Juan Antonio Castro Flores

Presentation and treatment of carotid cavernous aneurysms

We analyzed a group of patients with the diagnosis of internal carotid aneurysms in its intracavernous segment, with emphasis in prevalence, clinical features, treatments, evolution and neurological prognosis. Neurological signs and symptoms at initial presentation were registered and compared with final outcome. Patients were divided into two stratified groups, one with 19 patients which underwent interventionist treatment, and another with 21 patients who were conservatively treated. The present study demonstrated that intervention is significantly correlated with a better prognosis considering evolution of pain symptoms secondary to neurovascular compression (p=0,002). Regarding neurological deficits, an interventionist approach was also significantly correlated with better outcome in comparison with initial presentation (p=0,008). These results indicate that interventionist treatment determines improvement or resolution of pain symptoms in comparison with patients conservatively treated, as well as stabilization or partial improvement of neuro-ophthalmological deficits.

Spontaneous thrombosis of internal carotid artery: a natural history of giant carotid cavernous aneurysms

OBJECTIVE To describe five cases of giant carotid cavernous aneurysms which evolved with spontaneous thrombosis of internal carotid artery (STICA), with emphasis at epidemiology, clinical presentation, natural history, related factors and neurological outcome. METHOD There were 711 consecutives patients with 802 aneurysms with and without surgical treatment during a period of 19 years. We selected 35 patients with 40 carotid cavernous aneurysms (5%) of which 20 (50%) were giant aneurysms. Among those cases, 5 patients evolved with STICA (25%). Symptoms and findings at presentation were recorded and compared with those at outcome. RESULTS Clinical presentation was commonly related to atherosclerotic factors such as elevated blood pressure (80%), diabetes mellitus (40%) and dislipidemy (40%). All patients presented with hemicranial headache, ophthalmparesy and retro bulbar pain, and after STICA all presented improvement of symptoms. After STICA, 4 patients had regression of deficit, 2 partial and 2 complete. Four patients had sensorial trigeminal neuropathy in V1 and V2 territories, also showing improvement of symptoms after STICA. CONCLUSION STICA is a common outcome in giant carotid cavernous aneurysms, and is related with significant improvement of symptoms; however, it may be catastrophic for those patients without efficient collateral circulation.

Primary spinal meningioma in a 10-year-old boy

. Meningiomas are largely benign in nature and their recurrence is most associated to histologic type. The current treatment of choice is surgical resection.The aim of this report is to present a case of a ten year-old boy diagnosed with a psammomatous meningioma in the topog-raphy of the thoracic column (T4), and to review some epidemiological, pathophysi-ological, clinical and prognostic features.CaseA ten year-old male patient with no relevant past medical history sudden-ly showed progressive spastic parapare-sis of lower limbs with reduced sensitiv-ity to pain, 40 days prior to hospital ad-mission. Moreover, no infections had been observed prior to symptoms, nor relevant epidemiological antecedents or previous exposure to ionising radiation. Clinical ex-amination revealed bilateral reduction in muscular strenght of the legs and thighs (both power grade II) with normal bilat-eral deep tendon reflexes while no chang-es in sensitivity to heat, pain or proprio-ception were observed. The results of der-matologic examination were normal. Fun-doscopy was normal. The child also had normal CSF tests. Brain CT scan showed no signs of schwannomas or other tumors. A neuroaxis MR (Fig 1) showed a poste-rior intradural expansive mass at the lev-el of T4 and T5 vertebrae, in an appar-ent extra-medullary, well delimited, ho-mogenous, lobulated topography. The tu-mor measured around 1.8 × 1.2 × 0.9 cm and was characterized by T1 iso-signal, T2 hypersignal, and homogenous accentuat-ed enhancement following contrast injec-tion, and exerted a local expansive effect creating medullar dorsal compression with signs of local edema/trauma signs charac-terized by T2 hypersignal. The patient un-derwent laminectomy, and opening up of the dura exposed a whitish tumor com-pressing the adjacent medulla. The tumor presented a hard consistency, with little bleeding, a clear cleavage plane with the dura mater and weak adherences to the adjacent arachnoid. The tumor was ful-ly resected. Anatomopathologic study re-vealed a psammomatous meningioma (Fig 2). Post-operative evolution was satisfac-tory, with recovery of muscular strength to power grade 4 in three days. He is cur-rently undergoing motor rehabilitation with good clinical evolution.DisCussionMeningiomas are rare tumors in chil-dren, accounting for less than 5% of brain tumors in children and less than 2% of all

Preservation of the olfactory tract in bifrontal craniotomy

The bifrontal craniotomy approach used to be associated with a high percentage of olfactory tract damage. We present our experience with this technique, that was used with excellent results in a series of 11 patients that underwent the surgical approach described in this paper. We support the idea that bilateral subfrontal craniotomy allows a wide operative exposure as well as the complete anatomic and functional preservation of the olfactory tracts bilaterally.

Hemorragia vítrea após rotura de aneurisma cerebral: síndrome de Terson

Introduction Terson’s syndrome is described as an intraocular hemorrhage consequent to a spontaneous subarachnoid hemorrhage (SAH). We describe, in this article, cases of patients undergoing neurosurgical treatment of ruptured cerebral aneurysm at our institution over a period of one year, and who were diagnosed with Terson’s syndrome.

Mycotic Aneurysm Treated with Aneurysm Trapping. Case Report

The authors describe a rare case of mycotic aneurysm (MA) associated with subarachnoid hemorrhage treated with aneurysm trapping. The literature on management and the surgical techniques are controversial due to lack of randomize trials.

Cerebral revascularization ina case of ischemic cerebrovascular disease

Dr. Eberval Gadelha Figueiredo – Rua Oscar Freire 1456 / 34 05409-010 São Paulo SP Brasil. E-mail: ebgadelha@yahoo.com It is well established that patients with transient ischemic attacks (TIA) or minor strokes that are found to have occlusive lesions of major brain-supplying vessels are prone to develop subsequent significant stroke. The underlying pathophysiology of cerebral ischemia within this large and heterogeneous group of patients remains matter of debate. Considerable controversy exists on the relative importance of thrombembolic versus hemodynamic mechanisms. Following the introduction of extracranialintracranial (EC-IC) bypass, the procedure was rapidly accepted as a way to increase cerebral perfusion in patients with ischemic cerebrovascular disease. However, the disappointing results of the Cooperative Study on EC-IC Bypass in 1985, led to the virtual abandonment of this procedure for the management of occlusive cerebrovascular disease. With the advent of contemporary imaging methods and functional blood flow studies, it has been demonstrated that a subset of patients with occlusive cerebrovascular disease is characterized by a severely impaired hemodynamic status. In such cases, the EC-IC bypass may represent an attractive and effective procedure to prevent cerebral hemodynamic failure. Retrospectively and particularly in view of new evidence on the pathophysiology of cerebral ischemia, the decision of the ECIC trial of suggesting abandoning EC-IC bypass completely seems premature. We present a clinical case of an EC-IC bypass performed in a patient with proved cerebral hemodynamic impairment. Additionally, the current indications, surgical options and clinical outcome are discussed. These cases are rarely reported in the Brazilian literature and many patients who probably could benefit from this procedure are often overlooked.

Preservação do trato olfatório em craniotomias bifrontais

The bifrontal craniotomy approach used to be associated with a high percentage of olfactory tract damage. We present our experience with this technique, that was used with excellent results in a series of 11 patients that underwent the surgical approach described in this paper. We support the idea that bilateral subfrontal craniotomy allows a wide operative exposure as well as the complete anatomic and functional preservation of the olfactory tracts bilaterally.