Atos Alves de Sousa

Distal anterior cerebral artery aneurysms

BACKGROUND The incidence of saccular aneurysms in the distal anterior cerebral artery (DACA aneurysms), also called pericallosal or A2 aneurysms, has been estimated to be from 1.5 to 9.0% of all intracranial aneurysms in large series in the literature [5,10,12,18]. All reported series of DACA aneurysms have shown a high association with intracranial aneurysms in other locations. These aneurysms are fragile, frequently rupture prematurely during exposure, and have a higher morbidity than expected from their angiographic appearance and location. METHODS A total of 1,350 patients with cerebral aneurysms were operated in the Department of Neurosurgery at Santa Casa Hospital in Belo Horizonte from January 1982 to January 1998. Seventy-two of those 1,350 patients had DACA aneurysms (5.3%), 51 female and 21 male. The age ranged from 26 to 69 years, the mean age being 44 years. This group of patients is reported herein. We propose three different approaches to DACA aneurysms depending on their location, all of them performed through a unilateral triangular bone flap that can then vary from fronto-basal to parietal. RESULTS There was no mortality among patients with a single DACA aneurysm. Five deaths in this series were cases of multiple aneurysms. In patients with preoperative Hunt and Kosnick grades I and II [9], we had 90% good results. In grade III patients, we achieved 68.4% good results. The only grade IV patient had a full recovery. All 74 DACA aneurysms in the 72 operated patients were completely clipped, including two giant aneurysms. CONCLUSION DACA aneurysms have higher morbidity and mortality rates when compared to other supratentorial aneurysms. We recommend the use of a unilateral interhemispheric approach as the most appropriate for aneurysms in this location. In cases of patients with multiple aneurysms who require two different craniotomies, we propose two surgical stages, starting with the aneurysm that has bled. A high mortality rate was noted when two craniotomies were performed in the same sitting.

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.

Congenital inclusion cysts of the anterior fontanelle.

BACKGROUND Congenital inclusion cysts of the anterior fontanelle are rare lesions. Both dermoid and epidermoid cysts are located in the midline of the scalp and occupy the subgaleal space. METHODS We report 7 cases, 4 boys (57.1%), and 3 girls (42.9%), with ages ranging from 3 months to 16 years (mean 40.85 +/- 68.56 months; median 10 months). Four patients (57.1%) were white and 3 (42.9%) were Afro-Brazilian. RESULTS The cysts had manifested soon after birth in all patients. They gradually enlarged, with no intracranial extensions. Four patients had dermoid cysts and the others had epidermoid cysts. All of them underwent surgery with complete excision of the cyst and no capsular rupture. There were no complications and no deaths. CONCLUSIONS Congenital inclusion cysts of the anterior fontanelle are rare lesions that usually manifest at birth. The diagnosis is usually easy and surgery is mandatory, with a good prognosis. Recurrence is rare.

Giant posterior cerebral artery aneurysm in a 4-year-old child: Case report

Posterior cerebral artery aneurysms in children aged 5 years or less are very rare. We were able to find only 10 cases previously described in the literature. We present a case of giant bilobulated aneurysm of the distal right posterior cerebral artery in a 4-year-old child with an initial history of spontaneous subarachnoid hemorrhage. The aneurysm was clipped and the patient had full recovery. Based on the literature review, we discuss the characteristics of these rare aneurysms, making a comparison with different age groups.

An unusual case of Fahr's disease.

Resident, Department of Neurosurgery, Santa Casa de Belo Horizonte, Belo Horizonte MG, Brazil; Assistant, Department of Neurosurgery, Santa Casa de Belo Horizonte and Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte MG, Brazil; Assistant, Department of Neurology, Santa Casa de Belo Horizonte, Belo Horizonte MG, Brazil; Assistent I, Department of Psycology, Universidade Federal de Minas Gerais, Belo Horizonte MG, Brazil.

Malignant meningioma with extracranial metastases

Assistant, Head and Neck Surgery Service, Santa Casa de Belo Horizonte, Belo Horizonte MG, Brazil.Received 10 November 2008, received in final form 19 May 2009. Accepted 13 June 2009.Dr. Baltazar Leao Reis – Avenida Francisco Sales 1813 / 102 - 30150-221 Belo Horizonte MG - Brasil. E-mail: baltazarleao@yahoo.com.br

Cavernoma do ventrículo lateral: relato de caso

UNLABELLED Cavernous malformations are uncommon lesions that are usually present in the cerebral hemispheres. They occur rarely in the ventricular system, and even more rarely in the lateral ventricle. Only 28 cases have been previously reported in the literature. CASE We present one case of lateral ventricle cavernoma in a 15-years-old female patient, who suffered of mild chronic headache for 8 months, followed by two episodes of sudden intensive headache and stupor with complete recovery after 48 hours. CT scan was performed and revealed a voluminous size, hiperdense mass in the frontal horn of the lateral ventricle. The surgical access to site was through transcallosal interhemisphere approach. The patient had a good recovery without complications. CONCLUSION Although lateral ventricle cavernomas are rare they should be considered in the differential diagnosis of intraventricular tumors. A wrong preoperative diagnosis has sometimes induced a wrong therapy, such as radiotherapy, for these surgically curable benign lesions.

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.

Clinical experience with a novel bovine collagen dura mater substitute

UNLABELLED Dural substitutes are used to achieve watertight closure of the dura mater when adequate closure is not possible. The purpose of this study was to evaluate the efficacy and safety of a new collagen matrix dural substitute (Duradry, Technodry, Belo Horizonte MG) in the repair or expansion of cranial and spinal dura mater. METHOD Thirty patients, operated on between March and September, 2008, were studied. Surgical records were reviewed for sex, age, location of graft, technique, and presence of fistula or infection. The patients were followed up for at least 3 months, and presence of complications, such as cerebrospinal fluid leakage, infection, aseptic meningitis hydrocephalus, pseudomeningocele, was analyzed. RESULTS Only one patient presented cerebrospinal fluid fistula. No patients presented wound infections, hydrocephalus, pseudomenigocele, meningitis, brain abscesses or signs of toxicity related to the dural substitute. CONCLUSION The new dural substitute used in this study is effective and safe, and the initial results are similar to those of other dural substitutes reported in the literature.

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.