Jerônimo Buzetti Milano

Cervical Spondylotic Myelopathy: Pathophysiology, Diagnosis, and Surgical Techniques

Cervical spondylotic myelopathy is a degenerative spinal disease which may lead to significant clinical morbidity. The onset of symptoms is usually insidious, with long periods of fixed disability and episodic worsening events. Regarding the pathophysiology of CSM, the repeated injuries to the spinal cord are caused by both static and dynamic mechanical factors. The combination of these factors affects the spinal cord basically through both direct trauma and ischemia. Regarding the diagnosis, both static and dynamics X-rays, as well as magnetic resonance imaging are important for preoperative evaluation as well as individualizing surgical planning. The choice of the most appropriate technique is affected by patients clinical condition radiologic findings, as well as surgeons experience. In opposition to the old belief that patients presenting mild myelopathy should be treated conservatively, there has progressively been amount of evidence indicating that the clinical course of this disease is progressive deterioration and that early surgical intervention improves long-term functional recovery and neurological prognosis.

Doença de Creutzfeldt-Jakob forma Heidenhain: relato de caso com achados de ressonância magnética e DWI

A doenca de Creutzfeldt-Jakob (CJD) e uma forma de demencia pre-senil de rapida evolucao, geralmente fatal em um ano. Casos autoctones no Brasil tem sido raramente descritos assim como achados de ressonância magnetica. Mulher, natural de Ponta Grossa PR, branca , 54 anos , foi admitida no servico em outubro de 2001 com quadro de amaurose bilateral cortical progressiva desde ha 1 mes do internamento. Nunca viajou ao exterior e foi somente submetida a uma cirurgia de reducao do estomago, para obesidade. Historia familial sem relato de casos semelhantes. Logo apos o internamento a paciente desenvolveu quadro de disfasia mista, hemiparesia flacida direita, com movimentos coreoatetoticos e crises parciais motoras. Paciente evoluiu com quadro demencial progressivo; atualmente, acamada, torporosa, dependente de alimentacao enteral, recebendo mepacrina, fenitoina e clorpromazina , estabilizando o quadro ate final de maio de 2002. Exames laboratoriais negativos ou normais. Pesquisa de proteina 14-3-3 no liquor foi positiva; enolase-neuronio-especifica no liquor foi normal. Estudo genetico do gen PRNP nao revelou mutacao descrita anteriormente. EEG (23/10/2001) revelou intensa atividade irritativa hemisferio cerebral esquerdo. Estudo de ressonância magnetica revelou areas de hipersinal em T2 e FLAIR em regioes temporal esquerda e bioccipital; gânglios da base normal. Imagens de DWI mostraram hipersinal nas mesmas areas.Outro EEG (15/03/2002) revelou padrao periodico de ondas trifasicas sugestivos de CJD. A paciente fez uso de mepacrina associado a clorpromazina com aparente estabilizacao do quadro, ate seu obito por complicacoes infecciosas pulmonares em abril de 2003.

Peritoneal dissemination from central neurocytoma: case report

OBJECTIVE Central neurocytoma is a low grade tumor of neuroglial origin and a relatively new histological entity. Only a few cases have been reported and its biological behavior is still uncertain. Some cases have shown an aggressive behavior (local recurrence, malignant dedifferentiation or CSF dissemination) and challenged the initial view of its relative benignity. A case of central neurocytoma with peritoneal dissemination is presented. CASE A six years-old boy with recurrent neurocytoma of III ventricle and left thalamus showed fast growth of tumor rest and ascites three and a half years after subtotal removal of the lesion. Tumor cells were identified in the ascitic fluid and implanted in the peritoneum. Chemotherapy was initiated immediately after diagnosis of peritoneal dissemination (etoposide, carboplatin, doxorubicin and cyclophosphamide). The patient developed metabolic imbalance and respiratory failure due to rapid formation of ascitic fluid and died 3 days after the diagnosis of peritoneal dissemination was established. CONCLUSION Central neurocytoma is a low grade tumor with low values of the proliferative index in the majority of cases. In spite of that, some tumors may present a very aggressive behavior and extraneural dissemination. Evaluation of proliferative index may be a guideline parameter for planning adjuvant therapies after surgical treatment in selected cases. Extraneural dissemination may occur in some cases specially in patients with ventriculoperitoneal shunt.

Primary filum terminale ependymoma: a series of 16 cases

Filum terminale ependymomas are slow growing tumors of the cauda equina with a high incidence in young adults. Although a complete microsurgical resection can lead to a cure, recurrence is not uncommon. Sixteen cases of filum terminale ependymomas treated at the Instituto de Neurologia de Curitiba were analyzed. Eleven patients were females and 5 males, their age ranging from 7 to 84 years. Symptoms and signs included lumbar pain (31.25%), radicular pain (56.25%) and neurological deficits (12.5%). In three cases, patients had previously undergone surgery in other hospitals. All were tested through MRI and were operated on. Two underwent a laminoplasty and 14 a laminectomy. The last 8 patients of this series had neuro-physiological monitoring during surgery. In all patients a total microsurgical resection was achieved. Histologically, 2 cases were cellular ependymomas and 14 cases myxopapillary ependymomas. There was no recurrence during a 2 to 84 month follow-up period.

Análise comparativa de cortes de encéfalos humanos com coloração por três técnicas diferentes

Studing neuroanatomy at brain slices with gray matter staining techniques has several advantages. More often, the models described by Barnard, Robert and Brown, Mulligan, and Green are used. The aim of this study was to identify which of them achieves the best results on differentiation between the gray and the white matter. Thirty coronal slices of human brains underwent staining by the three techniques, and thus compared and analysed according this three parameters: degree of differentiation between white and gray matter, presence of a single and uninterrupted line dividing the white matter from the brain cortex; and degree of impregnation of the color staining in the white matter; scores from 0 to 3 have been given for the three parameters, with total score from 0 to 9. After statistic analysis, the Barnard, Robert and Brown model showed the best results, followed by Greens and Mulligans.

Is preoperative occupation related to long-term pain in patients operated for lumbar disc herniation?

Lumbar disc herniation (LDH) is a common cause of back and sciatic pain. When clinical treatment fails, surgery may be indicated in selected patients. Although surgery is effective in most cases, some of these patients may have a poor outcome. Different factors may influence these results and poor adaptation at work is one well-known cause of treatment failure. This study examines 350 patients on long-term follow-up after surgery for first-time LDH. The relationship was analyzed between occupation before surgery and outcome (maintenance of lumbar and leg pain, satisfaction with the surgical treatment and return to work). The preoperative occupation (employed in public or private services, autonomous, unemployed, housewife, retired or student) and the exertion at work were analyzed as prognostic factors for different clinical outcomes. Although unemployed people had higher numerical analog scale for lumbar pain and retired patients had a higher leg pain, this difference was not statistically significant. Retired people were significantly less satisfied with the surgical result. Higher exertion at work showed a statistically insignificant higher level of pain and lower degree of satisfaction. The authors conclude that preoperative occupation was not a statistically significant factor in this series of patients.

Os ácidos graxos de cadeia curta na cicatrização de anastomoses colônicas: estudo experimental em ratos

ABSTRACTBackground: The aim of the present study was to evaluate the intraluminal effects of short chain fatty acids(SCFA) on the healing of defunctioned colon and in the presence of faecal loading in rats. Methods: Fiftyadult Wistar rats were divided in four groups. Two of them, twenty six rats, were submitted to Hartmann’sprocedure (HC - Har tmann Contr ol - and HSCF A - Hartmann SCF A) and colonic anastomosis wer e performedin the other two groups (AC - Anastomosis Control - and ASCFA - Anastomosis SCFA). The control groups(HC and AC) received rectal infusions of saline, while the experimental groups (HSCFA and ASCFA)received the same kind of infusion but with an isosmolar solution of sodium butyrate at 80mmol/l (SCFA).The animals were sacrificed at the 7 th and 14 th postoperative day. Histologic preparations with sirius redstaining were performed to analyse the collagen densitometry by optic microscopy with a polarized light.Collagen I, collagen III and total collagen were quantified by a computer software. Results: In the groupssubmitted to Hartman’s operation – with bowel rest - the animals submitted to rectal infusions of SCFAshowed an increase in the quantity of total and collagen I. Evaluating the groups submitted to colonicanastomosis – with interference of intraluminal bulk – there was an increase in collagen I in the experi-mental group. The interference of the diet bowel content in the healing process, with or without SCFArectal infusions, was analyzed crossing the groups of different surgical procedures. Conclusion: The maineffect of rectal infusions of SCFA was related to the collagen I, either with or without interference of theintestinal bulk. The presence of diet bowel content also increased the collagen production.Key Words: Fatty acids, volatile; Wound healing; Colon; Collagen; Anastomosis, surgical.

Inflammatory myopathy on HTLV-I infection: case report

We describe a 41 years old woman who 17 years ago presented hypotonia and proximal muscular weakness in the upper and lower limbs. On neurological examination, the biceps, triceps and Achilles reflexes were absent; the brachioradialis reflexes were decreased and the patellar reflexes were normal. There was bilateral Babinski sign. The remainder of the neurological examination was unremarkable. In the investigation a myopathic pattern was found in the electromyography. The nerve-conduction study was normal; a ELISA method for HTLV-I antibodies was positive in the blood and in the cerebral spinal fluid. The muscle biopsy showed inflammatory myopathy, compatible with polymyositis. This paper focuses the polymyositis in the beginning of an HTLV-I infection case.

[Cerebral and systemic venous thrombosis associated to prothrombin G20210 mutation: case report].

Cerebral venous thrombosis is a clinical condition of difficult diagnosis, and poor prognosis when treatment is not started early. There is a long list of causes, and hereby we describe a case associated to prothrombin G20210 mutation. A 53-year-old man, white, was admitted with status epilepticus. After seizures control, he developed intracranial hypertension, with headache and vomiting, and bilateral papilledema. His past medical and familial history were unremarkable. He was a nonsmoker, no drug and alcohol user. CT scan and MRI showed right temporal and parietal infarct with hemorrhagic transformation. Spinal tap with opening pressure of 500 mmH2O showed normal CSF examination. MRI angiography disclosed superior sinus, right transverse and sigmoid sinus complete thrombosis. He was started with heparin and oral warfarin. In spite of anticoagulation, two months later he developed deep right inferior limb thrombosis. All the initial tests were normal, and test for prothrombin G20210 mutation was positive. He needed a much higher than conventional daily dose of warfarin to keep him asymptomatic.

Distal posterior inferior cerebellar artery aneurysm: case report

The majority of posterior inferior cerebellar artery (PICA) aneurysms are usually found on the bifurcation of the vertebral artery (VA) - PICA junction. Aneurysms arising from more peripheral PICA segments named distal PICA aneurysm are uncommon. The major clinical manifestation is that of an intracranial bleeding and the site of hemorrhage is related to the PICA segment originating the aneurysm. Lesions originating from distal PICA segments, particularly those arising from the telovelotonsillar segment, are associated with hemorrhage extending into the ventricular system, mainly the i.v. ventricle. A case of a 50-year-old woman with sudden headaches and vomiting, and intraventricular hemorrhage (four ventricles) caused by an aneurysm of the telovelotonsillar segment of the PICA, is presented. No signs of subarachnoidal hemorrhage were found in the computerized tomography. The aneurysm was clipped and the patient presented a favorable outcome. Anatomical aspects and clinical series are reviewed.