Cerebellar Tonsillar Cysts Associated with Chiari Malformation in Adults: A Short Series.

BACKGROUND: Authors analyzed surgical patients with Chiari malformation (CM) associated with cerebellar tonsillar cyst. This association is quite rarely encountered in the literature. CASE DESCRIPTION: We retrospectively reviewed 60 surgical adult patients with MRI evaluation who underwent posterior fossa decompression for treatment of CM type I. All surgeries were performed between January 1995 and July 2015. From 60 patients with CM, four cases presented cerebellar tonsillar cysts (male=2). Basilar invagination (BI) (n=4) and syringomyelia (n=1) were associated. There were pyramidal signs (n=4) and low cranial nerves dysfunction (n=1). Radiological evaluation showed T1-hypointense and T2-hyperintense image on the cystic tissue (n=4). The surgical technique was suboccipital craniectomy, C1-C2 laminectomy (if needed), y-shaped durotomy, total resection and coagulation/aspiration of tonsils. CONCLUSIONS: In the present series, we were able to identify 7% of tonsillar cysts among 60 patients with CM. MRI with Flair and Diffusion sequences should be pre-operatively used for evaluation of tissue characteristics as differential diagnosis of cystic lesion and gliosis. The clinical presentation endorses surgical indication, with a good chance of clinical improvement. This was the first time that the frequency of tonsillar cysts has been evaluated in a series of adult patients.

Cranial venous sinus dominance: what to expect? Analysis of 100 cerebral angiographies.

METHODS: Data of 100 cerebral angiographies were retrospectively analyzed (p = 0.05). RESULTS: Mean age was 56.3 years, 62% female and 38% male. Measurements and dominance are shown in the Tables. There was no association between age or gender and dominance. Right parasagittal division of the superior sagittal sinus was associated with right dominance of the transverse sinus, sigmoid sinus and internal jugular vein; and left parasagittal division of the superior sagittal sinus was associated with left dominance of the transverse sinus, sigmoid sinus and internal jugular vein. CONCLUSION: A dominance pattern of cranial venous sinuses was found. Age and gender did not influence this pattern. Angiographic findings, such as division of the superior sagittal sinus, were associated with a pattern of cranial venous dominance. We hope this article can add information and assist in preoperative venous analysis for neurosurgeons and neuroradiologists.

Cranial venous sinus dominance: what to expect? Analysis of 100 cerebral angiographies / Dominância dos seios venosos cranianos: o que esperar? Análise de 100 angiografias cerebrais

ABSTRACT We report an analysis of the cranial venous sinuses circulation, emphasizing morphological and angiographic characteristics. Methods Data of 100 cerebral angiographies were retrospectively analyzed (p = 0.05). Results Mean age was 56.3 years, 62% female and 38% male. Measurements and dominance are shown in the Tables. There was no association between age or gender and dominance. Right parasagittal division of the superior sagittal sinus was associated with right dominance of the transverse sinus, sigmoid sinus and internal jugular vein; and left parasagittal division of the superior sagittal sinus was associated with left dominance of the transverse sinus, sigmoid sinus and internal jugular vein. Conclusion A dominance pattern of cranial venous sinuses was found. Age and gender did not influence this pattern. Angiographic findings, such as division of the superior sagittal sinus, were associated with a pattern of cranial venous dominance. We hope this article can add information and assist in preoperative venous analysis for neurosurgeons and neuroradiologists.

RESUMO Relatamos uma análise da circulação dos seios venoso cranianos, enfatizando características morfológicas e angiográficas. Métodos Dados de 100 angiografias cerebrais foram retrospectivamente analisados (p = 0,05). Resultados Média de idade 56,3 anos, 62% feminino e 38% masculino. Medições e dominância expostos em tabelas. Sem associação entre idade ou sexo e dominância. Divisão parassagittal direita do Seio Sagital Superior (SSS) foi associada com dominância direita do Seio Transverso (ST), Seio Sigmóide (SS) e Veia Jugular Interna (VJI), e divisão parassagittal esquerda do SSS foi associada com dominância esquerda do ST, SS e VJI. Conclusão Um padrão de dominância dos seios venosos do crânio foi encontrado. Idade e sexo não influenciaram esse padrão. Achados angiográficos, como divisão do SSS, foram associados com o padrão de dominância venoso cerebral. Esperamos que este artigo acrescente informações e auxilie na análise venosa pré-operatória para neurocirurgiões e neuroradiologistas.

Lesión como malformación de Chiari secundaria a quiste aracnoidal de la cisterna cuadrigémina / Chiari malformation-like lesion secondary to arachnoid cyst of the quadrigeminal cistern

Se presenta el caso de una mujer de 31 años de edad con cefalea y cervicalgia que se agravaba con la maniobra de Valsalva, presentando además mareos, encontrándose una malformación de Chiari secundario a un quiste aracnoideo cuadrigeminal. Después de efectuada la resonancia magnética diagnóstica, la paciente fue sometida a descompresión del agujero magno y extirpación del quiste cuadrigeminal, seguido por la resolución tanto de la malformación de Chiari y el quiste. Los síntomas desaparecieron después de la cirugía y han permanecido completamente resuelto hasta la actualidad. En pacientes adultos que presentan signos y síntomas de una malformación de Chiari debido a la compresión de la médula por las las amígdalas cerebelosas, la presencia de un quiste aracnoideo de cisterna cuadrigéminal es una rara patología asociada que puede ser tratada quirúrgicamente.

We report a rare case of a 31-year-old woman with headache and pain manifested by cervicalgia that worsened with the Valsalva maneuver and dizziness, who was found to have a Chiari malformation secondary to a posterior fossa arachnoid cyst. After magnetic resonance imagining (MRI), the patient was submitted to foramen magnum decompression and arachnoid cyst removal that were followed by resolution of both the Chiari malformation and the cyst. The symptoms disappeared after surgery and have remained completely resolved to the present day. In adult patients who present with signs and symptoms of Chiari malformation due to direct medulla compression by the tonsils, a quadrigeminal cistern arachnoid cyst is a rare associated pathology that can be treated surgically.

Chronic subdural hematomas and the elderly: Surgical results from a series of 125 cases: Old "horses" are not to be shot!

BACKGROUND: To present the accumulated experience from treating chronic subdural hematomas (CSDH) in a local hospital of a third world country. METHODS: One hundred and twenty-five consecutive patients with CSDH who were surgically treated in the Neurosurgical Department of the Hospital da Restauração, Recife-PE, Brazil, between January 2006 and May 2008, were retrospectively studied. Glasgow Outcome Scale (GOS) was employed to define outcome at 6 months as good (GOS 4 and 5) or poor (GOS ≤ 3). Age, admission Glasgow Coma Scale (GCS), location of hematomas (unilateral/bilateral), drainage system placement and recurrence were all analyzed for potential impact on final outcome. RESULTS: The median age was 69 years, with a male/female ratio of 102/23. History of trauma was present in 60.8% of the patients. The median GCS on admission was 14. In 64 patients, the hematoma was on the left side, while in 42 patients it was on the right side. Bilateral hematomas were present in 19 cases (15.2%). Drainage systems were used in 93.6% of the cases. Recurrence occurred in 8.8% of the patients. One hundred and three patients obtained a good outcome at 6 months. The mortality rate was 11.2%. Patients with GCS ≥9 on admission presented better outcome (P < 0.05). Recurrent cases presented a poor outcome (P < 0.05). CONCLUSIONS: This study suggests that the main factors associated with outcome in patients harboring CSDH are the admission GCS score and the recurrence status. Advanced age is not a contraindication for surgical treatment. This study, solely focused on the Brazilian population, is the first of its kind in the English literature, and it could serve as a useful introduction to a more complex, multivariate, debate.

Ocular melanoma: Keep your eyes open for late brain metastases.

BACKGROUND: The most frequent intraocular malignant tumor is choroidal melanoma (CM). Although brain metastasis is a common feature of other types of cancers, metastasis of CM to the brain is a rare entity. CASE DESCRIPTION: The authors report a case of a 28-year-old woman presenting with a single brain metastasis, 10 years after the treatment of a CM. She underwent a total en-bloc resection of the lesion, and the diagnosis was confirmed histopathologically. The patient concomitantly received whole-brain irradiation therapy combined with chemotherapy, with a survival period of 24 months. CONCLUSION: The present case report draws attention to the necessity of a close and lifelong follow-up of patients treated for this malignancy. The international literature is also reviewed.

Intraventricular trigonal meningioma: Neuronavigation? No, thanks!

BACKGROUND: Most of the time meningiomas are benign brain tumors and surgical removal ensures cure in the vast majority of the cases. Thus, whenever possible, complete surgical resection should be the goal of the treatment. METHODS: This is a report of our surgical technique for the operative resection of a trigonal meningioma in a resource-limited setting. The necessity of accurate and deep knowledge of the regional anatomy is outlined. RESULTS: A 44-year-old male presented to our outpatient clinic complaining of cephalalgia increasing in frequency and intensity over the last month. His neurological exam was normal, yet a brain computed tomography scan revealed a lesion in the right trigone of the ventricular system. The diagnosis of possible meningioma was set. After thoroughly informing the patient, tumor resection was decided. An intraparietal sulcus approach was favored without the use of any modern technological aids such as intraoperative magnetic resonance imaging or neuronavigation. The postoperative course was uneventful and a postoperative computed tomography scan demonstrated the complete resection of the tumor. The patient was discharged two days later with no neurological deficits. In a two-year-follow-up he remains recurrence-free. CONCLUSION: In the current cost-effective era it is still possible to safely remove an intraventricular trigonal meningioma without the convenience of neuronavigation. Since the best neuronavigator is the profound neuroanatomical knowledge, no technological advancement could replace a well-educated and trained neurosurgeon.

Meningiomas do forâmen magno / Foramen magnum meningiomas

Contexto: Os meningiomas do forâmen magno são patologias raras e representam um dos mais desafiantes tumores do sistema nervoso central em relação ao seu tratamento cirúrgico. Sua frequência varia na literatura em torno de 3% dos meningiomas. Podem ser classificados como ventrais, ventrolaterais e dorsais. Tal classificação é importante, pois define a abordagem cirúrgica a ser utilizada. Objetivo: Revisão dos aspectos clínicos e terapêuticos desse raro e intrigante tumor. Método: Pesquisa eletrônica no PubMed (www.pubmed.com) utilizando as seguintes palavras-chave: meningioma do forâmen magno e acesso extremo lateral. Foram revisados dados de trabalhos do período de 1987 a 2008. Também foi realizada pesquisa das publicações mais citadas em relação ao tema. Artigos com dados clínicos incompletos não foram analisados. Resultados: Como todos os meningiomas, são mais frequentes no sexo feminino. Possuem uma apresentação clínica variável. O diagnóstico precoce é mandatório a fim de se atingir os melhores resultados terapêuticos. O tratamento de eleição, definido pela maioria dos autores, é o cirúrgico, embora a radiocirurgia estereotáxica esteja despontando como uma das possibilidades terapêuticas. A maioria das séries publicadas relata uma taxa de ressecção total em torno de 70% dos casos. Conclusões: A melhor opção terapêutica, até o presente momento, é a remoção cirúrgica do tumor. A abordagem ideal ainda não está estabelecida como um consenso, embora esteja se direcionando para o acesso extremo lateral e suas variantes segundo a maioria dos autores. A embolização pré-operatória tem o seu papel definido e deve ser utilizada sempre que possível. A radiocirurgia estereotáxica pode ser uma opção terapêutica para um grupo seleto de pacientes. O diagnóstico precoce continua sendo a melhor arma de todo esse arsenal para que os pacientes desfrutem de um bom resultado terapêutico e evoluam com um prognóstico favorável. Em virtude da complexidade de sua localização anatômica, é necessário o amplo conhecimento da anatomia dos acessos de base de crânio, em especial o acesso extremo lateral e suas variantes.

Context: Foramen magnum meningiomas are rare diseases and represent one of the most challenging tumors of the central nervous system for its surgical treatment. Its frequency varies in the literature corresponding to about 3% of all meningiomas. They are classified as ventral, ventrolateral and dorsal. This classification is important because it defines the surgical approach to be used. Objective: Literature review of clinical and therapeutic aspects of this rare and puzzling tumor. Method: An electronic search in PubMed (www.pubmed.com) using the following keywords: meningioma of the foramen magnum and extreme lateral access. We reviewed data from studies published during the period of 1987 to 2008. We also carried out research into the publications cited in the articles. Articles with incomplete clinical data were not analyzed. Results: Like all meningiomas they are more common in women. They have a variable clinical presentation. Early diagnosis is mandatory in order to achieve the best therapeutic results. The treatment of choice, as defined by most authors, is surgery, while stereotactic radiosurgery is emerging as one of the therapeutic possibilities. Most published series report a total resection rate of around 70%. Conclusions: The best therapeutic option, so far, is the surgical removal of the tumor. The ideal approach is not yet established as a consensus, although it is moving toward the extreme lateral access and its variants according to most authors. The preoperative embolization has its defined role and should be used whenever possible. The stereotactic radiosurgery may be a therapeutic option for a select group of patients. Early diagnosis remains the best factor to achieve a good outcome and a favorable prognosis. Due to the complexity of its anatomical location, one must have extensive knowledge of the anatomy of the skull base, especially that concerning with the extreme lateral access and its variants.