Yvens Barbosa Fernandes

Evaluation of the Thoracolumbar Injury Classification System in Thoracic and Lumbar Spinal Trauma

Study Design. Retrospective study. Objective. Evaluate the relationship among the neurologic status, the Thoracolumbar Injury Classification System (TLICS) score, and the Magerl/AO classification system. Summary of the Background Data. A wide range of classification schemes for thoracic and lumbar spine trauma have been described, but none has achieved widespread acceptance. A recent system proposed by Vaccaro et al has been developed to improve injury classification and guide surgical decision making. Methods. Analysis of 49 patients treated surgically for thoracic and lumbar spine trauma from 2003 to 2009 in 2 spine trauma centers. Clinical and radiologic data were evaluated, classifying the trauma according to American Spinal Injury Association status, the Magerl/AO classification for fractures, and the TLICS score. Results. The mean age was 37 years (range, 17–72). Thirty-five (71%) patients had a thoracolumbar fracture (T11–L2). A posterior approach was used in all the cases. American Spinal Injury Association status remained unchanged in 44 (4 had some improvement and 1 worsened). A total of 61.1% of the patients with a type A fracture were neurologically intact compared with 80% with complete neurologic deficit for type C fractures. The TLICS score range from 2 to 9 (average of 6.2). Forty-seven of 49 (96%) patients had a TLICS score greater than 4, suggesting surgical treatment. Seventy percentage of the patients with a TLICS score from 4 to 6 were neurologically intact compared with 87.5% of complete neurologic deficits in patients with TLICS 7 to 9. A statistic correlation was established between the neurologic status and AO type fracture (P = 0.0041) and the TLICS score (P < 0.0001). An association between the AO type fracture and the TLICS score was also found (P = 0.0088). Conclusion. The TLICS score treatment recommendation matched surgical treatment in 47 of 49 patients (96%). The TLICS was found to correlate to the AO classification. This suggests that the TLICS can be used to classify thoracolumbar trauma and can accurately predict surgical management.

Surgical removal of small petroclival meningiomas.

SummaryTreatment of large petroclival meningiomas causing brain stem compression is surgical removal followed by radiotherapy or radiosurgery if the lesion was partially resected. The management of small petroclival meningiomas is, however, controversial. Clinical observation, radiosurgery and surgical removal are the options of treatment. The natural history of these tumours is not well known. Published series of patients treated with radiosurgery are not comparable with surgical series because the latter also includes large size tumours. In this paper we present a series of 18 patients with small petroclival meningiomas (diameter ≤ 2.8 cm) treated with radical surgical removal. Total resection (Simpson’s Grade 1) [43] was possible with minimal morbidity and no mortality. Background. We present a series of small petroclival meningiomas (SPM) treated by radical surgical removal and compare the outcome with other management modalities proposed for these lesions. Methods. Eighteen patients with SPM were surgically treated at our department of neurological surgery. The tumours were classified as small when they had a diameter < 3.0 cm. Headaches (n = 12), diplopia (n = 8), facial hypoaesthesia (n = 3) and tinnitus (n = 6) were the most frequent symptoms at presentation. The approaches used were retrosigmoid (n = 14), fronto-orbito-zygomatic (n = 3) and presigmoid (n = 1). The post-operative follow-up ranged from 1 to 110 months (mean 41.8 months). Findings. Radical tumour resection (Simpson’s Grades 1 and 2) was achieved in all patients. There was no major morbidity or mortality related to the surgical procedure. Transient abducent nerve palsy was the only post-operative complication. The pre-operative cranial nerves deficits improved after surgery. Only one patient had persistent diplopia postoperatively. Conclusion. Radical surgical removal of SPM is possible with minimal morbidity and may cure the patient. The effectiveness and outcome of surgery for small petroclival meningiomas should be compared with series treated by radiosurgery.

Risk factors and outcome in 100 patients with aneurysmal subarachnoid hemorrhage.

OBJECTIVE Clinical and surgical outcome of patients with subarachnoid hemorrhage (SAH) due to ruptured aneurysm were assessed in comparison to pre-operative data and risk factors such as previous medical history, clinical presenting condition, CT findings and site of bleeding. METHODS We evaluated 100 consecutive patients with aneurysmal SAH. Gender, color, history of hypertension, smoking habit, site and size of aneurysm, admittance and before surgery Hunt Hess scale, need for cerebro-spinal fluid shunt, presence of complications during the surgical procedure, Glasgow Outcome Scale, presence of vasospasm and of rebleeding were assessed and these data matched to outcome. For statistical analysis, we applied the chi-squared test or Fishers test using the pondered kappa coefficient. Kruskal-Wallis test was used for comparison of continue variables. Tendency of proportion was analyzed through Cochran-Armitage test. Significance level adopted was 5%. RESULTS Patients studied were mainly white, female, without previous history of hypertension and non-smokers. Upon hospital admittance, grade 2 of Hunt-Hess scale was most frequently observed (34%), while grade 3 of Fisher scale was the most prevalent. Single aneurysms were most frequent at anterior circulation, between 12 and 24 mm. The most frequent Glasgow Outcome Scale observed was 5 (60%). Hunt Hess upon the moment of surgery and presence of complications during surgical procedure showed positive correlation with clinical outcome (p=0.00002 and p=0.001, respectively). Other variables were not significantly correlated to prognosis. Tendency of proportion was observed between Hunt-Hess scale and Fisher scale. CONCLUSION Among variables such as epidemiological data, previous medical history and presenting conditions of patients with ruptured aneurysms, the Hunt-Hess scale upon the moment of surgery and the presence of surgical adversities are statistically related to degree of disability.

Supraorbital eyebrow approach to skull base lesions

We report our experience with a supraorbital eyebrow minicraniotomy. This technique is suitable to lesions situated in the region of the anterior fossa, suprasellar cisterns, parasellar region and Sylvian fissure. A 50 mm incision in the eyebrow and a supraorbital minicraniotomy is performed. Sixteem patients harboring different lesions were operated on with good postoperative and cosmetic results. We conclude that this approach is safe and useful in selected cases.

Thrombosis of the internal carotid artery secondary to soft palate injury in children and childhood. Report of two cases.

Trauma to the soft palate is a uncommon event during childhood. Stroke following intraoral trauma is also rare, but has been well documented by the current literature as a potentially serious complication. In this article, we report 2 cases of posttraumatic internal carotid artery thrombosis depicted by imaging studies. We discuss pathogenesis, and the literature is reviewed.

Imaging features and treatment of an intradural lumbar cystic schwannoma

Spinal schwannomas are frequently observed among patients treated in a reference neurosurgery center. Cystic spinal schwannomas, however, are very scantly found. Due to its indolent behavior and benign course, the diagnosis of schwannomas may pose a challenge to the care giver, and the imaging findings can be misleading. In this article, we illustrate an example of a pauci-symptomatic 55 year-old male patient whose complaint was solely a non specific lumbar pain. Investigation revealed a large cystic lesion comprising the lower lumbar intradural space. He was then treated with microneurosurgical technique involving complete removal of the tumor and reconstruction of the dura mater. Histological and immunohistochemical diagnosis were consistent with cystic schwannoma. The patient presented with complete recovery of his symptom. In this article we aim to emphasize the clinical presentation and treatment of lumbar spine schwannomas, and to illustrate the imaging findings within this uncommon case.

Long-term facial nerve clinical evaluation following vestibular schwannoma surgery

BACKGROUND Facial function is important in accompaniment of patients operated on vestibular schwannoma (VS). OBJECTIVE To evaluate long term facial nerve function in patients undergoing VS resection and to correlate tumor size and facial function in a long-term follow-up. METHOD Transversal study of 20 patients with VS operated by the retrosigmoid approach. House-Brackmann Scale was used preoperatively, immediately after surgery and in a long-term follow-up. Student t test was applied for statistic analysis. RESULTS In the immediate postoperative evaluation, 65% of patients presented FP of different grades. Improvement of facial nerve function (at least of one grade) occurred in 53% in the long-term follow-up. There was statistically significant difference in facial nerve outcome in long-term follow-up when tumor size was considered (p<0.05). CONCLUSION The majority of patients had improvement of FP in a long-term follow-up and tumor size was detected to be a factor associated with the postoperative prognostic.CONTEXTO: A funcao facial e importante para acompanhamento dos pacientes operados de schwannoma vestibular (SV). OBJETIVO: Avaliar o grau de paralisia facial (PF) em pacientes operados de SV, correlacionando tamanho do tumor com funcao facial na avaliacao tardia. METODO: Estudo transversal com analise seriada de 20 pacientes com SV operados pela via retrosigmoide-transmeatal. A Escala de House-Brackmann foi utilizada no pre-operatorio, pos-operatorio imediato e pos-operatorio tardio. O teste t de Student foi aplicado para analise estatistica. RESULTADOS: No pos-operatorio imediato, 65% dos pacientes apresentaram graus variados de PF, sendo que 53% destes obtiveram melhora de pelo menos um grau de House-Brackmann na avaliacao tardia. Houve diferenca significativa no resultado da funcao facial no pos-operatorio tardio quando o tamanho do tumor foi considerado (p<0.05).Conclusao: A maioria dos pacientes da amostra apresentou melhora da PF no pos-operatorio tardio, sendo o tamanho do tumor um fator associado ao prognostico.

Intrinsic tectal low grade astrocytomas: is surgical removal an alternative treatment? Long-term outcome of eight cases

Low-grade gliomas arising in dorsal midbrain in children and young patients usually present few neurological symptoms and findings, and patients management is controversial. Some authors propose only clinical observation until the patient present signs of increased intracranial pressure when a shunt with or without biopsy, is inserted; others recommend radiotherapy after stereotactic or open biopsy. Microsurgical total removal of tumor may be curative. We present a retrospective analysis of eight patients (mean age 16.6 +/- 11.5 years-old) with low-grade astrocytoma of the tectal region operated on using an infratentorial/supracerebellar approach between 1981 and 2002. All patients presented hydrocephalus and had a shunt insertion before surgical resection of the lesion. The tumour could be totally resected in seven patients. In one case radical removal was not possible due to infiltrative pattern of the lesion. Postoperative radiotherapy was performed in two cases, one patient at the beginning of this series and in the case with infiltrative tumor. This patient presented progressive tumor growth and died five years after surgery. No recurrence occurred after total removal. Post-surgical follow-up time ranged from 2 1/2 to 22 1/2 years (mean 9.9 +/- 5.9 years). Radical microsurgical removal of non invasive tumors is possible without mortality or significant morbidity. It may be curative and should remain as an alternative to be discussed with the patient.

Intradural jugular foramen tumors

Eleven patients with jugular foramen lesions with or without extradural extension were operated at University Hospital of Campinas (UNICAMP), in Campinas, Brazil, between 1998 and 2001. Neck dissection, mastoidectomy without transposition of the facial nerve and myofascial flap reconstruction of the cranial base with an especially developed technique were carried out in 7 patients. Four patients were operated using retrosigmoid craniectomy. Total excision was accomplished in 9 cases. All patients did not show evidence of disease progression at least after 2 years follow-up. There was no mortality. New lower cranial nerve deficits occurred in 5 patients. Nine maintain or improved their preoperative status based on Karnofsky and Glasgow Outcome Scale. A complex anatomy of this region demand wide exposures for treat those tumors. For this reason, an adequate approach for curative resection of most lesions and an efficient skull base reconstruction decreasing postoperative morbidity are essential.

Orbital apex syndrome due to aspergillosis: case report

We report the case of a 73-year-old female who presented facial numbness and pain in the first division of the trigeminal nerve, ptosis, diplopia and visual loss on the right side for the previous four months. The neurological, radiological and histological examination demonstrated a rare case of invasive fungal aspergillosis of the central nervous system, causing orbital apex syndrome, later transformed in temporal brain abscess. She died ten months later due to respiratory and renal failure in spite of specific antimycotic therapy.