Prognostic factors for endoscopic third ventriculostomy success in hydrocephalus with myelomeningocele.

PURPOSE: Myelomeningocele (MMC) is a prevalent neural tube closure defect often associated with hydrocephalus, necessitating surgical intervention in a significant proportion of cases. While ventriculoperitoneal shunting (VPS) has been a standard treatment approach, endoscopic third ventriculostomy (ETV) has emerged as a promising alternative. However, factors influencing the success of ETV in MMC patients remain uncertain. This retrospective observational study aimed to identify clinical and radiological factors correlating with a higher success rate of ETV in MMC patients. METHODS: Medical records of MMC patients who underwent ETV at a tertiary care center between 2015 and 2021 were reviewed. Demographic, clinical, and radiological data were analyzed. ETV success was defined as the absence of further hydrocephalus treatment during follow-up. RESULTS: Of 131 MMC patients, 21 met inclusion criteria and underwent ETV. The overall success rate of ETV was 57.1%, with a six-month success rate of 61.9%. Age ≤ 6 months was significantly associated with lower ETV success (25%) compared to older patients (76.9%) (OR: 0.1; 95% CI 0.005-2.006; p = 0.019). Radiological factors, including posterior fossa dimensions and linear indices, did not exhibit statistically significant associations with ETV success. CONCLUSION: Age emerged as a significant factor affecting ETV success in MMC patients, with younger patients exhibiting lower success rates. Radiological variables did not significantly influence ETV outcomes in this study. Identifying predictors of ETV success in MMC patients is crucial for optimizing treatment strategies and improving patient outcomes.

Proposed radiological score for the evaluation of isolated fourth ventricle treated by endoscopic aqueductoplasty.

PURPOSE: Evidence supporting the effectiveness of endoscopic aqueductoplasty (EA) for the treatment of isolated fourth ventricle (IFV) is limited to small surgical series of cases. Additionally, studies adopted different radiological outcome criteria, which makes it difficult to compare outcomes accurately. Thus, we aimed to develop a radiological score (RS) as an alternative assessment method for EA. METHODS: The cases of 20 consecutive pediatric patients harboring IFV and treated by EA were retrospectively reviewed. Clinical data and pre- and 1-year postoperative brain images were analyzed. The RS was based on the enlargement of the fourth ventricle and deformation of the cerebellum and brainstem. After randomization, three experts, blinded to patient outcomes, analyzed the brain images and established a consensus for the values of the score. Outcomes were validated by comparing the maximum anteroposterior distance of the fourth ventricle using the RS, pediatric functional status score, and clinical symptoms. RESULTS: The RS was strongly correlated with the anteroposterior distance of the fourth ventricle (Pearson's coefficient = 0.78), and the mean RS dropped from 6.15 to 3.90 (p < 0.001) 1 year after EA. Upward extension (p = 0.021) and brainstem deformation (p = 0.010) were the most significant improved features. There was agreement among RS and symptom improvement in 16 children (80%) and the pediatric functional status score in 14 children (70%). CONCLUSION: In this study, the proposed radiological score proved to be an accurate tool for the evaluation of IFV treatment with EA.

Comparative study of complications after primary and revision transsphenoidal endoscopic surgeries.

A preferred treatment for residual/recurrent pituitary adenomas has not been established. The existence of higher complication rates for revision surgeries remains under debate. This study aimed to compare complication rates of primary and revision transsphenoidal endoscopic surgeries and to identify risk factors for complications. Data from 144 primary and 39 revision surgeries were analysed. The surgical complications evaluated were intraoperative and postoperative cerebrospinal fluid (CSF) leaks; meningitis; permanent diabetes insipidus (DI) and hypopituitarism; worsening visual acuity; ophthalmoplegias; visual field defects; otorhinolaryngological, systemic and vascular complications; and death. The variables that were potentially associated with surgical complications were gender, age, comorbidities, lumbar drain use, duration of lumbar drain use, invasion of the sphenoid and cavernous sinuses, presence and degree of suprasellar expansion, preoperative identification of the pituitary, CSF leaks and intraoperative pituitary identification. Intraoperative CSF leaks, visual field losses and worsening visual acuity were more common for revision surgeries. There were no between-group differences in the occurrence of postoperative CSF leaks; systemic, vascular and otorhinolaryngological complications; meningitis; DI and hypopituitarism; ophthalmoplegias; or death. Intraoperative identification of the pituitary was associated with lower rates of permanent DI and hypopituitarism, systemic complications, intraoperative CSF leaks and worsening visual acuity. Suprasellar expansion increased the risk of intraoperative CSF leaks but not endocrinological deficits or visual impairment. Intraoperative CSF leaks were associated with postoperative CSF leaks, meningitis, anterior hypopituitarism, DI and worsening visual acuity. Intraoperative CSF leaks, worsening visual acuity and visual field losses were more common in reoperated patients.

Microgliosis is associated with visual memory decline in patients with temporal lobe epilepsy and hippocampal sclerosis: A clinicopathologic study.

Hippocampal sclerosis (HS) is characterized by neuronal loss and gliosis. The intensity and distribution of these histopathological findings over the Cornu Ammonis (CA) subfields are important for the classification of HS and prognostication of patients with temporal lobe epilepsy (TLE). Several studies have associated the neuronal density reduction in the hippocampus with cognitive decline in patients with TLE. The current study aimed at investigating whether the expression of glial proteins in sclerotic hippocampi is associated with presurgical memory performance of patients with TLE. Before amygdalohippocampectomy, patients were submitted to memory tests. Immunohistochemical and morphometric analyses with glial fibrillary acidic protein (GFAP) for astrogliosis and human leucocyte antigen DR (HLA-DR) for microgliosis were performed in paraffin-embedded HS and control hippocampi. Sclerotic hippocampi exhibited increased gliosis in comparison with controls. In patients with TLE, the area and intensity of staining for HLA-DR were associated with worse performance in the memory tests. Glial fibrillary acidic protein was neither associated nor correlated with memory test performance. Our data suggest association between microgliosis, but not astrogliosis, with visual memory decline in patients with TLE.

A novel complex neurological phenotype due to a homozygous mutation in FDX2.

Defects in iron-sulphur [Fe-S] cluster biogenesis are increasingly recognized as causing neurological disease. Mutations in a number of genes that encode proteins involved in mitochondrial [Fe-S] protein assembly lead to complex neurological phenotypes. One class of proteins essential in the early cluster assembly are ferredoxins. FDX2 is ubiquitously expressed and is essential in the de novo formation of [2Fe-2S] clusters in humans. We describe and genetically define a novel complex neurological syndrome identified in two Brazilian families, with a novel homozygous mutation in FDX2. Patients were clinically evaluated, underwent MRI, nerve conduction studies, EMG and muscle biopsy. To define the genetic aetiology, a combination of homozygosity mapping and whole exome sequencing was performed. We identified six patients from two apparently unrelated families with autosomal recessive inheritance of a complex neurological phenotype involving optic atrophy and nystagmus developing by age 3, followed by myopathy and recurrent episodes of cramps, myalgia and muscle weakness in the first or second decade of life. Sensory-motor axonal neuropathy led to progressive distal weakness. MRI disclosed a reversible or partially reversible leukoencephalopathy. Muscle biopsy demonstrated an unusual pattern of regional succinate dehydrogenase and cytochrome c oxidase deficiency with iron accumulation. The phenotype was mapped in both families to the same homozygous missense mutation in FDX2 (c.431C > T, p.P144L). The deleterious effect of the mutation was validated by real-time reverse transcription polymerase chain reaction and western blot analysis, which demonstrated normal expression of FDX2 mRNA but severely reduced expression of FDX2 protein in muscle tissue. This study describes a novel complex neurological phenotype with unusual MRI and muscle biopsy features, conclusively mapped to a mutation in FDX2, which encodes a ubiquitously expressed mitochondrial ferredoxin essential for early [Fe-S] cluster biogenesis.

Circulating levels of adipokines are altered in patients with temporal lobe epilepsy.

OBJECTIVE: A persistent low-grade inflammatory state has been described in patients with temporal lobe epilepsy (TLE) in the interictal period. Adipokines are cytokines produced by the adipose tissue that can influence inflammatory response. The purpose of this study was to evaluate the plasma levels of adipokines in patients with TLE in comparison with controls. In addition, we sought to investigate whether the levels of adipokines were associated with clinical parameters in TLE. METHODS: Forty patients with TLE and 40 controls were enrolled in this study. All participants were subjected to clinical assessment that included the Mini International Neuropsychiatric Interview (MINI) and the Hamilton Depression Rating Scale (HAM-D). Peripheral blood was drawn, and plasma levels of adipokines (adiponectin, leptin, and resistin) were measured by enzyme-linked immunoassay (ELISA). RESULTS: People with TLE presented higher leptin and lower adiponectin and resistin levels in comparison with controls. The levels of these adipokines correlated negatively with illness length but not with other clinical parameters. In a binary logistic regression model, higher leptin and lower adiponectin levels remained as significant predictors of TLE diagnosis. CONCLUSIONS: These results corroborate the view that TLE is a multisystemic condition associated with low-grade inflammation.

Choroid plexus cauterization on treatment of hydranencephaly and maximal hydrocephalus.

INTRODUCTION: The standard treatment for hydranencephaly and maximal hydrocephalus consists of inserting shunts, although complications frequently occur. Choroid plexus cauterization (CPC) is an alternative, but its long-term efficacy and the factors associated with the success and failure of controlling head circumference (HC) are not well defined. OBJECTIVE: This study aims to evaluate the long-term efficacy and factors related to the success rate of CPC in the treatment of hydranencephaly and maximal hydrocephalus. METHOD: Forty-two children with maximal hydrocephalus and hydranencephaly underwent CPC from 2006 to 2014 and were retrospectively evaluated. Children with less than 3 months of follow-up were excluded. The long-term efficacy and success rate of possible variables (i.e., sex, type of malformation, type of surgery performed, treatment hospital, age, and HC at the time of surgery and birth) were evaluated. RESULTS: Thirty-four children were considered for the effectiveness analysis. Treatment was successful in 24 children (70.6%), and failure occurred in 10 children (29.4%). Failure was detected soon after the endoscopic procedure (average 116 days). There was no difference in effectiveness when comparing the age at the moment of surgery (p = 0.473), type of malformation (p = 1), HC at birth (0.699), and HC at the time of surgery (p = 0.648). The surgical death rate was 7.14%. CONCLUSION: Endoscopic CPC was a valid procedure used to treat hydranencephaly and maximal hydrocephaly, and it was effective in 70.6% of cases, with an average follow-up period of 32 months. When failures occurred, they occurred early. None of the analyzed variables interfered with the success of the treatment.

Bladder perforation by ventriculoperitoneal shunt.

BACKGROUND: Bladder perforation by ventriculoperitoneal shunt is a rare complication that has been describe in 19 cases in prior literature. CASE DESCRIPTION: This work describes the case of a 4-month-old baby who presented with extrusion of the distal catheter through the urethra. The patient underwent a laparotomy; the catheter was cut close to the bladder wall and repositioned into the peritoneal cavity. The bladder wall was sutured, and the remaining distal portion of the catheter was removed through the urethra. DISCUSSION AND CONCLUSION: Based on this single experience and a literature review, the authors classified the clinical signs and symptoms of bladder perforation by the ventriculoperitoneal shunt catheter. Finally, the authors propose a more conservative approach for this rare complication.

A tomographic study of the skull base in primary spontaneous cerebrospinal fluid leaks.

INTRODUCTION: This study aims to evaluate the existence of anatomic abnormalities in the skull base that could contribute to the origin of primary spontaneous cerebrospinal fluid leaks (PSL). METHODS: Twenty PSL patients were compared with 20 healthy individuals. The following features were measured through an analysis of computed tomography scans: the angles of the petrosal bones and skull base in both the sagittal and coronal planes; the anteroposterior and mediolateral diameters of the anterior skull base, sella, and sphenoid sinus; the depth of the olfactory fossa; the pneumatization of the sphenoid sinus; the position of the crista galli; and the state of the dorsum sellae. Body mass index (BMI) was compared. RESULTS: There were no differences between the two groups with respect to the angles and diameters of the anterior cranial fossa and the sphenoid sinus or the depth of the olfactory fossa. Pneumatization of the lateral recess of the sphenoid sinus was more frequent in the PSL group (55%) than in the control group (25%, p = 0.053). The dorsum sellae were eroded in 30% of the PSL patients but intact in all healthy subjects. PSL subjects showed higher sellae (1.0 versus 0.8 cm, p = 0.002). The average BMI of PSL patients was higher than that of the control group. CONCLUSION: Global alterations in the skull base of PSL patients were not found. The increase in the height of sellae and the erosion of its dorsum suggest intracranial hypertension. The higher BMI in the case group confirms the relation between obesity and PSL.

Endoscopic treatment of interhemispheric arachnoid cysts.

BACKGROUND: To describe the neuroendoscopic treatment of interhemispheric arachnoid cysts. METHODS: Five children (aged 1-9 months) harboring interhemispheric arachnoid cysts underwent the procedure. The neuroendoscopic technique included cystoventriculostomy and cystocisternostomy. Imaging exams were compared before and after surgery, and the differences in cyst diameters were calculated. Head circumference and neurological development were also evaluated. RESULTS: The cystoventriculostomy was performed through the lateral ventricle in 4 cases and through the third ventricle in 4 cases. An added cystocisternostomy was performed in 1 case. Cyst diameters were reduced in the anterior-posterior, lateral-medial and superior-inferior planes in 22, 31 and 31% of the cases, respectively. The rate of increasing head circumference slowed; however, all the children continued to show slight macrocrania. There were complications in 2 cases: cerebrospinal fluid fistula was managed by lumbar puncture in 1 case and subdural collection was treated with a shunt in another single case. CONCLUSION: The neuroendoscopic approach to interhemispheric arachnoid cysts was effective with few complications.

"Subclinical atherosclerosis in acromegaly: Possible association with cardiovascular risk factors rather than disease activity".

OBJECTIVE: Cardiovascular (CV) disease is still a major cause of excessive morbidity and mortality in patients with active acromegaly, which may be attributed to a high prevalence of associated pro-atherosclerotic risk factors. However, a direct effect of GH/IGF-1 excess on the vasculature has been previously suggested, warranting further investigation. The present study was designed to investigate whether chronic GH/IGF-1 excess is associated with an increased prevalence of subclinical atherosclerosis in patients with acromegaly. DESIGN: We measured carotid intima-media thickness (cIMT) and assessed carotid plaques by ultrasonography along with classical CV risk factors in 54 acromegaly patients (34 females, 50 ± 12 years and compared those with 62 (42 females, 53 ± 13 years) age-, sex- and CV risk factors- matched controls. In order to compare cIMT measurements between patients and controls we analyzed common carotid artery far wall data as well as a combined measurement result, which consisted of the mean value of the six different measurements, three at each side. RESULTS: mean ± SD serum GH and IGF-1 levels were 2.76 ± 4.65 ng/mL and 1.7 ± 1.25 x ULN, respectively, in all acromegaly patients. Age, body mass index, blood pressure, lipid levels, fasting glucose and Framingham's global cardiovascular risk score classification were similar comparing patients and controls. Combined median [IQR] cIMT measurements were similar in acromegaly patients and matched controls (0.59 [0.52-0.66] mm vs. 0.59 [0.52-0.69] mm; P = 0.872) as well as in acromegaly patients with active and controlled disease (0.59 [0.51-0.68] mm vs. 0.60 [0.54-0.68] mm; P = 0.385). No significant correlations were observed between cIMT measurements and GH (Spearman r = 0.1, P = 0.49) or IGF-1 (Spearman r = 0.13, P = 0.37) levels in patients with acromegaly. Carotid atherosclerotic plaques prevalence was similar in patients and controls (26% vs. 32%; P = 0.54) as well as in patients with active and controlled acromegaly (22% vs. 30%; P = 0.537). CONCLUSIONS: Our data suggest that GH/IGF-1 excess itself is not one of the main drivers of subclinical morphological atherosclerosis changes in patients with acromegaly and that optimal control of acromegaly-associated CV risk factors may preserve vasculature structure even when strict biochemical control is not achieved.

Endovascular treatment of residual or recurrent intracranial aneurysms after surgical clipping.

OBJECTIVE: Total aneurysm occlusion is crucial for the prevention of rebleeding of a ruptured aneurysm or to avoid rupture of an unruptured lesion. Both surgical and endovascular embolization fail to achieve complete aneurysm occlusion in all the cases. The objective of the study was to establish the safety and efficacy of endovascular treatment for previously clipped residual or recurrent aneurysms. METHODS: This was an observational, retrospective study of patients harboring incompletely occluded intracranial aneurysms after clipping who underwent endovascular treatment. Patients were treated using 4 different techniques: (1) simple coiling, (2) balloon remodeling, (3) stent-assisted coiling, and (4) flow diversion. Analyses were performed to identify predictors of total aneurysm occlusion, recanalization and complications. RESULTS: Between May 2010 and September 2018, 70 patients harboring incompletely occluded intracranial aneurysms after clipping met the inclusion criteria in 5 centers. The mean residual aneurysm size was 7.5 mm. Fifty-nine aneurysms were unruptured. Total aneurysm occlusion was achieved in 75.3% of the aneurysms after 1 year. All aneurysms treated with flow diversion revealed complete occlusion according to control angiography. Recanalization was observed in 14.5%. Permanent morbidity and mortality occurred in 2.9% and 1.4% of the patients, respectively. CONCLUSIONS: Endovascular treatment of recurrent or residual aneurysms after surgical clipping was safe and efficacious. Flow diversion seems to be associated with better anatomical results. A more rigid study, a larger group of patients, and longterm follow-up are required to provide stronger conclusions about the best approach for residual clipped aneurysms.

Minimally Invasive Approaches to the Lateral Cavernous Sinus and Meckel's Cave: Comparison of Transorbital and Subtemporal Endoscopic Techniques.

BACKGROUND: Transorbital and subtemporal keyhole approaches have recently been proposed to approach lesions in the lateral wall of the cavernous sinus (CS) and Meckel's cave (MC). Our goal was to compare these approaches and suggest indications for each of them. METHODS: Five cadaver heads (10 sides, 40 procedures) were used. The lateral transorbital approaches were carried out without and with the removal of the lateral orbital rim, herein referred to as the lateral transorbital approach (LTOA) and the lateral orbital wall approach (LOWA). The subtemporal approaches were performed without and with the removal of the zygomatic arch, referred to as the subtemporal approach (STA) and the subtemporozygomatic approach (STZA). Five targets were chosen and 2 triangles were created representing the lateral wall of the CS and MC. Stereotactic measurements were quantified to calculate angles of attack, surgical freedom, and temporal lobe retraction for each approach. RESULTS: LTOA presented the smaller horizontal angles of attack. LOWA increased the angles to the same level of STA and STZA. STA and STZA presented larger vertical angles of attack. The surgical freedom presented gradual increase from LTOA to LOWA, STA, and STZA. STA and STZA needed greater temporal lobe retraction for most targets. CONCLUSIONS: LTOA is a good option to biopsy a lesion in the lateral wall of the CS and LOWA increased the surgical corridor to work with microsurgical techniques. STA and STZA could be better options when wide exposure is necessary, but temporal lobe retraction should be taken into consideration.

Assessment of the Benefit of Intraoperative Cortical Stimulation in Patients with Lesions within Eloquent Brain Regions / Avaliação do benefício da estimulação cortical intraoperatória em pacientes com lesões em áreas cerebrais eloquentes

Objective The present study sought to evaluate the benefits of intraoperative cortical stimulation (CS) for reducing morbidity in neurosurgery. Method A total of 56 patients were submitted to neurosurgical procedure with the aid of CS. Initially, surgical exposure and planned resection were based on anatomy and imaging exams, which were followed by CS. According to the findings, the patients were divided into two groups. In group 1 the previous surgical strategy had to be altered, while in group 2 the surgical planning did not suffer any interference. Patients were also divided into subgroups according to the underlying disease: gliomas or other etiologies. Transient and definitive deficits occurrence were compared between groups 1 and 2 and subgroups of etiologies. The real benefit of CS technique was calculated by a specific formula. Results There were 20 patients (37.5%) whose surgical strategy was changed based on CS findings. Furthermore, 65% of group 1 patients had transient deficit, in comparison to 30.5% of patients in group 2 (p » 0.013). As for the definitive deficit, it occurred in 15.0% of group 1 patients versus 8.3% of patients in group 2 (p » 0.643). Definitive deficits with no statistical difference (p » 0.074) were found in 17.2% of patients with gliomas, while none were found in the other etiologies subgroup. The rate of real benefit of intraoperative CS was 30.4%. Considering the subgroups of gliomas and other etiologies, the benefit rates were 25.7% and 38.1%, respectively. Conclusions The surgical decision was influenced by CS in 35.7% of the cases and prevented definitive deficit in 30% of patients.

Objetivos O presente estudo procurou avaliar os benefícios da estimulação cortical (EC) intraoperatória na redução da morbidade em neurocirurgias. Métodos Um total de 56 pacientes foram submetidos ao procedimento neurocirúrgico com ajuda da EC. Inicialmente, a exposição cirúrgica e o panejamento da ressecção eram baseados nos achados de anatomia e imagem, que eram seguidos pela EC. De acordo com os achados neurofisiológicos, os pacientes foram divididos em dois grupos. No grupo 1, a estratégia cirúrgica teve que ser modificada, enquanto no grupo 2, o planejamento cirúrgico não foi alterado. Os pacientes foram ainda divididos em dois subgrupos de acordo com a doença subjacente: gliomas ou outras etiologias. A ocorrência de déficits transitórios e definitivos foram comparadas entre os grupos 1 e 2 e entre os subgrupos de etiologias. O benefício real da técnica de estimulação cortical foi calculado por uma fórmula específica. Resultados A estratégia cirúrgica foi alterada em 20 (37,5%) pacientes após a estimulação cortical. Além disso, 65% dos pacientes do grupo 1 tiveram déficits transitórios, em comparação com 30,5% dos pacientes do grupo 2 (p » 0,013). Quanto ao déficit definitivo, este ocorreu em 15% dos casos do grupo 1 contra 8,3% dos pacientes do grupo 2 (p » 0,643). Déficit definitivo sem diferença significativa (p » 0,074) foi observado em 17,2% dos pacientes com gliomas, enquanto nenhum foi encontrado no subgrupo de outras etiologias. A taxa de benefício real da EC intraoperatória foi de 30,4%. Considerando os subgrupos de gliomas e outras etiologias as taxas de benefício foram 25,7% e 38,1%, respectivamente. Conclusões A EC influenciou a decisão cirúrgica em 35,7% dos casos. Embora 90% dos pacientes não tenham cursado com déficits a longo prazo, a estimulação cortical preveniu tais déficits em cerca de um terço deles.

Does the Simultaneous Use of a Neuroendoscope Influence the Incidence of Ventriculoperitoneal Shunt Infection?

BACKGROUND: The relationship between the use of an endoscope during ventriculoperitoneal shunt (VPS) procedures and infection remains poorly defined. In this study, we sought to analyze whether the simultaneous use of an endoscope could in fact increase the infection rate associated with VPS procedures. METHODS: This study included 438 VPS procedures, 49 in which an endoscope was used (11.2%) and 389 in which an endoscope was not used (88.8%). The infection rates in these 2 main groups were calculated and compared. Subsequently, 4 new groups were created, composed of patients with a shunt inserted for the first time (groups 1A and 1B) and patients with a shunt reviewed or inserted for a second time (groups 2A and 2B). Groups 1A and 2A comprised patients in whom an endoscope was used simultaneously with VPS surgery, and groups 1B and 2B comprised patients in whom an endoscope was not used. These groups were compared to determine the infection rate. RESULTS: The overall infection rate was 18.5%, including 22.4% in the groups in which an endoscope was used and 18% in those in which an endoscope was not used (P = 0.449). Groups 1A and 1B and groups 2A and 2B were matched for possible intervening risk factors. The infection rate was 28.6% in group 1A and 16.2% in group 1B (P = 0.27), and 20% in group 2A and 19.8% in group 2B (P = 0.977). CONCLUSIONS: In the present study, the use of an endoscope during VPS procedures did not increase the risk of surgical infection.

Pathophysiology of posttraumatic temporal lobe lesions.

BACKGROUND: Posttraumatic parenchymal lesions in the temporal lobe may cause neurologic deterioration. An analysis was made of the natural evolution of this type of lesion, with emphasis on its 2 components: hemorrhage (hyperdense on computed tomography [CT]), and edema and necrosis (hypodense on CT). The clinical repercussions were studied, and the factors that might influence such evolution were investigated. METHODS: Forty head-injured patients with temporal lobe lesions admitted within 12 hours after the injury were selected in a prospective manner. Computed tomography scans were systematically repeated within the first 36 hours and at 7 and 30 days postinjury. Factors such as interval between injury and the first CT scan, age, velocity of the injury, alcohol consumption, coagulation abnormalities, and the presence of decompressive measures were compared between the patients that had enlargement of the hemorrhage and those who did not. Increase in hypodensity was compared with that in hyperdensity. RESULTS: Fourteen patients showed enlargement of the hemorrhage. In all cases but one, the interval between injury and admission was 3 hours or less. Other factors had no statistical significance as predisposing causes for such enlargement. In approximately half of the cases, the hypodense component increased in the first 36 hours and continued increasing until the end of the first week. Evolution of the hypodense component was not dependent on behavior of the hemorrhage, surgical drainage, or diameter of the hemorrhagic lesion. CONCLUSIONS: The natural evolution of the hyperdense component of temporal lobe lesions was to enlarge within the first few hours after the injury. Edema and necrosis developed more slowly and with no significant clinical manifestations.

[Post-traumatic temporal lobe lesions: surgical decision making based on CT scan findings].

BACKGROUND: The indication for surgical treatment of post-traumatic parenchymal lesions in the temporal lobe remains controversial. OBJECTIVE: We reviewed the tomographic parameters that might be useful in making surgical decisions. METHOD: The tomographic findings of 69 patients were analyzed in a retrospective manner considering: 1) the effects of the lesion (classified into 4 variables: midline shift, status of the cisterns, status of the ventricles, and status of the peripheral sulci); and 2) the characteristics of the lesion: anterior, posterior or anteroposterior location (as defined by a coronal plane tangent to the cerebral peduncles) and its mediolateral diameter. RESULTS: When none or only one of the aforementioned variables was found to be altered, conservative treatment was instituted (22 out of 38 lesions). In two cases, all four variables were altered, and surgery was performed in both. Anterior, anteroposterior and posterior lesions measuring 21, 23 and 28 mm in diameter, respectively, had a 50% chance of surgical removal. CONCLUSION: Amongst the patients who underwent surgical intervention, the more anterior the location of the temporal lobe lesion, the smaller the diameter.

Risk Factors for Graft Infection After Cranioplasty in Patients with Large Hemicranial Bony Defects.

OBJECTIVE: To identify infection incidence and related risk factors in patients who underwent cranioplasty (CP) after unilateral decompressive craniectomy (DC). METHODS: CP after DC was performed in 45 patients from April 2011 through January 2012. The covariates studied were compared with occurrence versus nonoccurrence of infection. Univariate analysis was performed, followed by a multivariate analysis and development of independent logistic regression models with significance of 5%. RESULTS: Wound infections were observed in 24% of cases. Patients treated with polymethyl methacrylate flaps had a 31% rate of infection compared with 12% in patients treated with autologous flaps, but the difference was not statistically significant (P = 0.279). Increased risk of infection was associated with performing CP during the same period of hospitalization as DC (45% vs. 8%; P = 0.006), recent systemic infection (53% vs. 10%; P = 0.003), a Glasgow Outcome Scale score lower than 4 (48% vs. none; P < 0.001), motor deficit (42% vs. 5%; P = 0.011), and lower levels of hemoglobin (P < 0.001). Another risk factor for infection was an interval between DC and CP of 29-84 days compared with >168 days (P = 0.007). CONCLUSIONS: The incidence of wound infection was high. Risk factors included motor deficits, Glasgow Outcome Scale score <4, lower hemoglobin levels, recent systemic infections, interval between DC and CP of 29-84 days, and DC and CP performed during the same hospitalization. Performing CP during a different hospitalization may reduce the risk of graft infection because the hemoglobin level would be higher, and patients would be less dependent and free of recent infection.

Pure Neuroendoscopic Resection of Cystic Cerebellar Tumors.

BACKGROUND: We describe the resection of cerebellar cystic tumors using pure neuroendoscopy. This technique consists of performing all of the procedures under an endoscopic view, with the instruments introduced into the operative field coaxially to the endoscope through a trocar. CASE DESCRIPTION: Three cases of cerebellar cystic lesions (two pilocytic astrocytomas and one hemangioblastoma) were approached using the pure neuroendoscopic technique. Under general anesthesia and prone positioning, a suboccipital burr hole was created. The endoscope was introduced into the tumor cavity, and a reddish nodule was identified. The monopolar electrode was used to coagulate and dissect the surrounding nodular tissue. Grasping forceps were used to remove the nodule. There were no complications related to tumor removal, and the patients recovered from their symptoms. The follow-up images showed reduction of the cavity with no contrast enhancement. CONCLUSION: The pure neuroendoscopic technique was shown to be minimally invasive and a successful and secure method to treat cystic cerebellar tumors.