Ricardo Alexandre Hanel

Primary pituitary abscess: case report

Pituitary abscesses are potentially life-threatening lesions if not appropriately diagnosed and treated. The authors have operated on more than five hundred cases of pituitary tumors and only one represented a case of pituitary abscess. A 35-year-old woman was investigated for chronic frontal headache. CT scan showed a cystic sellar lesion with ring enhancement after contrast injection leading to an initial diagnosis of pituitary adenoma. She underwent a sublabial transsphenoidal approach to the pituitary gland. After dural opening, purulent material was obtained and no tumor or other associated lesion was detected. There was no evidence of current or previous septicemic illness, meningitis, cavernous sinus thrombosis or sinus infection. Cultures were negative. She was put on antibiotics and discharged after 4 weeks. Nowadays, 10 years after treatment, she is doing well, with no anterior pituitary hormone deficit. MRI shows a partially empty sella without residual lesion and the pituitary stalck is in the midline. The early diagnosis and adequate treatment of this life-threatening lesion may result in excellent prognosis.

Posterior approach for soft cervical disc herniation: a neglected technique?

BACKGROUND The ideal approach to the treatment of soft cervical disc herniation remains controversial. Recent reports emphasize several variations of anterior cervical approaches, including the introduction of instrumentation techniques. New issues have been raised and modern neurosurgeons seem to be less familiar with the posterior approach. The objective of this study was to analyze the results obtained by surgical treatment via a posterior approach of soft cervical disc herniation. METHOD Fifty-one patients who underwent laminectomy/flavectomy and disc removal for the treatment of soft cervical disc herniation in the period of 1990 to 1999 were analyzed retrospectively. Relief of pain and motor and sensory improvement were the criteria used to measure the success of the procedure. RESULTS Most of the patients presented with acute radiculopathy. Radicular involvement was as follows: 25 cases-C7 root, 19 cases-C6 root, 4 cases-C5 root, and 3 cases-C8 root. Total relief of pain was obtained in 49 of 51 patients (96%). Motor improvement was obtained in 35 of 46 patients (76%) and sensory improvement in 22 of 35 patients (62.8%) in the short term. The mean time of hospitalization was 3 days. There was no mortality and no morbidity. CONCLUSION The advantage of this method, in selected cases, over the classical anterior approach, is that there is no need for grafting, thus avoiding the additional pain and possible complications at the donor and receptor sites, while obtaining similar results.

Cerebrospinal fluid fistula as the presenting manifestation of pituitary adenoma: case report with a 4-year follow-up

We report the case of a young woman who presented with cerebrospinal fluid (CSF) rhinorrhea due to an undiagnosed and untreated pituitary adenoma. The tumor had extended well beyond sella turcica and caused bony erosion. The patient initially refused surgery and was treated with bromocriptine and a radiation therapy. CSF leakage did not improved and she was submitted to surgery by the transsphenoidal approach with removal of a tumor mass located in sphenoid sinus and sellar region. Origin of the leak was localized and repaired with fascia lata and a lumbar subarachnoid drain was left in place for 5 days. After 4 years she has normal serum PRL levels and no rhinorrhea. The management, complications and mechanisms involved in this rare condition are discussed.

Síndrome neuroléptica maligna: relato de caso com recorrência associada ao uso de olanzapina

The neuroleptic malignant syndrome (NMS) consists in an idiosyncratic reaction to neuroleptic drugs, probably related to a blockage of dopamine receptors in basal ganglia. Research criteria for diagnosing NMS from DSM-IV require severe rigidity and fever accompanied by 2 of 10 minor features including diaphoresis, dysphagia, tremor, incontinence, altered mentation, mutism, tachycardia, elevated or labile blood pressure, leukocytosis and elevation of creatine phosphokinase. From a clinical point of view, the NMS may range a large spectrum of presentations. Haloperidol is the most frequent drug associated with this syndrome. We report the case of a 30 year-old man who developed NMS at two different occasions, the first related to haloperidol and chlorpromazine and the second related to olanzapine, to our knowledge without previous mention in the indexed literature.The neuroleptic malignant syndrome (NMS) consists in an idiosyncratic reaction to neuroleptic drugs, probably related to a blockage of dopamine receptors in basal ganglia. Research criteria for diagnosing NMS from DSM-IV require severe rigidity and fever accompanied by 2 of 10 minor features including diaphoresis, dysphagia, tremor, incontinence, altered mentation, mutism, tachycardia, elevated or labile blood pressure, leukocytosis and elevation of creatine phosphokinase. From a clinical point of view, the NMS may range a large spectrum of presentations. Haloperidol is the most frequent drug associated with this syndrome. We report the case of a 30 year-old man who developed NMS at two different occasions, the first related to haloperidol and chlorpromazine and the second related to olanzapine, to our knowledge without previous mention in the indexed literature.

Multiple brain abscesses caused by Salmonella typhi: case report

BACKGROUND Focal intracranial infections caused by Salmonella species are uncommon. The authors report a case of multiple brain abscesses caused by Salmonella typhi. CASE DESCRIPTION A 2-month-old girl was admitted to the hospital because of diarrhea, vomiting, fever, and poor feeding. Neurological examination revealed cervical hyperextension and absence of sucking and Moro reflexes. During the next 20 hours she developed complex partial seizures with secondary generalization and alternated irritability with drowsiness. Investigation showed hemoglobin 6.3 g/dl; white blood cell count of 19500/mm3 with a marked shift to the left. The analysis of the cerebrospinal fluid revealed white cell count of 1695/mm3, lymphocytes 61%, protein 300 mg/dl and glucose 6 mg/dl. The patient was treated for acute gastroenterocolitis, sepsis, and meningitis. Blood culture taken on the day of admission showed gram-negative bacilli, later identified as S. typhi. Computed tomography scan demonstrated a lesion in the right parietal lobe compatible with a brain abscess. Follow-up computed tomography after 7 days showed several other lesions with the same features. Surgical drainage of the right parietal lesion was performed on the 13th day, through a burr hole. The patient was discharged 5 weeks after admission without neurological deficit. CONCLUSION Bacteremia, sepsis, and meningitis are relatively common in children with Salmonella infection but intracranial abscesses are very rare. Surgical drainage combined with prolonged antibiotic therapy (drug of choice: chloramphenicol) is the best treatment for Salmonella brain abscesses. The possibility of intracranial infection should be considered in patients with Salmonellosis and neurological dysfunction.

Ressonância magnética dos cavernomas intraventriculares: aspectos diagnósticos

Cavernomas are vascular malformations that typically affect the white matter of cerebral hemispheres and brain stem. They are angiographically occult lesions that depend on magnetic resonance imaging (MRI) for their diagnosis, presenting a hypointense perilesional ring caused by hemossiderin deposition as seen in T2 sequences. The ventricular location is rare, and image features may differ. We present two cases with diagnosis made only by histopathologic examination, due to a lack of classic image findings. Cavernous hemangiomas must be included in the differential diagnosis of intraventricular tumors, and total surgical resection is the treatment of choice. Perilesional ring as demonstrated by MRI, must not be expected when dealing with such lesions.

Fatores prognósticos no tratamento dos tumores intramedulares

Between 1993 and 1999, in the Divisions of Neurosurgery of the Hospital Nossa Senhora das Gracas and the Hospital de Clinicas in Curitiba, Parana, Brazil, 35 patients harboring intramedullary spinal cord tumors who were submitted to microsurgery were analyzed. There were 24 males (68.6%) and average age was 32.9 years. The main location, with 40% of cases, was the thoracic level, followed by cervical and cervico-thoracic levels with 25.7%. Neurological exam, carried out between 6 and 12 months after surgery, showed that 42.9% of patients improved, 34.3% were stable and 22.9% presented neurological worsening. Total resection was obtained in 57.2% of cases and subtotal in 37.1%. In 5.7% of patients a biopsy was the accomplished procedure. Total resection was more often obtained among patients with ependymomas (13 out of 17) than with astrocytomas (5 out of 12). However, degree of resection and tumor histology did not interfer in postoperative morbidity. Factors as sex, age and tumors size also did not demonstrate significance in predicting prognostic after surgery, whereas tumor in a thoracic level was associated with higher morbidity (p=0.021).

Neurocitoma central com apresentação incomum por hemorragia intraventricular: relato de caso

Central neurocytoma was first described by Hassoun et al. in 1982 as a well-differentiated tumor from neuronal origin. This tumor typically occurs in young adults, localized in the ventricular system. It usually presents as intracranial hypertension due to obstructive hydrocephalus. The differential diagnosis should be done with others intraventricular tumors as oligodendroglioma, subependymoma and choroidal plexus papilloma. There are few cases of central neurocytoma presented by intraventricular hemorrhage in the literature. We report a case of 35 year-old woman, who presented with obstructive hydrocephalus due to intraventricular hemorrhage within the tumor. MRI revealed a tumor localized in the right lateral ventricle. Histopathological and immunohystochemical analysis confirmed the diagnosis of central neurocytoma. We review options for the treatment of this entity as well reinforce the inclusion of central neurocytoma as a differential diagnosis for intraventricular hemorrhage.

Angioma cavernoso espinhal epidural: relato de caso

Epidural spinal cavernous angiomas account for approximately 4% of all spinal epidural tumors. More recently the diagnosis has become more frequent due to refinement of imaging modalities. We describe a 50-year-old woman with a spinal epidural cavernous angioma at L1-L2, which was successfully surgical treated. Clinical picture, imaginology and treatment of this entity is reviewed.

Meningiomas em pacientes pediátricos: relato de 2 casos

Meningiomas correspond to 1% - 4% of primary intracranial tumors in pediatric group, with their incidence raising according to age. There is not gender prevalence, in spite of some authors describe a male tendency opposed to female one in adulthood. At present study we describe two cases of pediatric meningiomas reviewing clinical, radiological and histological aspects of these lesions. The authors review also treatment options and prognosis of childhood meningiomas. A two-year-old boy was admitted with seizures. Computerized tomography showed a right parietal lesion, which was totally resected. Histological features were compatible with meningioma. After 17 months the child is doing well, with no deficits or seizures. The second case is a 12-year-old girl, with a headache complain. During investigation, a CT revealed a right frontal lesion. She was operated under a right frontal craniotomy with total tumor resection. Nowadays she is asymptomatic, 20 months after surgery. Despite meningiomas in pediatric group are uncommon; they should be included in differential diagnosis list of expansive intracranial lesions of childhood.