Pediatric Skull Base Tumors: A Management Challenge.

CONTEXT: Skull base tumors are varied in children and are particularly challenging to pediatric neurosurgeons, with few papers in the literature describing the evolution, complications, and outcome. The authors evaluated long-term outcomes in children submitted to skull base tumor surgery and performed a literature review. AIMS: The aim of this study was to analyze surgical results, complications, and outcomes, on comparison with previous publications. MATERIALS AND METHODS: A retrospective analysis of children undergoing surgery at a single institution between 2000 and 2018 for lesions of the cranial base was carried out. In addition, a literature review was carried out describing a total of 115 children operated on for skull base tumors. STATISTICAL ANALYSIS: Chi-squared and Fisher's exact tests were performed to compare the distribution of categorical variables and a nonparametric Mann-Whitney U test was used to perform intergroup comparisons of continuous variables. RESULTS: Seventeen children ranging in age from 8 months to 17 years (mean, 10.9 years) underwent skull base approaches. Tumor types included schwannoma, meningioma, chondroid chordoma, mature teratoma, epidermoid cyst, hemangiopericytoma, rhabdomyosarcoma, myofibroblastic inflammatory tumor, fibromyxoid sarcoma, Crooke's cell adenoma, ossifying fibroma, osteoblastoma, nasopharyngeal angiofibroma and Ewing's sarcoma. Gross total resection was achieved in 6 patients (35.3%), 12 patients (70.6%) had benign histology, and 5 patients (29.4%) had a malignant tumor. Transient postoperative cerebrospinal fluid leak affected only one patient. Thirteen children (76.4%) had a residual neurological deficit at last follow-up evaluation. Three (17.6%) surviving patients received adjuvant therapy. The rate of recurrence or lesion progression was 17.6%. CONCLUSIONS: Skull base tumors in children present a therapeutic challenge because of their unique pathological composition and can lead to considerable morbidity and mortality in pediatric age.

Traumatic Brain Injury in the Elderly: Clinical Features, Prognostic Factors, and Outcomes of 133 Consecutive Surgical Patients.

Objective With the aging of the global population, an increase in the proportion of elderly patients presenting with traumatic brain injury (TBI) is expected. This population presents several distinctive characteristics that impact management and outcome of TBI, such as comorbidities, frailty, and preinjury use of medications - specially antiplatelets and anticoagulants. The purpose of this study was to assess the general characteristics and prognostic factors of elderly patients with TBI that were surgically managed at a single institution. Methods The authors performed a retrospective review of all elderly patients (age ≥ 65 years) with a history of TBI that underwent cranial neurosurgical procedures at their institution, between 2015 and 2019. Clinical characteristics, laboratory tests, and radiological scans, as well as surgeries, performed, outcome, and prognostic factors were analyzed, comprising 133 consecutive cases overall. Results The mean age of patients was 76.6 ± 7.3 years, ranging from 65 years to 97 years. There was a predominance of males (71.4%) and the most frequent mechanism of injury was fall (80.4%). Mild TBI comprised 57.1% of the cases, followed by severe TBI in 25.6%. Frequent signs and symptoms were impaired consciousness (69.9%), focal motor deficits (32.3%), and gait disturbances (12.8%). The majority had reported comorbidities upon admission (79.7%), with cardiac disease (79.2%) and diabetes (24.5%) as the most frequent. Preinjury anticoagulation was reported in 18.8% and use of antiplatelet drugs in 17.3%. The most common finding in the head CT was chronic subdural hematoma (48.1%), followed by acute subdural hematoma (37.6%). Coagulation was found to be altered in 12.8% of the patients. The most common neurosurgical procedure performed was trephination for hematoma evacuation (56.3%), followed by craniotomy (21.2%). Blood product transfusion was needed in 61.7% of the patients. Overall mortality was 42.1%, with the majority in the first month after admission (83.9%). Unfavorable outcome (Glasgow Outcome Scale <5) at discharge was identified in 73% of the patients. Identified prognostic factors were TBI severity, absent pupillary reactivity, acute intracranial bleeding on head CT, basal cisterns obliteration, altered coagulation status, and need for blood transfusion. Conclusions TBI severity, pupillary reactivity, coagulation status, need for blood products transfusion and acute bleeding, as well as basal cisterns obliteration found in head CT, are factors that influenced the outcome in this series of elderly patients with TBI that need surgical management. It is paramount to observe the particularities of this population in this context, to optimize outcomes, avoid complications and ultimately generate awareness focused on prevention.

Role of Methylene Blue in Trauma Neuroprotection and Neuropsychiatric Diseases.

The prevalence of central nervous system trauma, neurodegenerative and psychiatric diseases has significantly increased in recent years. Most of these diseases show multifactorial causes and several progression mechanisms. The search for a medication which positively interferes in these mechanisms and thereby changes the course of these diseases is of great scientific interest. The aim of the present review is to assess current literature on the possible role of methylene blue (MB) in the central nervous system due to the increasing number of citations in spite of the few articles available on the subject which suggest growing interest in the protective effects of MB on the central nervous system. Searches were performed on PubMed and Thomson Reuters Web of Knowledge. Therefore, we provide an overview of existing articles concerning: 1) MB actions; 2) MB neuroprotection and cardiac arrest; 3) MB neuroprotection and degenerative brain diseases; 4) MB neuroprotection and psychiatric diseases. PubMed was chosen because it holds the highest number of articles on the subject, Thomson Reuters was chosen due to its functionality which evaluates citations through analytic graphs. We conclude that MB has a beneficial effect and acts through many mechanisms and pathways of the central nervous system, being a potential alternative for the treatment of many neurodegenerative and psychiatric diseases.

Fas, FasL, and cleaved caspases 8 and 3 in glioblastomas: a tissue microarray-based study.

This investigation analyzed the immunoexpression of FasL, Fas, cleaved caspase-8, and cleaved caspase-3 in glioblastomas. Formalin-fixed and paraffin-embedded glioblastoma tissues and control brain tissues from 97 patients were analyzed by tissue microarrays and immunohistochemistry. Patients with glioblastomas that were negative or weakly stained (<50% of cells positive) for cleaved caspase-8 had worse cancer-specific overall survival (median=8.5 months) than did patients with tumors that highly expressed cleaved caspase-8 (median=11.7 months; P=0.0325), independent of clinical variables. There was no association of other markers with survival, treatment, sex, age, tumor size, and primary site. Among the tumors, there were reasonable to good positive correlations between the expression of FasL and Fas (r=0.47) and between Fas and cleaved caspase-8 (r=0.41), and there were poor positive correlations between Fas and cleaved caspase-3 (r=0.26), FasL and cleaved caspase-8 (r=0.22), and cleaved caspase-8 and -3 (r=0.31). Our results suggest that Fas-Fas-ligand signal transduction could be inhibited, especially at the stage of caspase-8 activation, thereby establishing a major mechanism for evasion of apoptosis by these tumors. The absence or low expression of cleaved caspase-8 in the tumors was a negative prognostic indicator for patient survival.

A comparison between magnetic resonance angiography at 3 Teslas (time-of-flight and contrast-enhanced) and flat-panel digital subtraction angiography in the assessment of embolized brain aneurysms.

PURPOSE: To compare the time-of-flight and contrast-enhanced- magnetic resonance angiography techniques in a 3 Tesla magnetic resonance unit with digital subtraction angiography with the latest flat-panel technology and 3D reconstruction in the evaluation of embolized cerebral aneurysms. INTRODUCTION: Many embolized aneurysms are subject to a recurrence of intra-aneurismal filling. Traditionally, imaging surveillance of coiled aneurysms has consisted of repeated digital subtraction angiography. However, this method has a small but significant risk of neurological complications, and many authors have advocated the use of noninvasive imaging methods for the surveillance of embolized aneurysms. METHODS: Forty-three aneurysms in 30 patients were studied consecutively between November 2009 and May 2010. Two interventional neuroradiologists rated the time-of-flight-magnetic resonance angiography, the contrast-enhanced-magnetic resonance angiography, and finally the digital subtraction angiography, first independently and then in consensus. The status of aneurysm occlusion was assessed according to the Raymond scale, which indicates the level of recanalization according to degrees: Class 1: excluded aneurysm; Class 2: persistence of a residual neck; Class 3: persistence of a residual aneurysm. The agreement among the analyses was assessed by applying the Kappa statistic. RESULTS: Inter-observer agreement was excellent for both methods (K = 0.93; 95 % CI: 0.84-1). Inter-technical agreement was almost perfect between time-of-flight-magnetic resonance angiography and digital subtraction angiography (K = 0.98; 95 % CI: 0.93-1) and between time-of-flight-magnetic resonance angiography and contrast-enhanced-magnetic resonance angiography (K = 0.98; 95% CI: 0.93-1). Disagreement occurred in only one case (2.3%), which was classified as Class I by time-of-flight-magnetic resonance angiography and Class II by digital subtraction angiography. The agreement between contrast-enhanced-magnetic resonance angiography and digital subtraction angiography was perfect (K = 1; 95% CI: 1-1). In three patients, in-stent stenosis was identified by magnetic resonance angiography but not confirmed by digital subtraction angiography. CONCLUSION: Digital subtraction angiography and both 3T magnetic resonance angiography techniques have excellent reproducibility for the assessment of aneurysms embolized exclusively with coils. In those cases also treated with stent remodeling, digital subtraction angiography may still be necessary to confirm eventual parent artery stenosis, as identified by magnetic resonance angiography.

A comparison between magnetic resonance angiography at 3 teslas (time-of-flight and contrast-enhanced) and flat-panel digital subtraction angiography in the assessment of embolized brain aneurysms

PURPOSE: To compare the time-of-flight and contrast-enhanced- magnetic resonance angiography techniques in a 3 Tesla magnetic resonance unit with digital subtraction angiography with the latest flat-panel technology and 3D reconstruction in the evaluation of embolized cerebral aneurysms. INTRODUCTION: Many embolized aneurysms are subject to a recurrence of intra-aneurismal filling. Traditionally, imaging surveillance of coiled aneurysms has consisted of repeated digital subtraction angiography. However, this method has a small but significant risk of neurological complications, and many authors have advocated the use of noninvasive imaging methods for the surveillance of embolized aneurysms. METHODS: Forty-three aneurysms in 30 patients were studied consecutively between November 2009 and May 2010. Two interventional neuroradiologists rated the time-of-flight-magnetic resonance angiography, the contrast-enhanced-magnetic resonance angiography, and finally the digital subtraction angiography, first independently and then in consensus. The status of aneurysm occlusion was assessed according to the Raymond scale, which indicates the level of recanalization according to degrees: Class 1: excluded aneurysm; Class 2: persistence of a residual neck; Class 3: persistence of a residual aneurysm. The agreement among the analyses was assessed by applying the Kappa statistic. RESULTS: Inter-observer agreement was excellent for both methods (K = 0.93; 95 percent CI: 0.84-1). Inter-technical agreement was almost perfect between time-of-flight-magnetic resonance angiography and digital subtraction angiography (K = 0.98; 95 percent CI: 0.93-1) and between time-of-flight-magnetic resonance angiography and contrast-enhanced-magnetic resonance angiography (K = 0.98; 95 percent CI: 0.93-1). Disagreement occurred in only one case (2.3 percent), which was classified as Class I by time-of-flight-magnetic resonance angiography and Class II by digital subtraction angiography. The agreement between contrast-enhanced-magnetic resonance angiography and digital subtraction angiography was perfect (K = 1; 95 percent CI: 1-1). In three patients, in-stent stenosis was identified by magnetic resonance angiography but not confirmed by digital subtraction angiography. CONCLUSION: Digital subtraction angiography and both 3T magnetic resonance angiography techniques have excellent reproducibility for the assessment of aneurysms embolized exclusively with coils. In those cases also treated with stent remodeling, digital subtraction angiography may still be necessary to confirm eventual parent artery stenosis, as identified by magnetic resonance angiography.

Endovascular therapy for selected (most non-surgical) intracranial aneurysms in a Brazilian University Hospital.

OBJECTIVE: The objective of this study was to evaluate technical, clinical and angiographic results of a nonsurgical series of intracranial aneurysms treated by endovascular approach at Hospital das Clínicas of Medical School of Ribeirão Preto - University of São Paulo. METHOD: Between August 2005 and November 2008, 137 aneurysms in 106 patients were endovascularly treated. Of these, 101 were unruptured in 75 patients and 36 aneurysms in 31 patients were treated during the acute phase. The data were prospectively studied. RESULTS: Sixty three aneurysms (46%) were treated with coils alone, 52 (38%) with balloon remodeling, 15 (10.9%) with stent remodeling, and 7 (5.1%) with therapeutic occlusion of the internal carotid artery. Six clinical complications (5.7%) were related to the procedures, 3 (2.8%) transitory and 3 (2.8%) permanent. Angiographic follow-up was available for 97 aneurysms (70.8%), clinical monitoring for 77 patients (72.6%) and telephone contact for 97 (91.5%). CONCLUSION: The technical, clinical and angiographic results found in this study are similar to those reported in the literature.

Endovascular therapy for selected (most non-surgical) intracranial aneurysms in a Brazilian University Hospital / Tratamento endovascular de aneurismas selecionados (maioria não cirúrgicos) em um hospital universitário brasileiro

OBJECTIVE: The objective of this study was to evaluate technical, clinical and angiographic results of a nonsurgical series of intracranial aneurysms treated by endovascular approach at Hospital das Clínicas of Medical School of Ribeirão Preto - University of São Paulo. METHOD: Between August 2005 and November 2008, 137 aneurysms in 106 patients were endovascularly treated. Of these, 101 were unruptured in 75 patients and 36 aneurysms in 31 patients were treated during the acute phase. The data were prospectively studied. RESULTS: Sixty three aneurysms (46 percent) were treated with coils alone, 52 (38 percent) with balloon remodeling, 15 (10.9 percent) with stent remodeling, and 7 (5.1 percent) with therapeutic occlusion of the internal carotid artery. Six clinical complications (5.7 percent) were related to the procedures, 3 (2.8 percent) transitory and 3 (2.8 percent) permanent. Angiographic follow-up was available for 97 aneurysms (70.8 percent), clinical monitoring for 77 patients (72.6 percent) and telephone contact for 97 (91.5 percent). CONCLUSION: The technical, clinical and angiographic results found in this study are similar to those reported in the literature.

OBJETIVO: Nosso objetivo foi avaliar os resultados técnicos, clínicos e angiográficos de uma série de aneurismas intracranianos não cirúrgicos tratados por via endovascular no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo e comparar com os dados disponíveis na literatura atualmente. MÉTODO: Entre agosto de 2005 e novembro de 2008, 137 aneurismas foram tratados por via endovascular em 106 pacientes. Destes, 101 eram não rotos em 75 pacientes e 36 aneurismas foram tratados em 31 pacientes durante a fase aguda de ruptura. Os dados foram incluídos de maneira prospectiva. RESULTADOS: Sessenta e três aneurismas (46 por cento) foram tratados com técnica simples, 52 (38 por cento) com remodelagem por balão, 15 (10,9 por cento) com remodelagem por stent e 7 (5,1 por cento) por oclusão terapêutica da carótida interna. Seis complicações clínicas ocorreram (5,7 por cento), 3 (2,8 por cento) transitórias e 3 (2,8 por cento) permanentes. Seguimento angiográfico foi realizado para 97 aneurismas (70,8 por cento), clínico para 77 pacientes (70,8 por cento) e contato telefônico para 97 pacientes (91,5 por cento). CONCLUSÃO: Os resultados encontrados nesta série, em termos técnicos, clínicos e angiográficos, são semelhantes aos encontrados na literatura.

Surgical management of glomus jugulare tumors: a proposal for approach selection based on tumor relationships with the facial nerve.

OBJECT: The goal of this paper is to analyze the extension and relationships of glomus jugulare tumor with the temporal bone and the results of its surgical treatment aiming at preservation of the facial nerve. Based on the tumor extension and its relationships with the facial nerve, new criteria to be used in the selection of different surgical approaches are proposed. METHODS: Between December 1997 and December 2007, 34 patients (22 female and 12 male) with glomus jugulare tumors were treated. Their mean age was 48 years. The mean follow-up was 52.5 months. Clinical findings included hearing loss in 88%, swallowing disturbance in 50%, and facial nerve palsy in 41%. Magnetic resonance imaging demonstrated a mass in the jugular foramen in all cases, a mass in the middle ear in 97%, a cervical mass in 85%, and an intradural mass in 41%. The tumor was supplied by the external carotid artery in all cases, the internal carotid artery in 44%, and the vertebral artery in 32%. Preoperative embolization was performed in 15 cases. The approach was tailored to each patient, and 4 types of approaches were designed. The infralabyrinthine retrofacial approach (Type A) was used in 32.5%; infralabyrinthine pre- and retrofacial approach without occlusion of the external acoustic meatus (Type B) in 20.5%; infralabyrinthine pre- and retrofacial approach with occlusion of the external acoustic meatus (Type C) in 41%; and the infralabyrinthine approach with transposition of the facial nerve and removal of the middle ear structures (Type D) in 6% of the patients. RESULTS: Radical removal was achieved in 91% of the cases and partial removal in 9%. Among 20 patients without preoperative facial nerve dysfunction, the nerve was kept in anatomical position in 19 (95%), and facial nerve function was normal during the immediate postoperative period in 17 (85%). Six patients (17.6%) had a new lower cranial nerve deficit, but recovery of swallowing function was adequate in all cases. Voice disturbance remained in all 6 cases. Cerebrospinal fluid leakage occurred in 6 patients (17.6%), with no need for reoperation in any of them. One patient died in the postoperative period due to pulmonary complications. The global recovery, based on the Karnofsky Performance Scale (KPS), was 100% in 15% of the patients, 90% in 45%, 80% in 33%, and 70% in 6%. CONCLUSIONS: Radical removal of glomus jugulare tumor can be achieved without anterior transposition of the facial nerve. The extension of dissection, however, should be tailored to each case based on tumor blood supply, preoperative symptoms, and tumor extension. The operative field provided by the retrofacial infralabyrinthine approach, or the pre- and retrofacial approaches, with or without closure of the external acoustic meatus, allows a wide exposure of the jugular foramen area. Global functional recovery based on the KPS is acceptable in 94% of the patients.

Surgical management of foramen magnum meningiomas.

The objective of the study is to describe our experience in the surgical management of foramen magnum meningiomas with regard to the clinical-radiological findings, the surgical approach and the outcomes after mid-term follow up. Over a 5-year period, 15 patients presenting with meningiomas of the foramen magnum underwent surgical treatment. The medical records were reviewed in order to analyze the clinical-radiological aspects, as well as the surgical approach and the outcomes. Based on the preoperative magnetic resonance imaging exams, the tumors were classified as anterior or anterolateral in the axial slices and clivospinal or spinoclival in the sagittal slices. The lateral approach was used in all cases. However, the extent of bone removal and the management of the vertebral artery were tailored to each patient. Fourteen patients were females, and one was male, ranging in age from 42 to 74 years (mean 55,9 years). The occipital condyle was partially removed in eight patients, and in seven patients, removal was not necessary. Total removal of the tumor was achieved in 12 patients, subtotal in two, and partial resection in one patient. Postoperative complications occurred in two patients. Follow-up ranged from 6 to 56 months (mean 23.6 months).There was no surgical mortality in this series. The extent of the surgical approach to foramen magnum meningiomas must be based on the main point of dural attachment and tailored individually case-by-case. The differentiation between the clivospinal and spinoclival types, as well as anterior and anterolateral types, is crucial for the neurosurgical planning of foramen magnum meningiomas.

Chordoma and chondrosarcoma: similar, but quite different, skull base tumors.

BACKGROUND: Chordoma and chondrosarcoma of the skull base are frequently amalgamated because of similar anatomic location, clinical presentation, and radiologic findings. The chondroid chordoma variant has been reported to carry a better prognosis. The objective of the current study was to investigate the distinctions between these 3 entities. METHODS: The data concerning 109 patients with chordoma, chondroid chordoma, and chondrosarcoma who were treated by a single surgeon with maximum surgical resection and frequently by adjunct proton beam radiotherapy between 1990 and 2006 were analyzed retrospectively. Pathologic distinction was established by cytokeratin and epithelial membrane antigen staining. Clinical, radiologic, pathologic, and cytogenetic studies were analyzed in relation to disease recurrence and death. RESULTS: The average follow-up was 48+/-37.5 months (range, 1-191 months). There were no reliable distinguishing clinical or radiologic features noted between the groups. Chondrosarcoma patients had a significantly better outcome compared with chordoma patients with regard to survival and recurrence-free survival (P=.028 and P<.001, respectively), whereas patients with chondroid chordoma had a poor outcome similar to chordoma patients with regard to survival and recurrence-free survival (P=.337 and P=.906, respectively). CONCLUSIONS: Chordoma and chondrosarcoma differ with regard to their origin and histology, and differ markedly with regard to outcome. Chondroid chordomas behave in a manner that is clinically similar to chordomas, with the same prognosis. Both chordoma types demonstrate an aggressive clinical course and poor outcome after disease recurrence. The optimal treatment for all groups of patients involves radical surgical resection followed by high-dose radiotherapy in patients with chordomas. Radiotherapy may not be necessary in patients with low-grade chondrosarcoma.

Pleiotrophin expression in astrocytic and oligodendroglial tumors and it's correlation with histological diagnosis, microvascular density, cellular proliferation and overall survival.

BACKGROUND: Pleiotrophin (PTN) is a secreted cytokine with several properties related with tumor development, including differentiation, angiogenesis, invasion, apoptosis and metastasis. There is evidence that PTN has also a relevant role in primary brain neoplasms and its inactivation could be important to treatment response. Astrocytic and oligodendroglial tumors are the most frequent primary brain neoplasms. Astrocytic tumors are classified as pilocytic astrocytoma (PA), diffuse astrocytoma (DA), anaplastic astrocytoma (AA) and glioblastoma (GBM). Oligodendroglial tumors are classified as oligodendroglioma (O) and anaplastic oligodendroglioma (AO). The aim of the present study was to compare PTN expression, in astrocytomas and oligodendrogliomas and its association with the histological diagnosis, microvascular density, proliferate potential and clinical outcome. METHODS: Seventy-eight central nervous system tumors were analyzed. The histological diagnosis in accordance with WHO classification was: 13PA, 18DA, 8AA, 15GBM, 16O and 8AO. Immunohistochemistry was realized with these specific antibodies: pleiotrophin, CD31 to microvascular density and Ki-67 to cell proliferation. RESULTS: PTN expression was significantly higher in GBM and AA when compared to PA and higher in GBM compared to DA. PTN expression did not differ between O and AO. Proliferate index and microvascular density were evaluated only in high grade tumors (AA, GBM and AO) divided in three groups according to PTN expression (low, intermediate and high). These results showed no statistical difference between PTN expression and index of cellular proliferation and neither to PTN expression and microvascular density. Overall survival (OS) analysis (months) showed similar results in high grade gliomas with different levels of PTN expression. CONCLUSIONS: Our results suggest that PTN expression is associated with histopathological grade of astrocytomas. Proliferation rate, microvascular density and overall survival do not seem to be associated with PTN expression.

Auditory brainstem response: prognostic value in patients with a score of 3 on the Glasgow Coma Scale.

OBJECTIVE: To evaluate the prognostic value of auditory brainstem response (ABR) recorded in comatose patients presenting a score of 3 on the Glasgow Coma Scale (GCS = 3). PATIENTS: One hundred thirty-eight patients in coma at GCS = 3 due to various etiologic agents. INTERVENTION: To record and analyze tracings of ABR. MAIN OUTCOME MEASURE: Tracings from ABR were classified into four types (B1, B2, B3, and B4) on the basis of synchrony of waves. RESULTS: The Fischer's exact test used for comparison between death proportions revealed that B1 is different from B2, B3, or B4 and the association B2 + B3 + B4. CONCLUSION: Auditory brainstem response is a useful tool with prognostic value for patients in coma with GCS = 3. It was demonstrated in our series that once the patient presented an abnormal ABR (B2, B3, or B4), he had a greater probability of dying than a patient with a normal ABR (B1).

Clear cell meningioma of the fourth ventricle.

Clear cell meningioma (CCM) has been identified and included in the World Health Organization classification of CNS tumors recently. CCMs are histologically characterized by sheets of polygonal cells with clear cytoplasm, which is the expression of high glycogen concentration. Compared with other variants of meningiomas, CCMs occur in younger patients and usually are located in the spinal canal and posterior fossa, the last ones mainly in the cerebellopontine angle. Some reports suggest that CCMs have high recurrence rate and potentially aggressive behavior. Poor outcome has been shown in intracranial and spinal tumor location, but indicators that predict outcome have not been established. The authors present two cases of intracranial CCMs, with excellent outcome in patients harboring tumor location (restricted to the fourth ventricle) and some clinical particular features (young age, gender, obesity, and moderate impairment of intellectual capacity). To the best of our knowledge, these are the two first reported cases of clear cell meningioma located primarily in the fourth ventricle.

Surgical treatment of cerebral cysticercosis: long-term results and prognostic factors.

OBJECT: Cysticercosis is the most frequent parasitosis of the central nervous system. Although anticysticercal drugs have proven efficient in some cases, many patients with NCC require palliative, occasionally curative, surgical procedures. The authors analyzed the data and prognostic factors obtained during the follow-up period (range 1-255 months, median 38 months) in 160 patients with cerebral cysticercosis who underwent surgical treatment. METHODS: Different surgical approaches were indicated to control increased intracranial pressure (ICP) in most patients, and some patients had undergone decompressive surgery for local brain lesions. Most patients required more than one surgical procedure. Statistical analysis was performed using the Fisher exact, the log-rank, and the Kruskall-Wallis tests. Survival curves were calculated according the Kaplan-Meier method. The removal of a giant cyst from the parenchyma or cisterns for relief of increased ICP and for chiasm/optic nerve decompression improved most symptoms in patients. The removal of ventricular cysts was effective in the control of increased ICP in most patients. Patients with a ventricular cyst and ependymitis/arachnoiditis required placement of a ventriculoperitoneal (VP) shunt after the cyst was removed. This therapy effectively controlled increased ICP. Patients younger than 40 years of age at the time of treatment and male patients had worse outcomes. The outcome in patients who underwent VP shunt surgery or shunt surgery combined with reservoir implantation was worse than that in those who underwent cyst removal alone. Shunt-related infection was the most frequent complication, and the global mortality rate during the follow-up period was 21.2%. Although both complications were more frequent in the first 2 postoperative years, they occurred at any time. CONCLUSIONS: Long-term prognosis in patients with cerebral cysticercosis who required surgery was not good. Cysts located in the basal cisterns and patient age younger than 40 years were poor prognostic factors.

Hipertensäo intracraniana / Intracranial hypertension

A relaçäo entre o conteúdo da caixa intracraniana e o seu volume determina a pressäo intracraniana (PIC), que tem como referência a pressäo atmosférica. Em condiçöes normais, a pressäo intracraniana tem flutuaçöes determinadas pelos ciclos respiratório e cardíaco. Várias doenças determinam o aumento da pressäo intracraniana, sendo a mais freqüente o traumatismo cranioencefálico. Para o diagnóstico da hipertensäo intracraniana (HIC) deve-se valorizar o quadro clínico, constituído de cefaléia, vômitos e papiledema. Dos exames subsidiários, os mais importantes säo os métodos de imagem principalmente Tomografia Computadorizada (TC) e Ressonância Nuclear Magnética (RNM). Para os casos graves de HIC, o ideal durante o tratamento é que a PIC esteja monitorizada. Diversas modalidades podem ser utilizadas, como a hipocapnia induzida pela hiperventilaçäo, os diuréticos osmóticos, a hipotermia e cuidados especiais no tratamento geral dos pacientes.

Estudo hidrodinâmico de válvulas para hidrocefalia substituídas em cirurgia de revisäo de derivaçäo liquórica: análise de 33 vávulas removidas / Hydrodinamic study of 33 malfunctioning CSF shunts removed during shunt revisions

O fluxo liquórico através da válvula para hidrocefalia nao é facilmente quantificado após a sua implantaçäo, o que seria útil frente a um hidrocéfalo derivado com queixas sugestivas de mau funcionamento valvular. É relatado um estudo prospectivo de 33 válvulas, retiradas de pacientes nessas condiçöes, submetidas a teste hidrodinâmico com fluxo estático e variaçäo da pressao entre 2,5 cm a 100 cm d'água, com bancada e metodologia inovadoras. O diagnóstico de mau funcionamento foi confirmado através da radiografia do trajeto valvular, punçäo do reservatório, tomografia computadorizada ou ultra-sonografia. O grupo-controle foi formado por 36 válvulas novas, näo implantadas. A análise estatística das curvas pressäo-fluxo foi realizada pela comparaçäo entre coeficientes angulares das retas de regressäo formadas pelo método dos mínimos quadrados. Os dados clínicos foram confrontados pelo método do qui-quadrado. O estudo confirmou alteraçöes de fluxo hidrodinâmico em 24 válvulas e, em 9 este fluxo foi semelhante aos controles. Fatores relacionados a estes mau funcionamentos também foram analisados.