Apio Cláudio Martins Antunes

Cerebral trypanosomiasis and AIDS

UNLABELLED A 36 year-old black female, complaining of headache of one months duration presented with nausea, vomiting, somnolence, short memory problems, loss of weight, and no fever history. Smoker, intravenous drugs abuser, promiscuous lifestyle. PHYSICAL EXAMINATION left homonimous hemianopsia, left hemiparesis, no papilledema, diffuse hyperreflexia, slowness of movements. Brain CT scan: tumor-like lesion in the splenium of the corpus calosum, measuring 3.5 x 1.4 cm, with heterogeneous enhancing pattern, suggesting a primary CNS tumor. Due to the possibility of CNS infection, a lumbar puncture disclosed an opening pressure of 380 mmH(2)0; 11 white cells (lymphocytes); glucose 18 mg/dl (serum glucose 73 mg/dl); proteins 139 mg/dl; presence of Trypanosoma parasites. Serum Elisa-HIV tests turned out to be positive. Treatment with benznidazole dramatically improved clinical and radiographic picture, but the patient died 6 weeks later because of respiratory failure. T. cruzi infection of the CNS is a rare disease, but we have an increasing number of cases in HIV immunocompromised patients. Diagnosis by direct observation of CSF is uncommon, and most of the cases are diagnosed by pathological examination. It is a highly lethal disease, even when properly diagnosed and treated. This article intends to include cerebral trypanosomiasis in the differential diagnosis of intracranial space-occupying lesions, especially in immunocompromised patients from endemic regions.

Melanotic neuroectodermal tumor of infancy: case report

INTRODUCTION Melanotic neuroectodermal tumor of infancy (MNTI) is a rare tumor, locally aggressive, usually originated from maxilla and mandible and rarely from the skull. A case of a 4 month-old child presenting a bulging lesion in the midline of the occipitoparietal region with progressive growth is reported. CASE REPORT The neurologic examination had normal developmental milestones. Computerized tomography scan and magnetic resonance Image showed a highly enhancing tumor, dislocating anteriorly and inferiorly the superior sinuses. In order to prevent excessive bleeding, surgical resection was performed in three stages, with complete removal. CONCLUSION Based on the absence of tumor recurrence, we believe in a favorable neurological prognosis and in a possible of cure, although the patient was not submitted to any adjuvant treatment.

Brainstem cavernomas: a surgical challenge

OBJECTIVE The authors show their experience with brainstem cavernomas, comparing their data with the ones of a literature review. METHODS From 1998 to 2009, 13 patients harboring brainstem cavernomas underwent surgical resection. All plain films, medical records and images were reviewed in order to sample the most important data regarding epidemiology, clinical picture, radiological findings and surgical outcomes, as well as main complications. RESULTS The mean age was 42.4 years (ranging from 19 to 70). No predominant gender: male-to-female ratio, 6:7. Pontine cases were more frequent. Magnetic resonance imaging was used as the imaging method to diagnose cavernomas in all cases. The mean follow-up was 71.3 months (range of 1 to 138 months). Clinical presentation was a single cranial nerve deficit, VIII paresis, tinnitus and hearing loss (69.2%). All 13 patients underwent resection of the symptomatic brainstem cavernoma. Complete removal was accomplished in 11 patients. Morbidity and mortality were 15.3 and 7.6%, respectively. CONCLUSIONS Cavernomas can be resected safely with optimal surgical approach (feasible entry zone) and microsurgical techniques, and the goal is to remove all lesions with no cranial nerves impairment.

Hemorragias em metastases intracranianas de melanoma: registro de dois casos

Two cases of intra-cerebral haemorrhage secondary to malignant melanoma metastasis are reported. When dealing with subarachoid haemorrhages, one should think of brain secondaries and a biopsy should always be performed whenever a spontaneous intra-cerebral hematoma is found.Sao relatados dois casos de metastases cerebrais de melanoma maligno cuja manifestacao clinica foi de hemorragia cerebro-meningea. E feita a revisao da literatura pertinente, enfatizando-se a importância da inclusao das metastases no diagnostico diferencial das hemorragias cerebrais e da realizacao de biopsia da parede de hematomas intra-cerebrais espontâneos.

Extradural cavernous hemangioma of thoracic spine

disconnection of intracranial pial single-channel arteriovenous fistulae. Neurosurgery 2001;49:1351-1363.4. Nelson K, Nimi Y, Lasjaunias P, et al. Endovascular embolization of con -genital intracranial pial arteriovenous fistulas. Neuroimaging Clin N Am 1992;2:309-317.5. Lasjaunias P, Ter Brugge KG, Berenstein A. Cerebral arteriovenous fis -tulas. In: Heilmann U (Ed). Surgical Neuroangiography 3. 2

Anatomia microcirúrgica da artéria carótida externa: um estudo estereoscópico

CONTEXTO: O conhecimento das estruturas anatomicas da arteria carotida externa por meio do estudo estereoscopico pode determinar melhores resultados em microcirurgias da arteria carotida externa. OBJETIVO: Descrever as estruturas da arteria carotida externa sob a visao estereoscopica, identificando seus multiplos aspectos. METODOS: Doze regioes cervicais foram dissecadas, utilizando-se microscopico cirurgico com 3 a 40x de aumento. As disseccoes anatomicas foram documentadas utilizando-se a tecnica para obtencao de imagens tridimensionais (3D), objetivando a producao de impressoes estereoscopicas. RESULTADOS: O uso da tecnica estereoscopica possibilitou a abordagem da circulacao arterial extracraniana, sendo realizados estudos cirurgicos do tipo combinado fossa posterior e fossa infratemporal, tornando as microcirurgias e os procedimentos neurocirurgicos vasculares mais precisos. CONCLUSAO: O uso das imagens obtidas pela tecnica estereoscopica produziu um resultado mais assertivo em relacao ao estudo da anatomia para a microcirurgia e procedimentos neurocirurgicos, facilitando melhor aprendizado previamente a realizacao de procedimentos complexos em neurocirurgia.

Prospective factors of temporary arterial occlusion during anterior communicating artery aneurysm repair.

INTRODUCTION This study was undertaken to determine variables that could predict, in the perioperative period of anterior communicating artery (ACom) aneurysms surgeries, the likelihood of postoperative sequelae and complications, after temporary arterial occlusion (TAO). PATIENTS AND METHODS In a universe of 32 patients submitted to ACom aneurysm repair in the last 7 years, 21 needed TAO intraoperatively, and had their data examined retrospectively. RESULTS Aneurysms larger than 7 mm were more likely to be treated with longer TAO time than small aneurysms, (p < 0.0001). There was no statistical correlation between time of occlusion and outcome. Age, Glasgow Coma Scale at initial evaluation, and Fisher scale at first CT scanning were independent factors of unfavorable outcome (p < 0.001). Meanwhile gender, tobacco addiction, obesity, arterial hypertension, dyslipidemia, location of TAO (A1 or A2), intraoperative rupture (IR) and the aneurysm size were not identified as independent prognostic factors.During follow-up period, two thirds of the patients had a favorable outcome, accomplishing normal daily life activities without major complications. Most patients developed clinical vasospasm (66.6 %), with 19 % of the patients harboring a severe disease. Delayed ischemic neurological deficit was observed in 28.5 %, without any statistical correlation to time of TAO or IR. CONCLUSION TAO during ACom aneurysm repair does not seem to add more morbidities to the procedure, and is not an independent prognostic factor.

Paracoccidioidomycosis simulating brain tumor.

Background: Paracoccidioidomycosis (PCM) is a systemic granulomatous disease caused by Paracoccidioides brasiliensis. Involvement of the central nervous system (CNS) occurs in about 10% of cases. Case Description: A 57-year-old white man presented with the complaint of headache and an episode of focal seizure 1 month earlier. Magnetic resonance imaging (MRI) revealed a ring-enhancing lesion in the right parietal lobe with peri-lesional vasogenic edema suggestive of a primary neoplasm. The patient underwent craniotomy and the intraoperative finding was a yellowish, hard lesion with thick content and yellow inside. Anatomo-pathological findings were pathognomonic of PCM: large, thick-walled, spherical yeast cells with multiple peripheral buds. The patient tested negative for human immunodeficiency virus (HIV). Encephalitis and meningitis were ruled out by cerebrospinal fluid analysis. Culture confirmed the diagnosis of PCM and the patient was treated with amphotericin B. The patient responded well to treatment with resolution of the headache and clinical improvement, despite a bitemporal hemianopia. He was clinically stable and then discharged in good general condition. Conclusions: Radiographic findings of PCM with CNS involvement may suggest neoplasia, making diagnosis difficult. In endemic areas, the diagnosis of PCM should be promptly considered when a ring-enhancing mass associated with peri-lesional edema is observed on MRI.

Mucoceles gigantes: visão neurocirúrgica. Relato de dois casos

Two patients harboring giant frontal mucoceles are reported. In both cases complaints of chronic headaches and progressive unilateral proptosis were preponderant. Surgical treatment included a frontal craniotomy with excision of the lesion, skull base reinforcement with pedicled galea and wide opening of the frontal sinuses. In the second case an intranasal endoscopic approach was combined with craniotomy at the same surgical operative time. Some aspects regarding etiology, association with other diseases and some surgical aspects are discussed.

Intracranial extra-axial hemangioma in a newborn: A case report and literature review.

Background: Congenital hemangiomas are benign vascular tumors, and the intracranial counterpart was described in very few cases. Case Description: A newborn presented with an intracranial tumor associated with an arachnoid cyst, diagnosed by antenatal ultrasound at 37 weeks of gestation. Surgery was indicated due to increased head circumference and bulging fontanelle, and a complete resection of an extra-axial red–brown tumor was performed at the 3rd week of life. Microscopy revealed a hemangioma. Conclusion: Hemangioma is a rare differential diagnosis that must be considered in extra-axial intracranial tumors affecting infants and neonates. The radiological features are not helpful in differentiating from other tumors, and surgery is indicated when the diagnosis is uncertain or whenever there are signs of increased intracranial pressure.