Biomedical subjects
Publications and source records attributed to R Ramina.
We a case of chronic Aspergillus sp. meningitis in a healthy 43-year-old woman successfully treated with fluconazole given orally (300 ms/day). The diagnosis was made by detection of anti-aspergillus antibodies and positive culture to Aspergillus sp. in the cerebrospinal fluid.
Fifty-three patients with arteriovenous malformation (AVM) were studied. The mean age at the time of diagnosis was 32.5 +/- 11.5 years (range 3 to 56 years); the sex ratio was male 1.9:1 female. The most common clinical presentation was intracranial hemorrhage, followed by focal neurological signs, headache, epilepsy, and acute deep coma. Fourty-three (82%) out of the total number of AVM were supratentorial and had the following distribution: 10 temporal lobe, 9 pariental lobe, 6 frontal lobe, 3 occipital lobe, 3 frontotemporal, 4 corpus callosum/pericalosal, 1 temporo-occipital, 1 temporoparieto-occipital, 6 deep-located (3 thalamic, 3 basal ganglia). Spetzler-Martin grade II was seen in 17 cases (32%), grade III in 21 cases (39%), and grade IV in 10 cases (19%). AVM-associated aneurysms were detected in 3 patients (5.6%). All three cases were middle artery aneurysms ipsilateral to AVM. Twelve (32%) out of 37 operated patients were submitted to embolization prior to surgery. AVM was totally removed in all cases except one. Embolization without posterior surgery was used in 11 patients; in 3 of them, embolization was partial. Two patients were neither embolized nor operated on. Three patients were, submitted to radiosurgery because they were poor candidates to embolization and/or surgery. Mortality rate was 1.8%. All patients returned to their normal life function after a period of recovery. Associated or isolated therapies should be individualized to each patient with AVM and is likely to provide results better than the expected outcome without any treatment.
Stroke following intraoral trauma is a rare complication of a common childhood injury. In the literature these complications have been well documented, however this condition is still infrequent. In order to alert the physicians about this possible injury we report our experience with one case. Computer tomography and magnetic resonance imaging evidenced complete occlusion of the internal carotid artery. Pathogenesis of this oral trauma is discussed.
OBJECTIVE AND IMPORTANCE: Our objective was to study the diagnosis and management of this rare condition. A review of the literature concerning chondrosarcomas related to Maffucci's syndrome is reported. Cause and management are discussed. CLINICAL PRESENTATION: We report a case of Maffucci's syndrome associated with a cranial base chondrosarcoma. To our knowledge, only five similar cases have been reported in the literature. The differential diagnosis between Ollier's disease and Maffucci's syndrome and the causes of these conditions are not clear. INTERVENTION: An 18-year-old female patient presented with a giant tumor involving the posterior fossa, clivus, middle fossa, and cavernous sinus. The lesion could be totally removed through a transzygomatic approach. The histological diagnosis was chondrosarcoma. It was confirmed by immunohistochemical studies. There were no postoperative complications. CONCLUSION: Maffucci's syndrome is a rare clinical condition that presents difficulties concerning its diagnosis and management. It is characterized by the presence of multiple enchondromas and cutaneous hemangiomas. Intracranial chondrosarcomas may be associated with this syndrome. Immunohistochemical studies are necessary to differentiate chondrosarcomas from chordomas. The treatment of choice for cranial base chondrosarcomas is total removal of the lesion. Total removal may be very difficult to achieve because of the involvement of neurovascular structures. Alternative therapies, such as proton beam radiosurgery, should be considered. In this case, radical removal of the tumor was possible using a transzygomatic approach. Gross total removal of large cranial base chondrosarcomas is possible, but a longer follow-up period is necessary to ascertain that radical resection was achieved.
In the surgical management of skull base lesions and vascular diseases such as giant aneurysms, involvement of the internal carotid artery may require the resection or the occlusion of the vessel. The anastomosis of the external carotid artery and the middle cerebral artery with venous graft may be indicated to re-establish the blood flow. To determine the best suture site in the middle cerebral artery, an anatomical study was carried out. Fourteen cerebral hemispheres were analysed after the injection of red latex into the internal carotid artery. The superior and inferior trunk of the main division of the middle cerebral artery have more than 2 mm of diameter. They are superficial allowing an anastomosis using a venous graft. The superior trunk has a disadvantage, it gives rise to branches for the precentral and post-central giri. The anastomosis with the inferior trunk presents lower risk of neurological deficit even though the angular artery originates from it.
We present our experience with 83 patients with acoustic neurinomas (January 1988 to November 1996); 81 patients underwent surgery and 2 patients with intracanalicular neurinomas received conservative therapy due to their advanced age (1 case) and patient's option (1 case). The surgical approach was retrosigmoid/transmeatal and the goal was total removal in one procedure with preservation of facial and cochlear nerves. Radical removal of lesion was attempted in 79 cases and it was possible in 77 patients. Subtotal tumor resection was planned in 2 cases. Facial nerve function (grades I to III, House and Brackman) was preserved in 90% and hearing in 58% of those with preoperative hearing. Three patients died due to postoperative complications. Early diagnosis of acoustic neurinomas is the most important factor in the prognosis and is one of the most important conquest of neurophysiology and modern neuroimaging. The management of these patients still present many controversial points. This article presents the diagnostic procedures used for acoustic neurinomas, the advantages and disadvantages of the different surgical approaches and the alternative management of these lesions.
Different distances related to the nasal transphenoidal approach were measured on the hemiheads of eighteen cadavers in order to study its limits and advantages. The main mean measures obtained (mm) were: major diameter of the nostril 15.18: height of the nasal cavity 44.11, nostril-sella turcica distance 71.71. These results show that the nasal approach is wide and direct to the sella turcica. The present study demonstrate the possibility of preservation of the cartilaginous septum and other structures which are usually damaged when the sublabial approach is employed.
Stereotactic surgery for Parkinson's disease can be performed using different neuroimaging methods. Ventriculography has been used to locate the coordinates of the structures close to the third ventricle. Although it has several potential disadvantages related to the intraventricular injection of iodine contrast, it is considered a precise method. Computed tomography and magnetic resonance imaging have been used in some centers. In order to compare their efficacy, 50 stereotactic thalamotomies for Parkinson's disease were performed using either ventriculography (VE) (25) or magnetic resonance imaging (MRI) (25). In 14 out of 25 VE procedures, computed tomography (CT-scan) was also used and showed a significant mean difference of coordinate Y and Z. The clinical results employing either VE or MRI were similar, with 80% abolition of tremor in the VE group, and 84% in the MRI group, after a follow up period of at least 3 months. Another 12% of VE and 16% of MRI group showed significant improvement of tremor. Complication rate was 4% in both groups. MRI-guided stereotactic thalamotomy in Parkinson's disease has shown good clinical results, comparable to VE-guided stereotaxis.
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The authors present a study about 50 stereotactic procedures for intracranial lesions. In 12 cases stereotaxis was used as a treatment: stereotactic surgical resection (5 patients) and aspiration of lesions (7 patients). This study confirms the great accuracy and low morbidity of the stereotactic techniques. Computed tomography and magnetic resonance imaging determinate the precise stereotactic coordinates, but in some cases it is necessary to perform stereo-angiography. The stereotactic surgical resection of brain tumors allows the treatment of deep lesions or located at functional areas and considered to be inoperable before. The related literature is discussed.
Optic nerve gliomas may occur alone or as components of neurofibromatosis. They are rare tumors accounting for 2 to 5% of all intracranial tumors and 6% of the intra-orbitary neoplasms. The authors present 11 cases of optic nerve-glioma diagnosed in Curitiba in the last 25 years. Out of these 11 patients there were 10 women and only 1 man. The ages ranged from 3 to 25 years old, and 6 patients were under 15 years. In this series, 27.3% (n = 3) of the cases were associated with neurofibromatosis. Five patients had their tumors restricted to the optic nerve while the others had either extension to the optic chiasm, supra-selar region, frontal or temporal lobe. All the patients had pilocytic astrocytomas.
An anatomical study about the anterior knee of the intracavernous carotid artery is presented. Twenty cavernous sinuses (CS) were dissected in cadavers using microsurgical techniques. A fibrous ring around the internal carotid artery (ICA) at the CS roof was found in all specimens. This fibrous attachment could be dissected from the surrounding dura and a loose connective tissue could be demonstrated around the ICA. This anatomical finding makes possible the microsurgical approach to vascular lesions of this portion of the ICA, without opening the cavernous sinus.
The authors describe a family with three members affected by glioblastoma. The proband patient, a 7 year-old girl, developed a rare complication, a pulmonary metastasis. Chromosomal analysis of her peripheral blood lymphocytes showed a normal karyotype (46, XX), without structural abnormalities. Cytogenetic study of the tumor cells disclosed several abnormalities: 46, XX, 7q-/46, XX, -2, 4p-, 7p-, +15/46, XX. Some aspects about genetics of glial neoplasms are discussed.
A 38 year-old man presented fever and a clinical picture of intracranial hypertension and ataxic syndrome. A CT-scan disclosed an expanding lesion of the cerebellum. Surgical excision of the lesion was performed and pathological examination made the diagnosis of an actinomycotic abscess. The probable primary source of infection were the lungs and/or oral cavity. The postoperative course was uneventful, with complete recovery after a long period of treatment with penicillin (IV and PO). The authors review some aspects about central nervous system involvement in actinomycosis.
The authors present a study of 50 patients with trigeminal neuralgia treated by posterior fossa microsurgery. Microvascular decompression of the trigeminal nerve was performed in 48 patients. In 2 cases no neuro-vascular compression was found, and a partial rhizotomy was carried out. In 98% of the cases there was postoperative abolition of the pain. Two cases of wound infection and three CSF fistulas were the operative complications. These patients were reoperated and cured. Twenty five patients were reviewed between 13 months and 8 years after surgery. Twenty one remained painfree without any drug, 3 were painfree taking 200 to 400 mg Carbamazepineper day, and 1 patient was reoperated after two years without pain because of recurrence of the neuralgia. There was no mortality or major morbidity in this series. Our results and the literature concerning this method are discussed in this article. In conclusion, microvascular decompression may be indicated in a large number of patients with essential trigeminal neuralgia due to its excellent pain control, no mortality and low morbidity.
A 42 year-old man with subarachnoid hemorrhage was admitted in our Service (Hunt & Hess grade II). CT-scan disclosed predominantly perimesencephalic subarachnoid hemorrhage. Digital subtraction angiographic study did not disclose either cerebral aneurysm or any other potential site of intracranial bleeding. The evolution was uneventful. A DSA was repeated one month later and was negative. Four months later, the patient was asymptomatic. The authors review the literature and emphasize the importance in recognizing this benign clinical form of nonaneurysmatic subarachnoid hemorrhage.
The authors report the case of a 37 year-old man with a solitary cysticercus cyst in the brainstem (pons) successfully removed through a suboccipital craniectomy. Surgery in neurocysticercosis has been indicated in patients with hydrocephalus and/or large cystic lesions. Cystic lesions in the brainstem and spinal cord may have indication for surgery for two reasons: (1) diagnosis; and (2) treatment. Aspects related to differential diagnosis and therapeutic alternatives are discussed.
The authors report the study of 35 cases of microvascular decompression for trigeminal neuralgia. No mortality and a very low morbidity were associated with this procedure. The choice of the treatment and the advantages of each method are discussed.