Neurosurgical implications of Pott's puffy tumor in children and adolescents.

INTRODUCTION: Pott's puffy tumor (PPT) is rare and usually seen as a complication of frontal sinusitis resulting in subperiosteal abscess of the frontal bone with underlying osteomyelitis. PPT is potentially severe and can lead to life-threatening intracranial complications. PATIENTS AND METHODS: The authors present a series of six pediatric patients diagnosed with PPT and intracranial complications between 1999 and 2012. There were five boys and one girl, and the mean age at diagnosis was 11.8 years. All patients presented with frontal swelling, headache, and fever. Two patients had lowered level of consciousness and severe hemodynamic instability. RESULTS: All patients had epidural abscess, and one also presented subdural empyema. Five patients underwent drainage of all associated abscesses, bone resection, and sinusitis treatment. One was treated conservatively with broad-spectrum antibiotics, and no surgical intervention was required. All patients fully recovered their neurologic status, without further complications.

The nature of double concomitant myxopapillary ependymoma: report of a case.

Myxopapillary ependymomas are almost exclusively seen at the conus medullaris/filum terminale/cauda equina region, usually as solitary space-occupying lesions. The authors report the case of a 14-year-old boy with double concomitant myxopapillary ependymoma, proximal and caudal on the filum terminale in which a totally gross removal was achieved in two stages. This presentation is rare and, so far, we have known just three similar cases that were previously reported in children. The true nature of these lesions is controversial, and while some argue that they are related to metastatic seeding, others consider them independent lesions developing synchronously. A review on dissemination of spinal myxopapillary ependymomas was done.

The natural rehabilitation of an anthropogenically acidified tropical Lake: two decades of monitoring.

The rehabilitation of a pond after approximately 20 years of strong acidified conditions due to industrial and domestic waste deposition in its catchment basin is reviewed. We describe in this study the acidification process that occurred in a tropical pond in Northeast Brazil (Dunas Lake), the rehabilitation plan for the pond and the subsequent monitoring conducted over two decades. After the contamination assessment by the late 80s, a rehabilitation plan was carried out in the early 90s, in which the contaminated soil and water have been removed and reduced, respectively. No further attempt to neutralize the water or any remediation has been carried out. A toxicity monitoring plan based on toxicity assays with the fish Poecilia reticulata was employed to verify the natural rehabilitation of the pond. The data on toxicity, pH, conductivity, sulphate and dissolved iron recorded from 1994 to 2010 were also compiled and discussed. The collected data in 2003 and 2004 indicated changes in water quality and from them complementary management actions, namely improvement in the containment plant, were conducted in 2005. Results for toxicity assays and pH results indicated interannual changes in the water quality similar to rainy-dry periods. Moving average approach using pH data clearly showed the recovery process of Dunas Lake as well as the importance of the containment plan to reduce the contamination. Finally, a summary of the recent situation after two decades of rehabilitation is provided.

Discriminating the pH toxicity to Poecilia reticulata Peters, 1859 in the Dunas Lake (Camaçari, BA, Brazil).

Toxic potential of the pH reduction to fingerlings of Poecilia reticulata, through acute toxicity bioassays, as well as the influence of increased pH on the toxicity were assessed. Acid lake samples (Dunas Lake) were collected during 19 months, and assessed with following treatments: water at local pH (+/-3.0) and samples with modified pH to 3.5, 3.8, 4.0, 4.3, 4.6, 5.0, 5.5, 6.0, and 6.5. Culture water samples with pH reduced to 3.0 were also assessed. Newborn P. reticulata were exposed during 96h, and dead/immobile organisms were counted at various time intervals during exposure (short intervals in the beginning and long towards the end). Mean results of LT50 and confidence intervals from the Dunas Lake and control water with reduced pH were 1.36 (+/-0.48)h, and 1.03 (+/-0.50)h, respectively, with no statistical difference. Samples with increased pH showed a significant reduction in toxicity, with no toxicity detected at pH 6.0 and higher. Relationship between pH and lethal toxicity for fingerlings of P. reticulata demonstrated that pH exerted a strong effect on the survival of this species at the Dunas Lake, explaining about 80% of the toxicity observed.

In situ and laboratory bioassays using Poecilia reticulata Peters, 1859 in the biomonitoring of an acidic lake at Camaçari, BA, Brazil.

The suitability and viability of acute in situ bioassays were investigated in the biomonitoring program of an acidic lake contaminated with sulphur residues. Responses of organisms observed in laboratory and in situ bioassays were also assessed to determine whether or not they were similar and comparable, regarding accuracy and precision. Newborn Poecilia reticulata were employed as test organisms and exposed to the same water samples under in situ and laboratory conditions. Mortality/immobility was the endpoint assessed and dead/immobile organisms were counted at various time intervals during exposure. The mean calculated LT50 values and 95% confidence intervals were 1.61 (1.36-1.87) h in the laboratory bioassays and 0.72 (0.55-0.89) h in the in situ bioassays. Statistical comparison of these values revealed a significant difference (p<0.05). In situ bioassays were more accurate than those carried out in the laboratory, demonstrating higher sensitivity and better reproduction of what occurs in nature, while laboratory bioassays were more precise.

Cystic spinal dysraphism of the cervical and upper thoracic region.

BACKGROUND: Cystic dysraphic lesions of the cervical and upper thoracic region are rare and only a few series have been published about the topic. These malformations can be divided into categories that include both myelocystoceles and the so-called cervical meningoceles or myelomeningoceles. METHODS: A retrospective study of 18 patients was conducted. RESULTS: In 17 patients a squamous or a cicatricial epithelium of variable thickness covered the dome of the lesions, while the base was covered with full-thickness skin. In one case the skin was entirely normal. Four patients displayed associated CNS malformations and three more had systemic congenital anomalies. All patients underwent surgical exploration and the length of time between birth and surgery ranged from 6 h to 9 months. The most frequent surgical finding, seen in 14 patients, was a stalk connecting the dorsal surface of the spinal cord to the cyst. In three patients the findings were consistent with myelocystocele. Only in one case was a true meningocele found. Hydrocephalus and Chiari II malformation were not as consistently associated as in myelomeningoceles. Neurological signs and symptoms were not so marked as in myelomeningoceles and were found in the follow-up of four patients. In two of them there was a non-progressive deficit, probably expressing an imperceptible involvement of the nervous system in the first year of life. The histopathological findings were of three types: neuroglial stalks, fibrovascular stalks and myelocystoceles. CONCLUSIONS: Cystic dysraphisms of the cervical and upper thoracic region differ clinically and structurally from meningomyelocele and have a more favorable outcome. We believe that these malformations have not been properly labeled and propose a classification based on the structures found inside the cyst.

Positive reaction for cysticercosis and multicentric anaplastic oligoastrocytoma.

INTRODUCTION: An unusual case of positive immunological testing for cysticercosis in the cystic fluid obtained from an anaplastic oligoastrocytoma is presented. CASE REPORT: A 15-year-old boy was admitted with multiple brain lesions. The biggest was a cyst with a mural node and neurocysticercosis was suspected. In order to relieve intracranial pressure, the cyst was punctured and the immunological testing for cysticercosis was positive, reinforcing the clinical suspicion and leading to a clinical trial with albendazole and steroids. As the patient deteriorated the cystic lesion was removed and the diagnosis of anaplastic oligoastrocytoma was established. A second lesion was eventually approached and the histopathological diagnosis of both specimens concurred. DISCUSSION: Although some authors believe that chronic inflammatory changes following neurocysticercosis could induce the formation of brain tumors, this association may be a mere coincidence. In our case no clinical evidence of a prior infestation by Cysticercus was found. In fact, an exhaustive examination of the specimens did not reveal any areas of inflammatory reaction. We believe that the similarity of the glioma and cysticercosis antigens may be the cause of the positive reactions in the cystic fluid.

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.

Malformaçäo de Chiari do tipo II sintomática / Symptomatic Chiari type II malformation

Os autores analisam uma série de 17 crianças portadoras de mielodisplasias que desenvolveram sinais e sintomas da malformaçoes de Chiari do tipo II. De acordo com a idade, dois grupos ficaram bem definidos: Grupo I, crianças no primeiro ano de vida, em que predominaram sinais e sintomas de comprometimento do tronco encefálico e nervos cranianos bulbares (n=13); Grupo II, composto por crianças com idade superior a um ano, em que as principais manifestaçoes foram dor cervical e sinais cerebelares (n=4). O resultado do tratamento cirúrgico nos dois grupos foi distinto: enquanto a mortalidade no Grupo I atingiu 46,1 por cento, nenhum paciente do Grupo II veio a falecer. O tratamento inicial consistiu na manifestaçao ou revisao de derivaçao ventricular, sendo a descompressao crânio-vertebral reservada àqueles que nao se beneficiaram com esses procedimentos. Os autores enfatizam a necessidade do imediato reconhecimento e tratamento do quadro, de modo a se obter resultados satisfatórios.

Cisto ósseo aneurismático da coluna vertebral / Aneurismal bone cyst of the spine

Os autores apresentam nove pacientes portadores de cisto ósseo aneurismático tratados de 1977 a 1992 no Grupo de Afecçöes da Coluna Vertebral do Departamento de Ortopedia e Traumatologia - Pavilhäo Fernandinho Simonsen, da Santa Casa de Misericórdia de Säo Paulo, Serviço do Prof. Dr. José Soares Hungria Neto.

Mielomeningocele: tratamento cirúrgico e resultados / Myelomeningocele: Surgical treatment and results

Os autores estudaram retrospectivamente 72 casos de mielomeningocele tratados em um hospital pediátrico do Rio de Janeiro,65(90,2 por cento) lesöes localizavam-se nos segmentos inferiores da coluna vertebral, e 87,5 por cento dos pacientes necessitaram de derivaçöes ventriculares para controle da hidrocefalia. Infecçöes de derivaçöes ventriculares foram três vezes mais frequentes em portadores de spina bifida cística que no restante da populaçäo de hidrocéfalos tratados na instituiçäo. Houve grande incidência de complicaçöes pós-operatórias relacionadas a infecçöes e necrose de ferida cirúrgica. Onze pacientes(15,3 por cento)desenvolveram sinais e sintomas relacionados à malformaçäo de Chiari do Tipo II. A mortalidade foi de 8,3 por cento e, na maioria absoluta dos casos, associada à mal-formaçäo de Chiari.

[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.