Oswaldo Ricciardi Cruz

Neurocisticercose: formas clínicas pouco freqüentes. I - formas hemiplégicas

Os autores salientam a raridade dos deficits motores com distribuicao mono ou hemiplegica, consequentes a lesoes encefalicas de natureza cisticer-cotica. Ressaltam, outrossim, a dificuldade dos problemas diagnosticos que eventualmente se impoem nesses casos. Discutindo a patogenia desses processos, apontam dois mecanismos principais: as paralisias determinadas por focos encefalicos, constituidos por granulomas, cisticercoticos ou a distância, e os acidentes cerebrovasculares ocasionadas pelas alteracoes vasculares, cuja importância e realcada. Sao apresentados 19 casos de neurocisticercose, incluindo 17 formas hemiplegicas e 2 monoplegicas. Em todos, o diagnostico etiologico foi estabelecido pela positividade da reacao de fixacao do complemento para cisticercose no liquido cefalorraqueano, corroborado, em 2 casos, pela cirurgia e pela necropsia. Convulsoes foram registradas em 10 casos (focais em 7 e generalizadas em 3). Sintomas de hipertensao intracraniana foram assinalados em 4 pacientes. A hemiplegia instalou-se sob forma de icto em 14 pacientes. Em 3 casos houve elementos altamente sugestivos de patogenia predominantemente vascular; em 3, a sintomatologia relacionou-se diretamente ao granuloma parasitario, embora deva ter havido participacao do processo angiopatico; em 1 caso, tratava-se, provavelmente, de paralisia pos-convulsiva; em 3, embora nao houvesse suficientes dados complementares, os elementos clinicos levaram a salientar a importância do fator vascular na determinacao da hemiplegia. Em 5 pacientes o deficit motor instalou-se de modo lento e progressivo. Em 2 casos foram encontrados e extirpados cisticercos situados no cortex cerebral, tendo a necropsia revelado, em um deles, amolecimento isquemico na regiao parietal contralateral a hemiplegia; em 1 havia eisticercose da fossa craniana posterior, associada a lesao cortical traduzida por intensas alteracoes eletrencefalograficas; 2 casos careciam de elementos subsidiarios que pudessem orientar melhor quanto ao mecanismo patogenico da hemiplegia. Os autores salientam a possibilidade de, em alguns desses casos, os comemorativos clinicos poderem ter conduzido ao diagnostico erroneo, ora de tumor cerebral, ora de acidente cerebrovascular de etiologia indeterminada. Em tais eventualidades, os pacientes ficariam privados dos possiveis beneficios do tratamento adequado, cirurgico ou medicamentoso.

Neurocisticercose: formas clínicas pouco frequentes. II - formas do ângulo pontocerebelar

The localization of cysticerci in the lateral recess of the cisterna pontis may bring about a cerebello-pontine angle syndrome, eventually simulating a neurinoma of the nervus acusticus. The authors made a review of such cases reported in the literature. The differential diagnosis with the neurinomas of the auditory nerve is discussed under the clinical and radiological viewpoints. The authors report 7 cases of cysticercosis of the cerebello-pontine angle. The etiologic diagnosis was established in 5 cases by a positive complement fixation test for cysticercosis in the cerebrospinal fluid, and by surgery and/or postmortem examination in 2. All the cases showed symptoms of cochlear involvement, bilateral in 2; in 4 cases there was a vestibular impairment. Signs of unilateral involvement of the trigeminal nerve occurred in 6 cases. Facial nerve paralysis was present in 4 cases. Three patients had pharynx paralysis and 2, internal strabismus. In 3 cases the absence of cerebellar signs would suggest the diagnosis of neurinoma of the nervous acusticus if it were not for the clinical and subsidiary data, which pointed to neurocysticercosis. Signs of intracranial hypertension were evident in 5 patients. Convulsions occurred in 2 cases. Commenting on the results of radiological examination the authors emphasize that, in one case, there was an amputation of the tip of the petrous pyramid ipsilateral to the cerebello-pontine angle syndrome; other data, however, led the authors to reject the hypothesis of a neurinoma of the nervous acusticus, and the surgeon actually recovered a racemose cysticercus from the lateral recess of the cisterna pontis.

Congenital tumors of the nervous system I - Epidermoid and dermoid cysts

The authors study the tumors derived from inclusions of foetal ectodermal tissues, either of Malpighian epithelium (epidermoid cysts) or those also including dermal elements (dermoid cysts). The authors criticize the words cholesteatoma and pearly tumor, often applied to the former growths. The rareness of these cysts among nervous system tumors (particularly spinal epidermoids and diploic dermoids) is stressed. Sluggish development and incidence in youth are clinical features of both. The neurological symptomatology is extremely varied, since these tumors can be found in ?very site of the neuraxis. Some forms show peculiar signs which can point to their etiologic diagnosis. The authors report 12 cases of epidermoid (including 3 of the spinal canal) and 2 cases of dermoid cysts (including one of the diploe). Attention is called to eventual changes of the cerebrospinal fluid that may lead to erroneous diagnosis such as neurosyphilis and cysticercosis of the nervous system. The general rules and results of the surgical management are briefly analysed. In their own cases the authors had three post-operative deaths and three deaths not related to craniotomy (two preoperative and one due to an intervening cause: perforation of gastric ulcer); in the other cases improvement was achieved by surgery.

Carcinomatose das meninges

A case of carcinomatosis of the meninges, metastatic from a gastric carcinoma, is presented. Tumoral cells were found in the suboccipital and ventricular fluid. Macrocoscopic encephalic metastases were not found. The disposition and the morphology of the tumoral cells detected in the leptomeninges were similar to those of the primary tumor.

Meduloblastoma do cerebelo: metástases cerebrais múltiplas após operação e radioterapia

Sao registrados dois casos de meduloblastoma do cerebelo com metastases cerebrais multiplas localizadas nos lobos frontal e parietal. Ao contrario do que e registrado na literatura, os caracteres macroscopicos das metastases cerebrais encontradas no caso 1 eram identicos aos do tumor cerebelar primitivo.

Meningeomas: acometimento isolado de nervos cranianos

A review of 41 cases of intracranial meningeomas, some with unilateral isolated lesions of cranial nerves, is presented. From these 41 cases, 25 presented neurological symptoms and 14 were asymptomatic, the diagnosis being made only by subsidiary methods. In two cases of supra-tentorial meningeomas there were only signs of involvement of cranial nerves. In one of them (case 41) six cranial nerves were affected without any other signs of lesion of the nervous system. In other case (case 32 - temporal meningeoma) involvement of the VIth and VIIIth nerves was the only presenting sign, thus suggesting a posterior fossa localization.

Mucocele frontal com extensão intracraniana: a propósito de dois casos

O autor apresenta dois casos de mucocele frontal com extensao intracraniana. Em um dos casos existia hipertensao intracraniana e quadro angiografico normal; no outro, os valores tensionais do liquido cefalorraquidiano eram normais e o exame angiografico demonstrou a presenca de um tumor de localizacao frontal. Em ambos os casos foi utilizada a via frontal - craniotomia osteoplastica - para o acesso intracraniano. O contato do material contido no cisto com as meninges nao determinou alteracoes meningencefaliticas.

Compressão segmentar do plexo venoso extra-raquidiano: Valor para o diagnóstico de localização das afecções bloqueantes do canal raquidiano

Outside and inside the vertebral canal, running along its entire length, there is a series of venous plexuses which anastomoses with each other and end in intravertebral veins. They form a real plexuses whose primary disposition is schematically segmental. The plexuses form a series of venous rings at the level of each vertebra. Considering these anatomic data it has been supposed that a strong and lengthened compression at the level of the outside venous plexus will cause a raise in the inside venous pressure which can be detected with a Strauss manometer connected with a needle inserted in the lumbar subarachnoid space. The test would be indicated to locate the lower level of the spinal canal block by the oscilations of the cerebrospinal fluid pressure registered under this level. The test was performed in 5 patients without blocking process in which the Stookey test was normal; in none these cases it was found any raise in the cerebrospinal fluid pressure by local compression of venous plexuses of the spine from cervical untill lumbar vertebrae. The procedure was applied to 5 patients with blocking conditions of the spinal canal, previously diagnosed by the Stookey test. In 4 of these a definite increase (2 to 10 cm.) of the cerebrospinal fluid pressure has been recorded; in these cases the procedure allowed the exact detection of the lower level of the block, later confirmed by myelography and neurosurgery. In one case, however, the test has detected a level that could not be confirmed by myelography or the surgical act.