Cerebral Venous Thrombosis in Patients With Traumatic Brain Injury: Epidemiology and Outcome.

The natural history and epidemiological aspects of traumatic cerebral venous thrombosis (CVT) are not fully understood. Due to the concomitant occurrence with intracranial hemorrhages, guidelines for medical treatment have been highly controversial. In this study, our objective was to carry out an analysis description of the population and to conduct a literature review. A prospectively gathered radiology registry data of patients hospitalized at the tertiary hospital of Centro Hospitalar Universitário do São João, Porto, Portugal, between 2016 and 2021 was carried out. All patients with traumatic brain injury (TBI) and concomitant CVT were identified. CVT was confirmed by CT venogram. Demographic, clinical, and radiological data and their medical management were reported. In-hospital complications and treatment outcomes were compared between patients measured by the Glasgow Outcome Score Extended (GOSE) at discharge and GOSE at three months. There were 41 patients with traumatic CVT admitted to this study. The majority (45.2%) had a hyperdense signal near the lateral sinus at admission, and only 26.2% presented with skull fractures. Of this cohort, 95% had experienced lateral sinus thrombosis. Twenty-five patients (60%) had occlusive venous thrombosis. Venous infarct was the main complication following CVT. Thirty-two patients (78%) were anticoagulated after CVT and four developed complications. At the three-month follow-up after discharge, 28.2% had good recovery (GOSE > 6). This study revealed a higher incidence of CVT in severe TBI and a mild association with skull fractures. There is a higher incidence of CVT in the lateral sinus. Management was inconsistent, with no difference in outcome without or with anticoagulation. Larger, prospective cohort studies are required to better comprehend this condition and determine evidence-based guidelines.

The impact of selection bias in the treatment for ruptured anterior communicating artery aneurysms: different results or different patients?

Background: Anterior communicating artery is one of the most frequent locations for the development of intracranial aneurysm. The availability and advances of different treatments modalities allows for case-specific selection, but potentially impacts our ability to assess equipoise among them. Objective: Investigate and compare clinical and morphological variables among surgical and endovascular treatment groups with ruptured anterior communicating artery aneurysms. Methods: Data from patients from a single university hospital treated for ruptured anterior communicating aneurysms after multidisciplinary discussion in a period from January 2009 to January 2020 were retrospectively reviewed. Demographics, clinical status, aneurysm morphologic features and in-hospital complications were registered for each treatment (endovascular coiling vs. microsurgical clipping). Clinical assessment was made from outpatient evaluation at 1-year follow-up. Results: A total of 119 patients was obtained adding surgical (n = 80) and endovascular (n = 39) treatment groups. No significant changes between groups were detected regarding gender, age of treatment or other risk factors. Global complication rate (p = 0.335, p = 0.225, p = 0.428) and clinical outcome (p = 0.802) was similar among both groups. Univariate and multivariate analysis revealed statistically significant differences between endovascular and surgical treatment groups regarding dome orientation (p = 0.011), aneurysm height (p < 0.001) and maximum diameter (p < 0.001), aspect-ratio (p < 0.001), dome-to-neck ratio (p < 0.001) and dome diameter (p = 0.014). Conclusions: Despite similar clinical outcomes and rate of complications, morphological differences highlight the presence of a selection bias and high heterogeneity, which hampers inferential analysis when comparing both techniques.

Real Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) in Pediatrics: A Clinical Case Report and Literature Review.

Spinal cord injury without radiological abnormality (SCIWORA) was first reported in 1974. The term was used to define "clinical symptoms of traumatic myelopathy without signs of fracture or spine instability on X-ray or CT scan." With the emergence of MRI, the gold standard method to identify spinal cord injuries, about two-thirds of former SCIWORA cases were found to have pathological findings, and, as such, the term has taken on an ambiguous meaning in the literature. We describe the clinical case of a 17-year-old boy who was admitted to the emergency department of a tertiary hospital after a fall during a soccer game. He suffered spinal and cranioencephalic trauma. A few minutes later, the boy began to show decreased strength in the right upper limb and lower limbs, as well as changes in sensation in the right hemibody. On objective examination, the boy presented a Glasgow Coma Scale score of 15 and the American Spinal Injury Association Impairment Scale D, with partial improvement of initial symptoms of monoparesis of the right lower limb. There were no other changes, specifically at the sensory level. The patient underwent a CT and MRI of the spine that showed no fractures, instability, or appreciable medullary signal changes. Electromyography was normal. Based on the clinical history and imaging findings, real SCIWORA was diagnosed. The patient was admitted to an inpatient rehabilitation program. At a follow-up visit two months later, a complete reversal of signs and symptoms was confirmed. The prognosis of this pathology depends on the extent of the spinal cord injury, as evidenced by MRI. Although neurological improvement when severe deficit is present at initial presentation is unlikely, most patients with incomplete neurological damage show good recovery. The absence of visible changes on MRI is associated with a better prognosis.

Primary Central Nervous System Lymphoma Mimicking the Presentation of Pituitary Apoplexy: A Case Report.

Pituitary lymphoma is one of the rare variants of primary central nervous system lymphoma (PCNSL), mostly arising due to the metastatic spread of systemic lymphoma. We report the case of a 69-year-old woman who initially presented to her family physician with a headache but without any other symptoms. The MRI scan revealed a sellar mass consistent with a pituitary macroadenoma. When the patient was referred to our hospital, two weeks later, the symptoms had progressed, comprising complete right-sided ophthalmoplegia and ptosis, with left-sided amaurosis. A repeat MRI revealed an increased size of the sellar mass, consistent with pituitary apoplexy. A right pterional craniotomy with partial resection of the mass was performed and an intraoperative frozen section biopsy was carried out. The final pathology revealed diffuse large B-cell lymphoma. A systemic follow-up including a whole-body CT, bone marrow aspiration, and cerebrospinal fluid studies ruled out any systemic manifestation, and the patient was HIV-negative. The patient underwent treatment with methotrexate, cytarabine, thiotepa, and rituximab for PCNSL. Although rare, PCNSL can mimic pituitary apoplexy, which needs to be considered if conservative therapy or surgery is to be offered to a patient with a radiological and clinical diagnosis of pituitary apoplexy.

Trans-lamina terminalis approach for third ventricle and suprasellar tumours.

BACKGROUND: The trans-lamina terminalis (TLT) approach to the suprasellar region and third ventricle is complex, with risks of visual and hormonal deficits. However, the postoperative deficits might not be directly related to opening of the lamina terminalis but to the close relationship of tumours with vital neural and vascular structures. The analysis of results using this approach was the objective of this study. MATERIAL AND METHODS: The TLT approach was used in 29 patients (18 craniopharyngiomas, 5 astrocytomas, 5 germinomas and 1 ganglioglioma). The extent of tumour removal, mortality and morbidity (especially visual or hormonal deficits) were studied. RESULTS: Complete tumour removal was achieved in 15 patients, subtotal extensive removal (more than 90%) in 9 cases and partial removal in 5 cases. Panhypopituitarism developed in 22 patients. Total tumour removal was associated with the development of endocrinological disturbances. There was worsening or the onset of new visual field defects in 4 cases. Postoperative endocrine and visual deficits were in the range generally described regarding surgery for tumours in this region. CONCLUSION: The TLT approach allows for extensive removal of third ventricle and suprasellar tumours, without increased risks of visual and hormonal deficits, compared to those described regarding surgery for lesions in this region.

The infratentorial supracerebellar approach in surgery of lesions of the pineal region.

BACKGROUND: Surgery of pineal region lesions is considered a challenging task, due to the particular relationship of lesions in this location with neural and vascular structures. Few series with a significant experience of dealing with these patients have been reported. METHODS: We review our experience using infratentorial supracerebellar approach in the surgery of pineal region, regarding the extension of the removal, postoperative morbidity, and discussing details of the surgical technique. In all cases, a supracerebellar infratentorial approach was used in the semi sitting position. RESULTS: A total of 32 patients were operated in the past 20 years (3 germinomas, 3 teratoma, 3 pineocitoma, 2 pineal tumor of intermediate differentiation, 6 pineoblastomas, 6 low grade astrocytoma, 2 glioblastoma, 2 metastasis, 1 ependymoma, 1 epidermoid tumor, 1 cavernoma, and 2 arachnoid cyst). Total removal was achieved in 15 cases and subtotal extensive removal in 7 patients. In the remaining cases, only partial removal was possible, due to the involved pathological types. There was no surgical mortality and no cases of cerebellar venous infarction. Morbidity consisted of transient ocular movement disturbance in 14 patients, transient ataxia in 3 patients, and 1 case of local cerebrospinal fluid (CSF) fistula with meningitis that required surgical treatment. CONCLUSION: Supracerebellar infratentorial is a safe approach to lesions in the pineal region, and total or extensive subtotal removal is possible in most cases, with acceptable morbidity.

Melanocitoma meníngeo intramedular dorsal / Thoracic spinal cord meningeal melanocytoma

O melanocitoma meníngeo é uma lesão infrequente, benigna, mas localmente agressiva. Sua localização intramedular é muito rara, existindo apenas três casos descritos na literatura. A propósito deste caso clínico, os autores reveem a literatura e discutem as características clínicas, imagiológicas e histológicas desse tipo de lesão. Relato do caso: Homem de 54 anos de idade com melanocitoma meníngeo intramedular dorsal (T11). Clinicamente apresentou, de início, disestesias torácicas, sem déficits neurológicos associados, que se mantiveram estáveis ao longo de dois anos. Após esse período teve instalação súbita de paraparesia. O diagnóstico definitivo foi estabelecido por exame histológico e imunocitoquímico após ressecção cirúrgica parcial da lesão. A pesquisa de melanoma maligno cutâneo--mucoso ou ocular foi negativa. Apesar de evolução inicial favorável apresentou recrescimento tumoral dois anos e meio após a primeira cirurgia, sendo reoperado. Apesar da ausência de complicações diretamente relacionadas com a cirurgia, acabou por falecer por sepsis na sequência de ruptura de diverticulite intestinal semanas depois.

Meningeal melanocytomas are infrequent, benign tumors but with a locally agressive behaviour. Extension to the spinal cord of these lesions is very rare and there are only three cases reported in the literature. The authors review the literature and discuss the clinical, neuroimaging and pathological features of this lesion. Case report: The authors present a case of a 54-year-old man with a thoracic spinal cord meningeal melanocytoma (T11). During two years the only complain was thoracic disestesias with no neurological deficit. After that period there was a sudden onset of paraparesia. The definitive diagnosis was made by histologic and immunocytochemical studies after parcial surgical excision of the lesion. No evidence of cutaneous, mucous or ocular malignant melanoma was found. Although an inicial favourable evolution, two and a half years after the first surgery the tumor regrowth and the patient was reoperated. No complications related to the surgery occurred but the patient had a rupture of an intestinal diverticulitis and died from sepsis some weeks later.