Cerebral Venous Thrombosis Due to Overdrainage in a Patient With Normal Pressure Hydrocephalus: A Case Report.

Mechanical shunting of cerebrospinal fluid (CSF) is an effective treatment for hydrocephalus but is not exempt from complications. A 67-year-old male with a history of normal pressure hydrocephalus (NPH) and ventriculoperitoneal shunting (VPS) one year ago presented with gait disturbance and memory impairment. His head computed tomography (CT) was normal, and the shunting pressure was reduced from 110 to 70 mmH20 with gait and memory improvement. One week later, he reported persistent pressure headaches, which worsen when lying down, accompanied by nausea and vomiting. His neurological examination was notable for a short-stepped wide-based gait. Two generalized seizures were observed. CT cerebral venography revealed sinus venous thrombosis (SVT). After two days, a new CT was performed, and bilateral subdural hygromas were found. The shunting pressure was readjusted to 110 mmH20, and symptom improvement was noted. One week later, CT showed enlargement and bleeding of subdural collections. The drainage system was closed, and the patient continue to recover. The temporal association between pressure adjustment and symptom onset and the evidence of progressive subdural effusions suggest that the decrease of CSF volume by overdrainage led to an increase in cerebral blood volume and the dilatation of the venous sinus, which precipitated thrombus formation.

Uterine Compression Sutures in Controlling Postpartum Haemorrhage: A Narrative Review.

INTRODUCTION: Postpartum haemorrhage is still the main cause of maternal morbidity and mortality. Many treatments are available, but they may threaten fertility potential. As a uterine sparing procedure, we aimed to review uterine compression sutures in order to better understand when they should represent an appropriate option. MATERIAL AND METHODS: A comprehensive search in MEDLINE and PubMed databases including the terms 'postpartum haemorrhage' and 'uterine compression sutures' was performed. Results were revised and articles reviewing or presenting case reports of uterine compression sutures to treat postpartum haemorrhage were included. RESULTS: The first description of uterine compression sutures to control postpartum haemorrhage was published in 1997, by B-Lynch et al. After this publication, many others have reported successful management of postpartum haemorrhage with different suturing techniques. Most of them describe success rates above 75% and the possibility of fertility preservation, with cases of uneventful pregnancy after uterine compression sutures already published. Complications associated with each technique are rare. DISCUSSION: Reports of use of uterine compression sutures include small series of cases or even single case reports which limits the quality of existing evidence to support one technique over another. Nevertheless, uterine compression sutures are recognized as an effective surgical conservative strategy to control postpartum haemorrhage due to uterine atony and its use is recommended, if possible, prior to hysterectomy. CONCLUSION: Uterine compression sutures are effective, safe and simple to perform in an emergent situation and preserve fertility potential in cases of postpartum haemorrhage.

Introdução: A hemorragia pós-parto é a principal causa de morbimortalidade materna. Apesar dos tratamentos disponíveis, o potencial fértil da mulher pode ser colocado em causa. As suturas uterinas de compressão representam uma terapêutica conservadora do útero. Assim, revimos os tipos de suturas uterinas de compressão para compreender quando devem ser uma opção terapêutica. Material e Métodos: Foi realizada pesquisa na MEDLINE e PubMed com os termos 'postpartum haemorrhage' e 'uterine compression sutures' separados e em conjunto. Os resultados foram revistos e os artigos de revisão ou descrevendo casos clínicos de suturas uterinas de compressão foram selecionados. Resultados: Em 1997, B-Lynch et al descreveu pela primeira vez as suturas uterinas de compressão para tratamento da hemorragia pós-parto. Desde aí, publicações de diferentes tipos de suturas uterinas de compressão, com registo de casos bem-sucedidos, têm sido publicadas. A maioria reporta taxas de sucesso acima de 75%, com preservação da fertilidade, existindo vários casos de bom desfecho obstétrico posteriormente descritos. As complicações associadas são raras. Discussão: A evidência acerca do uso de suturas uterinas de compressão é limitada pela qualidade dos artigos existentes que incluem apenas pequenas séries de casos ou descrições de casos isolados. Apesar disso, tem sido reconhecido o seu potencial enquanto estratégia conservadora no controlo da hemorragia pós-parto devido a atonia uterina, sendo recomendado o seu uso, se possível, antes de realizar histerectomia. Conclusão: Em situações de hemorragia pós-parto, as suturas uterinas de compressão são eficazes, seguras e simples de realizar, preservando o potencial reprodutivo.

HIPTCN: Prospective Observational Study of Hypocoagulated Head Trauma Patients with Normal Admission Computed Tomography Scan.

INTRODUCTION: Our national protocol for traumatic brain injury dictates that hypocoagulated patients with mild trauma and initial tomography scan with no intracranial traumatic changes must be hospitalized for 24 hours and do a post-surveillance tomography scan. The main goal of this study was to evaluate the clinical relevance of these measures. MATERIAL AND METHODS: A prospective observational study was undertaken in four hospitals. Adult hypocoagulated traumatic brain injury patients with a normal tomography scan were included. The main outcomes evaluated were rate of delayed intracranial hemorrhage, rate of admission in a neurosurgical department, rate of complications related with surveillance and rate of prolonged hospitalization due to complications. An analysis combining data from a previously published report was also done. RESULTS: A total of 178 patients were included. Four patients (2.3%) had a delayed hemorrhage and three (1.7%) were hospitalized in a neurosurgery ward. No cases of symptomatic hemorrhage were identified. No surgery was needed, and all patients had their anticoagulation stopped. Complications during surveillance were reported in seven patients (3.9%), of which two required prolonged hospitalization. DISCUSSION: The rate of complications related with surveillance was higher than the rate of delayed hemorrhages. The initial period of in-hospital surveillance did not convey any advantage since the management of patients was never dictated by neurological changes. Post-surveillance tomography played a role in deciding about anticoagulation suspension and prolongation of hospitalization. CONCLUSION: Delayed hemorrhage is a rare event and the need for surgery even rarer. The need for in-hospital surveillance should be reassessed.

Introdução: O nosso protocolo nacional para traumatismos cranioencefálicos recomenda que doentes hipocoagulados com trauma craniano ligeiro e tomografia inicial sem alterações traumáticas intracranianas sejam hospitalizados 24 horas e façam uma tomografia computorizada pós-vigilância. O principal objetivo deste estudo foi avaliar a relevância clínica dessas medidas. Material e Métodos: Foi realizado em quatro hospitais um estudo prospetivo e observacional. Foram incluídos adultos hipocoagulados com trauma craniano e tomografia normal. Os principais outcomes avaliados foram: taxa de hemorragia intracraniana tardia, taxa de internamento numa enfermaria de neurocirurgia, taxa de complicações relacionadas com a vigilância e taxa de hospitalização prolongada por complicações. Resultados: Foram incluídos um total de 178 doentes. Quatro doentes (2,3%) apresentaram hemorragia tardia e três (1,7%) foram mantidos hospitalizados numa enfermaria de Neurocirurgia. Não foram documentados casos de hemorragia tardia sintomática. Nenhuma cirurgia foi necessária e em todos estes doentes a anticoagulação foi interrompida. Durante a vigilância, foram relatadas complicações em sete doentes (3,9%), dos quais dois exigiram hospitalização prolongada. Discussão: A taxa de complicações relacionadas com a vigilância foi maior do que a taxa de hemorragia tardia. O período inicial de vigilância intra-hospitalar não trouxe qualquer vantagem, já que o manejo dos doentes nunca foi ditado por alterações neurológicas. A tomografia pós-vigilância desempenhou um papel importante na decisão sobre a suspensão da anticoagulação e o prolongamento da hospitalização. Conclusão: A hemorragia tardia é um evento raro e a necessidade de cirurgia ainda mais. Deve ser reavaliada a necessidade de vigilância intra-hospitalar.

Primary pituitary abscess: case report and suggested management algorithm.

PURPOSE: To describe a case of successful treatment of a patient with a rare primary pituitary abscess (PA) and propose a management algorithm. SUMMARY OF BACKGROUND DATA: PA is an infrequent entity that can be life-threatening if not promptly diagnosed and treated. PAs can be primary or secondary, the latter in the presence of sellar anomalies, risk factors or a systemic or local infection. Symptoms are nonspecific, making clinical suspicion imperative. Magnetic Resonance Imaging (MRI) is the radiological tool of choice. Despite some characteristic radiographic signs, oftentimes the diagnosis is not suspected until surgical exploration. Treatment includes transsphenoidal decompression surgery with sampling of purulent material and abscess wall for appropriate microbiological staining and cultures (bacteria, mycobacteria and fungus) and prolonged antibiotic treatment. Pituitary hormonal deficiencies must be addressed as well. METHODS AND RESULTS: We describe a case of a female patient who presented with headaches, anorexia and bitemporal hemianopsia. MRI revealed a peripherally enhancing sellar mass. Transsphenoidal surgery was performed, with intra-operative finding of purulent material. Cytology confirmed the presence of abundant leucocytes, but no pathogen was isolated. Patient completed three weeks of antibiotic therapy, with good clinical and radiological response. Headaches and visual deficits resolved. Hormonal substitution therapy was needed for six months after surgery. CONCLUSION: This report highlights the importance of early recognition and treatment of PAs. The diagnosis is commonly very difficult before surgery, due to overlapping clinical, radiological and laboratorial findings with various other pathologies. Prompt management, with surgical decompression and appropriate antibiotic treatment, typically results in a low mortality rate and higher chance of full recovery of pituitary function. We propose a management algorithm for sellar masses suspected of being PAs.

Reappraising the need for a control CT in mild head injury patients on anticoagulation.

BACKGROUND: Head injury is a frequent reason for admission to the emergency department. In parallel, there is a growing use of anticoagulants in an increasingly aging population, which renders this particular group of trauma patients more frequent. In several countries, including Portugal, a 24-h surveillance period followed by repetition of head computed tomography (CT) is the standard procedure for these patients. However, these recommendations have not been based on studies of prevalence of intracranial hemorrhages in control head CTs, namely in this group of anticoagulated patients. This study intends to evaluate the prevalence of de novo intracranial hemorrhages in control head CTs in anticoagulated patients. METHOD: An observational study was carried out, which included patients admitted to Hospital de Braga between June 2017 and January 2018, victims of head injury and on anticoagulation therapy, whose admission head CT excluded intracranial hemorrhage. RESULTS: We collected a total of 201 patients, with a mean age of 81.6 years, and 57.5% of them were prescribed warfarin; 181 of these patients repeated the head CT 24 h later. Of these 181 patients, 3 (1.66%) exhibited intracranial hemorrhage in control CT, without surgical indication. All patients were followed up 1 month after the trauma, and there was no readmission requiring hospitalization, surgery or death. CONCLUSIONS: In conclusion, de novo intracranial hemorrhage in control head CT of anticoagulated patients is rare. We propose that these patients may be discharged if the admission CT does not reveal intracranial hemorrhage, providing that they are accompanied by a caregiver and informed about red flags.

Pituitary apoplexy induced by gonadotropin-releasing hormone agonist administration: a rare complication of prostate cancer treatment.

SUMMARY: Gonadotropin-releasing hormone (GnRH) agonists, currently used in the treatment of advanced prostate cancer, have been described as a rare cause of pituitary apoplexy, a potentially life-threatening clinical condition. We report the case of a 69-year-old man with a known pituitary macroadenoma who was diagnosed with prostate cancer and started treatment with GnRH agonist leuprorelin (other hormones were not tested before treatment). Few minutes after drug administration, the patient presented with acute-onset severe headache, followed by left eye ptosis, diplopia and vomiting. Pituitary MRI revealed tumor enlargement and T1-hyperintense signal, compatible with recent bleeding sellar content. Laboratory endocrine workup was significant for low total testosterone. The patient was managed conservatively with high-dose steroids, and symptoms significantly improved. This case describes a rare phenomenon, pituitary apoplexy induced by GnRH agonist. We review the literature regarding this condition: the pathophysiological mechanism involved is not clearly established and several hypotheses have been proposed. Although uncommon, healthcare professionals and patients should be aware of this complication and recognize the signs, preventing a delay in diagnosis and treatment. LEARNING POINTS: Pituitary apoplexy (PA) is a potentially life-threatening complication that can be caused by gonadotropin-releasing hormone agonist (GnRHa) administration for the treatment of advanced prostate cancer. This complication is rare but should be taken into account when using GnRHa, particularly in the setting of a known pre-existing pituitary adenoma. PA presents with classic clinical signs and symptoms that should be promptly recognized. Patients should be instructed to seek medical care if suspicious symptoms occur. Healthcare professionals should be aware of this complication, enabling its early recognition, adequate treatment and favorable outcome.

Giant posterior fossa meningioma: the importance of early diagnosis and challenges concerning treatment.

Posterior fossa lesions may present with behavioural changes and/or progressive neurological deficit. Patients may have symptoms for long periods which may be attributed to other causes such as psychiatric diseases. We report a case of a 44-year-old woman with behavioural changes lasting for 5 years who lost her job, marriage and the guard of her sons. Latterly, she developed neurological deficit, hydrocephalus and intracranial hypertension. A giant left pontocerebellar angle mass was diagnosed. A retrosigmoid craniotomy was performed with total removal and cranial nerve function's preservation. Histology revealed a grade I meningioma. The surgical approach for such huge lesions on pontocerebellar angle is controversial concerning patient's positioning and surgical route. A brief revision is made. Since nowadays medical imaging is more easily accessible, it is mandatory to have a brain image in patients with behavioural changes and/or neurological deficit to exclude potential structural and curable causes such as in this case.

Metastasis of a Dorsal Melanoma to a Pituitary Adenoma Mimicking Pituitary Apoplexy

Metastases to pituitary adenomas are very rare. From the 20 cases found in the literature, none originated from a cutaneous melanoma. We present the case of a 67-year-old man with a history of transcranial approach to treat a pituitary macroadenoma followed by adjuvant radiotherapy. Fifteen years later, he presented a dorsal nodular melanoma, and three years after that, he developed symptoms of pituitary apoplexy. He was submitted to transsphenoidal surgery, and the histology result revealed metastasis of the melanoma into a pituitary adenoma. The similarity in the clinical presentation of the two entities­pituitary apoplexy and metastasis of the melanoma into a pituitary adenoma­and the rarity of this type of metastization alert to challenges in the differential diagnosis that may confound the neurosurgeon's decision.

As metástases em adenomas pituitários são muito raras. Dos 20 casos descritos na literatura, nenhum foi originado por um melanoma cutâneo. Apresentamos um caso de um homem de 67 anos de idade, com história de abordagem transcraniana para tratar um macroadenoma pituitário, seguido de radioterapia adjuvante. Quinze anos depois, o paciente apresentou um melanoma nodular dorsal e 3 anos mais tarde desenvolveu sintomas de apoplexia pituitária. Ele foi então submetido a uma cirurgia transfenoidal, e o resultado histológico revelou tratar-se de uma metástase do melanoma em um adenoma hipofisário. A semelhança na apresentação clínica entre as duas entidades­apoplexia pituitária e metástase do melanoma em um adenoma hipofisário ­ e a raridade deste tipo de metastização alertam para desafios no diagnóstico diferencial que podem confundir a decisão do neurocirurgião.