Alexandre Varella Giannetti

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.

Fourth ventriculostomy: an alternative treatment for hydrocephalus due to atresia of the Magendie and Luschka foramina

Atresia of the foramina of Magendie and Luschka is a rare cause of obstructive hydrocephalus. Although this condition has been classically treated by CSF shunting, recent treatments have also included endoscopic third ventriculostomy. In the present study, the authors present the case of a patient with hydrocephalus in whom an alternative method was used following a CSF shunt malfunction. A young female patient in whom a shunt was placed during the patients 1st year of life was faring well until she was 8 years old. She was admitted to the emergency department 5 times with signs of CSF shunt malfunction. Each time, the CT scan showed a slight dilation of the lateral and third ventricles and a large increase in the size of the fourth ventricle. In comparison, ventricles were smaller in a previous imaging study obtained when the patient was asymptomatic. Magnetic resonance imaging showed the same slight dilation of all the ventricles and a significant increase in the fourth ventricle. There was no aqueductal stenosis. An important enlargement of both lateral recesses of the fourth ventricle suggested the possibility of an atresia of the foramina. The foramen of Monro and the width of the third ventricle would not allow the passage of an endoscope. The decision was made to open those foramina endoscopically through the fourth ventricle. After induction of general anesthesia, with the patient in the prone position, a bur hole was made in the left paramedian and suboccipital region. The endoscope was introduced underneath the cerebellar hemisphere. The authors were then able to distinguish the floor of the fourth ventricle and other anatomical landmarks. Navigation through the lateral recesses allowed them to see the fine membranes closing the foramina. These membranes were opened with a monopolar cautery as a blunt instrument. The orifice was then enlarged with a 3 Fr Fogarty catheter. The authors also opened a bulging thin membrane located at the foramen of Magendie. During the postoperative period, the authors observed a marked improvement in the state of the patients alertness as well as a disappearance of her headaches and cessation of vomiting. In addition, the patients gait ataxia improved slowly. Six-month postoperative MR imaging demonstrated an unequivocal reduction in the size of the fourth ventricle. The patient was still doing well 36 months after the surgery. Endoscopic fourth ventriculostomy, the opening of the 3 foramina of the fourth ventricle, may be an alternative treatment in cases in which these structures are congenitally closed.

Neuroendoscopic biopsy of brain lesions: accuracy and complications.

OBJECT The authors conducted a study to analyze the accuracy of neuroendoscopic biopsies of ventricular and periventricular lesions and record any difficulties or complications of the neuroendoscopic biopsy procedure. METHODS A total of 50 patients with different diseases consecutively underwent endoscopic biopsy procedures. The biopsy result was considered diagnostic if the pathologist reported any specific finding on which clinicians could base decisions about treatment or observation. The biopsy result was referred to as accurate if the results matched results of a sample obtained later or if the treatment response and disease evolution were compatible with the diagnosis. The biopsy result was considered inaccurate if results showed any relevant differences from those of the later sample or if the patients disease did not evolve as expected. Complications were recorded and compared with those found in a literature review. RESULTS For 2 patients, the procedure had to be terminated. The biopsy diagnostic rate was 89.6%, and the accuracy rate was 86%. Complications associated with the procedure were 3 hemorrhages (6%), 2 infections (4%), and 1 death (2%); no reoperations were needed. CONCLUSIONS Endoscopic biopsy seems to be an accurate procedure with acceptable morbidity and mortality rates.

Comparative Study Between Primary Spontaneous Cerebrospinal Fluid Fistula and Late Traumatic Fistula

Objective. To compare primary spontaneous cerebrospinal fluid fistula (PSF) and late traumatic fistula (LTF). Study Design. Historical cohort study. Setting. Academic medical center. Subjects and Methods. There were 26 patients with PSF in group 1 and 23 patients with LTF in group 2. Gender, age, location of the osteomeningeal breach, time between symptom onset and surgical treatment, number of episodes of meningitis, and density of the incidence of meningitis were compared. Two factors related to chance of curing the fistula were analyzed: etiological type and fistula location. Results. In group 1, 92% of patients were women (mean age 50 years). In group 2, 74% were men (mean age 22 years). PSF predominated in the sphenoid sinus (60%), whereas LTF occurred mainly in the ethmoidal (33%) and frontal (28%) sinuses. Time between presentation and surgical treatment was 28.9 ± 50.2 and 12.4 ± 15.5 months in groups 1 and 2, respectively (P = .166). There were 0.6 and 1.3 episodes of meningitis per patient in groups 1 and 2, respectively (P = .038). Density of the incidence of meningitis was 0.1 and 0.2 events per patient-month, respectively (P = .016). The 4 not-cured patients had sphenoid lesions and were from the PSF group. Conclusions. Female sex, middle age, and sphenoidal fistula were prevalent in patients with PSF. Patients with LTF were twice as likely to develop meningitis, and male sex, young age, and leaks through the frontal and ethmoidal region were more common in this case. Osteomeningeal breach located in the sphenoid sinus had a lower chance of sealing.

Ventriculitis: a rare case of primary cerebral toxoplasmosis in AIDS patient and literature review.

Cerebral toxoplasmosis remains the most important neurological opportunistic infection and the most common cause of intracerebral mass lesion in patients with acquired immunodeficiency syndrome (AIDS). We report a case of an adult AIDS patient with an atypical pattern of toxoplasma encephalitis, presenting with ventriculitis and obstructive hydrocephalus without any focal parenchymal lesion.

Clinical and Molecular Characterization of Mcardle’s Disease in Brazilian Patients

McArdle’s disease, a glycogen storage disease type V, is caused by a deficiency of the enzyme myophosphorylase, encoded by the PYGM gene. Worldwide distribution of mutations has revealed interesting data about the prevalence of mutations and population migrations. Currently, more than 100 mutations in the PYGM gene have been described, with some recurrent mutations in the different populations. However, no molecular studies of McArdle’s disease were reported in Brazilian patients. Here, we describe the clinical phenotype and genotype of 10 patients from 8 unrelated Brazilian families. Among the 10 patients (3 females, 7 males), eight presented with the typical phenotype, with exercise intolerance, cramps, and myalgia; one patient showed permanent muscle weakness; and one patient showed a mild phenotype. Molecular analysis identified 5 different mutations in the 8 families, both in homozygosis or compound heterozygosis state. Four of them had already been described (p.R50X, p.T692kfs30, p.K609K, and p.G455R), and one, pI513V, is a novel heterozygous mutation. The common nonsense p.R50X mutation was found in 6 of the 8 families, being therefore the commonest mutation in the Brazilian population as well. Other mutations previously reported in European patients were also found in the patients in this study, which was expected considering the European ancestry of the Brazilian population.

Extensa falha cutânea e craniana em paciente com aplasia cutis congenita

Aplasia cutis congenita is a rare condition characterized by the absence of skin layers. It is most common on the scalp, middle line, and it can be seen as a congenital ulcer involving periosteum, skull and dura. We present the case of a female newborn infant with a dysmorphic facies, a large scalp and skull defect exposing the dura. There was no cerebrospinal fluid leakage. The rarity of cases with large defects and small series reported make difficult to determinate the ideal treatment for aplasia cutis congenita. More studies are necessary to define the etiology and best management of this patients.

Endoscope-controlled microneurosurgery to treat middle fossa epidermoid cysts: technical case report.

OBJECTIVE To present an alternative technique of endoscope-controlled microneurosurgery for the treatment of middle fossa epidermoid cysts. METHODS The three operations described were performed through an approximately 2-cm diameter temporal craniotomy after a straight skin incision was made. Resection was then performed under the magnification of a 30-degree rigid endoscope, which mandated the use of exclusively conventional microsurgical instruments. RESULTS Total resection was accomplished in all three patients with large middle fossa epidermoid cysts through a small temporal corticectomy, without damage to neurovascular structures. CONCLUSION This procedure allowed the association of a smaller craniotomy, better cosmetic results, and minor retraction of the brain to wide resection of the tumor and satisfactory functional outcomes.

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.

Purely neuroendoscopic resection of an intraventricular cavernous angioma: case report.

BACKGROUND Intraventricular cavernomas are rare and generally treated by microsurgical approach. With the advances in neuroendoscopy, intraventricular lesions have been managed by this technique. However, tumor size and vascular nature are considered restrictive factors. As far as we are concerned, there are two cases in the literature of intraventricular cavernoma resection done by neuroendoscopy. CASE We describe a case of a man who presented with hydrocephalus secondary to a mesencephalic cavernoma and a second cavernous angioma located at the dorsum thalamus. This second lesion was successfully removed using a pure neuroendoscopic technique at the same time as a third ventriculostomy was performed. CONCLUSION As neuroendoscopy evolves, we see that lesions considered impossible to be managed by neuroendoscopy before today are being treated with the advantages that the minimally invasive surgery offers.