Marcos Q. T. Gomes

Angioleiomyoma of the cavernous sinus: Case report

OBJECTIVE AND IMPORTANCE:Angioleiomyomas (ALMs) are relatively rare, benign, vascular soft tissue tumors that occur most frequently in the extremities of middle-aged individuals. To date, only two cases of intracranial ALMs have been described, both with little emphasis on the clinical, surgical, and radiological aspects. Neither of these reported cases of ALM involved the cavernous sinus. Furthermore, there is no previous intracranial ALM magnetic resonance imaging scan described in the literature. This report presents the first case of cavernous sinus ALM, emphasizing the clinical, radiological, and surgical aspects. CLINICAL PRESENTATION:A 52-year-old man had a 2-year history of horizontal diplopia and frontal headache. Facial numbness and impaired visual acuity in the previous 6 months were also reported. Physical examination revealed paralysis of right Cranial Nerves III, IV, and VI. A decrease in optical acuity was also noted. Computed tomographic and magnetic resonance imaging scans demonstrated a mass lesion located in the right cavernous sinus, which enhanced homogeneously with administration of intravenous contrast medium. INTERVENTION:A total resection was performed via a right frontotemporal craniotomy and a pretemporal approach with peeling of the middle fossa. The postoperative course was uneventful. Histological examination identified the ALM, with no recurrence noted during follow-up. CONCLUSION:It is unknown why intracranial ALMs have not been reported more frequently in the literature. Although ALMs are a rare occurrence, misinterpretation of this lesion may also have contributed to the lack of reported cases. Before surgery, ALMs can be distinguished from meningiomas and schwannomas but not from hemangiomas. The prognosis of intracranial ALM is good, as suggested in this case as well as the two previously reported cases.

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.

Complete motor recovery after acute paraparesis caused by spontaneous spinal epidural hematoma: case report

BackgroundSpontaneous spinal epidural hematoma is a relatively rare but potentially disabling disease. Prompt timely surgical management may promote recovery even in severe cases.Case presentationWe report a 34-year-old man with a 2-hour history of sudden severe back pain, followed by weakness and numbness over the bilateral lower limbs, progressing to intense paraparesis and anesthesia. A spinal magnetic resonance imaging scan was performed and revealed an anterior epidural hematoma of the thoracic spine. He underwent an emergency decompression laminectomy of the thoracic spine and hematoma evacuation. Just after surgery, his lower extremity movements improved. After 1 week, there was no residual weakness and ambulation without assistance was resumed, with residual paresthesia on the plantar face of both feet. After 5 months, no residual symptoms persisted.ConclusionsThe diagnosis of spontaneous spinal epidural hematoma must be kept in mind in cases of sudden back pain with symptoms of spinal cord compression. Early recognition, accurate diagnosis and prompt surgical treatment may result in significant improvement even in severe cases.

The clip-wrap technique in the treatment of intracranial unclippable aneurysms

UNLABELLED Fusiform and dolichoectatic aneurysms are challenging lesions to treat with direct clipping. Treatment of these aneurysms often requires alternative surgical strategies, including extracranial-intracranial bypass, wrapping, or clip-wrap techniques. Nonetheless, these alternatives methods of treatment have been underused and frequently overlooked. OBJECTIVE To report a series of nine cases of otherwise untreatable aneurysms managed using the clip-wrap technique and discuss its surgical nuances. METHOD In the last four years, 9 cases of ruptured aneurysms treated by the clip-wrap techniques were identified in the Division of Neurological Surgery, University of São Paulo, School of Medicine. RESULTS The aneurysms were located at middle cerebral artery (2), anterior choroidal artery (1), anterior communicating artery (1), carotid ophthalmic (3), posterior cerebral artery (1) and posterior-inferior cerebellar artery (1). Three were dolichoectatic, 4 were unsuitable to complete surgical clipping because parent or efferent vessels arises from the aneurysm sac (1 MCA, 1 AcomA, 1 CO, 1 PICA aneurysms) and two, although ruptured aneurysms, were too small (<2mm) to be directly clipped. No early or late rebleeding was observed after 2 years mean follow-up. One patient deceased due to pulmonary tromboembolism. CONCLUSION Clip-wrap techniques for the treatment of fusiform and otherwise unclippable aneurysms seem to be safe and it can be associated with a low rate of acute or delayed postoperative complications. It can prevent rebleeding and represents an improvement when compared with the natural history.

A rare case of olfactory groove schwannoma

Supervisor and Cerebrovascular Surgical Coordinator, Division of Neurological Surgery, University of Sao Paulo, School of Medicine, Sao Paulo SP, Brazil; Skull Base Surgical Coordinator, Division of Neurological Surgery, University of Sao Paulo, School of Medicine, Sao Paulo SP, Brazil; Assistant Professor, Department of Neurosurgery, Brain Research Institute, Nigata University, Nigata, Japan; Resident, Division of Neurological Surgery, University of Sao Paulo, School of Medicine, Sao Paulo SP, Brazil; Chairman, Department of Pathology, University of Sao Paulo, School of Medicine, Sao Paulo SP, Brazil; Chairman, Division of Neurological Surgery, University of Sao Paulo, School of Medicine, Sao Paulo SP, Brazil.

Tumoral form of aspergillosis in central nervous system (cerebral aspergilloma): case report

Aspergillosis of the central nervous system is an uncommon infection, mainly occurring in immunocompromised patients. It may be presented in several forms: meningitis, mycotic aneurysms, infarcts and the tumoral form (aspergilloma). The authors report a case of a diabetic patient with cerebral aspergilloma.

Double-Bladed Scalpel: A New Option for Harvesting Margins in Head and Neck Cancers

Background: In advanced head and neck tumors margins are very rarely comprehensively checked by frozen sections. The goal of this study was to analyze a new proposal for harvesting margins using a double-bladed scalpel.Methods:Thirty-eight patients underwent a comprehensive resection of advanced head and neck tumors with a double-bladed scalpel. Margins were mapped and checked by frozen sections, while tumor resection continued. When positive margins were identified, they were excised again, and checked by frozen sections. Results: Thirty-three patients (87%) had clear skin and soft tissue margins at frozen sections. Five patients (13%) had focal skin and soft tissue-positive margins at frozen sections, which were re-excised. Two patients (5%) had skin and soft tissue-positive margins only at permanent sections. One was reoperated and 1 received radiation therapy. The 3-year local control rate was 58%. Conclusions: In this preliminary study, the double-bladed scalpel appeared to be an interesting option for complete intraoperative evaluation of surgical margins of advanced head and neck tumors.

Abscesso cerebelar por Nocardia: relato de caso

The authors describe a case of cerebellar abscess by Nocardiain a patient with the acquired immunodeficiency syndrome (AIDS) that was submitted to a posterior fossa craniectomy for diagnosis and treatment. Pathological and neuroimage findings are discussed as well as the surgical approach taking into account literature data on the subject.

In reference to intervention for elevated intracranial pressure improves success rate after repair of spontaneous cerebrospinal fluid leaks

The distinguishing clinical-radiological features of idiopathic intracranial hypertension (IIH) are often found in patients with spontaneous cerebrospinal fluid (CSF) rhinorrhea. In such cases, CSF leak is probably a consequence of persistently increased intracranial pressure (ICP). In this context, it was with great delight that we read the study by Teachey et al. titled “Intervention for Elevated Intracranial Pressure Improves Success Rate After Repair of Spontaneous Cerebrospinal Fluid.” The authors presented a prospective case series of 108 patients with spontaneous CSF rhinorrhea who underwent endoscopic surgical repair and simultaneous evaluation and management of ICP over a period of 8 years. A surgical long-term success rate of 96.3% was reported. The authors also systematically reviewed the literature and collected the data of more 571 patients. The patients were then divided in two groups according to the treatment they had received for ICP: active (348) versus none (331). The groups presented significantly different long-term success rates after surgery (93% vs. 82%, respectively; P<.001). The authors concluded that correctly evaluating and treating ICP must be part of the optimal treatment of patients with spontaneous CSF rhinorrhea. Our group totally agrees and congratulates the authors for their meaningful work. It is interesting to note, however, that the active treatment group was quite heterogeneous and included all patients who 1) were prescribed acetazolamide, 2) had CSF diversion (vetriculoperitoneal or lumboperitoneal), or 3) had their ICP checked postoperatively, but did not require any further medical or surgical intervention. We were curious to know whether there were any differences in outcomes among these subgroups of patients. Possibly, better results were achieved with more aggressive and definitive CSF pressurelowering measures. With that in mind, since 1998 our team has advocated endoscopic repair and placement of permanent lumboperitoneal shunts (PLPS) for patients with spontaneous CSF rhinorrhea who are also suspected to have increased ICP. We have treated 18 patients meeting those criteria (16 females, 88.9%; 2 males, 77.8%; age average, 48.4 6 11.7 years). All of them underwent endoscopic surgery and placement of PLPS (follow-up: 129.8 6 68.7 months; minimum, 12 months; maximum, 226 months). None has presented recurrences to date (success rate5 100%), two (11.1%) presented symptoms of CSF hypotension, and one had transient abdominal discomfort (5.6%). None required revision surgery or shunt removal. Until now, there are no definitive guidelines for the treatment of IIH, with or without CSF leaks. Thus, beyond overstating that patients with spontaneous CSF rhinorrhea should also have their ICP addressed, it is time to take a step forward. We are anxious to see the best approach defined for patients with spontaneous CSF leaks and signs of IIH.

A giant partially thrombosed aica aneurysm

. Giant aneurysms of proximal portion of AICA are even more uncommon, being difficult to estimate their actual incidence. These aneurysms constitute formidable surgical challenge and a judicious preoperative planning is mandatory since surgical nuances often determined the final outcome.We present a case of giant partially thrombosed AICA aneurysm and discuss operative nuances required to min-imize the morbidity associated with such surgically chal-lenging lesions.CASE