Abdominal pseudocysts complicating CSF shunting in infants and children. Report of 18 cases.

Abdominal pseudocysts (APC) are rare complications of ventriculoperitoneal shunting for hydrocephalus. The authors studied retrospectively a series of 18 pediatric patients with APC. Signs and symptoms of shunt dysfunction were observed in 15 (83.3%), abdominal complaints in 10 (55.5%) and fever in 6 (33.3%). Prior to the diagnosis of APC, 2 patients suffered exploratory laparotomies due to important abdominal signs and symptoms. Ultrasonography was diagnostic in all cases and proved to be the method of choice in the evaluation of APC. Our series suggest that APC are strongly related to hardware infection and in some cases can result from a previous shunt infection not completely cured. The bacteriological examination of the tip of the peritoneal catheter was a reliable indicator of infection. According to our data, the best treatment seems to be the removal of the shunt system and the insertion of an external ventricular drainage. In our experience, almost half of the patients had a ventriculoatrial shunt replacing the peritoneal shunt at the end of the treatment.

[Symptomatic Chiari type II malformation]. / Malformação de Chiari do tipo II sintomática.

The Chiari type II malformation is the leading cause of death in infants with myelomeningocele. The authors report 17 cases of symptomatic Chiari type II malformation occurring in two distinct age dependent population. In Group I, 13 neonates and infants in the first year of life presented with cranial nerve and brain stem dysfunction characterized by vocal cord paralysis, apnea, dysphagia and laryngeal stridor. In Group II, 4 patients developed signs and symptoms after the first year of life. In this group, the presentation was more insidious and included neck pain and cerebellar manifestations. The surgical treatment consisted initially in shunt implantation or revision and when there was no improvement, posterior fossa decompression was performed. The response to the surgical treatment differed considerably between the two groups: older patients improved promptly after surgery and there was no casualties; in newborn and infants, especially those under 6 months of age, the mortality rate was 46.1%. The authors stress that prompt diagnosis and surgical intervention should be performed in order to produce a favorable outcome.

[Myelomeningocele: surgical treatment and results]. / Mielomeningocele: tratamento cirúrgico e resultados.

The authors made a retrospective study of 72 patients with myelomeningocele treated at a pediatric hospital in Rio de Janeiro, Brazil. 65 (90.2%) lesions involved the inferior segments of the spine and 87.5% of the patients needed shunt procedures for hydrocephalus control. Shunt infections in spina bifida cystica patients were more frequent than in any other group of hydrocephalic patients treated at the institution. There was a great incidence of postoperative complications such as wound infections and skin necrosis. 11 (15.3%) patients developed signs and symptoms related to Chiari II malformation. The overall mortality was 8.3%, and in most of the cases, ascribed to the Chiari malformation.

[Ambulatory follow-up of patients with myelomeningocele in a pediatric hospital]. / Acompanhamento ambulatorial de pacientes com mielomeningocele em um hospital pediátrico.

Myelomeningocele is the most common congenital malformation of the nervous system and despite its complexity and involvement of multiple organs is compatible with long survival. The peculiar characteristics of this malformation expose myelomeningocele patients to acute and chronic care problems with effects in quality of survival. In order to evaluate the quality of the follow-up of spina bifida patients in a pediatric hospital, the authors examined 54 patients attending the neurosurgical outpatient unity of a pediatric hospital. The lack of a multidisciplinary spina bifida clinic in Rio de Janeiro forced the patients to pursuit for complimentary medical and paramedical care outside the hospital with significant effects in the quality of survival. In consequence, only 25% of the patients were able to walk and community ambulation was nearly absent. Only 66.6% had a regular rehabilitation program and nearly 50% had routine orthopedics consultations. Almost half of the patients had no urological referral at all and 75% were incontinent, with recurrent urinary infections ranging 72.2%. The rates of neurosurgical complications were similar to those observed in the literature. We concluded that the quality of survival of patients with neural tube defects is strongly influenced by the adverse socio-economical conditions and the lack of a spina bifida multidisciplinary clinic.

[Spinal subdural empyema. A case report]. / Empiema espinhal subdural. Relato de um caso.

Spinal subdural empyema is a very unusual condition. About 40 cases have been previously reported. The authors describe another case, mentioning the difficulties in diagnosis particularly when no primary infection is known. In these circumstances, the neurological signs and MRI are important; MRI demonstrates the level of the lesion and its subdural localization. Surgical treatment and antibiotics are clearly indicated and the earliest it is done, the better the results.

[Intracranial cavernous angioma]. / Angioma cavernoso intracraniano.

Clinical, radiological and histopathological features of eight cases of symptomatic cavernous angioma are presented. Five patients were being evaluated for seizure, two for mass lesions and one for intracranial hemorrhage. CT and/or MRI detected the lesion in all cases, but there is not a characteristic image for cavernous angioma. Good results were obtained by microsurgical approach to these malformations in seven patients with only one patient suffering a worsening of neurological status after surgery.

[Benign intrinsic tectal tumors: apropos of 2 cases]. / Tumores intrínsecos benignos da região tectal: considerações a propósito de dois casos.

The introduction of computerized tomography and magnetic resonance imaging led to the knowledge that brain stem tumors are not a homogeneous group with regard to their clinical, pathological and biological features. The classical concept of an uniformly poor prognosis has been modified and some subtypes of tumors are amenable to surgical treatment and long-term survival. The authors report two cases of patients with tumors of the tectal region whose symptoms and CT features were consistent with late-onset aqueductal obstruction. In both cases definitive diagnosis was established by MRI and symptoms resolved after ventriculo-peritoneal shunt implantation. The clinic and pathological features and therapeutical alternatives as well, are discussed.

[Aneurysm of the distal portion of the posterior and inferior cerebellar artery in a child]. / Aneurisma da porção distal da artéria cerebelar posterior e inferior em criança.

The case of a 7-year-old boy presenting with recurrent episodes of subarachnoid hemorrhage due to a distal posterior inferior cerebellar artery aneurysm (PICA), successfully operated, is reported. The low incidence of intracranial aneurysms in the first decade of life and the rare occurrence of distal PICA aneurysms are unusual features of this case. The theories regarding the origin of intracranial berry aneurysms are discussed.

[Chronic subdural hematoma as a complication of ventriculoperitoneal shunts]. / Hematoma subdural crônico como complicação de derivações ventrículo-peritoneais.

Nine cases of chronic subdural hematoma occurring after the insertion of ventriculo-peritoneal shunts are described. Three patients were children, two were adults with stenosis of the Sylvian aqueduct, and the last four had normal pressure hydrocephalus. Patients with chronic hydrocephalus were initially treated with burr holes associated to transient occlusion of the distal catheter of the diversion in order to promote reexpansion of the compressed hemisphere. Two shunt-dependent patients were successfully treated with a concurrent subdural-peritoneal shunt. In two cases a higher pressure shunt was inserted, and in another craniotomy with membranectomy was required to treat persistent subdural fluid accumulation. One patient died due to infectious complications of multiple procedures.

[Chronic subdural hematoma: surgical treatment and results in 96 patients]. / Hematoma subdural crônico: tratamento cirúrgico e resultados em 96 pacientes operados.

Ninety-six patients with chronic subdural hematoma were treated surgically and their clinical features presented in detail. Carotid angiography gave the correct diagnosis in all patients. CT scan was performed in 38 and was diagnostic in 92.1% of the cases. The clots were removed through burr-holes or small trephines: 78 (81.3%) patients were cured, 6 (6.2%) had permanent disabilities and 12 (12.5%) died. Operative mortality was related to the degree of neurological impairment, advanced age and systemic diseases. Neurologic sequelae were mostly related to reoperations due to recurrence of the hematoma and bilateral clots, as well. Low intracranial pressure syndrome with brain collapse was seen in 3 cases and treated with lumbar injection of saline solution. The delay in diagnosis and operation as cause of bad outcome is stressed.

[Primary hematoma of the brain stem: considerations apropos of a case]. / Hematoma primário do tronco cerebral: considerações a propósito de um caso.

The case of a 48 year-old woman presenting with a primary pontine hematoma is reported. The clinical evolution simulated a brain stem tumor and the diagnosis of hematoma was not established before the operation. The preoperative neurological deficit improved except for a facial nerve palsy. These hematomas are thought to be due to rupture of "cryptic" arteriovenous malformations and should be differentiated from those secondary to systemic hypertension. The diagnosis of brain stem hematomas should be considered in any case of brain stem lesion, especially in young and normotensive patients.

[Cranial metastasis of adenocarcinoma of the prostate simulating parasagittal meningioma]. / Metástase craniana de adenocarcinoma de próstata simulando meningioma parassagital.

The authors report the case of a 69 year-old man in whom X-Ray, CT and angiography findings typical for a parietal parasagittal meningioma were caused by cranial metastasis from prostatic adenocarcinoma. The authors stress the importance of the correct interpretation of the clinical features in order to achieve a correct diagnosis.

[Schistosomiasis of the spinal cord: tumor form. Report of a case]. / Esquistossomose medular: forma tumoral. Relato de um caso.

A case of schistosomiasis of the spinal cord is presented. A 16 years old boy developed a progressive spinal cord compression syndrome suggesting an intramedullary tumor. At the operation a granulomatous mass of the conus and epiconus was found and partially resected. The histopathological examination showed a granulomatous reaction surrounding Schistosoma mansoni eggs. The authors review the various aspects of spinal cord schistosomiasis, particularly the tumoral or granulomatous form. A comprehensive review of the literature is made.

Deep brain stimulation in mesencephalic lemniscus medialis for chronic pain.

Stereotactic deep brain stimulation (DBS) with chronically implanted special devices intermittently activated by the patient himself has led to a new concept in the treatment of chronic central pain, such as the thalamic pain syndrome, herpes-zoster neuralgia, anaesthesia dolorosa, radicular and plexus lacerations, stump pain with and without causalgia and cancer pain. Our results in 32 cases (March 31, 1979) with lemniscus medialis stimulation, including the specific and nonspecific somatosensory nuclei or periaqueductal gray matter show in 53% of our cases, a reduction of pain of over 50%. The follow-up period was 47 months. These results are better than those obtained from stimulating only one of the systems. Mesencephalic lemniscus medialis DBS, introduced by one of the authors (Mundinger), leads to a functional blockade of spinothalamic, lemniscus medialis and spino-reticular systems. In cases where a positive morphine test had been done previously, endorphin secretion also plays a role. It is assumed that the effect of endorphin production lasts longer than the stimulation itself, especially in periaqueductal mesencephalic gray matter and medial pulvinar stimulation.