádica. MÉTODO: Quatro familias de nossa coorte de 9 familias foram completamente mapeadas geneticamente e demonstraram padrão mutacional sempre ligado ao gene CCM1. O paradigma de neurimagens dessa população foi mudado para a seqüência de susceptibility weighting MR phase imaging (SWI) em substituição à seqüência T2*gradient-echo (GRE). RESULTADOS: Apenas 2 casos indices foram submetidos à ressecção cirúrgica. Não houve intervenção cirúrgica em nenhum outro parente de toda a coorte de 9 familias no período de sete anos de acompanhamento. O sequenciamento genético em busca do perfil mutacional foi completado em 4 familias demonstrando o acometimento do gene CCM1 em todas. O manuseio e tratamento de nossa população de malformação cavernosa cerebral familiar está de acordo com a revisão feita sobre recomendações da literatura. CONCLUSÃO: O Projeto Malformação Cavernosa Cerebral Familiar detectou mutações do gene CCM1 nas primeiras quatro famílias estudadas. Os portadores dessa forma de malformação cavernosa cerebral da doença devem ser considerados à parte na rotina de avaliação e tratamento em relação à forma esporádica da doença. As recomendações foram buscadas na literature para nortear o manuseio dessa população específica.

Spinal root arteriovenous malformations and same-segment cord cavernous malformation in familial cerebral cavernous malformation. Case report.

Spinal vascular malformations are uncommon lesions, and controversy persists regarding optimal investigation, classification, and treatment strategies. The authors report on a patient with a spinal root arteriovenous malformation (AVM) associated with a parenchymal cavernous malformation (CM) in the same spinal cord segment and describe a complete familial and molecular investigation. This 35-year-old woman presented with symptoms of progressive clinical spastic paraparesis. Magnetic resonance imaging results were suggestive of a spinal cord cavernoma associated with cerebral CMs. Her family history included 2 sisters treated for epilepsy. At surgery an intraspinal root AVM was found at the same level of the cord CM, and both lesions were completely removed. Cerebral gradient echo MR imaging disclosed multiple cavernomas in her relatives, which prompted the molecular diagnosis. On sequence analysis, a novel mutation on the cerebral CM1 (CCM1) gene (c796insA) was found. The authors report on a unique case of familial cerebral CM in which a spinal root AVM was situated next to a cord CM, and discuss the concomitant occurrence of altered nervous system angiogenesis and vasculogenesis.

Complex paraclinoidal and giant cavernous aneurysms: importance of preoperative evaluation with temporary balloon occlusion test and SPECT.

In the treatment of complex paraclinoidal and giant cavernous aneurysms, preservation of the patency of the internal carotid artery (ICA) is not always possible, and therapeutic occlusion of the carotid is still an important option for their management. A complete preoperative evaluation of the carotid reserve circulation, including the use of temporary balloon occlusion test and single photon emission computerized tomography (SPECT) should be included in the current paradigms of paraclinoidal and intracavernous aneurysms management. We present a series of fifteen patients with sixteen giant or complex carotid cavernous or ophthalmic aneurysms that were treated following a protocol for our preoperative decision-making analysis. Extracranial to intracranial saphenous vein bypass was reserved to the cases where carotid occlusion would be associated with high risk of ischemic complications and was performed in three patients. Besides the difficulties in dealing with those complex aneurysms, good clinical outcome was possible in our experience with the designed paradigm.

Complex paraclinoidal and giant cavernous aneurysms: importance of preoperative evaluation with temporary balloon occlusion test and SPECT / Aneurismas paraclinoideos complexos e cavernosos gigantes: importância da avaliação pré-operatória com teste de oclusão temporária com balão e SPECT

In the treatment of complex paraclinoidal and giant cavernous aneurysms, preservation of the patency of the internal carotid artery (ICA) is not always possible, and therapeutic occlusion of the carotid is still an important option for their management. A complete preoperative evaluation of the carotid reserve circulation, including the use of temporary balloon occlusion test and single photon emission computerized tomography (SPECT) should be included in the current paradigms of paraclinoidal and intracavernous aneurysms management. We present a series of fifteen patients with sixteen giant or complex carotid cavernous or ophthalmic aneurysms that were treated following a protocol for our preoperative decision-making analysis. Extracranial to intracranial saphenous vein bypass was reserved to the cases where carotid occlusion would be associated with high risk of ischemic complications and was performed in three patients. Besides the difficulties in dealing with those complex aneurysms, good clinical outcome was possible in our experience with the designed paradigm.

No tratamento de aneurismas paraclinoideos complexos e cavernosos gigantes, a preservação da patência vascular nem sempre é possível, e a oclusão terapêutica da carótida ainda é uma opção importante no seu manejo. Uma avaliação pré-operatória completa da reserva circulatória carotídea, incluindo o uso do teste de oclusão temporária por balão associado à tomografia computadorizada por emissão de fóton único (SPECT) podem ser de grande utilidade para definir a opção terapêutica a ser adotada. Nós apresentamos uma série de quinze pacientes com dezesseis aneurismas complexos ou gigantes do segmento oftálmico e cavernoso da artéria carótida, que foram tratados de acordo com determinado protocolo de investigação pré-operatória. Anastomose com enxerto de veia safena entre a carótida extra e intracraniana foi reservada para os casos em que a oclusão carotídea estaria associada a um alto risco de complicações isquêmicas e foi realizado em três pacientes. Apesar das dificuldades em lidar com aneurismas complexos como os aqui relatados, é possível obter um bom resultado clínico nestes pacientes com o paradigma desenhado.

Cervical spondylotic myelopathy: 10 years of prospective outcome analysis of anterior decompression and fusion.

BACKGROUND: Fifty-one patients with cervical spondylotic myelopathy (CSM) treated by anterior cervical corpectomy with fusion (ACWF) at our institution were included in a study during a period of 10 years to evaluate neurological, anatomical, and functional outcomes including satisfaction levels. METHODS: We have completed a prospective evaluation of 39 patients with spondylotic myelopathy submitted to ACWF during the period of 1989-2000. The data were analyzed for age, duration of symptoms, severity of preoperative neurological deficit, and single-level or multilevel compressive status looking for possible association with prognostic surrogate data and clinical outcome that were evaluated with the Nurick score and a survey of level of satisfaction. RESULTS: Of the 51 patients, 39 fullfilled the intended follow-up being 28 men (71.8%) and 11 women (28.2%). The average age was 63.5 years. Duration of symptoms ranged from 1 to 240 months (mean, 38.1 months). The mean preoperative Nurick scale score was 2.97; the mean postoperative score was 2.1. The most frequently involved vertebral body was C5 (71.7%). The follow-up period was longer than 18 months for all patients. Postoperative nonneurological complications occurred in 8 patients (15.6%). The mortality rate was 1.9% (n = 1). Postoperative results showed improvement in 25 patients (64.1%), no change in 13 (33.3%), and worsening in 1 (2.6%). The correlation coefficient of preoperative and postoperative Nurick scores was 0.733 (R(2) = 0.53). Of the 39 patients, 31 answered the questionnaire for quality of life-19 (61.2%) were very satisfied, 6 were satisfied (19.35%), and 6 were not satisfied (19.35%). CONCLUSION: Most patients (80.6%) were very satisfied or satisfied with the outcome and would decide again for the surgery (87%) if the results were previously known. Anterior cervical corpectomy with fusion was a reliable and rewarding procedure for CSM, with functional improvement in most patients. Excellent long-term outcome results in cervical fusion can be achieved without the use of hardware instrumentation.

Optic pathways tuberculoma mimicking glioma: case report.

BACKGROUND: Optochiasmatic tuberculomas are very rare lesions. They can occur with concomitant tuberculous meningitis, and pulmonary tuberculosis or as the only manifestation of the disease. The authors present a case of optic pathways tuberculoma with radiologic appearance simulating an optic pathways glioma. CASE DESCRIPTION: We report a case of a 20-year-old man with mental retardation due to anoxic encephalopathy who developed a sudden bilateral amaurosis. He also presented with diabetes insipidus, panhypopituitarism, right proptosis, and chemosis. Computed tomography (CT) and magnetic resonance imaging (MRI) showed an enhancing lesion in the optochiasmatic region extending to both optic nerves, with a mass in the right orbit, mimicking an optic pathways glioma. There was no other evidence of systemic involvement of the tuberculosis. The lesion was explored through a right pterional transylvian approach with opening of the optic canal and orbital roof, and a biopsy and an internal decompression were performed. Histopathological studies demonstrated a granulomatous lesion with central caseous necrosis with acid-fast bacilli. The patient improved after treatment with tuberculostatic drugs, but vision recovery could not be achieved. CONCLUSIONS: Visual compromise in tuberculosis is associated with hydrocephalus, optical neuritis or tuberculomas involving the optic pathways. Reviewing the literature on tuberculomas of the optochiasmatic area, we could not find any other case with such extensive involvement of the optic pathways that was radiologically suggestive of an infiltrating glioma. Histopathological studies remain crucial in the diagnosis of intrinsic expansive processes of the optochiasmatic region.

Cavernous carotid artery pseudo-aneurysm treated by stenting in acromegalic patient.

We report on a case of endovascular management of pseudoaneurysm of the cavernous segment of the internal carotid artery with covered stent reconstruction. A 36 years-old woman with a history of previous transsphenoidal approach for pituitary macroadenoma and false aneurysma formation was studied in a protocol that included balloon test occlusion and cerebral blood flow evaluation. An endovascular covered stent deployment in the area of the carotid laceration was performed with isolation of the aneurysm from the circulation and maintenance of the carotid flow. Helical angio-CT and cerebral digital subtraction angiography showed the carotid preservation without stenosis in the stented area. In conclusion, endovascular stent reconstruction for post-transsphenoidal carotid artery laceration and false aneurysm is demonstrated as useful technical adjunct in the management strategy and with the potential for carotid sacrifice morbidity avoidance.

Lumbosacral angiolipoma: case report.

We present a case of a 46-year old woman with a ventral epidural angiolipoma at the lumbosacral level with erosion of the sacrum. About ninety cases of spinal angiolipomas have been previously described in the literature, most of them situated on the thoracic region, dorsal to the dural sac. Angiolipomas can be radically excised with a good prognosis even in the presence of bone erosion. We did not find any other angiolipoma at the sacral level surgically explored in the review of the literature.

Cavernous carotid artery pseudo-aneurysm treated by stenting in acromegalic patient

We report on a case of endovascular management of pseudoaneurysm of the cavernous segment of the internal carotid artery with covered stent reconstruction. A 36 years-old woman with a history of previous transsphenoidal approach for pituitary macroadenoma and false aneurysma formation was studied in a protocol that included balloon test occlusion and cerebral blood flow evaluation. An endovascular covered stent deployment in the area of the carotid laceration was performed with isolation of the aneurysm from the circulation and maintenance of the carotid flow. Helical angio-CT and cerebral digital subtraction angiography showed the carotid preservation without stenosis in the stented area. In conclusion, endovascular stent reconstruction for post-transsphenoidal carotid artery laceration and false aneurysm is demonstrated as useful technical adjunct in the management strategy and with the potential for carotid sacrifice morbidity avoidance

Lumbosacral angiolipoma: case report

We present a case of a 46-year old woman with a ventral epidural angiolipoma at the lumbosacral level with erosion of the sacrum. About ninety cases of spinal angiolipomas have been previously described in the literature, most of them situated on the thoracic region, dorsal to the dural sac. Angiolipomas can be radically excised with a good prognosis even in the presence of bone erosion. We did not find any other angiolipoma at the sacral level surgically explored in the review of the literature

Pituitary tuberculoma: an unusual lesion of sellar region.

Pituitary tuberculomas are extremely rare lesions, with only few cases described in the literature, usually mistaken as pituitary tumors. Its heterogeneous clinical and imaging profile preclude preoperative diagnosis which ultimately relies on the histopathological examination. We describe a 46 years old woman who presented with an episode of confusion and hypopituitarism with no evidence of systemic tuberculosis. Computed tomography (CT) showed a central calcified and enhancing sellar mass. Magnetic resonance imaging (MRI) showed a sellar mass with suprasellar extension and associated optic chiasm compression. She was submitted a craniotomy for biopsy and resection. A caseous material was found at the center of the lesion involved by a thick wall. Due to the wall adherence to the optic chiasm and the inflammatory aspects of the lesion, subtotal removal was achieved and the patient followed on anti-tuberculous and hormonal replacement therapy. Sellar tuberculomas should be considered in the differential diagnosis of sellar tumors in order to offer appropriate treatment.

Disfunçäo hormonal em lesöes näo hipofisárias das regiöes selar e periselar / Hormonal dysfunction of nonpituitary lesions from midline and perisellar area

OBJETIVO: Analisar a disfunçäo hormonal pré-operatória, clínica e/ou laboratorial, das lesöes intracranianas näo hipofisárias da linha média e regiäo peri-selar. MÉTODO: Foram analisados 44 pacientes com lesöes intracranianas näo hipofisárias, com exames de imagem (tomografia computadorizada ou ressonância magnética) e dosagens hormonais basais; 16 tinham provas de funçäo hipotálamo-hipofisária (megateste) pré-operatórios. Esses pacientes foram divididos em dois grupos: Grupo I - 34 lesöes da linha média: 11 craniofaringiomas, 8 meningiomas, 3 germinomas, 3 tumores do seio esfenoidal, 2 síndromes sela vazia, 2 astrocitomas pilocíticos, 1 aneurisma gigante, 2 mucoceles, 1 divertículo do III ventrículo e 1 cisto da bolsa de Rathke; Grupo II - 10 lesöes da regiäo peri-selar: 9 meningiomas e 1 aneurisma gigante. RESULTADOS: No grupo I, 25/34 (73,5 por cento) pacientes apresentavam déficit hormonal laboratorial (14 sem clínica evidente), 18/34 (52,9 por cento) hiperprolactinemia (apenas 5 com galactorréia) e, dos 15 megatestes realizados nesse grupo, 8 (53,3 por cento) mostraram deficiência do hormônio de crescimento (GH); 3 (8,8 por cento) pacientes apresentaram diabetes insipidus central (DIC) pré-operatório. No grupo II, 6/10 (60 por cento) pacientes apresentavam déficit hormonal laboratorial (5 sem clínica evidente), 1/10 (10 por cento) hiperprolactinemia e 1 deficiência de GH (único megateste feito nesse grupo); nenhum paciente apresentou DIC pré-operatório. CONCLUSÄO: A presença de manifestaçöes clínicas inespecíficas ou pouco valorizadas näo indica ausência de disfunçäo hormonal laboratorial; na presente série, 19/38 (50 por cento) pacientes com alteraçöes laboratoriais, näo apresentavam manifestaçöes clínicas. Disfunçäo hormonal é frequente em lesöes näo hipofisárias selares e peri-selares, especialmente, aquelas envolvendo a linha média

Reversal of severe SPECT asymmetry after venous extra-intracranial high flow bypass in a patient submitted to therapeutic internal carotid occlusion: case report

Therapeutic occlusion of the internal carotid artery is the main option for the treatment of the symptomatic intracavernous internal carotid artery aneurysms, but the issue of the best way of doing the balloon test occlusion (BTO) regarding prediction of future ischemic events remains debatable. Single photon emission computerized tomography (SPECT) has been offered as one of the best option of monitoring regional cerebral blood flow (rCBF) during the BTO, where severe asymmetry is predictive of delayed ischemia. We describe a case of important SPECT asymmetry during BTO clinically negative and its complete reversal with carotid occlusion after extra-intracranial bypass with high flow safenous vein bypass between the cervical carotid artery and the middle cerebral artery