Recurrence/Regrowth in Grade I Meningioma: How to Predict?

The HLA-G and HLA-E molecules, Ki67, progesterone (PR), estrogen (ER) and androgen receptors (AR), p53, COX-2, and HER2 were studied to assess whether the biological behavior of grade I meningiomas is related to their expression. Tissue samples from 96 patients with grade I intracranial meningiomas were analyzed by immunohistochemistry on tissue microarray blocks (TMA) using antibodies specific for HLA-G, HLA-E, Ki67, PR, ER, AR, p53, COX-2, and HER2. Meningiomas were classified as small (≤2 cm, 1.0%), medium (>2 and ≤4 cm, 32.3%), and large (>4 cm, 66.7%). Tumor size was not related to recurrence/regrowth (p = 0.486), but was significantly correlated with peritumoral edema (p = 0.031) and intratumoral calcifications (p = 0.018). Recurrent meningiomas were observed in 14.6% of cases. Immunostaining for each marker was: HLA-G 100%; HLA-E 95.6%; PR 62%; ER 2.1%; AR 6.5%; p53 92.6%; COX-2 100%; HER2 0%; Ki67, mean 2.61 ± 2.29%, median 2.1%. Primary and recurrent meningiomas showed no significant relation with HLA-E and hormone receptors (p > 0.05), except for Ki67, where a higher median was observed in recurrent tumors than in primary (p = 0.014). The larger the tumor, the more severe the peritumoral edema, and the greater the presence of calcifications. Ki67 appears to be a good biomarker of recurrence/regrowth in grade I meningiomas.

Tenth case of bilateral hemifacial spasm treated by microvascular decompression: Review of the pathophysiology.

BACKGROUND: Bilateral hemifacial spasm (BHFS) is a rare neurological syndrome whose diagnosis depends on excluding other facial dyskinesias. We present a case of BHFS along with a literature review. METHODS: A 64-year-old white, hypertense male reported involuntary left hemiface contractions in 2001 (aged 50). In 2007, right hemifacial symptoms appeared, without spasm remission during sleep. Botulinum toxin type A application produced partial temporary improvement. Left microvascular decompression (MVD) was performed in August 2013, followed by right MVD in May 2014, with excellent results. Follow-up in March 2016 showed complete cessation of spasms without medication. RESULTS: The literature confirms nine BHFS cases bilaterally treated by MVD, a definitive surgical option with minimal complications. Regarding HFS pathophysiology, ectopic firing and ephaptic transmissions originate in the root exit zone (REZ) of the facial nerve, due to neurovascular compression (NVC), orthodromically stimulate facial muscles and antidromically stimulate the facial nerve nucleus; this hyperexcitation continuously stimulates the facial muscles. These activated muscles can trigger somatosensory afferent skin nerve impulses and neuromuscular spindles from the trigeminal nerve, which, after transiting the Gasser ganglion and trigeminal nucleus, reach the somatosensory medial posterior ventral nucleus of the contralateral thalamus as well as the somatosensory cortical area of the face. Once activated, this area can stimulate the motor and supplementary motor areas (extrapyramidal and basal ganglia system), activating the motoneurons of the facial nerve nucleus and peripherally stimulating the facial muscles. CONCLUSIONS: We believe that bilateral MVD is the best approach in cases of BHFS.

[Central nervous system paracoccidioidomycosis: analysis of 13 cases]. / Paracoccidioidomicose do sistema nervoso central: análise de 13 casos.

Paracoccidioidomycosis (PCM) is a systemic granulomatous disease caused by Paracoccidioides brasiliensis, prevalent in Latin America, particularly in Brazil. Central nervous system (CNS) involvement occur in about 10% of cases. Thirteen patients with PCM involving CNS were studied considering clinical manifestation, neuroradiology and treatment modalities. Age ranged from 30 to 71 years-old (M=47.1+/-11.6 Me=46). There were eleven men and two women. The most frequent symptoms were motor deficits (53.8%), cognitive disturbance (53.8%), weight loss (46.1%), headaches (46.1%) and seizures (46.1%). The diagnosis was confirmed by the demonstration of P. brasiliensis. Granulomatous forms were present in all patients. Four (30.8%) of them had also meningeal involvement (mixed form). Computerized tomography (CT) scans were obtained in all cases and magnetic resonance imaging (MRI) was used in one case. Serology for HIV was done in ten patients (76.9%), and all the tests were negatives. Amphotericin B was used in twelve patients (92.3%), one of them by intraventricular infusion. In eight patients (61.5%), trimethopim and sulfamethoxazole were used, and, in two (15.4%), sulfadiazine and pirimetamine. Fluconazole, ketoconazole and itraconazole were each one used in a different patient as well. Six patients died (46.1%) and seven (53.9%) had satisfatory outcome. The follow-up period ranged from 2 to 74 (M=30.9) months. In conclusion, the CNS involvement in paracoccidioidomycosis is more frequent and more serious than thought before. The clinical manifestations, CT scans and MRI findings are not specific of paracoccidioidomycosis.

Profile of patients with brain tumors and the role of nursing care.

OBJECTIVE: to describe the profile of 200 patients with central nervous system tumors (CNST), and the role of the nursing care. METHOD: prospective, quantitative and descriptive analysis of medical records of 200 patients with TSNC. RESULTS: a total of 61% of our patients had benign CNST and 39% had malignant tumors. The extent of patient dependence, according to the Karnofsky Performance Status scale, was significantly greater for patients with malignant CNST (p < .05), indicating that these patients needed more support with their activities of daily living. CONCLUSION: patients with CNST need specialized care, with specific guidance regarding their disease and aspects of daily living after treatment. Thus, the nurse can function as a key element for the effectiveness of care provided to patients and family members with the aim of enhancing the quality of life of all those affected, directly or indirectly, by the disease.

Unilateral pterional approach to bilateral aneurysms of the middle cerebral artery.

BACKGROUND: The aim of the present study was to evaluate the technical viability of the unilateral pterional approach to simultaneously treat symmetrical bilateral aneurysm (mirror image) of the middle cerebral arteries (SBAMCA) and to determine the morbidity and mortality rates of this approach. METHODS: Forty-six patients with SBAMCA underwent unilateral pterional craniotomy within a period of 9 years. Most patients were women (24, 80.0%) and mean age was 40.7 years. RESULTS: Obliteration of the contralateral aneurysm was not possible in 16 patients (34.8%) because of brain edema in 8 patients operated on during the acute phase, lateral projection of the aneurysm in 3, a very long contralateral M1 segment in 4, and the presence of atheromatous plaques at the MCA bifurcation and aneurysm neck in 1. The remaining 30 patients (65.2%) were submitted to the proposed treatment. Final evaluation showed that 26 patients (86.7%) were Glasgow Outcome Scale (GOS) V, 1 patient (3.3%) was GOS IV, 2 patients (6.6%) were GOS III, and 1 patient (3.3%) was GOS I. CONCLUSIONS: The unilateral pterional surgical approach to treat SBAMCA is a technically viable procedure associated with low morbidity and mortality. However, it requires a neurosurgeon experienced in cerebral aneurysm surgery and the appropriate technical conditions.

Meningeal melanocytoma of the posterior fossa: case report and literature review.

BACKGROUND: Meningeal melanocytomas are rare primary melanotic tumors of the leptomeninges. According to our review of the literature, just 22 cases of meningeal melanocytoma (MM) of the posterior fossa have been previously reported. Some aspects related to diagnosis, radiological appearance, histopathologic features, and management are discussed in this paper. CASE DESCRIPTION: We describe the case of a 42-year-old female presenting with severe headache, nausea, and vomiting. Computed tomography and magnetic resonance imaging demonstrated a posterior fossa lesion that was surgically treated. Histopathologic examination showed a highly cellular melanocytic neoplasm with numerous dark pigments in the cytoplasm. Immunoperoxidase staining S-100 protein and HMB 45 demonstrated immunoreactivity for both, confirming the diagnosis of MM. CONCLUSIONS: In conclusion, MMs are rare histologically benign tumors that can be cured by complete surgical resection alone, which should be the goal of the treatment. These lesions, although rare, should be considered in the differential diagnosis of tumors of the posterior fossa.

E-learning for neurosurgeons: Getting the most from the new web tools.

As open access resource, the role of Internet has been increasing in our professional life. There are several emergent new tools that can facilitate and make it more efficient to get accurate and reliable information. In this article, we discuss how we can manage to get the most from these new instruments, like blogs, Facebook, Twitter, and LinkedIn, in order to improve clinical practice. With good sense and some caution, these can turn to be of valuable help in our careers.

[Cavernous malformations: surgical management in Belo Horizonte Santa Casa Hospital]. / Cavernomas: conduta no serviço de neurocirurgia da Santa Casa de Belo Horizonte.

The better understanding of the natural history of the cavernous malformations and the improvement of diagnostic methods and of microsurgical techniques have made the management of cavernous malformations possible through the conservative treatment, radiosurgery, and microsurgical resection. We present 33 cases operated at our service at Santa Casa Hospital, Belo Horizonte, from 1992 to 2001. Cortical and subcortical cavernomas manifested by epilepsy (57.5%) or mainly by hemorrhage (15.1%) were surgically approached. The deep lesions (basal ganglia, thalamus and brain steam) represented 27.7% of our cases. They should only be operated when located near the pial or ependimary surface. The resection of spinal cord lesions (5.5%) and of deep brain lesions is also recommended when they present progressive focal deficit (13.8%) or recurrent episodes of hemorrhage (13.8%). Small and deep seated cavernomas that do not present bleeding must be conservatively treated. There has been no evident favourable result related to radiosurgery so far.

Pituitary deficiency after aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Aneurysmal subarachnoid hemorrhage puts patients at high risk for the development of pituitary insufficiency. We evaluated the incidence of pituitary dysfunction in these patients and its correlation with clinical outcome. METHODS: Pituitary function was tested in 66 consecutive patients in the first 15 days after aneurysmal subarachnoid hemorrhage. The following were measured in all patients: thyroid-stimulating hormone, free thyroxine, triiodothyronine, luteinizing hormone, follicle-stimulating hormone, total testosterone (in males), estradiol (in females), prolactin, serum cortisol, plasma adrenocorticotropic hormone, growth hormone and insulin growth factor. RESULTS: The endocrine assessment was made at a mean of 7.4 days (standard deviation ±6.6) after subarachnoid hemorrhage. Forty-four (66.7%) female and 22 (33.3%) male patients were evaluated. Thirty-nine patients (59.1%) had some type of pituitary dysfunction. Follicle-stimulating hormone/luteinizing hormone deficiency was the most frequent disorder (34.8%), followed by growth hormone/insulin growth factor (28.7%), adrenocorticotropic hormone (18.1%) and thyroid-stimulating hormone (9%). Seventeen (25.7%) patients showed deficiencies in more than one axis. A greater incidence of hormone deficiency was observed in patients with a Glasgow Coma Scale score ≤13 (t test, p=0.008), Hunt-Hess grade ≥4 (t test, p<0.001), or Fisher grade 4 (t test, p=0.039). Hormone deficiency was not significantly associated (p>0.05) with increased hospitalization or clinical outcome. CONCLUSION: Pituitary dysfunction was identified in a substantial portion of patients with previous aneurysmal subarachnoid hemorrhage, but no association was found between this dysfunction and poor clinical outcome.

Importance of recognizing sentinel headache.

BACKGROUND: Sentinel headache (SH) is a kind of secondary headache and is characterized as sudden, intense, and persistent, preceding spontaneous subarachnoid hemorrhage (SAH) by days or weeks. METHODS: Eighty-nine consecutive patients with a diagnosis of spontaneous SAH were evaluated following admission to the Neurosurgical Service at Santa Casa Hospital, Belo Horizonte, between December 2009 and December 2010. RESULTS: Out of the 89 patients, 64 (71.9%) were women. Mean age was 48.9 years (SD ± 13.4, ranging from 18 to 85 years). Twenty-four patients (27.0%) presented SH, which occurred, in average, 10.6 days (SD ± 13.5) before a SAH. No statistically significant differences were observed between the presence of SH and gender, arterial hypertension and migraine (P > 0.05), Glasgow Comma Scale (GCS) and World Federation of Neurological Surgeons (WFNS) scale at admission. CONCLUSION: The prevalence of SH was 27% in this study but no related factors were identified. Therefore, further clarification of this important entity is required so as to facilitate its recognition in emergency services and improve the prognosis of patients with cerebral aneurysms.

Papillary tumor of the pineal region.

Tumors of the pineal region are rare in adulthood, accounting for approximately 1% of intracranial neoplasms in this age range. Papillary tumor of the pineal region (PTPR) was first described by Jouvet et al. in 2003. In 2007, PTPR was included by the World Health Organization as a distinct entity in their new classification of central nervous system tumors. We report a case of PTPR, and undertake a literature review of this rare neuroepithelial neoplasm. Patients with PTPR need long-term follow up, and new cases should be well documented so that we can gain a better understanding of this neoplasm.

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.

Profile of patients with brain tumors and the role of nursing care / Perfil dos pacientes com tumores cerebrais e o papel do enfermeiro / Perfil de pacientes con tumores cerebrales y el papel de la enfermería

ABSTRACT Objective: to describe the profile of 200 patients with central nervous system tumors (CNST), and the role of the nursing care. Method: prospective, quantitative and descriptive analysis of medical records of 200 patients with TSNC. Results: a total of 61% of our patients had benign CNST and 39% had malignant tumors. The extent of patient dependence, according to the Karnofsky Performance Status scale, was significantly greater for patients with malignant CNST (p < .05), indicating that these patients needed more support with their activities of daily living. Conclusion: patients with CNST need specialized care, with specific guidance regarding their disease and aspects of daily living after treatment. Thus, the nurse can function as a key element for the effectiveness of care provided to patients and family members with the aim of enhancing the quality of life of all those affected, directly or indirectly, by the disease.

RESUMO Objetivo: descrever o perfil de 200 pacientes com tumores no sistema nervoso central (TSNC) e o papel do cuidado em enfermagem. Método: análise prospectiva, quantitativa e descritiva de prontuários de 200 pacientes com TSNC. Resultados: 61% dos pacientes possuíam TSNC benignos e 39% tumores malignos. O grau de dependência do paciente de acordo com a Escala de Karnofsky foi significativamente maior para pacientes com tumores malignos (P <0,05), indicando que estes precisam de maior esforço e, consequentemente, apoio em suas atividades diárias. Conclusão: Pacientes com TSNC necessitam de cuidados especializados, com orientações específicas a respeito de sua doença e aos aspectos da sua vida diária após o tratamento. Assim, o enfermeiro pode ser um elemento-chave para a eficácia dos cuidados prestados aos pacientes e familiares com o objetivo de melhorar a qualidade de vida de todas as pessoas afetadas, direta ou indiretamente, pela doença.

RESUMEN Objetivo: describir el perfil de los 200 pacientes con tumores del sistema nervioso central (TSNC) y el papel de la enfermería. Método: análisis prospectivo, cuantitativo y descriptivo de los registros médicos de 200 pacientes con TSNC. Resultados: 61% de los pacientes tenían TSNC benignos y 39% tumores malignos. El grado de la dependencia de los pacientes según la Escala de Karnofsky fue significativamente mayor en los pacientes con tumores malignos (P <0,05), lo que indica que estos pacientes necesitan más apoyo en las actividades diarias. Conclusión: los pacientes con tumores cerebrales requieren atención especializada, con directrices específicas sobre su enfermedad y aspectos de la vida diaria después del tratamiento. Por lo tanto, los enfermeros pueden ser un elemento clave para la eficacia de la atención prestada a los pacientes y sus familias con el objetivo de mejorar la calidad de vida de las personas afectadas por la enfermedad.

Pituitary deficiency after aneurysmal subarachnoid hemorrhage

OBJECTIVE: Aneurysmal subarachnoid hemorrhage puts patients at high risk for the development of pituitary insufficiency. We evaluated the incidence of pituitary dysfunction in these patients and its correlation with clinical outcome. METHODS: Pituitary function was tested in 66 consecutive patients in the first 15 days after aneurysmal subarachnoid hemorrhage. The following were measured in all patients: thyroid-stimulating hormone, free thyroxine, triiodothyronine, luteinizing hormone, follicle-stimulating hormone, total testosterone (in males), estradiol (in females), prolactin, serum cortisol, plasma adrenocorticotropic hormone, growth hormone and insulin growth factor. RESULTS: The endocrine assessment was made at a mean of 7.4 days (standard deviation ±6.6) after subarachnoid hemorrhage. Forty-four (66.7%) female and 22 (33.3%) male patients were evaluated. Thirty-nine patients (59.1%) had some type of pituitary dysfunction. Follicle-stimulating hormone/luteinizing hormone deficiency was the most frequent disorder (34.8%), followed by growth hormone/insulin growth factor (28.7%), adrenocorticotropic hormone (18.1%) and thyroid-stimulating hormone (9%). Seventeen (25.7%) patients showed deficiencies in more than one axis. A greater incidence of hormone deficiency was observed in patients with a Glasgow Coma Scale score ≤13 (t test, p = 0.008), Hunt-Hess grade ≥4 (t test, p<0.001), or Fisher grade 4 (t test, p = 0.039). Hormone deficiency was not significantly associated (p>0.05) with increased hospitalization or clinical outcome. CONCLUSION: Pituitary dysfunction was identified in a substantial portion of patients with previous aneurysmal subarachnoid hemorrhage, but no association was found between this dysfunction and poor clinical outcome. .

Paracoccidioidomicose do sistema nervoso central: análise de 13 casos / Central nervous system paracoccidioidomycosis: analysis os 13 cases

A paracoccidioidomicose (PCM) é infecção granulomatosa sistêmica, causada pelo fungo Paracoccidioides brasiliensis, prevalente na América Latina, particularmente no Brasil. Acomete o sistema nervoso central (SNC) em 10 por cento dos casos. Foram estudados 13 pacientes com paracoccidioidomicose no SNC, entre 1991 e 2001, com ênfase para os aspectos clínicos, neuroradiológicos e terapêuticos. Onze pacientes eram do sexo masculino (84,6 por cento) e dois do feminino (15,4 por cento), com idade entre 30 e 71 anos (M= 47,1 ± 11,6 Me= 46). Os sintomas mais freqüentes foram déficits motores (53,8 por cento), alterações cognitivas (53,8 por cento), emagrecimento (46,1 por cento), cefaléia (46,1 por cento) e crises convulsivas (46,1 por cento). O diagnóstico foi confirmado pela detecção do P. brasiliensis no SNC. Todos os pacientes apresentavam a forma granulomatosa e quatro (30,8 por cento) tinham a forma meningoencefalítica associada. Todos foram estudados com tomografia computadorizada (TC) de crânio e um caso com ressonância magnética (RM) encefálica. Dez pacientes (76,9 por cento) realizaram sorologia para o HIV, todos com resultados negativos. A anfotericina B foi utilizada em 12 casos (92,3 por cento), em um deles por via intratecal. Em oito casos (61,5 por cento) o sulfametoxazol-trimetropim foi utilizado; em dois (15,4 por cento) a sulfadiazina e pirimetamina, e o fluconazol, cetoconazol e itraconazol, cada um deles em um paciente. Seis pacientes (46,1 por cento) morreram e sete evoluíram satisfatoriamente. O tempo de seguimento variou de 2 a 74 meses (M=30,9). Conclui-se que as manifestações clínicas assim como os exames de imagem na PCM do SNC são inespecíficos.