Leonardo C. Welling

Management strategy for brain tumour diagnosed during pregnancy

The occurrence of brain tumours during pregnancy is unusual, when this happen jeopardises the lives of both the mother and infant. This article aims at identifying the best medical management to be followed for a pregnant patient harbouring a brain tumour. The records of 10 patients with brain tumours diagnosed during pregnancy were retrospectively examined. The histological diagnosis revealed 3 grade 2 astrocytomas, and 1 grade 2 oligodendroglioma. All this gliomas (100%) developed dedifferentiation in the mean period of 27 months. The histology of the others tumours were 2 grade 1 meningiomas, 1 melanoma metastasis, 1 epidermoid tumour, 1 case of chemodectoma and 1 patient with a pituitary apoplexy in a non-function adenoma. There was no operative mortality in these series, and no fetal deaths were observed. Prior to craniotomy, five patients had caesarean sections, two others had vaginal deliveries. In three patients the delivery took place after the brain tumour treatment. Two patients had vaginal delivery and eight caesarean sections. The best moment to recommend the craniotomy and the neurosurgical removal of the tumour will depend of the mothers neurological condition, the tumour histological type as well as the gestational age. A multi-disciplinary approach was used to determine the optimal management for each patient.

Prospective randomized study comparing clinical, functional, and aesthetic results of minipterional and classic pterional craniotomies

OBJECT The object of this study was to compare the clinical, functional, and aesthetic results of 2 surgical techniques, pterional (PT) and minipterional (MPT) craniotomies, for microsurgical clipping of anterior circulation aneurysms. METHODS Fifty-eight patients with ruptured and unruptured anterior circulation aneurysms were enrolled into a prospective randomized study. The first group included 28 patients who underwent the MPT technique, and the second group comprised 30 patients who underwent the classic PT craniotomy. To evaluate the aesthetic effects, patients were asked to grade on a rule from 0 to 100 the best and the worst aesthetic result. Photographs were also taken, assessed by 2 independent observers, and classified as showing excellent, good, regular, or poor aesthetic results. Furthermore, quantitative radiological assessment (percentage reduction in thickness and volumetric analysis) of the temporal muscle, subcutaneous tissue, and skin was performed. Functional outcomes were compared using the modified Rankin Scale (mRS). Frontal facial palsy, postoperative hemorrhage, cerebrospinal fistula, hydrocephalus, and mortality were also analyzed. RESULTS Demographic and preoperative characteristics were similar in both groups. Satisfaction in terms of aesthetic result was observed in 19 patients (79%) in the MPT group and 13 (52%) in the PT group (p = 0.07). The mean score on the aesthetic rule was 27 in the MPT group and 45.8 in the PT group (p = 0.03). Two independent observers analyzed the patient photos, and the kappa coefficient for the aesthetic results was 0.73. According to these observers, excellent and good results were seen in 21 patients (87%) in the MPT and 12 (48%) in the PT groups. The degree of temporal muscle, subcutaneous tissue, and skin atrophy was 14.9% in the MPT group and 24.3% in the PT group (p = 0.01). Measurements of the temporal muscle revealed 12.7% atrophy in the MPT group and 22% atrophy in the PT group (p = 0.005). The volumetric reduction was 14.6% in the MPT and 24.5% in the PT groups (p = 0.012). Mortality and mRS score were similar in both groups at the 6-month evaluation (p = 0.99). CONCLUSIONS Minipterional craniotomy provides clinical results similar to those of the PT technique. Moreover, it provides better cosmetic results. It can be used safely and effectively to surgically treat aneurysms of the anterior circulation instead of the PT approach.

Surgical experience of minipterional craniotomy with 102 ruptured and unruptured anterior circulation aneurysms

The pterional approach was described in the 1970s and has become the most utilized cranial approach with many variations described, including the minipterional technique. Although described recently as an alternative to the pterional approach for anterior circulation aneurysms, to our knowledge a large series of cases using the minipterional approach in both ruptured and unruptured aneurysms has not been described. We present our clinical experience with the minipterional craniotomy in more than 100 ruptured and unruptured anterior circulation aneurysms. The results of 86 consecutive patients with 102 ruptured non-giant, anterior circulation aneurysms treated with early surgery utilizing the minipterional craniotomy were analyzed. Postoperative angiography was carried out in all cases. Outcome results were classified as excellent in 67 (77.9%), and good in seven (8.1%), while 16 (13.9%) patients died. The minipterional technique provides adequate surgical exposure and excellent outcomes for both ruptured and unruptured anterior circulation aneurysm clipping. It constitutes a safe and effective alternative to the pterional approach, with equivalent or potentially better aesthetic and functional outcomes.

Complete removal of the spinal nerve sheath tumors. Surgical technics and results from a series of 30 patients

OBJECTIVE Observe whether a microsurgical gross total removal (GTR) of a spinal nerve sheath tumors (SNSTs) is safe and decreases the tumor recurrence. METHOD We identify 30 patients with 44 SNSTs. RESULTS We operated upon 15 males and 15 females patients; mean age 40 years. GTR was achieved in 29 (96.6%) instances. Surgical mortality was 3.3% and the recurrence rate was 3.3%. The median follow-up time was 6.2 years. CONCLUSION The surgical approach used in this group of patients afford that the great majority of tumors could be totally removed with low mortality and low recurrence rates, proving to be safe and effective.

Ectopic pineal chordoma.

Background: Chordomas are rare tumors that arise from the remnants of embryonic notochord anywhere along the neuroaxis. Even though they may occur in an extraosseous intradural location, the most common sites include the sacrococcygeal and clivus regions. The authors report a unique presentation encompassing the pineal region with metastasis to the peritoneum after a ventriculoperitoneal (VP) shunt procedure and review the current knowledge about their pathophysiology and management. The presentation and clinical history endorse the idea that intradural extraosseous chordomas may be distinct from ecchordosis physaliphora and probably do not derive from it. Case Description: An 18-year-old male with previous history of VP shunt presented to the emergency room with pain and abdominal distension. Computed tomography (CT) scans revealed a mass in the pineal region and in the abdominal cavity. Histopathologic exams showed chordoma in both abdominal and cranial samples. The patient died due to systemic complications. Conclusion: The authors hypothesized that notochord remnants may subsist within the brain and occasionally may generate a neoplastic lesion.

Spinal melanotic schwannomas

MD, PhD Full Professor, Department of Neurosurgery, School of Medicine, USP, Sao Paulo SP, Brazil.Correspondence: Leonardo C. Welling; Rua Tiradentes 976; 84010-190 Ponta Grossa PR - Brasil; E-mail: leonardowelling@yahoo.com.brConflict of interest: There is no conflict of interest to declare.Received 06 August 2011; Received in final form 01 September 201; Accepted 09 September 2011

Vessel Wall Magnetic Resonance Imaging, Inflammatory Cascade, Aspirin, and Aneurysm Rupture: Future Paradigms?

Figure 1. A new perspective has come to cerebral aneurysm management. It is possible that the risk of aneurysm rupture, such as this internal carotid artery aneurysm, may be evaluated through modern imaging techniques. Intracranial aneurysms are common cerebrovascular lesions (Figure 1). Approximately 12% of patients die before receiving medical attention, 40% within 1 month after the event, and among those who survive, almost 30% will develop major neurologic deficits. Morbidity and mortality remain high despite advances in endovascular coiling and microsurgical clipping (4, 5). The need for noninvasive treatment is urgent, and in this context recent studies have shown the key role of inflammation in aneurysms progression to rupture. Leukocyte invasion, especially macrophage accumulation, is commonly observed in intracranial ruptured aneurysms. Innumerous mediators are involved, such as MMP-2, MMP-9, MCP-1, IL-1b, and TNF-a (6). The development of molecular and cellular imaging to monitor inflammation will lead to better prediction of the probability of intracranial aneurysm rupture (1). Hasan et al. visualized macrophages in the wall of cerebral aneurysm using a special T2*emagnetic resonance imaging sequence. Human patients with cerebral aneurysms were infused with ferumoxytol, and aneurysms with early ferumoxytol uptake showed increased expression of inflammatory molecules and cells when compared with those presenting later uptake. These results suggest that this “early uptake” points to vessel wall instability. Could such a radiological imaging technique play an essential role in clinical assessment and management of intracranial aneurysms? Edijali et al. described a technique in which circumferential aneurysmal wall enhancement could be an indirect marker of wall inflammation and therefore would be more frequent in unstable intracranial aneurysms. These authors studied 87 patients harboring 108 intracranial aneurysms and demonstrated that circumferential aneurysmal wall enhancement was the only independent factor associated with unstable status after a multivariate analysis (2). Recently Hasan et al. performed a secondary analysis of the International Study of Unruptured Intracranial Aneurysms (ISUIA) study and showed that frequent aspirin use leads to decreased risk of aneurysm rupture by 60%. Using radiological and histological techniques, the same group shows that a low-dose (81 mg) of acetylsalicylic acid for 3 months may attenuate inflammation. They

Cavernous carotid artery aneurysms: epidemiology, natural history, diagnostic and treatment. An experience of a single institution.

BACKGROUND Cavernous carotid aneurysms (CCA) account for 2-9% of all intracranial aneurysms. They have been considered benign lesions, most often asymptomatic, and to have a natural history with a low risk of life-threatening complications. These aneurysms are unique, their rupture can present in many different forms, they can suffer spontaneous thrombotic changes and the symptomatology related to the mass effect involves the neuro-ophthalmologic system. In this scenario the natural history and clinical presentation are largely different from other intracranial aneurysms. Some investigators advocate treatment of both symptomatic and asymptomatic CCAs, others recommend no treatment. The reason for this controversy relates to a lack of information on the long term natural history of these aneurysms, as well as on the long term results of treatment. METHODS In this article the authors discuss their single institution experience in diagnosis, natural history and management of 123 asymptomatic and oligosympotomatic aneurysms located in the cavernous portion of internal carotid artery. CONCLUSIONS According to our results asymptomatic or olygosymptomatic (pain) CCAs should be conservatively managed with serial images while the others presentations should be analyzed by a multidisciplinary team, involving the neuroendovascular and microsurgical services.

Socioeconomic and educational factors interference in the prognosis for glioblastoma multiform

Abstract Background. To compare the survival of glioblastoma multiforme (GBM) patients operated on at public hospital with that of patients operated on at the private hospitals. Method. We carried out a retrospective analysis of the patients’ medical records, the surgical reports and the pre- and post-operative images of patients with a histopathological confirmed adult supratentorial GBM. Sixty-three patients were treated at public hospital and twenty-one at private hospitals. Results. The present study revealed that the survival of patients treated in private hospitals was statistically superior to that of patients treated in public hospitals (11.9 vs. 7.7). Conclusions. Our study advances towards the confirmation of the hypothesis that socioeconomic and educational factors influence the Karnofsky Performance Score (KPS) and the performance of radiotherapy treatment, with negative effects over the GBM patients’ survival.

SOLITARY FIBROUS TUMOR WITH INTRACRANIAL INVASION

Residente do Servico de Patologia.Received 26 January 2009, received in final form 4 May 2009. Accepted 11 May 2009.Dr. Leonardo C. Welling – Rua Sacadura Cabral 178 - Hospital dos Servidores do Estado RJ / Servico de Neurocirurgia / 7° andar - 20221-161 Rio de Janeiro RJ - Brasil. E-mail: leonardowelling@yahoo.com.br