Jorge Luiz Kraemer

Brainstem compression syndrome caused by vertebrobasilar dolichoectasia: microvascular repositioning technique

. It ac-counts for approximately 3 to 5% of all cerebellopontine mass lesions. A variety of clinical syndromes have been re-lated due to pulsatile compression by the aberrant vessel: cerebellar dysfunction, hydrocephalus, ischemic stroke, transient or permanent motor deficits, central sleep ap-nea, trigeminal neuralgia, as well as brain stem compres-sion syndrome

Vertebrobasilar dolichoectasia as a cause of trigeminal neuralgia: the role of microvascular decompression. Case report

Our purpose is to report a case of trigeminal neuralgia caused by vertebrobasilar dolichoectasia treated with microvascular decompression. A 63-year-old man sought treatment for a recurrent lancinating left facial pain in V2 and V3 trigeminal territories. The computed tomography angiography revealed a mechanical compression of the left trigeminal nerve due to vertebrobasilar dolichoectasia. The patient was submitted to a left suboccipital craniotomy. Shredded Teflon was introduced in the conflicting neurovascular area, achieving a satisfactory decompression. The patients pain resolved immediately. Vertebrobasilar dolichoectasia is a rare cause of trigeminal neuralgia and a successful outcome can be achieved with microvascular decompression.

Infrasellar craniopharyngioma: case report

We report a case of infrasellar craniopharyngioma in a 34 year-old woman who presented with progressive headache and diplopia. Computed tomographic and magnetic resonance images showed a heterogeneous tumor originating from the sphenoid bone with ethmoid sinus and sella turcica extension. A sublabial rhinoseptal transsphenoidal surgery was performed. Craniopharyngiomas with infrasellar development are very rare. Infrasellar craniopharyngioma is uncommon, thirty-five cases has been reported in literature. The embryology, clinical features and radiographic investigation of these tumors are discussed.

BRAIN ABSCESS FOLLOWING ISCHEMIC STROKE WITH SECONDARY HEMORRHAGE

C) with negative blood cultures. Pseudomonas aeruginosa and Staphylococcus aureus were then isolated in the tracheal aspirate, being both ciprofloxacin sensitive. Patient persisted fe brile after seven days of antimicrobial therapy, and the previous germs were both once again isolated in the tracheal aspirate. Anaerobic gram positive cocci disposed in chains were identified in the blood culture; piperacilin and tazobactan for ciprofloxa cin resistant pseudomonas were introduced, with favorable outcome. Seven weeks after the stroke, patient started with low grade fever and local swelling over the decompressive craniotomy. Brain CT revealed a multiloculated hypodense lesion over the previously infarcted area, with mass effect and peripheral enhancement after contrast injection (Figs 2A and B), suggesting cerebral abscess. Eritrocyte sedimentation rate was elevated and blood count showed microcytosis and hypocromia, with mild leukocytosis and left shift. Transesophagic echocardiography revealed no abnormalities, similar to the one performed on admission. By means of a small skin incision, abscess punture was performed, with drainage of 40 ml of purulent secretion whose culture in anaerobic media revealed gram negative cocci organized in chains, identified as group C Streptococcus sp. Patient was treated with vancomycin and imipenem for 10 weeks, showing good response. She remains hemiparetic, but follows commands and articulates words. The area of cranial decompression became flacid, and con trol CT showed the infarcted territory still containing the enhanced abscess capsule. The bone flap, which had been kept transitorially in the subcutaneous fat of the abdomen, was replaced 12 months after the stroke, and the tomographic control demonstrated the left encephalomalatic area with complete resolution of the abscess (Fig 3).

Hematomas intraparenquimatosos espontâneos supratentoriais: a proposito de 28 casos

Os autores analisam 28 pacientes com hematomas intraparenquimatosos espontâneos supratentoriais. Comentam as diversas topografias baseadas no estudo angiografico, a mortalidade e a morbilidade da patologia. Os resultados sao analisados em relacao a presenca de hipertensao arterial sistemica, ao comprometimento da consciencia e a topografia do processo expansivo. Chamam a atencao para a indefinicao da escolha e da oportunidade do tratamento cirurgico identificada na literatura.Twenty eight patients with supratentorial spontaneous intracerebral hemorrhage have been reviewed as concerns the location disclosed by angiography, the morbidity and the mortality. The results are analysed with consideration to the presence of arterial hypertension, consciousness disfunction and topography of the lesion. The conflicting opinions in the literature concerning the surgical treatment of spontaneous intercerebral hemorrhage are pointed out.

Comparative study between cortical bone graft versus bone dust for reconstruction of cranial burr holes.

Background: As a consequence of the progressive evolution of neurosurgical techniques, there has been increasing concern with the esthetic aspects of burr holes. Therefore, the objective of this study was to compare the use of cortical bone graft and bone dust for correcting cranial deformities caused by neurosurgical trephines. Methods: Twenty-three patients were enrolled for cranial burr hole reconstruction with a 1-year follow-up. A total of 108 burr holes were treated; 36 burr holes were reconstructed with autogenous cortical bone discs (33.3%), and the remaining 72 with autogenous wet bone powder (66.6%). A trephine was specifically designed to produce this coin-shaped bone plug of 14 mm in diameter, which fit perfectly over the burr holes. The reconstructions were studied 12 months after the surgical procedure, using three-dimensional quantitative computed tomography. Additionally, general and plastic surgeons blinded for the study evaluated the cosmetic results of those areas, attributing scores from 0 to 10. Results: The mean bone densities were 987.95 ± 186.83 Hounsfield units (HU) for bone fragment and 473.55 ± 220.34 HU for bone dust (P < 0.001); the mean cosmetic scores were 9.5 for bone fragment and 5.7 for bone dust (P < 0.001). Conclusions: The use of autologous bone discs showed better results than bone dust for the reconstruction of cranial burr holes because of their lower degree of bone resorption and, consequently, better cosmetic results. The lack of donor site morbidity associated with procedural low cost qualifies the cortical autograft as the first choice for correcting cranial defects created by neurosurgical trephines.

Third ventriculostomy through the lamina terminalis for intracranial pressure monitoring after aneurysm surgery: technical note

OBJECTIVE A new ventriculostomy technique through the lamina terminalis is described. This technique is applied mainly during aneurysm surgery at the acute stage. METHOD Thirteen patients were operated on intracranial aneurysms and, during the procedure, had the lamina terminalis fenestrated. A ventricular catheter was inserted into the third ventricule, left in place and connected to an external drainage system for further intracranial pressure (ICP) monitoring and/or cerebrospinal fluid (CSF) drainage. RESULTS ICP readings and CSF drainage were obtained in all cases. No complication was recorded. CONCLUSION Third ventriculostomy through the lamina terminalis is a simple and easy technique that can be used as an alternative to conventional ventriculostomy. This procedure can be indicated in cases where the ventricule is not reached by means of another technique, and when the decision to perform ventriculostomy is made at the end of aneurysm surgery.

Quantitative computed tomography and cranial burr holes: a model to evaluate the quality of cranial reconstruction in humans.

Abstract Current methods to evaluate the biologic development of bone grafts in human beings do not quantify results accurately. Cranial burr holes are standardized critical bone defects, and the differences between bone powder and bone grafts have been determined in numerous experimental studies. This study evaluated quantitative computed tomography (QCT) as a method to objectively measure cranial bone density after cranial reconstruction with autografts. In each of 8 patients, 2 of 4 surgical burr holes were reconstructed with autogenous wet bone powder collected during skull trephination, and the other 2 holes, with a circular cortical bone fragment removed from the inner table of the cranial bone flap. After 12 months, the reconstructed areas and a sample of normal bone were studied using three-dimensional QCT; bone density was measured in Hounsfield units (HU). Mean (SD) bone density was 1535.89 (141) HU for normal bone (P < 0.0001), 964 (176) HU for bone fragments, and 453 (241) HU for bone powder (P < 0.001). As expected, the density of the bone fragment graft was consistently greater than that of bone powder. Results confirm the accuracy and reproducibility of QCT, already demonstrated for bone in other locations, and suggest that it is an adequate tool to evaluate cranial reconstructions. The combination of QCT and cranial burr holes is an excellent model to accurately measure the quality of new bone in cranial reconstructions and also seems to be an appropriate choice of experimental model to clinically test any cranial bone or bone substitute reconstruction.