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Intracranial hypertension (IH) develops in approximately 50% of all patients with severe traumatic brain injury (TBI) and is more common in patients with intracranial hematoma (ICH) 1,2 . Therefore, it is very important to identify a suitable animal model to study and understand the pathophysiology of refractory IH to develop effective treatments.Many models of neurosurgical experiments in small animals, such as rats and cats, have been developed; however, compared to humans, they have smaller brain volumes and more distinct behaviors 3,4 . While there are existing porcine models, they simulate ICH by infusing autologous blood into the brain tissue and do not replicate intracranial lesions [3][4][5][6] . ABSTRACTObjective: Intracranial hypertension (IH) develops in approximately 50% of all patients with severe traumatic brain injury (TBI). Therefore, it is very important to identify a suitable animal model to study and understand the pathophysiology of refractory IH to develop effective treatments. Methods: We describe a new experimental porcine model designed to simulate expansive brain hematoma causing IH. Under anesthesia, IH was simulated with a balloon insufflation. The IH variables were measured with intracranial pressure (ICP) parenchymal monitoring, epidural, cerebral oximetry, and transcranial Doppler (TCD). Results: None of the animals died during the experiment. The ICP epidural showed a slower rise compared with parenchymal ICP. We found a correlation between ICP and cerebral oximetry. Conclusion: The model described here seems useful to understand some of the pathophysiological characteristics of acute IH. Keywords: experimental model, intracranial hypertension, transcranial doppler sonography. RESUMOObjetivo: A hipertensão intracraniana (HIC) ocorre em até 50% de todos os pacientes com traumatismo cranioencefálico (TCE). Por isso, é importante estabelecer um modelo animal adequado para estudar a fisiopatologia da HIC refratária, com a perspectiva de desenvolver tratamentos eficazes. Métodos: Os animais foram submetidos a um protocolo padrão de anestesia. A hipertensão intracraniana foi estabelecida através de insuflação de um balão. As variáveis HIC foram medidas com a pressão intracraniana (PIC) do parênquima, oximetria, epidural e doppler transcraniano. Resultados: A PIC epidural apresentou elevação mais lenta, comparada com a PIC parenquimal. Houve correlação entre a PIC e a oximetria cerebral. O registro da PIC, oximetria e índice de pulsatilidade foi realizado em todos os animais sem dificuldade. Conclusão: O modelo descrito parece ser útil para a compreensão de algumas características fisiopatológicas na HIC aguda.Palavras-chave: pressão intracraniana, ultrassonografia, doppler transcraniana, modelos experimentais.

Carotid-cavernous fistulas (CCFs) are abnormal connections between arteries and veins of the cavernous sinus. 1 We describe a case of a 71-year-old woman presenting with left eye redness, chemosis, and proptosis over 4 months. Computed tomography and cerebral angiogram demonstrated an indirect CCF, with an enlarged venous pouch draining to a dilated left superior ophthalmic vein, without communication to the posterior portion of the cavernous sinus. Transvenous endovascular embolization through inferior petrous sinus and facial veins was attempted. However, it was unsuccessful because of the lack of venous access to the fistula. Subsequently, direct cannulation of the superior ophthalmic vein was also attempted, but again unsuccessful. A transcavernous open surgical approach was performed. The lateral wall of the cavernous sinus was exposed, and a puncture to the fistula point through the anteriomedial triangle was performed, followed by the injection of a flowable hemostatic matrix with thrombin. Informed consent for all procedures was provided. Patient had substantial improvement of the left eye congestion and proptosis immediately after the operation. Postoperative angiogram and 6-month MRA confirmed the exclusion of the CCF. Open surgical treatment of indirect CCF has been classically described before the development of modern endovascular techniques, consisting in trapping the internal carotid artery or exposing and packing its cavernous branches, through the anterolateral triangle. 2 Nowadays, endovascular technique is considered the preferred method for indirect CCF. 1 When standard and less invasive techniques fail, transcavernous surgical approach as we present in this video stands as an option in selected cases of indirect CCF.

Cranioplasty is a common procedure in neurosurgical practice, but associated with high complication rates. In the current study, the authors describe surgical characteristics and results of cranioplasty performed in a tertiary teaching hospital in Brazil. Data were obtained from electronic medical records of cranioplasties performed between January 2013 and November 2016. The sample comprised of 33 patients, and the mean follow-up time was 16 months. Patients presented most of the times a good preoperative status, with 84.8% of patients classified between 0 and 3 at modified Rankin scale and 78.7% with 4 or 5 points at Glasgow Outcome Scale. The most common initial diagnosis was vascular disease (48% of patients) followed by traumatic brain injury (36% of patients). The majority of cranioplasties used an autograft: the autologous bone flap removed during a previous surgery (craniectomy) and stored in the abdominal subcutaneous fat (67% of patients). In 3 patients, the polymethylmethacrylate prosthesis was custom-made prior to the operation using 3-dimensional printing, based on computed tomography images. Five patients (15% of patients) developed symptoms related to surgical site infection, manifesting at an average of 5 weeks following the procedure. Three of them presented scalp dehiscence before the infection symptoms. Cranioplasty should be performed early, as long as clinical conditions are good and the patient has overcome the acute phase of neurological injury.

Gender has influence on heart rate and blood pressure response to the EA-DSE in patients without use of drugs with negative chronotropic effects.

-Natural killer (NK) cells play an important role in immune surveillance against tumors. The present work aimed to study the cytotoxic activity of NK cells and T cell subsets in peripheral blood of 13 patients with primary tumors in central nervous system (CNS). As controls 29 healthy subjects with the age range equivalent to the patients were studied. The methods employed were: a) determination of cytotoxic activity of NK cells towards K562 target cells, evaluated by single cell-assay; b) enumeration of CD3+ lymphocytes and their CD4+ and CD8+ subsets defined by monoclonal antibodies; c) the identification of tumors were done by histologic and immunochemistry studies. The results indicated that adults and children with tumor in CNS display reduced percentage of total T cells, helper/inducer subset and low helper/suppressor ratio. The cytotoxic activity of NK cells was decreased in patients with CNS tumors due mainly to a decrease in the proportion of targetbinding lymphocytes. These results suggest that cytotoxic activity of NK cells may be affected by the immunoregulatory disturbances observed in patients with primary tumors in CNS. KEY WORDS: brain tumors, NK cells, T cell subsets.Alterações imunológicas em pacientes com tumores primários no sistema nervoso central RESUMO -As células natural killer (NK) desempenham importante papel na vigilância imunológica contra tumores. O objetivo do presente trabalho foi estudar a atividade citotóxica de células NK e as subpopulações de células T no sangue periférico de 13 pacientes com tumores primários no sistema nervoso central (SNC). Como controle foram estudados 29 indivíduos saudáveis com faixa etária equivalente aos pacientes. Os métodos empregados foram: a) determinação da atividade citotóxica de células NK contra células alvo K562; b) quantificação de linfócitos CD3+ e subpopulações CD4+ e CD8+ por meio de anticorpos monoclonais; c) identificação dos tumores por análise histológica e imuno-histoquímica. Os resultados indicaram que adultos e crianças com tumores no SNC apresentam diminuição na percentagem de linfócitos T, da subpopulação de células T auxiliares e da relação células auxiliares/supressoras. A atividade citotóxica de células NK esteve deprimida em pacientes com tumores devido principalmente à diminuição da capacidade de formar conjugados com a célula alvo K562. Os resultados sugerem que a atividade de células NK pode ser afetada por distúrbios imunorregulatórios observados em pacientes com tumores primários no SNC. PALAVRAS-CHAVE: tumores cerebrais, células NK, subpopulações de células T.Most cancers result from interaction of genetic and environment factors; however, genetic factors by themselves explains only about 5% of all cancer. The others have been atributed to environmental factors, that may interact with genetic cancer susceptibility and individual response 1 .

An unknown middle aged man was found unconscious and was brought to our service. On the admission, the patient was comatose and his Glasgow Coma Scale was 8/15. Both the pupils were isochoric and reactive to light with left periorbital edema and a report of seizure. ATLS (Advanced Trauma Life Support) primary survey did not reveal any other abnormality. A Computed Tomography (CT) was taken which showed asymmetric Bilateral Epidural Hematoma (BEH) that measuring 127cm³ at left and 57cm³ at right, with a total volume of 184cm³, and bilateral overlying skull fracture [Table/ Fig-1]. He underwent emergency surgery for removal of the Epidural Haematomas (EDH). Both the focal lesions had immediate surgical indication and the drainage was performed simultaneously. The head was placed in Mayfield tongs in neutral position; this cranial fixation system was placed in the midline of the skull, with the tongs fixation slightly diverted to avoid holes on the sagittal sinus.Tongs application on the skull fractures was avoid. Incisions were made at the same time. The craniotomies were also performed simultaneously. Once completed trepanation on one side, already was performed and the other side, quickly performed the two large craniotomies without complications, with satisfactory CT control [Table/ Fig-2]. The patient had a prolonged hospitalization due to clinical complications and the need for inpatient rehabilitation and was discharged after one month. During follow-up he presented with Glasgow Outcome Scale 4/5 ninety days after the trauma. DisCussionThe first BEH case was described by Roy in 1884. Since then, BEH reports have been sporadic with an incidence rangs from 0,5 to 2% of all EDH [1,2]. High mortality rates (42-100%) have been reported in old series of BEH. With the widespread use of CT scan, early diagnosis has changed the surgical results and prognosis with recent series reported a decrease in mortality rates to 15,7% [1].Linear skull fractures are associated with EDH in 61-95% of cases. In over one-half of all patients, the middle meningeal artery gives rise to the haematoma [3,4]. However, the main cause of bleeding in the BEH is usually venous bleeding [1]. We suppose that our case of BEH was caused by arterial bleeding after the laceration of both right and left middle meningeal arteries as a result of bilateral skull fracture. In general, haematomas secondary to arterial bleeding require more urgent evacuation since it can rapidly lead to intracranial hypertension (ICH). When surgery is indicated, either arterial or venous EDH are treated by craniotomy, with haematoma evacuation, haemostasis and dural retention sutures (along bone edges and centrally).Once the diagnosis of BEH is made, urgent surgical treatment should be considered, and in cases of asymmetric EDH, the responsible one for the neurological deterioration (when possible to identify) must be removed first. In cases which the hematoma is small, it can be followed with close clinical and tomographic abstractEpidural haematomas are one of the mos...

RESUMO -Relatamos um caso de aneurisma da bifurcação da artéria carótida interna, cuja ruptura se deu para dentro de cisto de aracnóide da fissura silviana. Em revisão da literatura apenas 3 casos foram descritos. Discutimos ainda os aspectos clínicos atípicos do caso, as características dos achados cirúrgicos e uma correlação etiopatogênica entre as duas patologias.PALAVRAS-CHAVE: aneurisma cerebral, cisto de aracnóide, hemorragia subaracnóide, hemorragia intracística, etiopatogenia. Cerebral aneurysm and arachnoid cyst: about a case with intracystic hemorrhageABSTRACT -We report a case of a carotid artery bifurcation aneurysm which ruptured into a silvian fissure arachnoid cyst. In the review of the literature, only three cases were before reported. We discuss about uncommom clinical findings, the surgical aspects and the associations among the lesions.