Paulo Puglia

The role of desmopressin in bilateral and simultaneous inferior petrosal sinus sampling for differential diagnosis of ACTH-dependent Cushing's syndrome

Objective   Bilateral inferior petrosal sinus sampling (BIPSS) with corticotrophin‐releasing hormone (CRH) stimulation is currently the gold standard test for the differential diagnosis of ACTH‐dependent Cushings syndrome. Reports on the use of desmopressin in this approach are limited. The aim of this study was to evaluate the use of desmopressin during BIPSS in a cohort of patients with ACTH‐dependent Cushings syndrome.

Congruence of the topography of intracranial calcifications and epileptic foci

Nodular intracranial calcifications (NIC) are frequent findings in CT scans of epileptic patients in countries where granulomatous central nervous disease such as neurocysticercosis is endemic. In 34 consecutive epileptic patients with NIC submitted to EEG, CT and CSF analysis, the correlation between the electroclinical localization of the focus and the topography of the NIC was studied. Twenty-nine patients had partial (Group I) and 5 had primarily generalized seizures (Group II). Twenty group I and 1 group II patients showed abnormal EEGs. CSF abnormalities consisted of increased protein content (n = 3) and positive Weinbergs reaction (n = 2). In 2 cases, viable neurocysticercotic vesicles were seen. Twenty-one patients had single NICs. No correlation could be established in group II patients. Within group I, 15 patients had a positive and 14 a negative correlation. Sixty-six percent of the patients with single NICs had negative correlations. These findings strongly suggest that the calcifications themselves are not the epileptogenic lesions in at least 50% of the studied cases.

Dissecção espontânea cervical carotídea e verbal: estudo de 48 pacientes

OBJECTIVE To report a Brazilian series of spontaneous cervical arterial dissections, risk factors, warning symptoms, clinical manifestations, diagnostic tests, treatment and prognosis. METHOD We performed the retrospective analysis of clinical and neuroradiological records (MRI, A-MRI and Angiography) of patients with this diagnosis who were evaluated in a tertiary hospital for the period of 1997-2003. RESULTS 48 patients (24 men) with median age 37.9 years: 26 patients with unilateral internal carotid dissection (ICAD), 15 with unilateral vertebral artery dissection (VAD) and 7 with multivessel dissections. All patients presented neurological deficits. Hypertension, smoking and dyslipidemia were the main risk factors. More than 80% of patients presented at least one initial symptom, most of them temporoparietal headache. 44% of patients with VAD and only 3.4% of patients with ICAD had neck pain. The median interval between the onset of symptom and the appearance of neurological deficit was 5.4 days for ICAD and 13.5 days for VAD. Five patients with ICAD presented preceding TIA. Angiography was performed in 93% of patients. In 42% of these patients, MRI and A-MRI were associated. In three patients the diagnosis was made just through cervical MRI. 75% of patients received anticoagulation. Two patients received intravenous thrombolytic therapy with no complications. Prognosis was good for all patients but two patients with bilateral ICAD died. CONCLUSION Our results are similar to the literature, except for the low frequency of neck pain in ICAD patients and predominance of temporoparietal headache in cervical artery dissection patients. Vascular risk factors were commonly found.

Bilateral occipital infarcts associated with carotid atherosclerosis and a persistent hypoglossal artery

The persistent hypoglossal artery (PHA) is the second most common persistent embryological carotid-basilar connection and usually represents an incidental finding in cerebral arteriograms. The hypoglossal artery connects the primordial carotid artery with the longitudinal neural arteries, which later form the basilar artery. The PHA leaves the internal carotid artery as an extracranial branch, enters the skull through the anterior condyloid foramen, the hypoglossal canal and joins the caudal portion of the basilar artery. We report magnetic resonance and digital subtraction angiography findings in the first case of bilateral occipital infarctions associated with PHA and carotid atherosclerosis. The probable mechanism underlying bilateral occipital infarcts was embolism from the carotid territory to the posterior cerebral arteries. PHA may present a challenge in diagnosis and management of patients with carotid atherosclerosis and vertebrobasilar ischemia.

Intracranial vascular lesions associated with small epidural hematomas.

OBJECTIVE We studied the angiographic findings in patients with small epidural hematomas and cranial fractures crossing over the trajectory of the middle meningeal artery and its branches. Additionally, the occurrence of traumatic vascular lesions and their clinical relevance and treatment are discussed. METHODS A consecutive analysis was performed for 24 patients who harbored small epidural hematomas in middle meningeal artery topography associated with cranial fractures. Computed tomographic scans and plain x-ray studies were used to diagnose linear cranial fractures. Patients with large epidural hematomas or associated traumatic lesions were excluded from the study. Selective ipsilateral external carotid angiograms were obtained, and an endovascular procedure was performed if any vascular injury was evidenced. RESULTS In all patients with cranial fractures crossing over the middle meningeal artery and its branches, some kind of vascular lesion was seen. Two types of findings were noted: active extravasation of the contrast medium (71%) and pseudoaneurysms (29%). Early filling of diploic vessels was found in 8.3% of fractures concomitantly with active extravasation. Embolization was performed in all patients. No additional enlargement of the epidural hematoma was observed, and the postoperative period was uneventful. CONCLUSION This study shows that pseudoaneurysms and active extravasation of contrast are common findings in this subset of patients. Although the natural history of these lesions is still poorly understood, additional investigation with ipsilateral external carotid angiography may be recommended, considering the potentially catastrophic consequences of late rupture.

Surgical treatment of extracranial arteriovenous malformations after multiple embolizations: outcomes in a series of 31 patients.

Background: Surgical resection after embolization is the most accepted approach to treating arteriovenous malformations. The authors analyzed the outcome of surgically treated patients and how surgical resection was influenced by multiple embolizations. Methods: Thirty-one patients were included from January of 2000 to December of 2012. The mean patient age was 24.9 years. Anatomical involvement, definition of limits, functional impairment, number of embolizations, type of resection, reconstruction method, blood transfusion, and hospital stay were evaluated. Morbidity, mortality, and regrowth rates and need for additional procedures were evaluated. Results: Lesions were preferentially located at the orbits, cheeks, and lips. The number of embolizations per patient increased with lesion complexity. In 22 cases, total excision was accomplished, and in nine, subtotal resections were performed to favor function. After multiple embolizations, better lesion identification was observed. Primary closure was performed in 20 cases, local flaps were performed in seven cases, axial flaps were performed in two patients, and free flaps were performed in two cases. There were no deaths. Regrowth rates were influenced by limits between arteriovenous malformations and surrounding tissues (15.8 percent of cases with precise limits versus 58.3 percent of lesions with imprecise limits; p = 0.021) and by type of resection (18.2 percent of cases after total resection versus 66.7 percent after subtotal resections; p = 0.015). Conclusions: Multiple therapeutic embolizations seem to increase safety in the treatment of arteriovenous vascular malformations and suggest an additional positive effect besides bleeding control. Preoperative definition of limits and establishment of conditions for total resection are critical to determine management and risk of regrowth. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Intracranial vertebral artery dissection presenting as subarachnoid hemorrhage: successful endovascular treatment

Introduction– Intracranial vertebral artery dissection is a rare condition which may present as subarachnoid hemorrhage. In this situation, treatment is controversial. Case report– A case of intracranial right vertebral artery dissection in a 55‐year‐old woman presenting with subarachnoid hemorrhage is reported. The patient underwent therapeutic occlusion of the dissected artery through microcatheterization using pushing detachable platinum microcoils and had a good outcome. At this moment, the patient has a normal neurologic examination and a control digital subtraction angiography 1 year after the procedure showed an occluded right vertebral artery at V3; there was retrograde flow in the right intracranial vertebral artery up to the origin of a meningeal branch; the artery was thin and had mural irregularities, without any evidence of aneurismatic dilatation. Discussion– We review the literature and discuss the role of endovascular therapy and other therapeutic options in the treatment of this condition.

Revascularização clínica e intervencionista no acidente vascular cerebral isquêmico agudo: opinião nacional

Arq Neuropsiquiatr 2006;64(2-A):342-348* P a rticipantes: Ana Claudia Ferraz, Alexandre L. Longo, Aroldo Luiz Bacellar, Ay rton Roberto Massaro, Carla Heloisa Cabral Moro ,Cesar N. Raffin, Charles Andre, Edson Matos Novak, Eli Faria Evaristo, Elza Dias Tosta, Fabio Iuji Yamamoto, Gabriel Rodriguez deF reitas, Ibsen Thadeo Damiani, Jamary Oliveira Filho, Jayme Antunes Maciel Junior, Jefferson Gomes Fernandes, Jorge El KadumNoujaim, Jose Ibiapina Siqueira Neto, Marcia Maiumi Fukujima, Maria Lucia Pimentel, Mauricio Friedrich, Paulo Puglia, Roberto deMagalhaes Carn e i ro Oliveira, Rogerio Darwich, Rubens Jose Gagliardi, Sebastiao Eurico Mello-Souza, Sergio Roberto Haussen,Soraia Ramos Cabete Fabio, Viviane Flumignan Zetola, Waldir Antonio Tognola. O forum de “Opiniao Nacional” foi realizado emSao Paulo-SP, no dia 1o de julho de 2004. Os temas de trabalho foram divididos para analise inicial por grupos de 5 a 6 neuro l o g i s t a s .Os coordenadores do presente tema foram os Drs. Cesar N. Raffin e Jefferson Gomes Fernandes. Um esboco de texto foi propostopara analise em plenario em leitura publica. Comentarios, criticas e sugestoes de mudancas foram amplamente debatidos por esteplenario e incorporados ao texto final, redigido pelo grupo responsavel pelo tema. Recebido 8 Novembro 2005. Aceito 24 Janeiro 2006.

Treatment of subclavian steal syndrome with percutaneous transluminal angioplasty and stenting: case report.

Subclavian steal syndrome refers to the association of neurological symptoms related to vertebrobasilar insufficiency and the phenomenon of subclavian steal. We report the case of a 63 year-old male patient that presented subclavian steal syndrome and severe proximal (80%) stenosis of the left subclavian artery. The patient was submitted to percutaneous transluminal angioplasty and stenting on the left SA. The procedure was well tolerated and immediately afterwards, there was complete remission of the symptoms and of the phenomenon of subclavian steal evaluated by angiography and transcranial doppler. We propose that percutaneous transluminal angioplasty with stenting placement is a good therapeutic option for subclavian steal syndrome.

Basilar artery occlusive disease in stroke survivors in a multiethnic population

OBJECTIVES To describe clinical, radiological findings, and outcome in a multiethnic population of stroke survivors with basilar artery occlusive disease (BAOC). METHODS Forty patients with infarcts in the basilar artery (BA) territory, alive 30 days after the ictus, participated in the study. BA stenosis (>50%) or occlusion was shown by magnetic resonance or digital subtraction angiography in all patients. Demographical, clinical and radiological characteristics were described. Modified Rankin Scale (MRS) scores at 30 days and 6 months after the ischemic event were evaluated. Association between demographical, clinical, radiological features and outcome were analyzed with Chi-square and Fishers exact tests. MRS scores at 30 days and 6 months were compared with the Wilcoxon test. RESULTS Sixty percent of the patients were men, and 33% were Afro-Brazilian. Mean age was 55.8+/-12.9 years. Most (90%) had multiple vascular risk factors. Stroke was preceded by TIA in 48% of the patients, and 80% had a history of arterial hypertension. The most common neurological symptom was vertigo/dizziness (60%) and the sign, hemiparesis (60%). Most of the infarcts were located in the pons (85%) and the BA middle third was the most frequently affected segment (33%). BA occlusion occurred in 58% of the patients. More severe vascular occlusive lesions were present in Whites (p=0.002) and in patients with involvement of the middle third of the BA (p=0.021). Large-artery atherosclerosis was the most common stroke etiology (88%) and was more frequent in older patients (p<0.001). Most patients were treated with anticoagulation. MRS scores improved significantly at 6 months (p<0.001); at this time, 78% of the patients had MRS scores between 0 and 2. CONCLUSIONS We observed different results compared with other series: greater proportion of Afro-descendents, higher frequency of atherosclerosis and BA occlusion. Rates of preceding TIAs and good outcome at 6 months were similar to previously published data. These results represent a step forward towards understanding BAOC in a multiethnic context.