Nelson Martelli

Cysticercosis of the central nervous system: I. Surgical treatment of cerebral cysticercosis. A 23 years experience in the hospital das clínicas of Ribeirão Preto Medical School

Cysticercosis is the most frequent parasitosis of the nervous system and nowadays it is widespread through the world. Despite the development of anticysticercal drugs (praziquantel and albendazole), their efficacy is more marked in cases with parenchymal active cysts and they do not prevent complications such as hydrocephalus. Thus, many patients with neurocysticercosis require surgical intervention, generally of palliative nature, but that may occasionally produce a cure. The clinical outcome of 180 patients with cerebral cysticercosis who underwent surgical treatment form 1970 to 1993 was analyzed. Surgical treatment was performed to control increased ICP in 177 patients and due to local compression of cranial nerves or brainstem in five. Some patients had more than one surgical procedure, totalizing 287 interventions. Increased intracranial pressure (ICP) was caused by hydrocephalus in 91%, by intracranial mass lesion (tumoral form) in 6.2% and by pseudotumor cerebri (pseudotumoral form) in 2.8% of the case. Based on the pathophysiological mechanisms of intracranial hypertension identified through conventional CT-scan, ventriculography, cysternotomography, ventriculotomography and MRI, different surgical approaches were indicated. Patients with tumoral form were submitted to direct approach and cyst removal and generally they had benefits from this procedure. Patients with pseudotumoral form whose clinical treatment failure underwent decompressive craniectomies and had a poor outcome (40% of good results). Direct removal of ventricular/cisternal cysts and/or ventriculoatrial/peritoneal shunting (VA/VPS) was performed in patients with hydrocephalus. Removal of free ventricular cysts in patients who had no ependimitis/arachnoiditis generally allowed a good outcome. Patients with adherent cysts and inflammatory process needed a VA/VPS posteriorly and the outcome was not so good. One hundred thirty-two patients were submitted to VA/VPS (109 as the first procedure and 23 after another surgical treatment). The VA/VPS was effective to control increased ICP, despite many complications observed mainly during the two first postoperative years. After this period the surviving patients generally had a better outcome. The patients submitted to cyst removal due to local compression of cranial nerves/brainstem generally had good results. Based on the experience acquired with the management of these patients we present our recent policy for the treatment of patients with neurocisticercosis.

Infantile hydrocephalus: brain sonography as an effective tool for diagnosis and follow-up

Infantile hydrocephalus is a common disease. In most affected children the process starts before the age of 2 when the bregmatic fontanel is still open. Brain sonography has emerged as an effective tool in diagnosing progressive ventricle dilation and may be used for continuous follow-up. It gives such important information as: (a) cortical thickness, an expression of proper shunt function and of prognostic value concerning neuropsychological development; (b) position of the tip of the catheter, which is considered by some to be a predictive factor of shunt failure; (c) other complications such as subdural collections, isolated IV ventricle, and slit ventricles. This methodology permits frequent examinations and allows better comprehension of the pathological process by the parents and medical staff.

Forma tumoral da neurocisticercose: exerese de cisticerco de 70x77 mm e tratamento com praziquantel: relato de caso

The authors report a case of a female patient, age 22, who presented episodes of focal seizures, right hemiparesis and dysphasia of five months duration. The neurologic exam revealed bilateral papilledema and computarized tomography of the head showed a cystic lesion (70x77 mm) in the left fronto-temporo-parietal area, midline shift and similar lesions scattered in the brain parenchyma. She was submitted to a left craniotomy with the diagnosis of cerebral cysticercosis and the major cyst (Cysticercus racemosus) and a small cortical cyst (10x10 mm) were removed to aliviate the increased intracraneal pressure and for histopathological examination. Thirteen days after surgery she was discharged without neurological deficits, except mild papilledema. One month later she was treated with praziquantel (50 mg/kg/day) during 21 days. The CSF examination was normal before the treatment started and showed a transient eosinophilic cellular reaction with positivation of the complement fixation test for cysticercosis while on treatment. The CT-Scan performed before the medical treatment revealed ventricular dilatation and several low density areas (10 to 40 mm) scattered in the cerebral parenchyma, including the operative site. CT-Scan performed three months later showed small low density areas only in the left cerebral hemisphere, including the operative site, calcification in the parenchyma, and slight dilatation of the left lateral ventricle. The clinical evolution was uneventfull and the neurologic examination was normal three months later.

Surgical Treatment of Cysticercosis of the Central Nervous System

Summary:Cysticercosis is the most frequent parasitosis of the central nervous system. Because anticysticercal drugs do not prevent complications such as hydrocephalus, many patients with cysticercosis require surgical intervention. A review of the pathophysiology and surgical treatment of this disease is presented. Free spinal cysts may need surgical removal, generally with transient good results. Cysts compressing cranial nerves or the brainstem may be removed, generally with good results. Frequently patients with cysticercosis need surgery to control increased intracranial pressure. Based on the pathophysiological mechanisms of intracranial hypertension, different surgical approaches may be indicated. Giant cysts are removed with good results. Patients with the pseudotumoral form of cyst whose clinical treatment has failed generally have poor outcomes when subjected to decompressive craniectomies. Removal of cysts and/or ventriculoperitoneal shunting are performed in patients with hydrocephalus. Removal of free ventricular cysts generally produces a good outcome. Patients with adherent cysts need ventriculoperitoneal shunting posteriorly. Patients with inflammatory hydrocephalus require ventriculoperitoneal shunting. Despite many complications, ventriculoperitoneal shunting is effective to control increased intracranial pressure. Generally, patients with intraparenchymal forms of cysticercosis (normal size or giant cysts) have a better prognosis than do patients with the extraparenchymal form (cisternal, ventricular, and spinal), except for cases of free intraventricular cysts. We present our recent policy for management of patients with this disease.

Ultrasonographic evaluation of infantile hydrocephalus before and after shunting

The authors present the results of a prospective study of 20 children with congenital or acquired hydrocephalus of nontumoral etiology and submitted to ventriculo-(or cyst-) peritoneal shunting with valve. The diagnosis was established by B-mode or real-time brain sonography, in association with another neuroradiological procedure (computed tomography, ventriculography with air or Dimer-X, cerebral angiography). Among the proposed measurements (cortical thickness, lateral ventricle height, III ventricle width and ventricular ratio) for pre- and postoperative comparison, the cortical thickness and the lateral ventricle height were the ones that changed significantly when analyzed by sonography. The routine use of brain sonography allowed the visualization of the ventricular catheter position and the diagnosis of complications, such as subdural collection, progressive enlargement of cysts, isolated IV ventricle, etc, even before symptoms arise. The authors conclude that sonography is easily performed, inexpensive and innocuous, and should be used routinely during the follow-up of children with hydrocephalus.

Goma sifilitica intra-raquidea causando compressão medular: relato de um caso

A case of an syphilitic intraspinal gumma is reported. A 48 years-old woman developed severe spastic crural paraparesis of two months duration, associated with sensory and sphincteric disturbances. Myelography revealed an intraspinal tumor at T3 level. Surgical exploration by dorsal laminectomy showed a syphilitic gumma attached to the spinal cord. Clinical observations and laboratory studies are discussed. Revision and comments on previous reports are presented.A case of an syphilitic intraspinal gumma is reported. A 48 years-old woman developed severe spastic crural paraparesis of two months duration, associated with sensory and sphincteric disturbances. Myelography revealed an intraspinal tumor at T3 level. Surgical exploration by dorsal laminectomy showed a syphilitic gumma attached to the spinal cord. Clinical observations and laboratory studies are discussed. Revision and comments on previous reports are presented.E relatado o caso de uma paciente de 48 anos que apresentou um quadro de paraparesia crural espastica muito acentuada com evolucao de dois meses, acompanhada de disturbios da sensibilidade e disturbios esfincterianos. As mielografias ascendente e descendente revelaram processo expansivo intra-raquideo ao nivel de T3. A laminectomia de T2-T4 e o exame histopatologico mostraram tratar-se de uma goma sifilitica justaposta a medula. As evolucoes clinica e dos exames complementares sao comentadas a luz de algumas observacoes encontradas na literatura.

Cerebromeningeal hemorrhage: analysis of autopsies performed over a 10-year period

A study was conducted on the medical records of 353 patients who died of a subarachnoid hemorrhage (SAH) and who were submitted to autopsy over the last 10 years. SAH was associated with arterial hypertension in 180 (51%) cases, with ruptured aneurysms in 102 (28.9%), and with other pathologies in 71 (20.1%). The patients with hemorrhage associated with arterial hypertension were mostly males, and those with hemorrhage due to aneurysms were mostly females. Of the patients with aneurysms, 36 (35.3%) had aneurysms in the anterior communicating artery, 30 (29.4%) in the internal carotid artery, and 23 (22.6%) in the middle cerebral artery. Among the patients with aneurysms who suffered rebleeding and vasospasm, 59.1% and 61.5%, respectively, were classified as grade I and II upon admission, and all evolved toward grade IV after these complications. Vasospasm predominated from the 3rd to the 10th day after hemorrhage, and rebleeding from the 9 to 16th day and both were most frequent among patients with aneurysms of the anterior communicant artery. Sixty eight percent of the patients with aneurysms died during the first 9 days after hemorrhage. Because of our conduct was to operate systematically late, a considerable number of patients lost the opportunity to be treated surgically with possible favorable evolution due to vasospasm or rebleeding.

Tomografia computadorizada em pacientes portadores de neurocisticercose com hipertensao intracraniana por hidrocefalia obstrutiva: comparacao com ventriculografia com Dimer-X.

The authors reviewed the alterations observed on computerized tomography (CT) examinations of 16 patients with increased intracranial pressure and obstructive hydrocephalus due to cerebral cysticercosis. Plain radiograms of the skull were available in all cases and Dimer-X ventriculography in 12 cases. In 7 cases there were radiologic signs of increased intracranial pressure. CT scan showed normal cerebral parenchyma in 9 cases and low density areas, with various size, with or without surround contrast enhancement, and/or small calcifications in the parenchyma. Hydrocephalus was the only alteration observed in the ventricular system in the case that the examination was done before ventricular drainage. Ventriculography was analyzed in other paper and permitted to situate the obstruction, determine its morphological characteristics and identify occuping space lesions within the ventricles. Comparison between ventriculography and CT scan made in the same period evidence that the former gives best information about the ventricular system and that tomography gives additional information about the cerebral parenchyma. In conclusion, CT scan and ventriculography are investigations that complete each the other for evaluation and diagnosis of cerebral cysticercosis.The authors reviewed the alterations observed on computorized tomography (CT) examinations of 16 patients with increased intracranial pressure and obstructive hydrocephalus due to cerebral cysticercosis. Plain radiograms of the skull were available in all cases and Dimer-X ventriculography in 12 cases. In 7 cases there were radiologic signs of increased intracranial pressure. CT scan showed normal cerebral parenchyma in 9 cases and low density areas, with various size, with or without surround contrast enhancement, and/or small calcifications in the parenchyma. Hydrocephalus was the only alteration observed in the ventricular system in the case that the examination was done before ventricular drainage. Ventriculography was analyzed in other paper and permitted to situate the obstruction, determine its morphological characteristics and identify occuping space lesions within the ventricles. Comparison between ventriculography and CT scan made in the same period evidenced that the former gives best information about the ventricular system and that tomography gives additional information about the cerebral parenchyma. In conclusion, CT scan and ventriculography are investigations that complete each the other for evaluation and diagnosis of cerebral cysticercosis.

Ultra-sonografia cerebral em crianças no primeiro ano de vida: método para o diagnóstico e acompanhamento das dilatações ventriculares

The ultrasonography (Mode B--Real Time) experience was analyzed to evaluate neurological diseases in children during their first year of life. Forty-two examination were accomplished in twenty-eight children with the following diagnosis: hydrocephalus (22), normal (15), subdural hygroma (3), intracranial cyst and hydrocephalus (1), giant encephalocele (1). The technique consists of positioning the transducer in the coronal, sagital and axial direction and selecting dynamically the images to be photographed. In the coronal position, the height of the lateral ventricle and the width of the third ventricule were obtained. In the axial position, the ventricular ratio-lateral ventricle width cerebral hemisphere width was obtained. Although it was a small group of patients, those indexes can objectify the ventricular size variation in children with well or poor functioning shunts. The importance of this method was the possibility to follow the development of hydrocephalus in cases of myelomeningocele and to analyze the etiology and features of hydrocephalus with or without shunts. In conclusion, this test is very usefull, mainly because it is very brief (about 20 minutes), the patient does not need sedation, it is innocuous, very precise even when compared with computerized tomography and for its low cost.

Hidrocefalia infantil resultados tardios em 102 pacientes e importância da neuro -sonografia

A personal series (in 94% of the cases) of 102 children who underwent 170 procedures (1.66 procedures/patient) for hydrocephalus has been followed for 5 1/2 years (Jan-S3 to Jun-88). Most of the children were under two years of age (80%) and in these cases brain sonography was the examination of choice for both diagnosis and follow-up (307 examinations, 4.4 per patient). Only occasionally was computed tomography necessary for better study in these cases. Our results suggest that there was no significant difference between our cases and those published in the litterature concerning the number of procedures/patient (1.66)., infection rate (5.2%), mortality rate (6.8%) and intellectual performance. We recommend the use of brain sonography both in diagnosis and follow-up studies for hydrocephalic children since this examination is innocuous, inexpensive and easy to perform by neurosurgeons. Also it provides a good interaction between the examiner, the child and the parents, which is of utmost importance for the comprehension of the disease by the parents and early diagnosis of complications by the neurosurgeon.