Aggressive dissemination of central nervous system hemangioblastoma without association with von Hippel-Lindau disease: A case report and literature review.

Background: Hemangioblastomas (HBs) typically present with benign behavior and are most commonly found in the posterior fossa. Multiple central nervous system (CNS) HBs are usually associated with von Hippel-Lindau disease, and leptomeningeal dissemination of sporadic HBs is extremely rare. A review of the literature identified 30 cases of leptomeningeal dissemination of sporadic HBs previously published in the literature. Case Description: We report the case of a patient who was diagnosed with multiple CNS HBs with aggressive progression 6 years after resection of a posterior fossa HB. He underwent multiple surgeries and died 4 years after the diagnosis of the first spinal dissemination. Conclusion: Dissemination of sporadic HBs is rare and aggressive disease evolution is usually observed. Further studies are necessary to determine the optimal therapeutic options.

A Simple Method to Avoid Brain Shift during Neuronavigation: Technical Note

Introduction The precise identification of anatomical structures and lesions in the brain is the main objective of neuronavigation systems. Brain shift, displacement of the brain after opening the cisterns and draining cerebrospinal fluid, is one of the limitations of such systems. Objective To describe a simple method to avoid brain shift in craniotomies for subcortical lesions. Method We used the surgical technique hereby described in five patients with subcortical neoplasms. We performed the neuronavigation-guided craniotomies with the conventional technique. After opening the dura and exposing the cortical surface, we placed two or three arachnoid anchoring sutures to the dura mater, close to the edges of the exposed cortical surface. We placed these anchoring sutures under microscopy, using a 6­0 mononylon wire. With this technique, the cortex surface was kept close to the dura mater, minimizing its displacement during the approach to the subcortical lesion. In these five cases we operated, the cortical surface remained close to the dura, anchored by the arachnoid sutures. All the lesions were located with a good correlation between the handpiece tip inserted in the desired brain area and the display on the navigation system. Conclusion Arachnoid anchoring sutures to the duramater on the edges of the cortex area exposed by craniotomy constitute a simple method to minimize brain displacement (brain-shift) in craniotomies for subcortical injuries, optimizing the use of the neuronavigation system.

Cervical Myelopathy Caused by Engorgement of the Epidural Venous Plexus due to Cerebrospinal Fluid Overdrainage: Case Report and Review of the Literature

This is a case report of a 33-year-old woman with cervical myelopathy caused by an enlargement of the cervical venous plexus, after she was submitted to a ventriculoperitoneal (VP) shunt that evolved to overdrainage. Magnetic Resonance Imaging (MRI) revealed an epidural venous enlargement within the spinal channel, with a 50% narrowing from C2 to C5, and spinal cord compression. A shunt revision was performed using a programmable drainage system, and a second MRI revealed the absence of the venous enlargement, resulting in cervical spinal cord decompression and remission of neurological symptoms. Compressive myelopathy consequent to the enlargement of the epidural venous plexus related to the overdrainage of the ventriculoperitoneal shunt system without typical signs of intracranial hypotension may result in misleading etiological diagnoses. Acknowledging this disorder is important to distinguish it from neoplastic processes or hematomas, for which surgical intervention may be needed.

Este é um relato de caso de uma paciente de 33 anos de idade que apresentou mielopatia cervical devido a alargamento do plexo venoso cervical, após ser submetida a uma derivação ventriculoperitoneal que evoluiu com hiperdrenagem. Exame de Ressonância Nuclear Magnética (RNM) revelou alargamento do plexo venoso epidural no canal espinhal, com estreitamento de 50% em C2 a C5, e compressão da medula espinhal. Uma revisão da derivação foi feita com um sistema de drenagem programável, e uma segunda RNM revelou ausência de ingurgitamento venoso, resultando em descompressão medular e remissão dos sintomas neurológicos. Mielopatia compressiva consequente ao alargamento do plexo venoso epidural relacionado à hiperdrenagem do sistema de derivação ventriculoperitoneal sem sinais típicos de hipotensão intracraniana pode resultar em diagnósticos incorretos. O conhecimento dessa patologia é importante para distingui-la de processos neoplásicos ou hematomas, nos quais intervenções cirúrgicas podem ser necessárias.

Extracranial­Intracranial Cerebral Revascularization: Indications and Results / Revascularização cerebral extracraniana-intracraniana: indicações e resultados

Objective To present a case-series study of extracranial­intracranial (EC­IC) bypass procedures performed in our service and evaluate indications and results. Method The medical records of 30 patients undergoing 32 EC­IC anastomosis procedures were evaluated. Seventeen patients were male (56.6%). The age ranged from 26 to 85 years (mean: 58.2). The follow-up ranged from 1 to 211 months (mean: 54). We evaluated the indications and complications of the surgical procedures. Results The bypass procedures comprised 28 STA­MCA anastomosis (87,5%) and four posterior circulation anastomosis. The main indications included cervical internal carotid artery occlusion (19 cases), Moyamoya disease (3 cases), giant aneurysms (3 cases), intracranial arterial stenosis (2 cases), and vertebral­basilar insufficiency (3 cases). On follow-up, graft patency was 93.7%, confirmed in half of the cases by arterial digital subtraction angiography, magnetic resonance angiography, and CT angiography. There was no surgical mortality. Three patients had PO complications (9.3%), including one case of ischemia (3.1%). Conclusion The EC­IC bypass is a procedure with low morbidity and mortality. The indication of EC­IC bypass surgery for cerebral atherosclerotic disease should not be generalized. The EC­IC bypass can be indicated for cerebral revascularization in Moyamoya disease, intracranial stenosis, and in the management of complex aneurysms. This procedure can be an alternative in the treatment of vertebral­basilar insufficiency.

Objetivo Apresentar uma série de casos de anastomose extra-intracraniana (EC-IC) avaliando suas indicações e resultados. Método Foram avaliados retrospectivamente os prontuários de 30 pacientes submetidos a 32 procedimentos de anastomose EC-IC. Dezessete pacientes eram do sexo masculino (56,6%) com média de idade de 58,2 anos. O período de seguimento variou de um a 211 meses (média: 54). Foram avaliadas as indicações e complicações dos procedimentos cirúrgicos. Resultados Foram realizadas 28 anastomoses entre a artéria temporal superficial e a cerebral média (87,5%) e quatro anastomoses na circulação posterior. As principais indicações foram oclusão de carótida interna cervical (19 casos), doença de Moyamoya (3 casos), aneurismas gigantes (3 casos), estenose arterial intracraniana (2 casos) e insuficiência vertebrobasilar (3 casos). A patência tardia do bypass confirmada em metade dos casos por angiografia, angiorressonância ou angiotomografia foi de 93,7%. Não houve mortalidade cirúrgica. Um paciente (3,1%) apresentou isquemia no pósoperatório. Outros dois pacientes (6,2%) apresentaram complicações não isquêmicas. Conclusões A revascularização EC-IC é procedimento de baixa morbidade e mortalidade. A indicação do procedimento para oclusão carotídea não pode ser generalizada. O bypass EC-IC pode ser indicado na doença deMoyamoya, nas estenoses intracranianas e no manejo de aneurismas complexos. Pode ser alternativa no tratamento da insuficiência vertebrobasilar.

Comparative morphometric study of the sigmoid sinus sulcus and the jugular foramen.

OBJECTIVE: To compare the right and left sides of the same skulls as far as the described landmarks are concerned, and establish the craniometric differences between them. METHOD: We carried out measurements in 50 adult dry human skulls comparing both sides. RESULTS: The sigmoid sinus width at the sinodural angle level was larger on the right side in 78% of the cases and at the level of the digastric notch in 72%. The jugular foramen width was also larger on the right side in 84% of the cases. The sigmoid sinus distance at the level of the digastric notch was larger on the right side in 64% of the cases, and the sigmoid sinus distance at the level of the digastric notch to the jugular foramen was larger on the right side in 70% of the cases. CONCLUSION: Significant craniometric differences were found between both sides of the same skulls.

Comparative morphometric study of the sigmoid sinus sulcus and the jugular foramen / Estudo morfométrico comparativo do sulco do seio sigmóideo e do forame jugular

Objective To compare the right and left sides of the same skulls as far as the described landmarks are concerned, and establish the craniometric differences between them. Method We carried out measurements in 50 adult dry human skulls comparing both sides. Results The sigmoid sinus width at the sinodural angle level was larger on the right side in 78% of the cases and at the level of the digastric notch in 72%. The jugular foramen width was also larger on the right side in 84% of the cases. The sigmoid sinus distance at the level of the digastric notch was larger on the right side in 64% of the cases, and the sigmoid sinus distance at the level of the digastric notch to the jugular foramen was larger on the right side in 70% of the cases. Conclusion Significant craniometric differences were found between both sides of the same skulls. .

Objetivo Comparar os lados direito e esquerdo no mesmo crânio nos pontos referenciais descritos e definir as diferenças craniométricas entre ambos. Método Realizamos mensurações em 50 crânios secos de humanos adultos comparando os lados direito e esquerdo. Resultados Como resultado, obtivemos as medidas da largura do seio sigmóideo na altura do ângulo sinodural maiores no lado direito em 78% dos casos e na altura do ponto digástrico em 72%. A largura do forame jugular foi também maior no lado direito em 84% dos casos. A distância do seio sigmóideo na altura do ângulo sinodural até a altura do ponto digástrico foi maior do lado direito em 64% dos casos, e a distância do seio sigmóideo na altura do ponto digástrico até o forame jugular foi maior do lado direito em 70% dos casos. Conclusão Diferenças craniométricas significativas foram encontradas entre os dois lados do crânio. .

Medicina baseada na indiferença / Based medicine indifference

A Medicina atual requer para si o estatuto de ciência, e o estado atual desta arte científica chama-se medicina baseada em evidência. Os principais pilares dessa nova Medicina são as análises críticas de estudos randomizados e controlados e esses estudos propriamente ditos. Entretanto, várias barreiras devem ser vencidas pelos médicos na tradução para sua prática diária das evidências desses estudos. Nãoraro, os médicos praticam o oposto do preconizado pelas evidências, baseando sua atividade na indiferença.

Current Medicine aspires to the status of science, and the current state of this scientific art is called evidence-based medicine. The main pillars of this new medicine are critical analyzes of randomized, controlled trials, and these studies themselves. However, physicians must overcome several barriers in their daily practice to translate the evidence from these studies. Often doctors practice the opposite of what is recommended, based on indifference.

Pseudotumoral form of cerebral Schistosomiasis mansoni.

OBJECTIVE: To describe published cases of cerebral mansoni schistosomiasis and three others and discuss the diagnosis and treatment of cerebral pseudotumoral schistosomiasis. CASE DESCRIPTIONS: In case 1, a 20-year-old man presented with occipital headache, intense dizziness, visual alterations, nausea, decreased appetite, and asthenia. Cranial computed tomography (CT) revealed an expansive cerebellar lesion in the right hemisphere with no contrast enhancement. The patient had complete resection of the lesion. Anatomicopathological examination revealed a schistosomal granuloma. In case 2, a 22-year-old man presented with generalized tonic-clonic seizure. Cranial CT and magnetic resonance imaging (MRI) revealed an expansive bilateral middle frontal lesion, with contrast uptake close to the cingulate gyrus and corpus callosum. The patient underwent left frontal craniotomy, and an interhemispheric approach was used to resect part of the lesion. In case 3, a 32-year-old man presented with generalized tonic-clonic seizures. Cranial CT showed a hyperdense intense intracranial expansive lesion that presented contrast uptake in the left temporal region. The patient had complete resection of the lesion. CONCLUSIONS: A surgical approach with lesion resection or stereotaxic biopsy is warranted to determine the diagnosis definitively. Antiparasitic drugs must be administered to complete treatment.

A new landmark for finding the sigmoid sinus in suboccipital craniotomies.

BACKGROUND: The suboccipital craniotomy is one of the most commonly performed neurosurgical approaches. OBJECTIVE: To define a new cranial landmark, the digastric point, located at the top of the mastoid notch in the mastoid portion of the temporal bone that may assist surgeons performing this craniotomy and to study the relationships between this point and other surface landmarks. METHODS: Craniometric measures were taken from 127 dry human adult skulls (90 male and 37 female). The measures were taken in millimeters by a digital caliper. Transillumination of the skull with laser or light-emitting diode was used to assess the correspondence of the digastric point in the inner surface of the skull. RESULTS: The mean distance between the digastric point and the sigmoid sulcus in 254 measures was 3.10 mm (SD, 3.11 mm). The digastric point was over the sulcus of the sigmoid sinus in 49.6% of the cases on the right side and in 29.9% of the cases on the left side. The distance between the jugular point and the stylomastoid foramen was smaller on the right side (mean, 8.89 mm; SD, 2.61 mm; P = .041). Comparing genders regardless of side, the distances between the digastric and jugular points and from the jugular point to the stylomastoid foramen were smaller in female skulls (P = .000 and .006, respectively). CONCLUSION: The digastric point may be a useful landmark to expose the sigmoid sinus during suboccipital approaches.

Bridge-therapy with enoxaparin in the preoperative period of endarterectomy.

Cervical clot is one of the complications of endarterectomy. This risk may be higher in patients using aspirin or clopidogrel. On the other hand, stroke may occur if the medication is interrupted before surgery. We carried out a prospective study of 124 endarterectomies in 119 patients in which aspirin or clopidogrel was stopped and a bridge-therapy with enoxaparin was administered preoperatively. There was no case of stroke during the period of the bridge-therapy. One patient developed cervical clot (0.8%) in the fifth postoperative day. Mortality rate in this series was 0.8%. There was no complication directly related to the use of enoxaparin. Bridge-therapy with low molecular weight heparin is a safe strategy for patients elected for endarterectomy.

Bridge-therapy with enoxaparin in the preoperative period of endarterectomy / Terapia-ponte com enoxaparina no período pré-operatório da endarterectomia

Cervical clot is one of the complications of endarterectomy. This risk may be higher in patients using aspirin or clopidogrel. On the other hand, stroke may occur if the medication is interrupted before surgery. We carried out a prospective study of 124 endarterectomies in 119 patients in which aspirin or clopidogrel was stopped and a bridge-therapy with enoxaparin was administered preoperatively. There was no case of stroke during the period of the bridge-therapy. One patient developed cervical clot (0.8 percent) in the fifth postoperative day. Mortality rate in this series was 0.8 percent. There was no complication directly related to the use of enoxaparin. Bridge-therapy with low molecular weight heparin is a safe strategy for patients elected for endarterectomy.

Hematoma cervical é uma das complicações graves de endarterectomia. O risco dessa complicação pode ser maior em pacientes em uso de antiagregante plaquetário. Por outro lado, a suspensão de antiagregante plaquetário no período pré-operatório de endarterectomia eleva o risco de acidente vascular cerebral (AVC). Realizamos estudo prospectivo de 119 pacientes submetidos a endarterectomia (124 procedimentos), nos quais foi suspenso antiagregante plaquetário (aspirina ou clopidogrel) e foi administrada terapia-ponte com enoxaparina subcutânea no período pré-operatório. Nessa série, não houve ocorrência de AVC no período pré-operatório. Um paciente (0,8 por cento) desenvolveu hematoma cervical no quinto dia pós-operatório. A mortalidade nessa série foi de 0,8 por cento. Não houve nenhuma complicação atribuída diretamente ao uso de enoxaparina. A terapia-ponte com heparina de baixo peso molecular demonstrou ser estratégia segura no preparo de pacientes para endarterectomia.

[Management of odontoid fractures using anterior screw fixation: analysis of 15 cases]. / Tratamento cirúrgico das fraturas do odontóide tipo II com parafuso anterior: análise de 15 casos.

A retrospective analysis of the results of 15 patients with odontoid fractures type II P and II N, according to Roy-Camille's classification is presented. They were operated on by an anterior approach and direct fixation of the odontoid process through a screw. There were 13 men and 2 women, the age ranging from 14 to 74 years. The follow up period was from 6 to 36 months (mean 20 months). There was only one complication related to the surgical technique: one screw was misplaced and it was necessary another surgery to replace it. There were no deaths in this series. There were no screw breakdown and the fusion rate was 94%. We propose, based on this study, that the classification of Roy-Camille for odontoid fractures should be always used, since it proposes one surgical approach for each type of fracture. The results of this series show that this technique is useful and has advantages over another modalities of treatment. The correct diagnosis of the type of fracture and an appropriate selection of patients are the main elements to achieve good results.

Tratamento cirúrgico das fraturas do odontóide tipo II com parafuso anterior: análise de 15 casos / Management of odontoid fractures using anterior screw fixation: analysis of 15 cases

Apresentamos estudo retrospectivo dos resultados de 15 pacientes consecutivos, com fratura do odontóide tipo II P (fratura com traço oblíquo e deslocamento posterior) e II N (fratura com traço horizontal na base do odontóide), segundo a classificaçäo de Roy-Camille , que foram submetidos a fixaçäo anterior direta do odontóide com parafuso. A série é composta por 13 homens e 2 mulheres, com idade variando entre 14 a 74 anos e período de acompanhamento de 6 a 36 meses (média 20 meses). Tivemos apenas uma complicaçäo relacionada com a técnica cirúrgica: um parafuso mal posicionado necessitando de uma reoperaçäo para ser reposicionado. Näo houve óbito. Näo houve saída nem quebra de parafuso. Obteve-se 94 por cento de fusäo óssea. Propomos que seja utilizada a classificaçäo de Roy-Camille na seleçäo dos casos cirúrgicos de fraturas do odontóide, pois ela fornece uma abordagem cirúrgica específica para cada tipo de fratura

Doença de Forestier. Relato de caso / Forestier's disease. Case report

A doença de Forestier, ou hiperostose esquelética idiopática difusa (diffuse idiopatic skeletal hyperostosis) é uma doença sistêmica de etiologia desconhecida caracterizada pela presença de calcificação e ossificação da face ântero-lateral de no mínimo quatro corpos vertebrais adjacentes, relativa preservação da altura dos discos intervertebrais dos segmentos envolvidos e grandes osteófitos. Os autores apresentam um caso de um paciente do sexo masculino de 55 anos de idade com quadro de disfagia conseqüente a essa doença. Discutem no presente registro os aspectos clínicos da dença, o tratamento e o diagnóstico diferencial.

Tratamento da instabilidade degenerativa da coluna lombar com fixação transpedicular / Transpedicular lumbar fixation for degenerative lumbar instability. An analysis of 53 cases

Os autores apresentam um estudo retrospectivo dos resultados de 53 pacientes, com instabilidade degenerativa da coluna lombar e toracolombar, que foram tratados consecutivamente com fixaçãotranspedicular por via posterior usando material Socon e Spine System da Aesculap. A casuística é constituída por 27 homens e 26 mulheres, com média etária de 53,4 anos (27 a 81 anos). A média do acompanhamento foi de 15 meses. O procedimento foi feito nos casos de espondilolistesedegenerativa (25 casos), instabilidade pós-operatória (12 casos), escoliose degenerativa (7 casos), fraturas degenerativas (5 casos), canal estreito lombar (2 casos) e instabilidade segmentar (2 casos).A cirurgia consistiu em descompressão neural, fixação interna com instrumentação transpedicular e enxerto ósseo. Em 18 casos foi associado o cage metálico. Obtiveram-se 90% de resultados bons e satisfatórios pela escala de Stauffer e Coventry, com 96% de taxa de fusão e 4% de pseudo-artrose. As complicações incluíram quatro casos de radiculalgia pós-operatória em virtude do contato da raiz com o instrumental, dois de fístulas liquóricas com resolução espontânea, duas infecções (uma profunda e outra superficial) e dois casos de estenose acima do nível t ratado. Destes pacientes, sete (14%) necessi taram dereoperação. Não houve óbito nem quebra do instrumental. Os resul tados comprovaram que, apesar do cur to per íodo de acompanhamento, a fixação transpedicular é um bom método para instrumentação e tratamento das instabilidades degenerativas, oferecendo vantagens biomecânicas comparadas com outras formas de tratamento, permitindo montagens curtas, preservando segmentos adjacentes e a lordose fisiológica. A seleção apropriada dos pacientes para a cirurgia é provavelmente o fator mais importante associado com bons resultados.

The authors present the results of the treatment of 53 consecutive patients with lumbar and thoraco-lumbar spine degenerative instability by a posterior transpedicular fixation using Socon and Spine Aesculap instrumentation systems. The mean follow-up was 15 months. Surgery was performed for degenerative spondilolisthesis (25 cases), post-surgical instability (12 cases), degenerative scoliosis (7 cases), degenerative fractures (5 cases), lumbar spine stenosis (2 cases) and segmental instability (2 cases). There were 27 men and 26 women, aging from 27 to 81 years (mean 53,4), all of them complained of back pain.The surgical procedure consisted in neural decompression, transpedicular fixation and instrumentation and bone graft. In eighteen cases we associated the use of a metallic cage. The results were good or fair in 90% of the cases (according to the Stauffer and Coventry?s scale), with 96% of fusion rate and 4% of pseudarthrosis. Complications included: four cases of radiculopaty due the contact of the nerve roots with the instrumentation system; two cases of CSF leak, both clearing spontaneously; two cases of infection (one superficial, the other deep) and two cases of stenosis above the level of instrumentation. Seven (14%) of these complication cases required reoperation. There were no deaths in this series and no problems with the instrumentation device itself. We concluded that, despite the short follow-up period, the transpedicular fixation is a good methodfor treatment of degenerative instability, with biomechanical advantages if compared with other modalities of treatment. It allows short instrumentation, sparing adjacent segments and the physiological lordosis is preserved. Careful selection of the patients for surgery is probably themost important factor associated with good outcome.

Extrusäo de prótese de acrílico em artrodese cervical anterior / Extrusion of acrylic prosthesis in anterior cervical arthrodesis

Relato de caso de extrusäo pela boca de acrílico usado em artrodese cervical anterior no tratamento cirúrgico de fratura-esmagamento de vértebra cervical secundária a plasmocitoma