The history of neurosurgery at the University of Sao Paulo.

The history of neurosurgery at University of São Paulo comes from 1918, since its origins under the Department of Neurology from Chair of Psychiatric Clinic and Nervous Diseases. Professor Enjolras Vampré was the great inspiration for such medical specialty in the State of Sao Paulo. In 1929, the first neurosurgical procedures were performed in the recently (at time) organized Section of Neurosurgery. The official inauguration of the Division of Functional Neurosurgery occurred at June 1977, with the presence of worldwide well-known neuroscientists. The division suffered a deep streamlining under the leadership of Professor Raul Marino Jr., between the decades of 1990 and 2000. At this time, it was structured with the sections of neurological surgery, functional neurosurgery and neurosurgical emergency. Since 2008, Professor Manoel Jacobsen Teixeira is the Chairman of the Division and has provided the Division with the best available technological resources, performing more than 3,000 surgeries a year and training professionals who will, certainly, be some of the future leaders of brazilian neurosurgery.

The history of neurosurgery at the University of Sao Paulo / A historia da neurocirurgia na Universidade de Sao Paulo

The history of neurosurgery at University of São Paulo comes from 1918, since its origins under the Department of Neurology from Chair of Psychiatric Clinic and Nervous Diseases. Professor Enjolras Vampré was the great inspiration for such medical specialty in the State of Sao Paulo. In 1929, the first neurosurgical procedures were performed in the recently (at time) organized Section of Neurosurgery. The official inauguration of the Division of Functional Neurosurgery occurred at June 1977, with the presence of worldwide well-known neuroscientists. The division suffered a deep streamlining under the leadership of Professor Raul Marino Jr., between the decades of 1990 and 2000. At this time, it was structured with the sections of neurological surgery, functional neurosurgery and neurosurgical emergency. Since 2008, Professor Manoel Jacobsen Teixeira is the Chairman of the Division and has provided the Division with the best available technological resources, performing more than 3,000 surgeries a year and training professionals who will, certainly, be some of the future leaders of brazilian neurosurgery.

A história da neurocirurgia na Universidade de São Paulo remonta a 1918, quando surge sob o Departamento de Neurologia da cadeira de Clínica Psiquiátrica e Doenças Nervosas. O Professor Enjolras Vampré foi o grande inspirador da especialidade no estado de São Paulo. Em 1929, foram realizadas as primeiras intervenções neurocirúrgicas na então recentemente organizada Seção de Neurocirurgia. A fundação oficial da Divisão de Neurocirurgia Funcional data de junho de 1977 e contou com a participação de diversos cientistas de renome internacional. A Divisão passou por profunda reorganização sob a direção do Professor Raul Marino Jr. entre as décadas de 1990 e 2000, quando foi estruturada com os setores de neurocirurgia geral, neurocirurgia funcional e emergência neurocirúrgica. Desde 2008, o Professor Manoel Jacobsen Teixeira é responsável pela Divisão, que conta com os melhores recursos tecnológicos disponíveis, realizando mais de 3.000 cirurgias por ano e formando profissionais que certamente serão futuros líderes na neurocirurgia brasileira.

Perspective of the frontolateral craniotomies.

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

Perspective of the frontolateral craniotomies / Perspectivas das craniotomias frontolaterais

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

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

[Crouzon syndrome: factors related to the neuropsychological development and to the quality of life]. / Síndrome de crouzon: fatores envolvidos no desenvolvimento neuropsicologico e na qualidade de vida.

Crouzon syndrome is characterized by cranial and facial abnormalities and exophtalmos. Mental retardation is sometimes observed. The objective of this study was to correlate brain malformations, timing for surgery and also social classification of families and parents education to the neuropsychological evaluation and to the quality of life of these families. Eleven patients with Crouzon syndrome were studied, whose ages were between 16 and 132 months. The multidisciplinary evaluation included : social evaluation, cognitive evaluation, brain studies by magnetic resonance imaging and quality of life evaluation. The intelligence quotient values observed were between 46 and 102 (m=84.2) and was correlated (inverted correlation) to the factor IV of the short-form of the Questionnaire on Resources and Stress. Mental development was not correlated to brain malformation, neither to the age at time of operation or to the level of family environment and parents education.

Síndrome de crouzon: fatores envolvidos no desenvolvimento neuropsicologico e na qualidade de vida / Crouzon syndrome: factors related to the neuropsychological development and to the quality of life

A síndrome de Crouzon é caracterizada por deformidade craniana, alterações faciais e exoftalmia. O retardo no desenvolvimento neuropsicomotor é observado em alguns casos. Este estudo tem como objetivo analisar a influência do momento da cirurgia, da classe sócio-econômica associada ao nível educacional dos pais e da ocorrência de malformações do sistema nervoso central no desenvolvimento cognitivo destes pacientes correlacionando estes achados à qualidade de vida deles e de suas famílias. Foram estudados 11 pacientes com diagnóstico de síndrome de Crouzon com idade entre um ano e quatro meses e treze anos. A avaliação multidisciplinar dos pacientes incluiu, avaliação social, avaliação cognitiva, estudo do encéfalo por ressonância magnética e avaliação da qualidade de vida. O quociente de inteligência variou de 46 a 102 (m=84,2) e foi correlacionado de forma inversa com o Fator 4 do Questionário de Recursos e Estresse Simplificado (incapacidade da criança); não se correlacionou com as alterações encefálicas, com a condição sócio-econômica dos pais e nem com o momento do tratamento neurocirúrgico.

Crouzon syndrome is characterized by cranial and facial abnormalities and exophtalmos. Mental retardation is sometimes observed. The objective of this study was to correlate brain malformations, timing for surgery and also social classification of families and parents education to the neuropsychological evaluation and to the quality of life of these families. Eleven patients with Crouzon syndrome were studied, whose ages were between 16 and 132 months. The multidisciplinary evaluation included : social evaluation, cognitive evaluation, brain studies by magnetic ressonance imaging and quality of life evaluation. The intelligence quotient values observed were between 46 and 102 (m=84.2) and was correlated (inverted correlation) to the factor IV of the short-form of the Questionnaire on Resources and Stress. Mental development was not correlated to brain malformation, neither to the age at time of operation or to the level of family environment and parents education.

CSF markers for diagnosis of bacterial meningitis in neurosurgical postoperative patients.

OBJECTIVE: To evaluate the diagnostic usefulness of cerebral spinal fluid (CSF) cellularity, protein, neutrophils, glucose and lactate for detection of postoperative bacterial meningitis. METHOD: This prospective study was conducted in 28 postoperative neurosurgical patients from 2002 to 2005 at University of São Paulo. The CSF markers were plotted in a receiver operating characteristic (ROC) curve to evaluate their accuracy. RESULTS: Based on the area under ROC curve CSF glucose, cellularity, and lactate were considered good tests. Polymorphonuclear and protein did not achieve enough accuracy to be used clinically. CONCLUSION: The CSF glucose, lactate, and cellularity can be used for the diagnosis of bacterial meningitis. Moreover, it can be helpful to differentiate bacterial from aseptic meningitis.

CSF markers for diagnosis of bacterial meningitis in neurosurgical postoperative patients / Marcadores liquóricos para o diagnóstico de meningite bacteriana em pós-operatório neurocirúrgico

OBJECTIVE: To evaluate the diagnostic usefulness of cerebral spinal fluid (CSF) cellularity, protein, neutrophils, glucose and lactate for detection of postoperative bacterial meningitis. METHOD: This prospective study was conducted in 28 postoperative neurosurgical patients from 2002 to 2005 at University of São Paulo. The CSF markers were plotted in a receiver operating characteristic (ROC) curve to evaluate their accuracy. RESULTS: Based on the area under ROC curve CSF glucose, cellularity, and lactate were considered good tests. Polymorphonuclear and protein did not achieve enough accuracy to be used clinically. CONCLUSION: The CSF glucose, lactate, and cellularity can be used for the diagnosis of bacterial meningitis. Moreover, it can be helpful to differentiate bacterial from aseptic meningitis.

OBJETIVO: Para avaliar a utilidade diagnóstica dos marcadores liquóricos de celularidade, concentração de proteína, neutrofilia, concentração de glicose e lactato para a detecção da meningitie bacteriana no pós-operatório neurocirúrgico. MÉTODO: Esse estudo foi conduzido de maneira prospectiva na Universidade de São Paulo no período de 2002 a 2005 em 28 pacientes no pós-operatório neurocirúrgico. Os marcadores liquóricos foram colocados em uma curva ROC (receiver operating characteristic) para avalição da sua acurácia. RESULTADOS: Baseadas na área sob a curva ROC, glicorraquia, celularidade e concentração de lactato foram considerados bons testes. A contagem de polimorfonucleares e a proteínorraquia não atingiram acurácia suficiente para serem utilizadas clinicamente. CONCLUSÃO: A glicorraquia, a concentração de lactato e a celularidade podem ser utilizadas clinicamente para o diagnóstico da meningite bacteriana. Esses marcadores também podem ser úteis na diferenciação entre meningite bacteriana e asséptica.

Apert syndrome: factors involved in the cognitive development

A síndrome de Apert é caracterizada por cranioestenose, sindactilia simétrica e outras malformações sistêmicas. O retardo no desenvolvimento neuropsicomotor é freqüentemente observado. Este trabalho tem como objetivo analisar as malformações do sistema nervoso central, o momento da cirurgia e a classe sócio-econômica associada ao nível educacional dos pais como variáveis que possam influenciar no desenvolvimento cognitivo. Foram estudados 18 pacientes com diagnóstico de síndrome de Apert com idade entre 14 e 322 meses e as alterações encefálicas foram observadas em 55,6%. O quociente de inteligência variou de 45 a 108 e estava correlacionado com a classe sócio-econômica e com o nível de instrução dos pais; não se correlacionou com as alterações encefálicas nem com o momento do tratamento neurocirúrgico. Em conclusão, a condição sócio-econômica e o nível de instrução dos pais foram relevantes na determinação do desenvolvimento cognitivo destes pacientes.

Apert syndrome: factors involved in the cognitive development.

Apert syndrome is characterized by craniosynostosis, symmetric syndactyly and other systemic malformations, with mental retardation usually present. The objective of this study was to correlate brain malformations and timing for surgery with neuropsychological evaluation. We also tried to determine other relevant aspects involved in cognitive development of these patients such as social classification of families and parents education. Eighteen patients with Apert syndrome were studied, whose ages were between 14 and 322 months. Brain abnormalities were observed in 55.6% of them. The intelligence quotient or developmental quotient values observed were between 45 and 108. Mental development was related to the quality of family environment and parents education. Mental development was not correlated to brain malformation or age at time of operation. In conclusion, quality of family environment was the most significant factor directly involved in mental development of patients with Apert syndrome.

Leptomeningeal dissemination of pilocytic astrocytoma at diagnosis in childhood: two cases report.

Pilocytic astrocytoma (PA) is a benign tumor that rarely spread along the neuraxis. At the moment there are no more than five cases of leptomeningeal dissemination (LD) from PA at diagnosis described in the literature. Different patterns of presentation or recurrence may be noted: local recurrence, malignant transformation, multicentric disease or metastatic disease. LD and multicentric disease can be distinct pathological entities. We report two cases and analyse literature, emphasizing leptomeningeal spread at presentation. Hydrocephalus, biopsy and parcial ressection are likely to be favorable factors to the occurrence of LD. Otherwise, LD may be part of natural history of PA, as evidenced by its ocurrence in non-treated cases.

Leptomeningeal dissemination of pilocytic astrocytoma at diagnosis in childhood: two cases report

Pilocytic astrocytoma (PA) is a benign tumor that rarely spread along the neuraxis. At the moment there are no more than five cases of leptomeningeal dissemination (LD) from PA at diagnosis described in the literature. Different patterns of presentation or recurrence may be noted: local recurrence, malignant transformation, multicentric disease or metastatic disease. LD and multicentric disease can be distinct pathological entities. We report two cases and analyse literature, emphasizing leptomeningeal spread at presentation. Hydrocephalus, biopsy and parcial ressection are likely to be favorable factors to the occurrence of LD. Otherwise, LD may be part of natural history of PA, as evidenced by its ocurrence in non-treated cases

Association between prenatal sonographic findings and post-natal outcomes in 30 cases of isolated spina bifida aperta.

This study presents 30 cases of fetal isolated spina bifida aperta (SBA) to identify prenatal ultrasound findings that could predict the prognosis. Comparisons between surviving patients who had normal (group 1) and abnormal (group 2) post-natal neurological outcomes were made for three different prenatal signs, that is, site of vertebral lesion, presence and degree of ventriculomegaly and presence of talipes. The site of the lesion was the most significant outcome predictor, as high spinal dysraphisms were observed in 2 patients (2/7-28.6%) in group 1 and in 15 patients (15/19-79.0%) in group 2 (p = 0.03). The presence of fetal ventriculomegaly was associated with impaired post-natal neurological development, as it occurred in 4 patients (4/7-57.1%) in group 1 and in 18 patients (18/19-94.7%) in group 2 (p = 0.04). The presence of talipes did not significantly differ between the two groups. Patients with abnormal intellectual outcome (8/26-30.8%) had significantly greater (p = 0.018) lateral ventricle/hemisphere ratios (mean = 0.74, standard deviation = 0.13) than those with normal intellectual development (mean = 0.54, standard deviation = 0.18). Mean post-natal follow-up was at 23 months (standard deviation = 15 months).

Dificuldades na microdissecção da fissura e da cisterna silvianas / Technical difficulties in the microsurgical dissection of the sylvian fissure and cistern

Os sulcos, as fissuras e as cisternas subaracnóideas são vias naturais de circulação do líquido cefalorraquidiano que podem ser utilizadas pelo cirurgião para alcançar regiões mais profundas do cérebro e da base do crânio. Dessas vias, as mais utilizadas na prática neurocirúrgica são afissura e a cisterna silvianas. No entanto, apesar da ampla divulgação da técnica, nem sempre a microdissecção desses espaços é simples e, por vezes, mesmo o neurocirurgião experiente e persistente encontra dificuldades técnicas em executá-la. Com a finalidade de detectar os fatores que contribuem para essas dificuldades, analisamos 10variáveis observadas em 152 pacientes submetidos ao tratamento cirúrgico de aneurismas da circulação anterior do polígono de Willis por via pterional, que foram confrontadas com o resultado da dissecção. As ocorrências cirúrgicas ? lesão pial extensa na superfície dos opérculos e tempo de dissecção da fissura e da cisterna silvianas maior que 60 minutos ? foram assumidas como evidências indiretas de dificuldade técnica na dissecção e consideradas, isoladamente ou em conjunto, como representativas de uma dissecção difícil. O percentual de casos com fissura e cisterna silvianas de difícil dissecção foi significantementemaior nos pacientes que apresentavam membrana aracnóide espessa, aderência moderada ou intensa entre os opérculos frontal e temporal, cisterna silviana virtual e veia silviana superficial com calibre maior que 3 milímetros. No entanto, quando empregada a técnica de regressãologística múltipla para estudar o efeito conjunto dessas variáveis na probabilidade da dissecção ser difícil, somente as duas primeiras apresentaram significância estatística (p = 0,005 e p = 0,015, respectivamente). A probabilidade de uma dissecção difícil da fissura e da cisterna silvianas é 2,76 vezes maior nos pacientes que têm uma membrana aracnóide espessa e 3,11 vezes maior quando a aderência entre os opérculos é moderada ou intensa. Quando o paciente não apresenta nenhuma das duas variáveis consideradas como fatores de risco, a probabilidade estimada de uma dissecção difícil é de apenas 12%. Por outro lado, quando ambos fatores estão presentes, essa probabilidade sobe para 53%. A ocorrência de uma lesão pial extensa ou a necessidade de um tempo cirúrgico maior que 60 minutos para uma dissecção completa da fissura e da cisterna silvianas não teve relação direta com qualquer tipo de repercussão clínica. Levando em consideração essa constatação e a impor tância fundamental da aber tura por microdissecção da fissura e da cisterna silvianas na via de acesso pterional, podemos concluir que a existência de dificuldades técnicas não invalida a execução dessa etapa cirúrgica.

The sulci, fissures and subarachnoid cisterns are natural pathaways of circulation of the cerebrospinal fluid that may be used by the surgeon to reach deep regions of the brain and the skull base. Among these routes, the sylvian fissure and cistern is the most commonly utilized in the neurosurgical practice. The surgical microdissection of these spaces is not always simple and even the most tenacious and experienced surgeon finds it difficult at times. With the purpose of detecting the factors that might contribute to these technical difficulties during the microsurgical dissection of the sylvian fissure and cistern we have analysed 10 variablesobserved during 152 surgical procedures carried through the pterional route for the treatment of aneurysms of the anterior circulation. These variables were confronted with the dissection results. The surgical occurrence of extensive pial lesion and extended microsurgical dissection time (over 60 minutes) were considered as indirect evidence of technical difficulty during dissection and representative of a difficult dissection.

Displasia fibrosa óssea isolada em osso parietal: relato de caso e revisão de literatura / Osseous fibrous dysplasia isolated on parietal location: case report and review of the literature

Os autores descrevem o caso de uma criança do sexo masculino de 10 anos e que apresentou abaulamento progressivo na região parietal esquerda, percebido pela mãe 15 dias antes de procurar nossa clínica. Havia sido submetido à tomografia computadorizada do crânio há dois anos, por causa de cegaléia, cujas imagens dos cortes mais altos mostrava discreto abaulamento na região parietal esquerda, que não fora notado na ocasião. A repetição do exame, solicitada por nós, mostrou crescimento importante dessa lesão. Foi submetido à craniectomia com exérese do tumos ósseo cujo exame anatomopatológico revelou displasia fibrosa óssea, Esse tumor ósseo é raro e encontramos apenas sete casos descritos nesta região. A evolução é lenta e progressiva, tendendo a se estabilizar na adolescência. Os autores discutem a etiopatogenia, o diagnóstico diferencial, a classificação e o tratamento.

Angiolipoma de coluna torácica: relato de caso / Thoracic spinal angiolipoma: case report

Os autores apresentam um caso raro de um paciente de 46 anos, sexo masculino, portador de angiolipoma intrarraquiano torácico epidural que foi submetido a tratamento cirúrgico. Os aspectos clínicos e histopatológicos do tumor sao discutidos e enfoque especial é dado à sintomatologia, de início abrupto, e de evoluçao rápida característica desta patologia. Após o tratamento cirúrgico houve recuperaçao completa dos déficits neorológicos. Apresentamos, também, revisao da literatura sobre o assunto.

Cisto de aracnóide e pseudotumor cerebral: relato de caso / Arachnoid cyst and pseudotumor cerebri: case report

Relato do caso de paciente de 12 anos de idade com cisto de aracnóide na fossa craniana posterior e pseudotumor cerebral dependente de derivaçäo cisto-peritoneal previamente instalada. Esta constataçäo corrobora assertivas da literatura que srgerem um mecanismo fisiopatológico em comum para estas duas entidades e que estaria relacionado a defeito no fluxo do líquido cefalorraqueano