Arnolfo de Carvalho Neto

Glioblastoma multiforme of the pineal region: case report

PURPOSE pineal region tumors are uncommon, and comprise more frequently three categories: germ cell, parenchymal cell and glial tumors. Most pineal gliomas are low-grade astrocytomas. Glioblastoma multiforme, the most aggressive and common brain tumor, is extremely rare at this location with only few cases reported. CASE DESCRIPTION a 29-year-old woman with a two month history of headache, nuchal pain, fever, nausea and seizures and physical examination showing nuchal rigidity, generalized hypotony, hypotrophy and hyper-reflexia, Babinski sign and left VI cranial par palsy. CT scan examination revealed a ill-defined hypodense lesion at the pineal region with heterogeneous contrast enhancement. MRI showed a lesion at the pineal region infiltrating the right thalamic region. The patient underwent a right craniotomy with partial resection of the mass. The histological examination of paraffin-embedded material defined the diagnosis of glioblastoma multiforme. Post-operative radiotherapy was indicated but the patient refused the treatment and died two months afterwards. CONCLUSION in spite of its rarity at this location, glioblastoma multiforme should be considered in the differential diagnosis of aggressive lesions at the pineal region.

Septo-optic dysplasia plus: case report

Septo-optic dysplasia (SOD) is a syndrome composed by optic nerve and septum pellucidum dysgenesis. It has been classified into two subsets according to the embryogenesis and the neuropathological findings. Basically, the difference between these two groups is the presence or not of schizencephaly. The term SOD-Plus was recently proposed to describe SOD associated with cortical dysplasia. We report a 6-month-old female patient who presented absent visual fixation since 4 months of age and delayed psychomotor development. Neurological examination demonstrated spastic left hemiparesis and ophtalmological evaluation revealed bilateral optic disc hypoplasia. The head computed tomography (CT) scan showed absence of the septum pellucidum, ventricular asymmetry and schizencephaly. The magnetic resonance imaging (MRI) showed complete absence of the septum pellucidum associated to optic nerves and chiasma atrophy, schizencephaly and cortical dysplasia. The patient underwent an evoked potential examination with flash stimulation, which revealed bilateral absence of cortical evoked potential. She was referred to visual stimulation and physiotherapy. We emphasize the neuroimaging of this syndrome and stress the importance of the clinical investigation for patients with septum pellucidum dysgenesis on MRI or CT scans.

Observer agreement of spine stenosis on magnetic resonance imaging analysis of patients with cervical spine myelopathy.

OBJECTIVES The purpose of this study was to measure the intraobserver and interobserver reliability of magnetic resonance detection of cervical spondylotic myelopathy with and without operational guidelines. METHODS Seven radiologists examined images from 10 patients with cord signal abnormalities and clinical signs of myelopathy. Radiologist examined films twice, with and without operational guidelines designed to define stenotic changes, while blinded to the clinical findings of the patients. Analyses included a Fleiss kappa assessment of intraobserver and interobserver reliability. RESULTS Results demonstrated high percentage of agreement and strong intraobserver reliability and variable Fleiss kappa values for interobserver assessment. Operational guidelines did not improve the intraobserver or interobserver agreement. CONCLUSION Although the percentage of agreement was high in some cases, the kappa agreement was low-most likely a result of the base rate problem of a kappa analysis. Sample bias toward severe degenerative changes resulted in highly prevalent selections and kappa adjusted values. Nonetheless, the results do suggest that substantial intraobserver kappa agreement and a wide range of interobserver kappa agreement exists among trained radiologists during detection of stenotic changes associated with cervical spondylotic myelopathy.

Adult cerebellar medulloblastoma: CT and MRI findings in eight cases

Medulloblastoma is a brain tumor of neuroepithelial origin, which represents 15 to 30% of all pediatric brain tumors, and less than 1% of CNS adult neoplasms. We report the imaging findings of 8 adult patients with medulloblastoma. The mean age was 35 years, ranging from 20 to 65 years, and the male:female rate was 3:5. The tumors were predominantly lateral (63%), hyperdense on CT scans (83%), and on the MRI, hypointense on T1 (100%) and hyperintense on T2 (80%) weighted images. It was seen intratumoral necrosis and cysts in six cases and calcifications in three. Hydrocephalus was observed in 5 cases and brain stem invasion in four. The imaging findings of medulloblastomas in adults are different of those in child, and also nonspecific. Although these tumors are uncommon in adults, they must be considered in the differential diagnosis of cerebellar masses in the posterior fossa of this age group.

Aneurisma de artéria cerebral em criança com síndrome da imunodeficiência adquirida: relato de caso

Cerebral aneurysmal arteriopathy of the circle of Willis is an uncommon manifestation of acquired human immunodeficiency virus (HIV) infection and up to now only 15 cases have been published in the literature. For this reason we add our experience of this rare case, and review the most important aspects related to this entity. The patient is a 6 year old male with perinatal transmitted AIDS, tetraparethic, developed symptoms characterized by episodes of dystonic postures. The computed tomography of the brain showed aneurismal arteriopathy of the circle of Willis. He had a previous normal examination. The review of the literature shows the pathological abnormalities of the affected vessels are mainly medial fibrosis, with destruction of the internal elastic lamina and intimal hyperplasia. The etiology for the vasculitis is unknown. Varicela zoster virus, as well as HIV by itself, can be related to the physiopathology of the vasculitis. On conclusion, it can be said that although uncommon, such complications are of great importance by the fact that the patients with vascular aneurismal arteriopathy are in high risk for vascular accidents, and once a diagnosis was made, death occurs in less than 6 months, according to the literature.

Neurocysticercosis: a clinical and pathological study of 27 necropsied cases

Neurocysticercosis is the most frequent and widespread neuroparasitosis of the human being. The development of brain and leptomeningeal lesions, with subsequent symptoms, are mainly related with the immune status of the host, and to the number and evolutional phase of the parasites. We present the pathological findings in 27 necropsies of patients with neurocysticercosis, which accounted for 3.1% of the necropsies. 77% of the patients were male and the age ranged from 18 to 85 years. In 26% there was previous history of alcoholism. Clinicopathological study showed that 50% of the cases were classified as asymptomatic form, 11% epileptic form, 11% intraventricular form and 11% combined form. 33% of the patients presented seizures as a factor of aggravation of the clinical picture. There was a single cysticercus in 60% of the cases, the cellulosae form present in 82% and the racemous form in 7% of the cases; the remaining 11% had both forms present. In 30% of the patients the cause of death was directly related with the presence of the cysticercus in the central nervous system. Our findings confirm the high morbidity of this disease.

Histoplasmoma como lesão isolada do sistema nervoso central em paciente imunocompetente

The cerebral lesions are uncommon in patients with histoplasmosis, occurring more frequently in the disseminated form of the disease. Rarely, the disease may present as a histoplasmoma, simulating a neoplastic lesion. The histoplasmoma as the only manifestation of this infection in immunocompetent patients is even rarer. This case report describes a 13 year-old male patient with headache, vomit, low visual acuity and auditive deficit on the left, and paresis on the right. The magnetic resonance image showed an expansible lesion in the thalamic, hypothalamic, and chiasmatic regions, which showed ring enhancement. The stereotactic biopsy was performed and the histological diagnosis of histoplasmosis was defined. The treatment was initiated with fluconazole. The patient showed important clinical improvement after 6 months.

Disseminated tuberculosis in a pregnant woman presenting with numerous brain tuberculomas: case report

Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis, which has the pulmonary form as the most common presentation. Dissemination of the disease is common in immunocompromised patients, but immunodeficiency related to pregnancy severe enough to cause dissemination of the Mycobacteria is exceedingly rare. When dissemination occurs, any organ may be affected and in central nervous system, the infection presents as meningitis and single brain parenchyma tuberculomas. We report the case of a 17 year-old woman at the 34th week of pregnancy with respiratory and high intracranial pressure symptoms. On the day before admission she had a sudden onset of paraparesis and urinary retention and ten hours after the delivery she presented with paraplegia. The chest X-ray and CT scan were compatible with miliary tuberculosis. The cranial CT scan revealed numerous rounded hypodense lesions located at cerebral and cerebellar hemispheres, which presented ring-like enhancement after contrast injection. The patient underwent a craniotomy with biopsy of the lesions confirming the diagnosis of brain tuberculomas. The three-drug regimen was started and the cranial CT scan performed a year after diagnosis showed no brain lesions. We emphasize the aggressive dissemination of the disease in this case associated with pregnancy and the importance of early diagnosis and institution of therapy resulting in regression of the lesions.

Subependymal giant cell astrocytoma with high choline/creatine ratio on proton MR spectroscopy

OBJECTIVE To report a case of subependymal giant cell astrocytoma (SEGA) in a patient with tuberous sclerosis, emphasizing the proton MR spectroscopy (MRS) findings. CASE A three year-old boy with tuberous sclerosis presented with a 3-month history of mild headache. The physical examination showed discrete mental retardation and multiple hypomelanic macules in the legs and back. MRI showed many cortical tubers and subependymal nodules. At the left foramen of Monro, there was a 15 mm nodule, with heterogeneous signal on T1 and T2-weighted images, and strong enhancement after contrast administration. MRS study (multi-voxel PRESS, TE=144ms) showed the following ratios: a) left foramen of Monro nodule N-acetylaspartate (NAA)/creatine (Cr)=0.93 and Choline (Cho)/Cr=1.6 and b) at the right Monro foramen NAA/Cr=1.56 and Cho/Cr=1.29. CONCLUSION The MRS performed at the SEGA may show high Cho/Cr and low NAA/Cr ratios, similar to the other brain neoplasms. As a consequence, MRS may be a valuable tool for the early detection of neoplastic transformation of subependymal nodules near the foramina of Monro in patients with tuberous sclerosis.

Adrenoleucodistrofia ligada ao X: correlação entre o escore de Loes e parâmetros do tensor de difusão

Objective The present study was aimed at evaluating the correlation between diffusion tensor imaging parameters and Loes score as well as whether those parameters could indicate early structural alterations. Materials and Methods Diffusion tensor imaging measurements were obtained in 30 studies of 14 patients with X-linked adrenoleukodystrophy and were correlated with Loes scores. A control group including 28 male patients was created to establish agematched diffusion tensor imaging measurements. Inter- and intraobserver statistical analyses were undertaken. Results Diffusion tensor imaging measurements presented strong Pearson correlation coefficients (r) of –0.86, 0.89, 0.89 and 0.84 for fractional anisotropy and mean, radial and axial diffusivities (p < 0.01). Analysis of changes in diffusion tensor measurements at early stage of the disease indicates that mean and radial diffusivities might be useful to predict the disease progression. Conclusion Measurements of diffusion tensor parameters can be used as an adjunct to the Loes score, aiding in the monitoring of the disease and alerting for possible Loes score progression in the range of interest for therapeutic decisions.Objective: The present study was aimed at evaluating the correlation between diffusion tensor imaging parameters and Loes score as well as whether those parameters could indicate early structural alterations. Materials and Methods: Diffusion tensor imaging measurements were obtained in 30 studies of 14 patients with X-linked adrenoleukodystrophy and were correlated with Loes scores. A control group including 28 male patients was created to establish agematched diffusion tensor imaging measurements. Inter- and intraobserver statistical analyses were undertaken. Results: Diffusion tensor imaging measurements presented strong Pearson correlation coefficients (r) of –0.86, 0.89, 0.89 and 0.84 for fractional anisotropy and mean, radial and axial diffusivities (p < 0.01). Analysis of changes in diffusion tensor measurements at early stage of the disease indicates that mean and radial diffusivities might be useful to predict the disease progression. Conclusion: Measurements of diffusion tensor parameters can be used as an adjunct to the Loes score, aiding in the monitoring of the disease and alerting for possible Loes score progression in the range of interest for therapeutic decisions.