BACKGROUND AND PURPOSE:The T2-weighted gradient-echo (GRE) imaging is currently the gold standard MR imaging sequence for the evaluation of patients with cerebral cavernous malformation (CCM) lesions. We aimed to compare the sensitivity of susceptibility-weighted imaging (SWI) with T2-weighted fast spin-echo (FSE) and GRE imaging in assigning the number of CCM lesions in patients with the familial form of the disease.

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-We present a case of a 46-year old woman with a ventral epidural angiolipoma at the lumbosacral level with erosion of the sacrum. About ninety cases of spinal angiolipomas have been previously described in the literature, most of them situated on the thoracic region, dorsal to the dural sac. Angiolipomas can be radically excised with a good prognosis even in the presence of bone erosion. We did not find any other angiolipoma at the sacral level surgically explored in the review of the literature. Spinal angiolipoma is a benign tumor of the epidural space. It is a rare cause of spinal cord compression, accounting for 0.14% to 1.2% of the spinal tumors 1 . It is considered a distinct clinical and pathological entity traditionally grouped as a variant of lipoma 1 . Characteristically the tumor lies over the dorsal aspect of the dura at the thoracic level 2-7 . Its port-wine color or dark brown appearance contrasts very well with the normal epidural fat 1,8,9 . Sometimes the tumor can be more aggressive and invade the contiguous bone and adjacent soft tissues 10,11 . We report a patient with a lumbosacral angiolipoma with bone erosion associated with a L4-L5 left sided disc herniation. CASEA 46-year old female with a history of ten years of low back pain had a worsening of the symptoms in the three months before diagnosis. The pain radiated down the posterior aspect of the left thigh, calf and ankle, and increased with walking and physical strength. The patient also referred a progressive numbness of the perineum. A neurological examination demonstrated a mild paresis of the plantar flexion of the left toe and hypoactive left jerk reflex. A positive straight leg-raising test at ten degree at the left side could be elicited. Superficial hypoesthesia at the lateral aspect of the left foot, buttocks and perineum was noted. An X-ray of the lumbar spine and sacrum showed erosion of the posterior aspect of the sacrum and widening of the sacral canal. A MRI scan revealed an epidural mass displacing the dural sac posteriorly, eroding the bone and projecting to the anterior sacral foramina with the sacral root. The mass was isointense in T1-weighted and hyperintense in T2-weighted and showed a homogeneous and intense enhancement with gadolinium infusion. There was also a left sided disc herniation associated with the upper limit of the tumor at the level of L4-L5 space (Fig 1).She was submitted to a L4-L5 laminectomy and a posterior opening of the sacral canal with a wide exposure of the dura and sacral roots bilaterally. The dural sac was pushed back and ventrally compressed by a firm and large port-wine highly vascularized mass, which partially encased the sacral roots and infiltrated the sacrum (Fig 2). The mass was totally resected with preservation of the roots.

Neurocysticercosis (NCC) is an endemic disease and important public health problem in some areas of the World and epilepsy is the most common neurological manifestation. Multiple intracranial lesions, commonly calcified, are seen on cranial computed tomography (CT) in the chronic phase of the disease and considered one of the diagnostic criteria of the diagnosis. Magnetic resonance imaging (MRI) is the test that better depicts the different stages of the intracranial cysts but does not show clearly calcified lesions. Cerebral cavernous malformations (CCM), also known as cerebral cavernomas, are frequent vascular malformations of the brain, better demonstrated by MRI and have also epilepsy as the main form of clinical presentation. When occurring in the familial form, cerebral cavernomas typically present with multiple lesions throughout the brain and, very often, with foci of calcifications in the lesions when submitted to the CT imaging. In the countries, and geographic areas, where NCC is established as an endemic health problem and neuroimaging screening is done by CT scan, it will be important to consider the differential diagnosis between the two diseases due to the differences in adequate management.

Background: Cerebral cavernous malformations (CCM) are clusters of dilated sinusoidal channels lined by a single layer of endothelium. In contradistinction to arteriovenous malformations, these lesions do not have smooth muscle or elastin in their lining and they are angiographically occult, and the MRI is the most sensitive test for CCM detection. CCM are one of the most prevalent vascular malformations of the central nervous system, affecting about 0.4-0.6% of the general population. The main complication of this malformation is the risk of bleeding, which may cause neurological deficits that affect the quality of life (QoL) in patients. When symtomatic, they may be surgically treated for relieving the mass effect and seizures refractory to drug uses, hemorrhage and drug-refractory epilepsy. Patient-reported outcome (PRO) may be a strategy that can be used to evaluate QoL of CCM population and was used in a sample of non-operated patients. Methods: An observational, cross-sectional analysis to evaluate the PRO using the SF-36 and EuroQol 5 dimensions (EQ-5D) questionnaires of QoL added to functional metrics using the Karnofsky Performance Status (KPS) in 49 patients not submitted to intervention and with long-term follow-up. Results: During the 364 person-years of follow-up, there was an average of individual follow-up of 7.42 years. The mean age was 46.8 years (18-84) - 57% of them were female, 71% had superficial lesions, and 65% had the familial form. Comparisons of SF-36 dimensions with KPS graded <100 had a worse score only in terms of the pain (p = 0.04), vitality (p = 0.001), and general state of health (p = 0.03) domains. The domain mental health was worse in patients without surgical indication (p = 0.032). The functional capacity domain had the highest overall grading in the group. The EQ-5D dimensions of mobility (p = 0.03) and pain/discomfort (p = 0.001) were the ones with lower score compared to KPS <100. Conclusion: The study is the first to evaluate, with validated tools, the PRO of non-operated CCM patients and has demonstrated in a selected group of patients that it was possible to achieve long-term clinical stability, thereby maintaining QoL and functional neurological outcome.

-We report on a case of endovascular management of pseudoaneurysm of the cavernous segment of the internal carotid artery with covered stent reconstruction. A 36 years-old woman with a history of previous transsphenoidal approach for pituitary macroadenoma and false aneurysma formation was studied in a protocol that included balloon test occlusion and cerebral blood flow evaluation. An endovascular covered stent deployment in the area of the carotid laceration was performed with isolation of the aneurysm from the circulation and maintenance of the carotid flow. Helical angio-CT and cerebral digital subtraction angiography showed the carotid preservation without stenosis in the stented area. In conclusion, endovascular stent reconstruction for post-transsphenoidal carotid artery laceration and false aneurysm is demonstrated as useful technical adjunct in the management strategy and with the potential for carotid sacrifice morbidity avoidance.KEY WORDS: cerebral aneurysms, intravascular stents, transsphenoidal surgery, pituitary tumor. P P P P Pseudoaneurisma

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-In the treatment of complex paraclinoidal and giant cavernous aneurysms, preservation of the patency of the internal carotid artery (ICA) is not always possible, and therapeutic occlusion of the carotid is still an important option for their management. A complete preoperative evaluation of the carotid reserve circulation, including the use of temporary balloon occlusion test and single photon emission computerized tomography (SPECT) should be included in the current paradigms of paraclinoidal and intracavernous aneurysms management. We present a series of fifteen patients with sixteen giant or complex carotid cavernous or ophthalmic aneurysms that were treated following a protocol for our preoperative decision-making analysis. Extracranial to intracranial saphenous vein bypass was reserved to the cases where carotid occlusion would be associated with high risk of ischemic complications and was performed in three patients. Besides the difficulties in dealing with those complex aneurysms, good clinical outcome was possible in our experience with the designed paradigm.KEY WORDS: intracranial aneurysm, cavernous aneurysm, SPECT, balloon occlusion.Aneurismas paraclinoideos complexos e cavernosos gigantes: importância da avaliação pré-operatória com teste de oclusão temporária com balão e SPECT RESUMO -No tratamento de aneurismas paraclinoideos complexos e cavernosos gigantes, a preservação da patência vascular nem sempre é possível, e a oclusão terapêutica da carótida ainda é uma opção importante no seu manejo. Uma avaliação pré-operatória completa da reserva circulatória carotídea, incluindo o uso do teste de oclusão temporária por balão associado à tomografia computadorizada por emissão de fóton único (SPECT) podem ser de grande utilidade para definir a opção terapêutica a ser adotada. Nós apresentamos uma série de quinze pacientes com dezesseis aneurismas complexos ou gigantes do segmento oftálmico e cavernoso da artéria carótida, que foram tratados de acordo com determinado protocolo de investigação pré-operatória. Anastomose com enxerto de veia safena entre a carótida extra e intracraniana foi reservada para os casos em que a oclusão carotídea estaria associada a um alto risco de complicações isquêmicas e foi realizado em três pacientes. Apesar das dificuldades em lidar com aneurismas complexos como os aqui relatados, é possível obter um bom resultado clínico nestes pacientes com o paradigma desenhado.PALAVRAS-CHAVE: aneurisma intracraniano, aneurisma cavernoso, SPECT, oclusão com balão.Advances in surgical techniques and cranial base approaches have greatly improved surgical outcomes with paraclinoidal aneurysms. However, they still represent a challenge for surgical management. A significant number of paraclinoidal aneurysms present as giant and complex aneurysms. Although most of them are manageable by direct clipping, occasionally proximal and distal temporary occlusion and defla-