Awake craniotomy for eloquent pial arteriovenous fistula: anesthetic and surgical consideration of a rare case

Abstract Intracranial pial Arteriovenous Fistulas (AVFs) are rare cerebral vascular lesions composed of one or more arterial connections to a single venous channel. We report a 50-year-old patient with a ruptured pial AVF located in an eloquent area. Microsurgery for pial AVF occlusion was proposed with awake craniotomy for motor function and neurological evaluation. Awake craniotomy is a technique that is especially useful for cerebral vascular lesions in eloquent areas, where an occlusion often compromises or suppresses the blood supply, culminating in ischemia with consequent transient or definitive deficits in neurological function.

Two-Stage Pulsatile Human Placenta Model for Microvascular Anastomosis Training in Neurosurgery.

OBJECTIVE: The development of microsurgical skills is crucial for neurosurgical education. The human placenta is a promising model for practicing vascular anastomosis due to its similarities with brain vessels. We propose a 2-stage model for training in extracranial-to-intracranial anastomosis using the placenta. METHODS: Initially, we propose practicing anastomosis in 2 adjacent placentas. Once successful, the procedure advances to a more challenging configuration that employs a 3-dimensionally printed skull with a window simulating a pterional craniotomy. It is positioned an intracranial placenta and an extracranial one, and the latter has a prominent vessel exposed toward the side of the craniotomy. Both placentas have one artery and vein cannulated in the umbilical cord, and we present an artificial placental circulation system for microvascular training that regulates pulsation and hydrodynamic pressure while keeping veins engorged with a pressurized bag. To verify anastomosis patency, we utilize sodium fluorescein and iodine contrast. RESULTS: The 2-stage model simulated several aspects of microvascular anastomosis. Our perfusion system allowed for intraoperative adjustments of hydrodynamic pressure and pulsation. Using iodine contrast and fluorescein enabled proper evaluation of anastomosis patency and hydrodynamic features. CONCLUSIONS: Training in the laboratory is essential for developing microsurgical skills. We have presented a model for microvascular anastomosis with artificial circulation and postoperative imaging evaluation, which is highly beneficial for enhancing the learning curve in microvascular procedures.

Evaluation of konjac noodle as a microsurgery training model: learning curve analysis.

BACKGROUND: classical models of microsurgical anastomosis training are expensive and have ethical implications. Some alternatives join low cost and easiness to store. However, the translation of knowledge acquired by training in these methods into the traditional ones is not clear. This project aims to assess the feasibility of konjac noodles as a reliable microsurgery-training model. METHODS: 10 neurosurgery residents performed an end-to-end anastomosis in a 2-3mm placenta artery. The anastomoses were evaluated quantitatively, recording time; and qualitatively, applying a validated score (Anastomosis Lapse Index - ALI) by three experienced neurosurgeons and verifying the presence of gross leakage through the infusion of fluorescein. Subsequently, they performed 10 non-consecutive sessions of anastomosis training in the konjac noodle. Eventually, a final anastomosis in the placenta model was performed and the same parameters were scored. RESULTS: we observed a 17min reduction in the mean time to perform the anastomosis in the placenta model after the training in the konjac (p<0.05). There was a non-significant 20% reduction in gross leakage, but the training sessions were not able to consistently improve the ALI score. CONCLUSIONS: we demonstrate a reduction in anastomosis performing time in placental arteries after training sessions in the konjac noodle model, which can be regarded as a feasible low-cost method, particularly useful in centers with surgical microscopes only in the operation room.

Evaluation of konjac noodle as a microsurgery training model: learning curve analysis / Avaliação do uso de macarrão japonês para treinamento microcirúrgico: análise objetiva da melhora na performance

ABSTRACT Background: classical models of microsurgical anastomosis training are expensive and have ethical implications. Some alternatives join low cost and easiness to store. However, the translation of knowledge acquired by training in these methods into the traditional ones is not clear. This project aims to assess the feasibility of konjac noodles as a reliable microsurgery-training model. Methods: 10 neurosurgery residents performed an end-to-end anastomosis in a 2-3mm placenta artery. The anastomoses were evaluated quantitatively, recording time; and qualitatively, applying a validated score (Anastomosis Lapse Index - ALI) by three experienced neurosurgeons and verifying the presence of gross leakage through the infusion of fluorescein. Subsequently, they performed 10 non-consecutive sessions of anastomosis training in the konjac noodle. Eventually, a final anastomosis in the placenta model was performed and the same parameters were scored. Results: we observed a 17min reduction in the mean time to perform the anastomosis in the placenta model after the training in the konjac (p<0.05). There was a non-significant 20% reduction in gross leakage, but the training sessions were not able to consistently improve the ALI score. Conclusions: we demonstrate a reduction in anastomosis performing time in placental arteries after training sessions in the konjac noodle model, which can be regarded as a feasible low-cost method, particularly useful in centers with surgical microscopes only in the operation room.

ABSTRACT Introdução: modelos tradicionais de treinamento de anastomose microcirúrgica costumam ter custos elevados e implicações éticas de aquisição e manutenção, buscando-se alternativas que reúnam baixo custo e facilidade de armazenamento. Existem diferentes propostas, porém há poucas evidências de que conhecimentos adquiridos com o treinamento nessas plataformas se traduza em melhora na performance, quando estes são comparados a modelos consagrados. Este projeto objetiva avaliar a viabilidade do macarrão de konjac como modelo confiável de treinamento microcirúrgico. Métodos: 10 residentes de neurocirurgia realizaram uma anastomose término-terminal em artéria placentária humana de 2-3mm. As anastomoses foram avaliadas quantitativamente, registrando-se o tempo de confecção e qualitativamente, aplicando-se um escore validado (Anastomosis Lapse Index - ALI) por neurocirurgiões experientes e verificando-se a presença de vazamento grosseiro através da visualização no modo fluorescente injetando-se fluoresceína. Subsequentemente, realizaram 10 sessões de treinamento não consecutivos de anastomose términoterminal no modelo de konjac. Por fim, uma anastomose final foi realizada no modelo placentário e os mesmo parâmetros reavaliados. Resultados: observamos uma redução de 17 min no tempo médio de confecção da anastomose no modelo de placenta após os treinos no modelo do macarrão (p<0.05). Houve uma redução não significativa de 20% no vazamento grosseiro. As sessões de treino no macarrão não foram capazes de melhorar consistentemente o score ALI. Conclusão: o treinamento em modelo de macarrão konjac é capaz de reduzir o tempo para realização das anastomoses no modelo em placenta humana, mostrando-se alternativa viável de baixo custo e manutenção, útil em serviços que disponham de microscópio apenas no ambiente cirúrgico.

An economic study of neuro-oncological patients in a large developing country: a cost analysis.

BACKGROUND: Neuro-oncological patients require specialized medical care. However, the data on the costs incurred for such specialized care in developing countries are currently lacking. These data are relevant for international cooperation. OBJECTIVE: The present study aimed to estimate the direct cost of specialized care for an adult neuro-oncological patient with meningioma or glioma during hospitalization in the largest philanthropic hospital in Latin America. METHODS: The present observational economic analysis describes the direct cost of care of neuro-oncological patients in Santa Casa de São Paulo, Brazil. Only adult patients with a common primary brain tumor were included. RESULTS: Due to differences in the system records, the period analyzed for cost estimation was between December 2016 and December 2019. A group of patients with meningiomas and gliomas was analyzed. The estimated mean cost of neurosurgical hospitalization was US$4,166. The cost of the operating room and intensive care unit represented the largest proportion of the total cost. A total of 17.5% of patients had some type of infection, and 66.67% of these occurred in nonelective procedures. The mortality rate was 12.7% and 92.3% of all deaths occurred in emergency procedures. CONCLUSIONS: Emergency surgeries were associated with an increased rate of infections and mortality. The findings of the present study could be used by policymakers for resource allocation and to perform economic analyses to establish the value of neurosurgery in achieving global health goals.

ANTECEDENTES: Pacientes neuro-oncológicos demandam tratamento médico especializado. Em países em desenvolvimento, há falta de dados sobre custos em neurocirurgia. Estes dados são relevantes para ajudar na cooperação internacional. OBJETIVO: O presente estudo objetiva estimar o custo direto de um paciente neuro-oncológico adulto com meningioma ou glioma durante sua internação no maior hospital filantrópico da América Latina. MéTODOS: A presente análise econômica observacional descreve os custos diretos de um paciente neuro-oncológico da Santa Casa de São Paulo. Apenas pacientes adultos e com os dois tumores cerebrais primários mais comuns foram considerados. RESULTADOS: Devido a uma mudança no sistema de prontuários, para análise de custos o período analisado foi de dezembro de 2016 a dezembro de 2019. Uma amostra significativa de pacientes com gliomas e meningiomas foi analisada. O custo médio da hospitalização foi de U$ 4.166. O tempo de sala cirúrgica e os cuidados em terapia intensiva representaram a maior proporção dentro do custo total. Um total de 17.5% dos pacientes teve algum tipo de infecção e 66.67% delas ocorreram em procedimentos não eletivos. A taxa de mortalidade foi de 12.5% e 92.3% dos óbitos ocorreram em procedimentos de urgência. CONCLUSõES: Cirurgias de urgência foram mais associadas a taxas de infecção e mortalidade. Os achados do presente estudo podem ser usados por planejadores em política pública de saúde para alocação de recursos e para análise econômica para estabelecer o valor dos procedimentos neurocirúrgicos para atingir metas mundiais.

An economic study of neuro-oncological patients in a large developing country: a cost analysis / Um estudo de análise econômica dos pacientes neuro-oncológicos em um grande país em desenvolvimento: uma análise de custos

Abstract Background Neuro-oncological patients require specialized medical care. However, the data on the costs incurred for such specialized care in developing countries are currently lacking. These data are relevant for international cooperation. Objective The present study aimed to estimate the direct cost of specialized care for an adult neuro-oncological patient with meningioma or glioma during hospitalization in the largest philanthropic hospital in Latin America. Methods The present observational economic analysis describes the direct cost of care of neuro-oncological patients in Santa Casa de São Paulo, Brazil. Only adult patients with a common primary brain tumor were included. Results Due to differences in the system records, the period analyzed for cost estimation was between December 2016 and December 2019. A group of patients with meningiomas and gliomas was analyzed. The estimated mean cost of neurosurgical hospitalization was US$4,166. The cost of the operating room and intensive care unit represented the largest proportion of the total cost. A total of 17.5% of patients had some type of infection, and 66.67% of these occurred in nonelective procedures. The mortality rate was 12.7% and 92.3% of all deaths occurred in emergency procedures. Conclusions Emergency surgeries were associated with an increased rate of infections and mortality. The findings of the present study could be used by policymakers for resource allocation and to perform economic analyses to establish the value of neurosurgery in achieving global health goals.

Resumo Antecedentes Pacientes neuro-oncológicos demandam tratamento médico especializado. Em países em desenvolvimento, há falta de dados sobre custos em neurocirurgia. Estes dados são relevantes para ajudar na cooperação internacional. Objetivo O presente estudo objetiva estimar o custo direto de um paciente neuro-oncológico adulto com meningioma ou glioma durante sua internação no maior hospital filantrópico da América Latina. Métodos A presente análise econômica observacional descreve os custos diretos de um paciente neuro-oncológico da Santa Casa de São Paulo. Apenas pacientes adultos e com os dois tumores cerebrais primários mais comuns foram considerados. Resultados Devido a uma mudança no sistema de prontuários, para análise de custos o período analisado foi de dezembro de 2016 a dezembro de 2019. Uma amostra significativa de pacientes com gliomas e meningiomas foi analisada. O custo médio da hospitalização foi de U$ 4.166. O tempo de sala cirúrgica e os cuidados em terapia intensiva representaram a maior proporção dentro do custo total. Um total de 17.5% dos pacientes teve algum tipo de infecção e 66.67% delas ocorreram em procedimentos não eletivos. A taxa de mortalidade foi de 12.5% e 92.3% dos óbitos ocorreram em procedimentos de urgência. Conclusões Cirurgias de urgência foram mais associadas a taxas de infecção e mortalidade. Os achados do presente estudo podem ser usados por planejadores em política pública de saúde para alocação de recursos e para análise econômica para estabelecer o valor dos procedimentos neurocirúrgicos para atingir metas mundiais.

The Fluorescent Patient: An Unusual Effect of Fluorescein Angiography.

Although fluorescein is widely used for intraoperative angiography, some of its side effects remain obscure. In this report, we present the case of a 41-year-old patient with chronic ischemia caused by moyamoya syndrome who underwent bypass revascularization with intraoperative fluorescein angiography (FA). Immediately after the surgery, the patient presented homogeneous fluorescence of the entire skin. We discuss this curious phenomenon as well as other side effects that may arise due to FA.

Awake craniotomy in brain tumors - Technique systematization and the state of the art.

The anesthesia for awake craniotomy (AC) is a consecrated anesthetic technique that has been perfected over the years. Initially used to map epileptic foci, it later became the standard technique for the removal of glial neoplasms in eloquent brain areas. We present an AC anesthesia technique consisting of three primordial times, called awake-asleep-awake, and their respective particularities, as well as delve into the anesthetic medications used. Its use in patients with low and high-grade gliomas was favorable for the resection of tumors within the functional boundaries of patients, with shorter hospital stay and lower direct costs. The present study aims to systematize the technique based on the experience of the largest philanthropic hospital in Latin America and discusses the most relevant aspects that have consolidated this technique as the most appropriate in the surgery of gliomas in eloquent areas.

Awake craniotomy for eloquent pial arteriovenous fistula - Anesthetic and surgical consideration of a rare case.

Intracranial pial Arteriovenous Fistulas (AVFs) are rare cerebral vascular lesions composed of one or more arterial connections to a single venous channel. We report a 50-year-old patient with a ruptured pial AVF located in an eloquent area. Microsurgery for pial AVF occlusion was proposed with awake craniotomy for motor function and neurological evaluation. Awake craniotomy is a technique that is especially useful for cerebral vascular lesions in eloquent areas, where an occlusion often compromises or suppresses the blood supply, culminating in ischemia with consequent transient or definitive deficits in neurological function.

Safety and Efficacy of 980nm Diode Laser for Brain Tumor Microsurgery-A Pioneer Case Series.

BACKGROUND: Quality of life is essential for oncologic patients. Several tools are available to improve microsurgery and reduce morbidity. Diode laser is a precise and useful technology for microsurgery. The goal of this pioneer case series is to describe the oncologic use of the 980nm diode laser and the qualitative variables analyzed. Besides, review the current literature about lasers in neurosurgery. METHODS: A longitudinal prospective study described patients with meningioma or glioma submitted to neurosurgical laser-assisted procedures. Also, we performed a review in medical databases using the terms "diode laser" and "neurosurgery." RESULTS: No paper described the use of a diode laser in neurooncology. The 980nm diode laser was used in 15 patients. The device is thin, silent, and easy to handle. Excellent hemostasis was observed, especially in skull base meningiomas. Also, it was easy and fast to delimit tumor from normal brain tissue without damage to surrounding parenchyma. No postoperative complications occurred. CONCLUSIONS: The diode laser is a useful tool for brain tumor surgery, particularly concerning hemostasis. Surgical site coagulation is effective without damage to adjacent structures, especially in gliomas near eloquent regions. We consider this technique a suitable adjuvant resource for brain tumor surgeries to provide an excellent hemostasis and help cut and vaporize a lesion.

Awake craniotomy in brain tumors - Technique systematization and the state of the art / Craniotomia em paciente acordado nos tumores cerebrais - Sistematização da técnica anestésica e o estado da arte

ABSTRACT The anesthesia for awake craniotomy (AC) is a consecrated anesthetic technique that has been perfected over the years. Initially used to map epileptic foci, it later became the standard technique for the removal of glial neoplasms in eloquent brain areas. We present an AC anesthesia technique consisting of three primordial times, called awake-asleep-awake, and their respective particularities, as well as delve into the anesthetic medications used. Its use in patients with low and high-grade gliomas was favorable for the resection of tumors within the functional boundaries of patients, with shorter hospital stay and lower direct costs. The present study aims to systematize the technique based on the experience of the largest philanthropic hospital in Latin America and discusses the most relevant aspects that have consolidated this technique as the most appropriate in the surgery of gliomas in eloquent areas.

RESUMO A anestesia para craniotomia em paciente acordado (CPA ou awake craniotomy) é técnica anestésica consagrada e aperfeiçoada ao longo dos últimos anos. Utilizada inicialmente para mapeamento de focos epilépticos, consolidou-se posteriormente como técnica padrão para a remoção de neoplasias de origem glial em áreas eloquentes cerebrais. A técnica de anestesia CPA apresentada constitui-se em três tempos primordiais denominados acordado-dormindo-acordado (asleep-awake-asleep) e respectivas particularidades, assim como o manejo quanto às medicações anestésicas utilizadas de forma pormenorizada. A utilização em gliomas de baixo e de alto grau se demonstrou favorável para a ressecção de tumores dentro dos limites funcionais dos pacientes, com menor tempo de internação hospitalar e de custos diretos. O presente estudo visa realizar a sistematização da técnica baseada na experiência do maior Hospital Filantrópico da América Latina e discute os aspectos mais relevantes que consolidaram essa técnica como a mais adequada na cirurgia dos gliomas em áreas eloquentes.

Microsurgical Cisternostomy for Treating Critical Patients with Traumatic Brain Injury - An alternative Therapeutic Approach

Introduction Traumatic brain injury (TBI) is a major cause of mortality around the world. Few advances regarding surgical approaches have been made in the past few years to improve its outcomes. Microsurgical cisternostomy is a well-established technique used in vascular and skull base surgery and recently emerges as a suitable procedure with lesser costs and morbidity when compared with decompressive craniectomy in patients with diffuse TBI. This study aims to describe the technique, indications, and limitations of cisternostomy and to compare it with decompressive craniectomy (DC). Methods A prospective study is being conducted after obtaining approval of the local human ethics research committee. Once the inclusion and exclusion criteria are applied, the patients are submitted to microsurgical cisternostomy, pre and postoperative neurological status and brain computed tomography (CT) evaluation. A detailed review was also performed, which discusses diffuse TBI, DC, and cisternostomy for the treatment of TBI. Results Two patients were submitted to cisternostomy after TBI and the presence of acute subdural hematoma and hugemidline shift at admission computed tomography. The surgery was authorized by the family (the informed consent form was signed). Both patients evolved with a good recovery after the procedure, and had a satisfactory control brain CT. No further surgeries were required after the initial cisternostomy. Conclusions Cisternostomy is an adequate technique for the treatment of selected patients affected by diffuse TBI, and it is a proper alternative to DC with lesser costs and morbidity, since a single neurosurgical procedure is performed. A prospective study is being conducted for a better evaluation and these were the initial cases of this new protocol.

Superficial Temporal Artery-Middle Cerebral Artery Bypass Ex Vivo Hybrid Simulator: Face, Content, Construct, and Concurrent Validity.

BACKGROUND: Cerebrovascular bypass surgical procedures require highly developed dexterity and refined bimanual technical skills. To attain such a level of prowess, neurosurgeons and residents have traditionally relied on "flat" models (without depth of field), such as chicken wings, live rats, silicone vessels, and other materials that stray far from the reality of the operating room, albeit more accessible. We have explored the use of a hybrid ex vivo simulator that takes advantage of the availability of placenta vessels and retains the complexity of surgery performed on a human skull to create a more realistic method for the development of cerebrovascular bypass surgical skills. METHODS: Twelve ex vivo simulators were constructed using 3 human placentas and 1 synthetic human skull for each. Face, content, construct, and concurrent validity were assessed by 12 neurosurgeons (6 trained vascular surgeons and 6 general neurosurgeons) and compared with those of other bypass models. RESULTS: The fidelity grade was ranked as low (Linkert scale score, 1-2), medium (score, 3), and high (score, 4-5). The face and content validity of the model showed high fidelity to superficial temporal artery-middle cerebral artery bypass surgery. Construct validity showed that cerebrovascular neurosurgeons had better performance, and concurrent validity highlighted that all surgical steps were present. CONCLUSION: The simulator was found to have strong face and content, construct, and concurrent validity for microsurgical cerebrovascular training, allowing for simulation of all surgical steps of the bypass procedure. The hybrid simulator seems to be a promising method for shortening the bypass surgery learning curve. However, more studies are required to evaluate the predictive validity of the model.

Septum Pellucidum Cavernoma: A Case Report and Anatomical Consideration of an Extremely Rare Lesion.

Cavernous angiomas (cavernomas) are vascular malformations of the brain characterized by abnormal capillaries. Ventricular cavernomas are considered rare; however, an extremely unusual topography is the septum pellucidum, with only five reported cases in the English literature. These malformations may rupture and cause very large hematomas, leading to neurological impairment. Cavernomas can be familial or sporadic; additionally, these may appear following brain radiotherapy in extremely rare cases. Herein, we present an extremely rare and unique case of a septum pellucidum cavernoma that occurred in a young male who had previously undergone brain radiotherapy in childhood due to acute lymphoid leukemia. Following presentation, he was diagnosed with generalized seizures. The cavernoma was resected via an anterior interhemispheric transcallosal approach, following which the patient remained stable without neurological sequelae. To conclude, ventricular cavernomas are rare lesions, especially when located at the septum pellucidum, thus constitute a challenging neurosurgical approach.

The Use of Osirix for Surgical Planning Using Cranial Measures and Region of Interest Tools: Technical Note.

BACKGROUND: During the surgery for intrinsic brain lesions, it is important to plan the proper site of the craniotomy and to identify the relations with the gyri and superficial veins. This might be a challenge, especially in small subcortical lesions and when there is a distortion of the cortical anatomy. MATERIALS AND METHODS: Using the free computer software Osirix, we have created a 3-dimensional reconstruction of the head and cerebral showing the gyri and superficial veins. With the aid of some tools, it is possible to create a colored image of the lesion and also to calculate the distance between the areas of interest and some easily identifiable structure, making it easier to plan the site of the craniotomy identify the topography of the lesion. RESULTS: The reconstructions were compared to the intraoperative view. We found this technique to be useful to help identify the gyri and cortical veins and use them to find the lesions. The use of a region of interest to show better the lesion under the cortical surface and in the three-dimensional reconstruction of the head was also helpful. CONCLUSIONS: This is a low-cost and easy technique that can be quickly learned and performed before every surgery. It helps the surgeon to plan a safe craniotomy and lesionectomy.

An Affordable Stereomicroscope for Microsurgery Training with Fluorescence Mode.

BACKGROUND: Laboratory training is a very important step on the development of the skills necessary for a neurosurgeon. This can be achieved using animal models and surgical microscopes or stereomicroscopes. Methods, like the use of fluorescein, increase the lifelike situation and allow anyone to assess the patency of an anastomosis and improve the quality of this training. METHODS: We report the use of a stereomicroscope with white light and a fluorescence mode used to perform dissection of small arteries and anastomosis using a chicken wing model. Using an affordable device, we could perform fluorescein videoangiography to asses the patency of those anastomosis and improve the quality of the training skills in microsurgery. RESULTS: The stereomicroscope is a useful tool for laboratory training and can be used as a substitute of a surgical microscope for microsurgery training. The fluorescence mode allowed us to perform fluorescein videoangiography with very a good quality of image. CONCLUSIONS: Microsurgery training is important part in the life of any neurosurgeon. Using a stereomicroscope with a fluorescence mode is an affordable method that can be reproduced in any laboratory in the world.

Quality Assurance During Brain Aneurysm Microsurgery-Operative Error Teaching.

INTRODUCTION: Quality assurance (QA) is a way to prevent mistakes in advance. Although it has been previously reported for surgical setup, there is no effective approach for minimizing microsurgical technical errors before an operation is done. Neurosurgery resident operative errors during brain aneurysm surgery could be foreseen by practicing in an ex vivo hybrid simulator with microscopic fluorescein vessel flow image. METHODS: Five vascular neurosurgeons and 8 junior/senior neurosurgical residents voluntarily joined this research initiative. The following methodology was adopted: 1) Identification of the 7 most-common resident operative performance errors during brain aneurysm surgery; 2) Design of exercises to prevent common mistakes in brain aneurysm microsurgery using a placenta simulator; and 3) Blinded staff neurosurgeon evaluation of resident performance during real brain aneurysm microsurgery. RESULTS: All key steps to perform such intervention were accomplished with a simulator that uses 2 placentas, a synthetic cranium, and microscopic fluorescein vessel flow image. Neurosurgery residents trained in this model had better surgical performance with fewer perioperative mistakes (P < 0.05). Fine microsurgical dissection of the arachnoid membrane and aneurysm sac were the most commonly improved tasks among the 7 common operative mistakes. Brain parenchyma traction with secondary bleeding was the only error not prevented after previous simulator training. CONCLUSIONS: There was a left-shift on the quality assurance line with residents who practiced brain aneurysm microsurgical errors in an ex vivo model. A multicentric prospective study is necessary to confirm the hypothesis that real operative error could be reduced after training in a realistic simulator.

Cryptococcoma mimicking a brain tumor in an immunocompetent patient: case report of an extremely rare presentation

ABSTRACT CONTEXT: Central nervous system (CNS) infectious diseases have high prevalence in developing countries and their proper diagnosis and treatment are very important for public health planning. Cryptococcus neoformans is a fungus that may cause several CNS manifestations, especially in immunocompromised patients. Cryptococcal meningitis is the most common type of involvement. Mass-effect lesions are uncommon: they are described as cryptococcomas and their prevalence is even lower among immunocompetent patients. The aim here was to report an extremely rare case of cryptococcoma causing a mass effect and mimicking a brain tumor in an immunocompetent patient. The literature on CNS cryptococcal infections was reviewed with emphasis on cryptococcomas. Clinical, surgical and radiological data on a female patient with this rare presentation of cryptococcoma mimicking a brain tumor are described. Case Report: A 54-year-old female patient presented to the emergency department with a rapid-onset progressive history of confusion and completely dependency for basic activities. Neuroimaging showed a left occipital lesion and neurosurgical treatment was proposed. From histopathological evaluation, a diagnosis of cryptococcoma was established. She received clinical support with antifungals, but despite optimal clinical treatment, her condition evolved to death. CONCLUSIONS: Cryptococcal infections have several forms of presentation and, in immunocompetent patients, their manifestation may be even more different. Cryptococcoma is an extremely rare presentation in which proper surgical and clinical treatment should be instituted as quickly as possible, but even so, there is a high mortality rate.

Cryptococcoma mimicking a brain tumor in an immunocompetent patient: case report of an extremely rare presentation.

CONTEXT: Central nervous system (CNS) infectious diseases have high prevalence in developing countries and their proper diagnosis and treatment are very important for public health planning. Cryptococcus neoformans is a fungus that may cause several CNS manifestations, especially in immunocompromised patients. Cryptococcal meningitis is the most common type of involvement. Mass-effect lesions are uncommon: they are described as cryptococcomas and their prevalence is even lower among immunocompetent patients. The aim here was to report an extremely rare case of cryptococcoma causing a mass effect and mimicking a brain tumor in an immunocompetent patient. The literature on CNS cryptococcal infections was reviewed with emphasis on cryptococcomas. Clinical, surgical and radiological data on a female patient with this rare presentation of cryptococcoma mimicking a brain tumor are described. CASE REPORT: A 54-year-old female patient presented to the emergency department with a rapid-onset progressive history of confusion and completely dependency for basic activities. Neuroimaging showed a left occipital lesion and neurosurgical treatment was proposed. From histopathological evaluation, a diagnosis of cryptococcoma was established. She received clinical support with antifungals, but despite optimal clinical treatment, her condition evolved to death. CONCLUSIONS: Cryptococcal infections have several forms of presentation and, in immunocompetent patients, their manifestation may be even more different. Cryptococcoma is an extremely rare presentation in which proper surgical and clinical treatment should be instituted as quickly as possible, but even so, there is a high mortality rate.

Retroauricular pain caused by Eagle syndrome: A rare presentation due to compression by styloid process elongation.

Eagle syndrome is a rare condition presenting with retroauricular pain (usually as main symptom) associated with dysphagia, headache, neck pain on rotation and, much rarelier, stroke. This occurs due to styloid process elongation. Sometimes, there is also styloid ligament calcification, which can cause compression of nerves and arteries and the symptoms above. Treatment can be conservative with pain modulators (e.g. pregabalin) or infiltrations (steroids or anesthetics drugs). In refractory cases, surgical approach aiming to reduce the size of the styloid process can be performed. We present a rare case of Eagle syndrome (documented by computed tomography) with good response to clinical treatment.