Flávio Ramalho Romero

Suboccipital craniectomy with or without duraplasty: what is the best choice in patients with Chiari type 1 malformation?

The best surgical treatment for Chiari malformation is unclear, especially in patients with syringomyelia. We reviewed the records of 16 patients who underwent suboccipital craniectomy at our institution between 2005 and 2008. Of the six patients who did not undergo duraplasty, four showed improvement postoperatively. Two patients without syringomyelia showed improvement postoperatively. Of the four patients with syringomyelia, three showed improvement, including two with a decrease in the cavity size. One patient showed improvement in symptoms but the syringomyelia was unchanged. The cavity size increased in the one patient who did not show improvement. Among the 10 patients who underwent duraplasty, improvements were noted in four of the five patients without syringomyelia and in all of the five with syringomyelia. There is a suggestion that patients with syringomyelia may have a higher likelihood of improvement after undergoing duraplasty.

Outcomes from intracerebral hemorrhage among patients pre-treated with statins

OBJECTIVE 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, or statins, have been associated with improved clinical outcomes after ischemic stroke and subarachnoid hemorrhage, but with an increased risk of incidental spontaneous intracerebral hemorrhage (ICH). We investigated whether the statin use before ICH, was associated with functional independence, 90 days after treatment. METHOD We analyzed 124 consecutive ICH patients with 90-day outcome data who were enrolled in a prospective cohort study between 2006 and 2009. Eighty-three patients were included in this study. Among ICH survivors, univariate Cox regression models and Kaplan-Meier plots were used to determine subject characteristics that were associated with an increased risk of recurrence. Statin usage was determined through interviewing the patient at the time of ICH and confirmed by reviewing their medical records. Independent status was defined as Glasgow Outcome Scale grades 4 or 5. RESULTS Statins were used by 20 out of 83 patients (24%) before ICH onset. There was no effect from pre-ICH statin use on functional independence rates (28% versus 29%, P=0.84) or mortality (46% versus 45%, P=0.93). CONCLUSION Pre-ICH statin use is not associated with changes to ICH functional outcome or mortality.

Microsurgical techniques using human placenta.

Dr. Flavio Ramalho Romero – Praca Amadeu Amaral 27 / 5o andar 01327-010 Sao Paulo SP Brasil. E-mail: romerocnr@gmail.com / icne@icne.com.br Training in microsurgical techniques is the first step to allow procedures in the central nervous system. One of them is the dissection of human placenta. Others include mannequin head, virtual reality environment, animal and cadaver dissections. The human placenta is a maternalfetal structure constituted of a bigger fetal portion and a smaller maternal portion. The fetal membranes and the placenta are responsible for protection, nutrition, breath, excretion and hormone production. The placenta usually shows an ovoid shape with a 16–20 cm diameter and a 2–3 cm thickness. It weighs between 500 and 600 gr. The umbilical cord is usually composed of a vein and two arteries. The fetal surface has a fetal corion – amniotic membrane which is very similar to the cerebral arachnoid and a rich vascular component with 1–6 mm diameter vessels. The anterior cerebral artery has 1–3 mm diameter and the medium cerebral artery one is between 2.4 and 4.6 mm. On the other hand, the vertebral artery has 0.92–4.09 mm diameter, the posterior cerebral and the lower posterior cerebelar arteries ones are between 0.65 and 1.78 mm. Therefore, the human placenta is an excellent material for microsurgical technique training.

Desmoplastic ganglioglioma: report of a non-infantile case.

Neurosurgeon, Serviço de Neurocirurgia do Hospital São Luiz, Unidade Anália Franco, São Paulo SP, Brazil. Desmoplastic infantile gangliogliomas (DIGs) are rare, superficial, supratentorial tumours of early childhood i.e. they occur within the first two years of life representing 1.25% of all intracranial tumors in children. Tumours with similar characteristics are exceedingly rare in the non infantile population. These tumours, which are composed of a mixture of glial and neuronal cells and a fibrous stroma, affect mainly young patients and arise at the surface of the cerebral hemispheres. Despite its histologically malignant appearance, DIGs are associated with excellent prognoses. A 19 year old young man presented with history of a year old headache and generalized tonic clonic seizures 3 days before consultation. MRI showed a right temporal lobe solid-cystic lesion, causing mass effect and cerebral edema (Fig 1A). The patient was operated by craniotomy and micro neurosurgery and the lesion totally removed. Light microscopy revealed a cellular glioneuronal tumour showing lobules of dysplastic neuronal cells and multinucleated giant cells. Immunohistochemistry demonstrated GFAP positive glial component and synaptophysin and chromogranin positive ganglion cells. Post operative MRI showed no evidence of residual lesion (Fig 1B). The patient and his parents agree with this report. In 1982 Taratuto et al. defined desmoplastic infantile astrocytomas as meningocerebral astrocytomas attached to the dura mater with a desmoplastic reaction. Five years later VandenBerg et al. recognized a ganglion cell component in part of these tumours, and such tumours were called “desmoplastic infantile gangliogliomas”. Desmoplastic infantile gangliogliomas are a distinct form of developmental neuroepithelial tumours probably arising from neural progenitor cells in the subcortical zone along with mature subpial astrocytes. They are rare WHO Grade I tumours of infancy characterized by large volume, superficial location, invariable supratentoriality, fronto-parietal lobe predilection and morphologically by an admixture of astroglial and neuroepithelial elements in