Walter C. Pereira

Lesões neurológicas na blastomicose sul-americana estudo anatomopatológico de 14 casos

Several case reports of involvement of the nervous system by Paracoccidioides brasiliensis have been published, changing thus the concept that the nervous system would no be adequate to the proliferation of this fungus. In the material of the Department of Pathology of the University of Sao Paulo Medical School, collected up to September 1964, 145 cases of paracoccidioidomycosis were found. In 14 of them there were lesions of the nervous system, giving an incidence of 9,65%. This high incidence contradicts the frequent assumption that the involvement of the nervous system in cases of South American blastomycosis is exceptional. In our material most of the cases of neuroblastomycosis had not systemic lesions, 2 of them having isolated involvement of the nervous system. This fact does not agree with the frequent observation of patients with lesions in all organs but the nervous system. There are no pathophysiologic reasons to explain such contradiction, but it can be assumed that individual conditions, in some cases, make the nervous system vulnerable to the parasite. Of the 14 cases studied, 5 had lesions of the meninges and 9 had gra-nulomata of the brain. Of the 5 cases with meningitis, 3 had an isolated basilar leptomeningitis; in 1 case lesions of the pia-arachnoid of the brain convexity were also found, and in another one the spinal meninges were also involved as well the spinal roots. The granulomata of the brain were isolated in 5 cases and multiple in 4. The most frequent site of the lesions was the cerebral hemispheres (6 cases); in 2 cases the cerebellum was involved; the thalamus, pons and medulla were involved in one case each. This predominance of the hemispheric localization must be related to the larger blood supply of this parte of the nervous system, owing to the hematogenic route followed by the parasite. In our material no lesions of the spinal cord were found. However, no definitive conclusions can be drawn, as there was no systematic study of that parte of the nervous system. From a histopathologic viewpoint the meningeal inflammatory lesions were of the productive type, with a nodular or diffuse distribution. The characteristic cellular elements of this process are the gigantocytes of the Langhans type, the histiocytes, lymphocytes and plasmocytes, the two latter showing a predominant perivascular distribution. In the nodular forms there is a trend to the confluence of the granulomata and focal zones of caseous or gummous necrosis can be found. Arterites also can be found, causing degeneration of the nervous structures. The Paracoccidioides brasiliensis are generally abundantly found either free or phagocyted by histiocytes or gigantocytes. The inflammatory infiltrate grows along the Virchow-Robins spaces, reaching the outer layers of the nervous parenchyma. The parenchymatous forms present a large central necrotic areas, with the characteristics of caseous or gummous necrosis, surrounded by histiocytes, gigantocytes, lymphocytes and plasmocytes. Fibroblasts and collagenous fibers surround and limit these granulomata of the encephalic parenchyma. Arterites are also observed and seem to play an importante role in the necrotic processes. The fungi are generally abundant, being found especially at the periphery of the necrotic areas or within the inflammatory tissues, free or phagocyted by histiocytes. In the nervous tissue neighboring the granulomata various degrees of degenerative processes of the neurons and glia are observed, as well as hyperplastic reaction of the oligodendroglia, microglia and astroglia. The inflammatory reaction of South American blastomycosis of the nervous system is not specific and, by itself, does not permit the etiologic diagnosis of the process. Only the finding of the parasite, with its characteristic forms, make it possible to establish the cause of the lesion.

Craniotomia descompressiva bifrontal no tratamento do edema cerebral grave

The authors present the results observed with large bifrontal decompressive craniotomy performed on 12 patients with severe cerebral edema, 10 of them related to cerebral contusion, which did not respond to conventional methods of therapy. All patients had before surgery very bad prognosis, with severe neurological signs of higher brain stem compression. Bilateral carotid angiography was sistematically performed before and after surgery, constituting as a matter of fact the decisive element indicating cerebral decompression. Six patients (50 per cent) survived and 5 of them (41.6 per cent) had an excellent neurological and mental improvement. Considering these results, we think that a large bifrontal decompressive craniotomy is the best method of treatment in such cases, specially when performed precociously. These patients, however, need very special care after surgery, if possible in units of intensive therapy, owing to the large incidence of complications.Sao apresentados os resultados obtidos com craniotomia descompressiva bifrontal ampla em 12 doentes com edema cerebral grave e irreversivel com os metodos convencionais de tratamento, provocado em 10 por traumatismo crânio-encefalico. Todos os pacientes apresentavam quadro neurologico muito grave, com sinais de comprometimento do tronco cerebral superior. Angiografia caro-tidea bilateral foi praticada sistematicamente, tanto no pre como no pos-operatorio, constituindo-se no fator decisivo para a indicacao cirurgica. Seis (50%) dos doentes sobreviveram, apresentando 5 (41,6%) recuperacao neurologica e psiquica praticamente totais. Levando em conta estes resultados, consideramos esta tecnica cirurgica o melhor recurso de tratamento em tais casos, maxime se indicada precocemente. Sao necessarios, contudo, cuidados pos-operatorios especiais com estes pacientes, que devem, sempre que possivel, ser mantidos em unidade de terapia intensiva, em virtude da grande incidencia de complicacoes, mormente respiratorias.

Localização encefálica da blastomicose sul-americana. Considerações a propósito de 9 casos

The involvement of brain by the Paracoccidioides brasiliensis is rather frequent. Many authors call attention to the difficulty of diagnosis in almost every case, most of them being made through surgery or post mortem examination. The intracranial hypertension syndrome is the most common manifestation, almost always leading to the diagnosis of intracranial tumor. The laboratorial tests, including the spinal fluid examination, are very poor of specific data; the finding of the parasite or a positive test for blastomycosis in this fluid is rarely verified. This disease is only suspected when there are true paracoccidioidal lesions in other organs. Nine cases of South American blastomycosis of brain are reported, seven of which were submitted to surgery. From these seven, three had a fair evolution, beeing the only ones to survive. In the three cases, amphothericin B was used sometime after operation, intravenously or intratecally. The authors are favorable to the surgical management in blastomycosis of brain, whenever reliable localization signs of compression are found. After remotion of the granulomata, amphothericin B must be used in order to avoid recurrence of the disease.

Ventriculo-auriculostomia nos bloqueios ao trânsito do líquido cefalorraqueano na cisticercose encefálica

Sixteen cases of brain cysticercosis with obstruction of cerebrospinal fluid circulation were operated from 1960 to 1965, through ventriculo-auri- culostomy with Holter valve. Five patients died, ten are alive and free of signs of intracranial hypertension and one could not be followed up. Considering the usual bad prognosis of the disease, mainly when increased intracranial pressure is present, the results obtained can be considered good. Therefore, the ventriculovenous shunts are a valuable resource in the treatment of the neurocysticercosis with ventricular dilatation caused by cerebrospinal fluid obstruction either in the intraventricular pathway or in the subarachnoid space. Sometimes the evolution is not satisfatory owing to the progressive course of the disease itself and not as a consequence of a bad control of the increased intracranial pressure.

Cisto dermóide na região do bregma: relato de dois casos

Two cases of extracranial dermoid cysts located upon the bregmatic fontanel in 4 and 8-month-old male children are reported. The preoperative diagnosis in both cases was meningoencephalocele. The authors emphasize the normality of the neurologic and angiographic findings in the two patients; these features will be remembered in the differential diagnosis in further cases.

Derivação ventriculoperitoneal com válvula no tratamento da hidrocefalia do lactente

As derivacoes ventriculovenosas, se bem que tenham propiciado grande progresso no tratamento da hidrocefalia, nao podem ser consideradas como solucao definitiva do problema. Entre os varios inconvenientes que surgiram com estas tecnicas, o embolismo e a fibrose pulmonares avultam entre os mais serios, sendo suas consequencias tardias ainda desconhecidas. Julgamos, portanto, justificada a busca de novas tecnicas cirurgicas ou o aprimoramento de outras ja conhecidas. De dezembro de 1965 a marco de 1969 empregamos a derivacao ventriculoperitoneal com valvula em 110 doentes, 79 dos quais eram criancas com hidrocefalia. Nossos resultados permitiram verificar que, do ponto de vista mecânico, as derivacoes para a corrente sanguinea e para o peritonio funcionam de maneira semelhante, nao sendo necessarias revisoes frequentes, como ocorria quando eram feitas drenagens para o peritonio sem valvula. Por outro lado, com as derivacoes ventriculoperitoneais evitamos a microembolia pulmonar; alem disso as infeccoes no sistema de drenagem provocam quadro menos grave e de mais facil solucao que o observado nas ventriculo -atriostomias.

A lesão do trato de Lissauer e do corno posterior da substância cinzenta da medula espinal e a estimulação elétrica do sistema nervoso central para o tratamento da dor por avulsão de raízes do plexo braquial

We analyze the effectiveness of the treatment of 10 patients of brachial plexus avulsion pain. Seven underwent dorsal root entry zone lesions (DREZ), 3, dorsal column stimulation (DCS) and, 2 thalamic stimulation (TS). DCS resulted in immediate improvement of pain in 50% of the patients. After a long term follow up period, just 25% of the patients were still better. TS resulted the in temporary improvement of 2 patients. Both had full recurrence few months after the operation. Immediate improvement of the symptoms occurred in all patients treated by DREZ. After a long term follow up period, excellent results were observed in 71.4% of the patients and good results in the remainder. The complication rate was higher among DREZ patients. It is concluded that DREZ is a better procedure for treatment of brachial plexus avulsion pain than DCS and TS (p = 0,0046); however, DCS and TS are safer.We analyze the effectiveness of the treatment of 10 patients of brachial plexus avulsion pain. Seven underwent dorsal root entry zone lesions (DREZ), 3, dorsal column stimulation (DCS) and, 2 thalamic stimulation (TS). DCS resulted in immediate improvement of pain in 50% of the patients. After a long term follow up period, just 25% of the patients were still better. TS resulted the in temporary improvement of 2 patients. Both had full recurrence few months after the operation. Immediate improvement of the symptoms occurred in all patients treated by DREZ. After a long term follow up period, excellent results were observed in 71.4% of the patients and good results in the remainder. The complication rate was higher among DREZ patients. It is concluded that DREZ is a better procedure for treatment of brachial plexus avulsion pain than DCS and TS (p = 0.0046); however, DCS and TS are safer.We analyze the effectiveness of the treatment of 10 patients of brachial plexus avulsion pain. Seven underwent dorsal root entry zone lesions (DREZ), 3, dorsal column stimulation (DCS) and, 2 thalamic stimulation (TS). DCS resulted in immediate improvement of pain in 50% of the patients. After a long term follow up period, just 25% of the patients were still better. TS resulted the in temporary improvement of 2 patients. Both had full recurrence few months after the operation. Immediate improvement of the symptoms occurred in all patients treated by DREZ. After a long term follow up period, excellent results were observed in 71.4% of the patients and good results in the remainder. The complication rate was higher among DREZ patients. It is concluded that DREZ is a better procedure for treatment of brachial plexus avulsion pain than DCS and TS (p = 0,0046); however, DCS and TS are safer.

Cranioplastias e correção de rinoliquorréias com metilmetacrilato: considerações a propósito de 35 casos

The principal methods in the treatment of cranial bony defects are briefly reviewed and some advantages and disadvantages of them are discussed. According to several authors the results obtained with the use of methymethacrylate in cranioplasties are very satisfactory, the complications being unusual. The experience of the authors in 35 cases of skull defects treated with methylmethacrylate is presented: 32 cranioplasties, two corrections of cerebrospinal fluid rhinorrhea and one case in which cranioplasty and blockage of a cranionasal fistula was simultaneously made. The longest follow-up was of four years in only one case; in ten cases it was from one to three years and in the others the pursuing was less than a year. In four cases there was local suppuration, the remotion of the acrylic plate becoming necessary in three of them; in one case the plate was not removed, and the infection still remains. One patient died two months after the cranioplasty in consequence to a brain abscess. In 26 cranioplasties the cosmetic results were satisfactory; only in one case there was a slight displacement of the prothesis. In the three patients with rhinorrhea the drainage of cerebrospinal fluid ceased completely after surgery. In 29 cranioplasties the methylmethacrylate was applied directly into the skull defect without protection of the encephalic tissue; there were no signs of damage of the nervous system in any case. Only in three cranioplasties the Spences technique was used; in this technique the acrylic resin is molded within a polyethylene bag, thus being put in place after polymerization. In the cases of cerebrospinal fluid rhinorrhea the dural injuries were carefully repaired before the blockage of the bony defects with methylmethacrylate.

Atividade elétrica cerebral do rato com lesões da formação reticular mesencefálica

Seventy three rats were prepared for acute and chronic experiments. The midbrain reticular formation was electrolitically destroyed (3,5 — 4,0 mA and 5 — 10 sec) by means of an active electrode estereotactically guided according with the atlas of Konig an Klippel. The procedure was destined to provoke parcial, total, unilateral and bilateral lesions in different preparations. The ECoG was recorded with a 4-channel Beckman polygraph. Short bipolar leads were used in all experiments. 1. Spindling wich occurred after the operation was similar to spindling found in phisiological sleep and in barbiturate narcosis as well. Similarity was striking as to the electrophysiological properties and cortical projections. However, the duration of the individual potentials dispersed much more than in the above mentioned conditions (20 — 80 msec), wich may be related to the higlher complexity exhibited by the spindles which appear on the ECoG after destruction of the reticular formation of the midbrain, possibly due to lack of reticular timing of the thalamic synchronizing system activity, since spindling was more regular when circumscribed lesions of the midbrain were made. 2. The mechanisms involved in production of spindles during spontaneous and barbiturate sleep and after lesioning of the midbrain reticular formation are at least partially dependent upon reticular blocking. 3. The midbrain reticular formation activates mainly the ipsilateral hemisphere. The crossed component of the activating system is, probably, brought in action only when arousing stimuli are very strong. 4. Besides midbrain reticular formation other cortical activating mechanisms certainly play a role in arousing, since, in acute preparations, simultaneously with neocortical spindling, we frequently recorded: a) short-lasting periods of desynchronization of the ECoG; b) synchronization of the ECoG is not steady but waxes and wanes in time; c) theta waves, wich are associated with limbic arousal, are recorded on the cortical limbic areas.

Ventrículo-auriculostomia nos bloqueios inflamatorios e tumorais à circulação do líquido cefalorraqueano

The results obtained in 32 patients with obstruction of the cerebrospinal fluid circulation caused by cerebral tumors and inflammatory reactions of the leptomeninges or ventricular ependima, are presented. The results were satisfactory in 20 cases; 3 patients did not come back for follow-up and 9 died. All deaths occurred in the group of neoplasms, and only in one case this bad evolution was related to infectious complication of the ventriculo-venous shunt.