RESUMO -Estudo prospectivo mostrando a importância da biópsia cerebral estereotáxica no manuseio do paciente com AIDS e que apresenta sintomatologia neurológica confirmada através de imagens. Todos estes pacientes obedecem a escalonamento terapêutico e, depois de terem sido dados os passos prévios, a biópsia passa a ser indicada visando ao diagnóstico etiológico adequado. O protocolo foi iniciado em agosto-1995 e concluído em dezembro-1996. Vinte pacientes foram biopsiados. Nosso protocolo é semelhante ao descrito por Levy e col. (Chicago IL, USA). Linfoma primário foi o diagnóstico predominante, seguido de leucoencefalopatia multifocal progressiva, toxoplasmose e leucoencefalopatia pelo HIV. Um caso de linfoma de células gigantes diplóico foi incluído. Nossa morbi/mortalidade foi nula. Por esta amostragem é possível concluir que a biópsia cerebral estereotáxica é um procedimento seguro e eficaz em pacientes com AIDS.PALAVRAS-CHAVE: biópsia cerebral estereotáxica, síndrome da imunodeficiência adquirida, linfoma, toxoplasmose, leucoencefalopatia multifocal progressiva, encefalopatia pelo HIV. Image guided stereotactic brain biopsy in AIDS patients with neurological manifestationsABSTRACT -Prospective series showing the importance of computerized stereotactic brain biopsy in the management of AIDS patients neurologically symptomatic and confirmed by images. Patients undergone an algorithm step by step done by their own doctors and referred to us for stereotactic biopsy. Our protocol was opened in August 1995 and closed in December 1996. Twenty patients were biopsied. This protocol is similar to the Levy's one (Chicago IL, USA). We have got diagnosis in all cases. Lymphoma was predominant and followed by toxoplasmosis, progressive multifocal leukoencephalopathy and HIV encephalopathy. We included one patient with diploic giant cells lymphoma. Our mortality and morbidity was zero. By these results we conclude that stereotactic biopsy in AIDS patients is safe and effective.KEY WORDS: stereotactic brain biopsy, acquired immunodeficiency syndrome, lymphoma, toxoplasmosis, progressive multifocal leukoencephalopathy, HIV encephalopathy.Este estudo é o resultado de toda uma avaliação de pacientes com AIDS que, em seu curso de doença, apresentaram sintomas neurológicos. A partir deste instante, inicia-se a investigação através da aplicação de um algoritmo, visando identificar e tratar corretamente a lesão que está levando a este problema. Para isto, no diagnóstico por imagens a tomografia computadorizada do crânio (TC) e a ressonância magnética (RM) são imperativas, dando início ao protocolo de investigação. Este nosso protocolo é semelhante ao descrito por Levy e col. da Northwestern University (Chicago IL, USA) 1,2 . Desta forma foi possível conduzir o estudo de maneira coerente e sistematizada, proporcionando a perfeita análise e comparação de várias séries.
The authors present the preliminary results of 20 patients selected to be operated on between January 1996 and April 1997. These patients presented one of the present indications for stereotactic posteroventral pallidotomy (PVP), such as: rigidity, akinesia/bradykinesia, gait dysfunction, drug induced dyskinesias and tremor. Every patient of this protocol was evaluated by: UPDRS score, Schwab and England scale, Hoehn and Yahr Staging Scale before and after surgery. The results in 3 months showed a remarkable improvement after PVP (P < 0.01) in all functional assessments, except for facial expression, speech and posture. The morbidity was 5%. 5 patients (25%) who were in Hoehn and Yahr 5 underwent a bilateral simultaneous PVP. In 5 patients (25%), who had tremor, during the PVP, VIM thalamotomy was added. These preliminary results, suggest that PVP is highly effective for PD symptoms.
In a series of 44 image guided stereotactic biopsy from August 1995 until March 1997, findings were as follows (frequency order). Tumors, glioblastoma was the most frequent. Primary lymphoma and other conditions associated to AIDS. Metastasis, three cases, Vasculites, two cases, Arachnoid cyst, Creutzfeldt-Jakob, cortical degeneration, inespecific calcification (one case each). The age varied from 1 to 83 years. Forty one lesions were supratentorial, two infratentorial, and one was outside the brain (dura and skull) and we used stereotaxy to localize it. There was no mortality and morbidity was 2.3%. The literature is reviewed. We conclude that this procedure is safe and highly diagnostic.
-The authors present the preliminary results of 20 patients selected to be operated on between January 1996 and April 1997. These patients presented one of the present indications for stereotactic posteroventral pallidotomy (PVP), such as: rigidity, akinesia/bradykinesia, gait dysfunction, drug induced dyskinesias and tremor. Every patient of this protocol was evaluated by: UPDRS score, Schwab and England scale, Hoehn and Yahr Staging Scale before and after surgery. The results in 3 months showed a remarkable improvement after PVP (P<0.01) in all functional assessments, except for facial expression, speech and posture. The morbidity was 5%. 5 patients (25%) who were in Hoehn and Yahr 5 underwent a bilateral simultaneous PVP. In 5 patients (25%), who had tremor, during the PVP, VIM thalamotomy was added. These preliminary results suggest that PVP is highly effective for PD symptoms.KEY WORDS: Parkinson's disease, postero-ventral pallidotomy, VIM thalamotomy, simultaneous bilateral postero-ventral pallidotomy, stereotaxis. Resultados preliminares em cirurgia na doença de ParkinsonRESUMO -Os autores apresentam seus resultados iniciais, no período de janeiro de 1996 até abril de 1997, em pacientes selecionados para cirurgia. Todos apresentavam indicação para palidotomia póstero ventral (PPV), como: rigidez, acinesia/bradicinesia, distúrbio da marcha, discinesia induzida por medicamentos e tremor. Todos os pacientes do protocolo foram submetidos a: UPDRS, escala de Hoehn e Yahr, escala de Schwab e England antes e após a cirurgia. Os resultados mostraram melhora significativa nos 3 meses iniciais (p<0,01) para todas as provas motoras exceto para expressão facial, postura e fala. A morbidade foi de 5%. 5 pacientes em Hoehn e Yahr 5 foram submetidos a palidotomia bilateral simultânea. 5 talamotomias (núcleo VIM) foram acrescentadas no mesmo tempo para pacientes com tremor. Os resultados sugerem que PPV é um procedimento seguro e altamente eficaz para os sintomas da doença de Parkinson. PALAVRAS-CHAVE: doença de Parkinson, palidotomia póstero-ventral, talamotomia VIM, palidotomia póstero-ventral simultânea, estereotaxia.The understanding of pathophysiology of Parkinson's disease (PD), the signs and symptoms and also the improvement of modern techniques in neuroradiology, functional neurosurgery and neurophysiology assessment have renewed the right place of surgery in PD. Leksell's posteroventral pallidotomy (PVP) 1,2 has become the procedure of choice. The indications are: rigidity, akinesia or bradykinesia, muscle pain, L-Dopa induced dyskinesias and resting tremor. Ventrolateral thalamotomy is more indicated for those PD patients with resting and intention tremor, and those who initially did not respond to pallidotomy for tremor. It is not uncommon a combination peroperatively of pallidotomy and ventralis intermedius (VIM) thalamotomy if the tremor does not respond satisfactorily after PVP 1,[3][4][5] . This paper report the authors preliminary results on PVP in PD.
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