T he primary goal of intracranial aneurysm treatment is complete, permanent, and safe aneurysm occlusion while maintaining flow in the vessels associated with the aneurysm. Aneurysms are very diverse; therefore, the surgical approach depends in large part on the specific aneurysm to be treated, its relationship to the skull, the surrounding structures, and morphology. In this context, the pterional (PT), or frontotemporosphenoidal, approach is one of the most commonly used in vascular neurosurgery. 1,2,6,12,[26][27][28] abbreviatioNs MPT = minipterional; mRS = modified Rankin Scale; PT = pterional; ROI = region of interest. methods Fifty-eight patients with ruptured and unruptured anterior circulation aneurysms were enrolled into a prospective randomized study. The first group included 28 patients who underwent the MPT technique, and the second group comprised 30 patients who underwent the classic PT craniotomy. To evaluate the aesthetic effects, patients were asked to grade on a rule from 0 to 100 the best and the worst aesthetic result. Photographs were also taken, assessed by 2 independent observers, and classified as showing excellent, good, regular, or poor aesthetic results. Furthermore, quantitative radiological assessment (percentage reduction in thickness and volumetric analysis) of the temporal muscle, subcutaneous tissue, and skin was performed. Functional outcomes were compared using the modified Rankin Scale (mRS). Frontal facial palsy, postoperative hemorrhage, cerebrospinal fistula, hydrocephalus, and mortality were also analyzed. results Demographic and preoperative characteristics were similar in both groups. Satisfaction in terms of aesthetic result was observed in 19 patients (79%) in the MPT group and 13 (52%) in the PT group (p = 0.07). The mean score on the aesthetic rule was 27 in the MPT group and 45.8 in the PT group (p = 0.03). Two independent observers analyzed the patient photos, and the kappa coefficient for the aesthetic results was 0.73. According to these observers, excellent and good results were seen in 21 patients (87%) in the MPT and 12 (48%) in the PT groups. The degree of temporal muscle, subcutaneous tissue, and skin atrophy was 14.9% in the MPT group and 24.3% in the PT group (p = 0.01). Measurements of the temporal muscle revealed 12.7% atrophy in the MPT group and 22% atrophy in the PT group (p = 0.005). The volumetric reduction was 14.6% in the MPT and 24.5% in the PT groups (p = 0.012). Mortality and mRS score were similar in both groups at the 6-month evaluation (p = 0.99). coNclusioNs Minipterional craniotomy provides clinical results similar to those of the PT technique. Moreover, it provides better cosmetic results. It can be used safely and effectively to surgically treat aneurysms of the anterior circulation instead of the PT approach.Clinical trial registration no.: NCT01872741 (clinicaltrials.gov)
Traumatic head injury is a common cause of mortality and acquired neurological impairment in children. However, pediatric epidural hematomas (EDHs) are not common and few series have studied the evolution of these patients. In this study, we present the results from a sample of patients with EDH with long-term follow-up. Method: Between January 2006 and December 2008, 49 patients with traumatic EDH were treated at our unit. Clinical course, radiological findings and outcomes were evaluated. Neurological status was assessed using the Glasgow Coma Scale (GCS). The patients' ages ranged from one day to 16 years. The mean follow-up was six months. Results: On admission, most of the patients presented mild trauma and 57% had a GCS of 13-15. The most common symptom was irritability. The most frequent mechanisms of injury were: falling from a height in 29 cases and motor vehicle accidents in 16 cases. Three of these patients presented GCS 3, but only one died. We found a late neurological deficit in nine patients. Conclusion: These lesions may occur following mild head trauma and in alert children with nonfocal neurological examinations. However, in children presenting irritability with subgaleal hematomas and a history of loss of consciousness, skull computed tomography must be performed. Key words: epidural hematoma, head trauma, children.Tratamento de hematoma epidural supratentorial em crianças: avaliação em 49 pacientes RESUMO Trauma craniocerebral é uma causa frequente de mortalidade e comprometimento neurológico adquirido em crianças. No entanto, hematomas epidurais (HED) são raros em pacientes pediátricos, com poucas series estudando a evolução destes pacientes. Neste estudo, os autores apresentam os resultados de uma casuística de pacientes com HED acompanhados em longo prazo. Método: Entre janeiro de 2006 e dezembro de 2008, 49 pacientes com HED foram tratados em nossa unidade. Curso clínico, achados radiológicos, e resultados foram avaliados. O estado neurológico foi avaliado com o Glasgow Coma Scale (GCS). A idade variou de 1 dia a 16 anos. A média de acompanhamento foi de 6 meses. Resultados: Na admissão, a maioria dos pacientes apresentava trauma leve e 57% estavam com GCS de 13-15. O sintoma mais comum foi irritabilidade. Os mecanismos de trauma mais frequentes foram queda de altura em 29 casos e acidentes de trânsito em 16 casos. Três destes pacientes apresentavam GCS 3, mas somente um morreu. Verificou-se déficit neurológico tardio em nove pacientes. Conclusão: Esta lesão pode ocorrer após traumas leves e em crianças alerta com exames neurológicos não focais. No
-Background:Primary spinal cord intramedullary tumors are rare and present with insidious symptoms. Previous treatment protocols emphasized biopsy and radiation/chemotherapy but more aggressive protocols have emerged. Objective: To report our experience. Method: Forty-eight patients were diagnosed with primary intramedullary tumors. The cervical cord was involved in 27% and thoracic in 42% of patients. Complete microsurgical removal was attempted whenever possible without added neurological morbidity. Results: Complete resection was obtained in 33 (71%) patients. Neurological function remained stable or improved in 32 patients (66.7%). Ependymoma was the most frequent tumor (66.7%). Conclusion: Neurological outcome is superior in patients with subtle findings; aggressive microsurgical resection should be pursued with acceptable neurological outcomes.KEy words: spinal cord, spastic paraparesis, spinal cord neoplasms, ependymoma; microsurgery. tratamento cirúrgico de tumores intramedulares primários em adultosResumo -Introdução: Tumores intramedulares primários são raros e apresentam-se com sintomas insidiosos. Protocolos de tratamento anteriores enfatizavam biópsia e radio/quimioterapia, mas protocolos mais agressivos têm surgido. Objetivo: relatar nossa experiência. Método: Tumores intramedulares foram diagnosticados em 48 pacientes. o segmento cervical estava envolvido em 27% e torácico em 42% dos pacientes. remoção completa foi tentada quando possível sem aumento da morbidade neurológica. Resultados: ressecção total foi obtida em 33 (71%) pacientes. Função neurológica: permaneceu inalterada/melhorou em 32 (66,7%) pacientes. o tumor mais freqüente foi ependimoma (66,7%). Conclusão: o prognóstico é melhor em pacientes oligossintomáticos; ressecção microcirúrgica agressiva deve ser tentada sempre, com resultados clínicos aceitáveis.PALAVrAs-CHAVE: medula espinhal, paraparesia espástica, neoplasias da medula espinhal, microcirurgia.
Schwannomas are solitary, benign, slow-growing, encapsulated neoplasms composed of differentiated neoplastic Schwann cells. The melanocytic schwannoma, a schwannian tumor variant, is rarely encountered and its ocurrences have been described as single case reports 1 . The most common site of these tumors is the posterior spinal nerve root 1,2 . However, they can occur in other locations, such as the sympathetic chain, acoustic nerve, cerebellum, orbit, choroid, soft tissues, heart, oral cavity, esophageal wall, stomach, bronchus, retroperitoneum, uterine cervix and parotid gland 2,3 . The melanotic schwannomas can be related as a part of a syndrome named Carney complex (described in 1990), characterized by the association of cutaneous pigmentation, fibromyxoid tumors of the skin, myxoma of the heart, endocrine overactivity and autosomal dominant inheritance 4 . The largest series in spinal melanotic schwanommas is composed by 5 cases. In these series, we report our experience with three cases. CASESThree cases of spinal melanotic schwannoma were studied between 2006 and 2010 in authors' institution. None of the patients had a familial history or any component of Carney complex (spotty pigmentation, endocrine overactivity or myxomas).The patients were two male and one female. The mean age was 50 years (range 42-59 years). The most frequent symptom was pain followed by motor deficit. The mean duration of symptoms was 15 months. Magnetic resonance images showed intradural, extramedullary lesions iso/hyperintense in T1- (Fig A) and hypointense in T2-weighted sequences.The histological examination revealed fusiform and epithelioid cells, with highly pigmented cytoplasm ( Fig B). Immunohistochemical studies revealed intense cytoplasm and nuclear expression of S100 protein (Fig C), HMB-45 and Melan-A (Fig D). DiSCuSSionGenerally, melanotic schwannomas affect spinal nerves, the central nervous and the autonomous nervous system, but extra-nervous locations also occur 1 . The dorsal location represents 30.5% of the spinal melanotic schwannomas and clinical presentation is similar to other extramedullary spinal tumors 5 . Psammomatous melanotic schwannoma is a distinct clinicopathologic entity and may be considered as a part of the Carney complex, which is characterized by myxomas (heart, skin and breast), mucocutaneous spotty pigmentations and endocrine overactivity (due to thyroid dysfunction or hypophysial adenoma, or Cushing's syndrome secondary to primary pigmented nodular adrenocortical hyperplasia) 4 . About 50% of patients with melanotic psammomatous schwannomas are affected by the syndrome of Carney and one-fifth of them present multiple lesions 1 . None of our patients exhibits these manifestations.The preoperative diagnosis is based on magnetic resonance imaging. While conventional schwannomas are hypointense on T1-weighted and hyperintense on T2-weighted sequences, the melanotic variant is hyperintense on T1-and hypointense on T2-weighted sequences 1 . Zhang et al. 3 demonstrated that melanotic schwannomas rec...
There are time-dependent improvements in visual memory in patients with DAI. Neuroplasticity in the 1st months after trauma provides an opportunity for visuospatial memory learning. The present findings may be useful to formulate management plans for long-term TBI rehabilitation.
BackgroundDiffuse axonal injury (DAI), a common cause of neurological sequelae in patients with traumatic brain injury (TBI), is considered one of the most prevalent forms of primary neuronal injury in patients with severe TBI. Cognitive deficits induced by DAI can persist over time, especially following moderate or severe injuries. The aim of the present study was to compare verbal fluency (VF) performance at 6 and 12 months after the trauma in a same group of patients with DAI.MethodsEighteen patients with moderate to severe DAI and 17 healthy volunteers were enrolled. All DAI participants had sustained a TBI at least 6 months prior to the start of the study, were between 18 and 50 years of age, and had at least 4 years of education. The VF test was administered within an extensive neuropsychological test battery. We evaluated the same patients at 6 months (DAI1 group) and 12 months (DAI2 group) and compared the results of neuropsychological tests with a control group of healthy volunteers who were matched to patients for sex, age, and educational level.ResultsIn comparison to controls, the DAI1 group produced significantly fewer words. The DAI2 group produced significantly more semantic words than DAI1 (P<0.05) and demonstrated a trend towards the production of more clusters for letter A (P=0.09) and total words generated in a phonemic test (P=0.09). No significant differences were observed between DAI2 and the control group in the total number of words generated in phonetic FAS or semantic fluency scores.ConclusionThe present findings may be useful in the construction of a management plan for long-term TBI rehabilitation that considers the trauma of each patient. Further, our results suggest the VF test is a suitable instrument for the assessment of cognitive difficulties following TBI.
Our findings suggest that MHL may be a predictor of WMV reduction but cannot predict EF or EVM in DAI. Brain atrophy progresses over time, but patients showed better EF and EVM in some of the tests, which could be due to neuroplasticity.
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