Júlio Leonardo Barbosa Pereira

Correlation between magnetic resonance imaging findings and histological diagnosis of intrinsic brainstem lesions in adults

Management of brainstem mass lesions remains a controversial issue, especially when the lesion cannot be excised and when infiltration occurs; moreover, the benefits of a stereotactic procedure are still under debate. In most studies, treatment decisions are based solely on MRI features and do not include a histopathological diagnosis. In the current study, we compared MRI characteristics with histopathological findings of intrinsic brainstem lesions and identified the characteristics associated with the diagnosis of pathologies other than diffuse glioma. From February 1988 through August 2007, 96 brainstem biopsies were performed at the Roger Salengro Hospital in Lille, France, on adult patients with intrinsic brainstem lesions not amenable to excision. Of the 96 patients, 42 were women and 54 were men, with a mean age of 41 years (range, 18-75 years). Data analysis of the MRI findings revealed focal (P < .05) and contrast enhancing lesions (P < .05), and these lesions were significant factors associated with the diagnosis of pathologies other than diffuse glioma. Focal lesions were a significant factor associated with a diagnosis of nontumor lesions (P < .05). In conclusion, the diagnostic effect of stereotactic biopsy on intrinsic brainstem lesions was greater in patients with focal or enhancing lesions shown by MRI, in whom the diagnosis of diffuse glioma was less frequent.

Stereotactic biopsy for brainstem tumors: comparison of transcerebellar with transfrontal approach.

Background: An important aspect of evaluating patients submitted to stereotactic biopsy of the brainstem is the trajectory used. The literature describes two principal approaches: the suboccipital transcerebellar and the transfrontal; however, no studies exist comparing these two techniques. Objective: The purpose of this study was to compare diagnosis success rates and complications between the suboccipital transcerebellar and transfrontal trajectories. Methods: The study evaluated 142 patients submitted to stereotactic biopsy. The patients presented brainstem tumors in the following areas: pons (n = 31), midbrain (n = 36), medulla (n = 2), pons-medulla (n = 30), pons-midbrain (n = 33), and midbrain-pons-medulla (n = 10). On 123 patients, the transfrontal approach was used, and on 19 the suboccipital transcerebellar approach. Results: Comparing success rates between the two approaches, it was observed that in the group of patients submitted to the transfrontal approach, 95.1% (117 cases) were successful, while in those submitted to the suboccipital transcerebellar approach, 84.2% (16 cases) were successful. Despite a higher success rate among patients in the first group, the difference was not statistically significant. Regarding complications, in patients who were biopsied via the transfrontal trajectory, the morbidity rate was 9.8% (12 cases), while in patients submitted to the suboccipital transcerebellar approach, the morbidity rate was 5.3% (1 case) and the mortality rate 5.3% (1 case). Conclusions: This study verified a higher diagnosis rate in patients submitted to the transfrontal approach than in those submitted to the suboccipital transcerebellar approach (95.1 vs. 84.2%); however, the difference was not statistically significant. Regarding complications, the rate was similar in both groups of patients.

Diffuse brainstem glioma: prognostic factors

OBJECT Brainstem gliomas were regarded as a single entity prior to the advent of MRI; however, several studies investigating MRI have recognized that these lesions are a heterogeneous group, and certain subgroups have a better prognosis for long-term survival. The aim of this study was to conduct a retrospective analysis of prognostic factors of patients with brainstem gliomas confirmed by histopathological diagnosis, particularly regarding assessment of whether histological grade, age, and MRI findings are prognostic factors for patient survival. METHODS The study evaluated 100 patients diagnosed with brainstem glioma. There were 63 adults (40 men and 23 women; age range 18-75 years, mean 41 years) and 37 children (19 boys and 18 girls; age range 2-12 years, mean 6.9 years). RESULTS The mean overall survival of this population, measured from the date of biopsy, was 57 months for diffuse low-grade glioma and 13.8 months for diffuse high-grade glioma (p < 0.001). The mean survival among patients with nonenhancing contrast lesions on MRI was 54.2 months, whereas for patients with enhancing lesions, it was 21.7 months (p < 0.001). Comparisons between the Kaplan-Meier survival curves of adults and children revealed similar median survival periods of 25 and 16 months, respectively (p > 0.05). The multivariate analysis (Cox proportional hazards regression) revealed that only histological grade was a significant prognostic factor (p < 0.001). CONCLUSIONS The study revealed that histological grade and MRI features were significant prognostic factors for survival in these patients, but in multivariate analysis, only histological grade remained a significant factor.

Correlation among magnetic resonance imaging findings, prognostic factors for survival, and histological diagnosis of intrinsic brainstem lesions in children.

OBJECT The aim of this study was to compare MR imaging characteristics with histopathological findings of intrinsic brainstem lesions and also to show the prognostic factors in patients with diffuse brainstem glioma. METHODS Between February 1988 and August 2007, 44 brainstem biopsies were performed at the Roger Salengro Hospital in Lille, France, in children with intrinsic brainstem lesions not amenable to excision. Twenty-six were female and 18 male, and the mean age was 6 years. RESULTS Histological evaluation revealed diffuse brainstem glioma in all patients with diffuse nonenhancing brainstem lesions. Diffuse brainstem glioma was found in 18 patients (90%) with diffuse enhancing brainstem lesions. Pathological entities different from diffuse glioma were verified in 2 patients (10%)-1 with ependymoma and 1 with ganglioglioma. In 4 of 5 patients with a focal nonenhancing brainstem lesion, the histopathological diagnosis was diffuse low-grade glioma. In 6 of 10 patients with focal enhancing brainstem lesion, the diagnosis was diffuse brainstem glioma, and pathological entities different from diffuse brainstem glioma were verified in 2 (20%), both with pilocytic astrocytoma. The mean 1-year actuarial survival rates for patients classified with low-grade and high-grade glioma were 80.4% ± 0.08% and 48.6% ± 0.14%, respectively. CONCLUSIONS The impact of stereotactic biopsy on intrinsic brainstem lesions was greater in patients with MR imaging-documented enhancing lesions in whom the diagnosis of diffuse glioma was less frequent. Patients with low-grade glioma seem to have longer survival than those with high-grade glioma.

Pituitary deficiency after aneurysmal subarachnoid hemorrhage

OBJECTIVE: Aneurysmal subarachnoid hemorrhage puts patients at high risk for the development of pituitary insufficiency. We evaluated the incidence of pituitary dysfunction in these patients and its correlation with clinical outcome. METHODS: Pituitary function was tested in 66 consecutive patients in the first 15 days after aneurysmal subarachnoid hemorrhage. The following were measured in all patients: thyroid-stimulating hormone, free thyroxine, triiodothyronine, luteinizing hormone, follicle-stimulating hormone, total testosterone (in males), estradiol (in females), prolactin, serum cortisol, plasma adrenocorticotropic hormone, growth hormone and insulin growth factor. RESULTS: The endocrine assessment was made at a mean of 7.4 days (standard deviation ±6.6) after subarachnoid hemorrhage. Forty-four (66.7%) female and 22 (33.3%) male patients were evaluated. Thirty-nine patients (59.1%) had some type of pituitary dysfunction. Follicle-stimulating hormone/luteinizing hormone deficiency was the most frequent disorder (34.8%), followed by growth hormone/insulin growth factor (28.7%), adrenocorticotropic hormone (18.1%) and thyroid-stimulating hormone (9%). Seventeen (25.7%) patients showed deficiencies in more than one axis. A greater incidence of hormone deficiency was observed in patients with a Glasgow Coma Scale score ≤13 (t test, p = 0.008), Hunt-Hess grade ≥4 (t test, p<0.001), or Fisher grade 4 (t test, p = 0.039). Hormone deficiency was not significantly associated (p>0.05) with increased hospitalization or clinical outcome. CONCLUSION: Pituitary dysfunction was identified in a substantial portion of patients with previous aneurysmal subarachnoid hemorrhage, but no association was found between this dysfunction and poor clinical outcome.

Importance of recognizing sentinel headache.

Background: Sentinel headache (SH) is a kind of secondary headache and is characterized as sudden, intense, and persistent, preceding spontaneous subarachnoid hemorrhage (SAH) by days or weeks. Methods: Eighty-nine consecutive patients with a diagnosis of spontaneous SAH were evaluated following admission to the Neurosurgical Service at Santa Casa Hospital, Belo Horizonte, between December 2009 and December 2010. Results: Out of the 89 patients, 64 (71.9%) were women. Mean age was 48.9 years (SD ± 13.4, ranging from 18 to 85 years). Twenty-four patients (27.0%) presented SH, which occurred, in average, 10.6 days (SD ± 13.5) before a SAH. No statistically significant differences were observed between the presence of SH and gender, arterial hypertension and migraine (P > 0.05), Glasgow Comma Scale (GCS) and World Federation of Neurological Surgeons (WFNS) scale at admission. Conclusion: The prevalence of SH was 27% in this study but no related factors were identified. Therefore, further clarification of this important entity is required so as to facilitate its recognition in emergency services and improve the prognosis of patients with cerebral aneurysms.

Long-Term Follow-Up of Anterior Pituitary Deficiency after Aneurysmal Subarachnoid Hemorrhage: Prospective Cohort

OBJECTIVE The aim of this study was to evaluate the prevalence of hypopituitarism in the acute stage after aneurysmal subarachnoid hemorrhage (SAH) as well at the chronic stage, at least 1 year after bleeding, to assess its implications and correlation with clinical features of the studied population. PATIENTS AND METHODS This was a prospective cohort study that evaluated patients admitted between December 2009 and May 2011 with a diagnosis of SAH secondary to cerebral aneurysm rupture. Clinical and endocrine assessment was performed during the acute stage after hospital admission and before treatment at a mean of 7.5 days (SD ± 3.8) following SAH, and also at the follow-up visit at a mean of 25.5 months (range: 12-55 months) after the bleeding. RESULTS Out of the 119 patients initially assessed, 92 were enrolled for acute stage, 82 underwent hormonal levels analysis, and 68 (82.9%) were followed up in both acute and chronic phases. The mean age and median age were lower among patients with dysfunction in the acute phase compared to those without dysfunction (P < .05). The prevalence of dysfunction in the acute phase was higher among patients with hydrocephalus on admission computed tomography (57.9%) than among those without it (P < .05). At chronic phase, there was an association between dysfunction and Hunt & Hess scale score greater than 2 (P < .05). CONCLUSIONS We believe that there is not enough literature evidence to incorporate routine endocrinological evaluation for patient victims of SAH, but we should always keep this differential diagnosis in mind when conducting long-term assessments of this population.

E-learning for neurosurgeons: Getting the most from the new web tools

As open access resource, the role of Internet has been increasing in our professional life. There are several emergent new tools that can facilitate and make it more efficient to get accurate and reliable information. In this article, we discuss how we can manage to get the most from these new instruments, like blogs, Facebook, Twitter, and LinkedIn, in order to improve clinical practice. With good sense and some caution, these can turn to be of valuable help in our careers.

Indices of agreement between neurosurgeons and a radiologist in interpreting tomography scans in an emergency department

UNLABELLED The power of interpretation in the analysis of cranial computed tomography (CCT) among neurosurgeons and radiologists has rarely been studied. This study aimed to assess the rate of agreement in the interpretation of CCTs between neurosurgeons and a radiologist in an emergency department. METHOD 227 CCT were independently analyzed by two neurosurgeons (NS1 and NS2) and a radiologist (RAD). The level of agreement in interpreting the examination was studied. RESULTS The Kappa values obtained between NS1 and NS2 and RAD were considered nearly perfect and substantial agreement. The highest levels of agreement when evaluating abnormalities were observed in the identification of tumors, hydrocephalus and intracranial hematomas. The worst levels of agreement were observed for leukoaraiosis and reduced brain volume. CONCLUSIONS For diseases in which the emergency room procedure must be determined, agreement in the interpretation of CCTs between the radiologist and neurosurgeons was satisfactory.

Levels of MMP-9 in patients with intracranial aneurysm: Relation with risk factors, size and clinical presentation.

BACKGROUND Intracranial aneurysms are arterial anomalies affecting 2% to 3% of the general population in the world and these ruptures are associated with a high mortality. Some risk factors, such as age, gender, smoking, alcohol, hypertension and familial history are associated with the number of aneurysms and their size. In addition, inflammatory processes within the blood vessels of the brain can activate matrix metalloproteinase-9 (MMP-9), which degrades various components of the extracellular matrix, such as elastin. Thereby, this work has aimed at evaluating the relationship between plasma MMP-9 levels and the risk factors that are associated with intracranial aneurysm, as well as investigating the aneurysm statuses (ruptured and unruptured) and comparing them with the control volunteers. METHODS Between August 2014 to June 2016, blood samples were collected from 282 patients (204 ruptured and 78 unruptured saccular intracranial aneurysms) and 286 control volunteers. The MMP-9 plasma levels were measured by ELISA. Statistical analyzes were performed with SPSS software when using parametric or nonparametric tests, after the normality tests. RESULTS Higher levels of MMP-9 were found in the aneurysm groups as a whole and when they were stratified by rupture status, then compared with the control group (p < 0.0001). When stratifying them by diameter, those smaller than 7 mm presented high levels of MMP-9 (p < 0.0001), especially in the ruptured ones. As for risk factors, hypertension and smoking were the most important. However, hypertension was mostly associated with the ruptured aneurysms (p < 0.0001). CONCLUSIONS High levels of MMP-9 were found in smaller ruptured and unruptured intracranial aneurysms (<7 mm) with strongest statistical associations than other sizes, especially when associated with smoking and hypertension.