Hydrocephalus is a pathological entity that has been known since Hippocrates and Galen [33]. It is one of the most common disorders treated by neurosurgeons. The overall incidence and prevalence of the disease can be difficult to estimate, as it can occur as an isolated entity or in association with other neurological disorders. Congenital hydrocephalus is present in 3 of 1000 live births [97]. Aside from the congenital etiology, hydrocephalus can result from a series of neurological conditions such as head trauma, intracranial hemorrhage, tumor, or infection of the central nervous system at any time during life.Whatever its cause, the symptomatology of hydrocephalus is remarkably similar among patients. The radiological appearance is also deceptively alike for most age groups. However, age is an important factor in determining the clinical picture. Hydrocephalus due to a congenital infection of the central nervous system in a neonate is a different disorder from the normal-pressure hydrocephalus of the adult, despite the fact that both are morphologically represented by ventriculomegaly. Like the etiology, the specific damage caused by hydrocephalus is also strongly influenced by the age at onset of the disease.The pathophysiology of hydrocephalus is much more complex than its clinical or radiological presentation, going beyond the ventricular dilatation and mantle thinning obvious at first inspection. Together with gross macroscopic changes, hydrocephalus leads to alterations of the normal physiology, biochemistry, and ultrastructure of the brain. Three factors are basic for the determination of the severity of the injuries caused by hydrocephalus and the ultimate outcome. They are: age at onset, etiology, and the duration of the disease.The stage of maturation of the brain afflicted by hydrocephalus must be taken into account when discussing pathophysiology. Development is a fundamental aspect of the physiology of the brain in young immature animals and humans: metabolic pathways are maturing, neuronal activity is greatly increased, biosynthetic activity is intense, and myelination proceeds at a
A acromegalia é uma síndrome causada pela hipersecreção do hormônio de crescimento (GH). No entanto, alguns pacientes podem apresentar níveis séricos limítrofes, ou mesmo dentro da normalidade, dificultando o diagnóstico. Relatamos um caso de acromegalia cuja investigação diagnóstica inicial evidenciou níveis séricos basais de GH dentro dos limites da normalidade e tomografia computadorizada (TC) de sela túrcica normal. A confirmação da doença só foi estabelecida através de testes dinâmicos que avaliam a regulação do GH (dosagem de GH durante o teste oral de tolerância à glicose e após TRH) e confirmada pela ressonância nuclear magnética (RNM) de sela túrcica que evidenciou imagem sugestiva de microadenoma. A paciente foi submetida à cirurgia hipofisária pela via de acesso oronaso esfenoidal e a área tumoral encaminhada para estudo imunohistoquímico, corroborando o diagnóstico de acromegalia. A avaliação dinâmica no pós operatório evidenciou regulação normal do GH. Discutimos os critérios diagnósticos da acromegalia, com ênfase na importância de se prosseguir com a investigação sempre que houver uma forte suspeita clínica, mesmo que os exames iniciais se apresentem dentro dos limites da normalidade. ABSTRACTAcromegaly is a syndrome caused by growth hormone (GH) hypersecretion. However, some patients can present normal or near normal levels of GH, difficulting diagnosis. We report an acromegalic patient with normal levels of GH and negative imaging at initial investigation. Acromegaly was confirmed by dynamic tests (glucose tolerance test and GH-TRH), and RMI was suggestive of a microadenoma. The patient was submitted to a transesphenoidal pituitary surgery and imunohistochemistry study, corroborating the diagnosis of acromegaly. Dynamic tests performed after surgery evidenced normal GH regulation. Considerations on the diagnosis of acromegaly were also done, emphasizing the importance of continuing the investigation whenever clinical suspicion persists, even though the initial tests are within the normal range.
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