João Paulo Cavalcante de Almeida

Headache associated with pituitary tumors.

The objective of this study is to analyze the presence of headache in pituitary tumors and their characteristics, the relationship between pituitary tumor size, biological type, local extension and intrasellar pressure (ISP). This is a prospective study, of 64 consecutive patients presenting with primary pituitary masses at Neuroendocrinological Department of General Hospital of Fortaleza from October 2005 to December 2006. We analyzed sex, age, headache (laterality, site, severity, quality, frequency, duration, associated symptoms, time of onset, trigger, alleviating factors and familial history) and tumor characteristics (type, size, quiasmatic compression, cavernous sinus invasion, sella turcica destruction, cystic or solid mass and ISP). We observed a statistic significant factor between pituitary tumor and tumor size, optic compression, sellar destruction, cavernous sinus invasion and ISP. Biochemical-neuroendocrine factors, mainly in prolactinomas, seem to be an important factor in the determination of headache. The presence of headache in pituitary tumor is related to a combination of factors, including ISP, tumor extension, relationship with the sellar structures, patient predisposition, familial history, and functional disturbance within the hypothalamo-pituitary axis.

Outcome of surgical intrasellar growth hormone tumor performed by a pituitary specialist surgeon in a developing country

BACKGROUND Acromegaly is an excessive GH secretion, which in most cases, is caused by a pituitary GH-secreting adenoma. Traditional treatment of acromegaly consists of surgery, drug therapy, and eventually radiotherapy. The aim of this retrospective study is to evaluate the results of transsphenoidal endoscopic surgery in a group of patients with intrasellar GH adenoma who were operated by a pituitary specialist surgeon. We shall then argue about the economical advantages, for the NHS of a developing country, between surgical and medical treatment. METHODS We have analyzed data from 33 patients with intrasellar GH tumor who had been referred to the neuroendocrine department of the HGF, Brazil. The patients underwent a transsphenoidal endoscopic adenomectomy for acromegaly between 2000 and 2005. Their ages were between 20 and 67 years (mean, 44 years) at the moment of surgery. No cavernous sinus invasion was present. Follow-up was a median of 2 years (range, 12 months-6 years). RESULTS All 33 patients had intrasellar adenoma, 84.84% of patients achieved remission by surgery. One patient was operated twice and reached hormonal normalization. Five patients still had the disease and refused a second surgery. A treatment with octreotide was started for these 5 patients and resulted in an adequate control of GH and IGF-1 levels. No patients had radiotherapy. CONCLUSION Our patients, with intrasellar GH tumor, operated by a pituitary specialist neurosurgeon had remission rates approaching those obtained by most specialized neurosurgical centers worldwide. For equal results, our study shows that the surgical treatment is the best issue for the patient and for the NHS.

Decompressive craniectomy in massive cerebral infarction

Twenty one patients were submitted to decompressive craniectomy for massive cerebral infarct. Ten patients (47.6%) presented a good outcome at the 6 months evaluation, eight had a poor outcome (38%) and three died (14.2%). There was no outcome statistical difference between surgery before and after 24 hours of ictus, dominant and non-dominant stroke groups. Patients older than 60 years and those who had a Glasgow Coma Scale (GCS)<8 in the pre-surgical exam presented worst outcome at six months (p<0.05). Decompressive craniectomy for space-occupying large hemispheric infarction increases the probability of survival. Age lower than 60 years, GCS >8 at pre-surgical exam and decompressive craniectomy before signs of brain herniation represent the main factors related to a better outcome. Dominant hemispheric infarction does not represent exclusion criteria.

Preemptive analgesic effect of lidocaine in a chronic neuropathic pain model

Preemptive analgesia inhibits the progression of pain caused by surgical lesions. To analyze the effect of lidocaine on postoperative pain relief, we performed compression of the right sciatic nerve in Wistar rats and observed the differences on behavior between the group that received lidocaine and the group that was not treated with the local anesthetics pre-operatively. Group 1 was not operated (control); group 2 underwent the sciatic nerve ligature without lidocaine; group 3, underwent surgery with previous local infiltration of lidocaine. Group 2 showed significantly longer scratching times with a peak on day 14 post-operative (p=0.0005) and reduction in the latency to both noxious (p=0.003) and non-noxious (p=0.004) thermal stimulus. Group 3 presented significantly shorter scratching times (p=0.004) and longer latency times when compared to Group 2. Preemptive use of lidocaine 2% can potentially reduce the postoperative neuropathic pain associated with sciatic nerve compression.

McCune-albright syndrome and acromegaly: hormonal control with use of cabergoline and long-acting somatostatin - case report

OBJECTIVES The use of drug therapy based on cabergoline, octreotide and long-acting release (LAR) octreotide has presented varying results in the treatment of GH excessive production in patients with McCune-Albright Syndrome. METHODS We report the case of a 29 year-old female patient presenting McCune-Albright Syndrome and complaint of excessive bone growth. RESULTS The patient presented a pituitary adenoma involving the right internal carotid artery and excessive secretion of growth hormone (no GH suppression was observed after the oral glucose tolerance test). Due to the presence of diffuse thickness in skull base bones, surgical approach was not considered effective and the patient was submitted to drug therapy with octreotide LAR and cabergoline. At the one year follow-up, GH and IGF-1 levels were normal and no adverse effects were present. CONCLUSION The use of drug therapy based on the association of cabergoline and octreotide is safe and able to achieve complete hormonal control in the treatment of acromegaly for McCune-Albright patients.

Aplasia cutis congenita of the scalp

Dr. João Paulo Cavalcante de Almeida – Rua Paulo Morais 130 60175-175 Fortaleza CE Brasil. E-mail: jpaulocavalcante@yahoo.com.br Aplasia cutis congenita (ACC) is an uncommon disorder that presents as a focal defect of the skin at birth, frequently involving the midline over the skull vertex (70%), but it may affect any region of the body. Since 1767, about 500 cases have been reported in medical literature. The skin lesions are quite variable, ranging from absence of skin to a complete lack of subcutaneous tissue, bone or even the dura. The ACC can be isolated or associated with other malformations in a genetic syndrome, like Adams-Oliver syndrome. There are no exact etiologies for ACC, but some conditions have been associated to it like intrauterine vascular ischemia, amniotic adherences and viral infections. Teratogenic medications like metimazole and misoprostol have been proposed as causes of ACC. There is no consensus about the ideal treatment for the ACC, which is probably related to the low prevalence and incidence of this condition. The treatment options are conservative management or surgical correction, based on the clinical picture presented by each patient.

Giant intradural extramedullary arachnoid cyst of the thoracic spine

Spinal intradural arachnoid cysts (ACs) are found frequently in the thoracic region, and often extend over four or five vertebral levels. We present a 28-year-old patient who had a giant thoracic congenital intradural extramedullary AC (T1-T12) with a 10-month history of pain, paresthesia, paraparesis and gait ataxia. A T3 to T6 laminectomy was performed. After durotomy, the posterior wall of the AC was visualized compressing the spinal cord. We resected the cyst wall as widely as possible and connected the cyst to the subarachnoid space using a catheter. There were no postoperative complications. At 1-year follow-up, the patient presented with no motor deficits or pain, and had experienced progressive resolution of the gait ataxia. The treatment of giant intradural extramedullary ACs, especially for those that cannot be totally excised, should include generous fenestration and the insertion of a cyst-subarachnoid shunt.

Neuroendoscopic treatment of quadrigeminal arachnoid cyst in a two-year-old child.

Professor and Chairman, Department of Neurosurgery, Hospital da Restauracao, Recife PE, Brazil.Received 29 May 2008, received in final form 21 July 2008. Accepted 28 July 2008.Dr. Joao Paulo Cavalcante de Almeida – Rua Paulo Morais 130 - 60175-175 Fortaleza CE - Brasil. E-mail: jpaulocavalcante@yahoo.com.br

Endovascular treatment of cerebral aneurysms: a retrospective study of 163 embolized aneurysms.

OBJECTIVE To present the results of cerebral aneurysms treated by endovascular technique. METHOD Retrospective analysis of patient files of Hospital Geral de Fortaleza, Brazil. RESULTS We report the results of 163 cerebral aneurysms treated by endovascular techniques from January 2002 to October 2005. Patients with ruptured aneurysms (87.2%), according to Hunt-Hess scale were: 33.7% HH I, 28.4% HH II, 24.1% HH III, 13.8% HH IV. The Fisher scale grade IV was the most common (39.7%). Remodeling, coil embolization, arterial occlusion and histoacryl embolization were the techniques employed. Effective occlusion was achieved in 87.7%, partial occlusion in 5.3% and non-effective occlusion in 7.0% of the patients. Glasgow outcome scale results were: 76.3% GOS 5, 5.0% GOS 4, 5.8% GOS 3, 1.4% GOS 2 and 11.5% GOS 1. CONCLUSION Endovascular treatment seems to be feasible within Brazilian public health system, with results as good as those obtained in larger international centers.

MESENCEPHALIC TUBERCULOUS ABCESS IN A PATIENT WITH AIDS

The review of recent published papers demonstrates that a considerable amount of brain abscesses has been as-sociated to opportunist microorganism, such as Toxoplas-ma ghondii, Aspergillus spp., Nocardia spp., Mycobacte-ria spp., Criptococcus neoformans and Listeria monocyto-genes. Those data reflects the enlarging number of imuno-compromised patients (AIDS, post-transplantation) as an important risk group for this condition