Tenth case of bilateral hemifacial spasm treated by microvascular decompression: Review of the pathophysiology.

BACKGROUND: Bilateral hemifacial spasm (BHFS) is a rare neurological syndrome whose diagnosis depends on excluding other facial dyskinesias. We present a case of BHFS along with a literature review. METHODS: A 64-year-old white, hypertense male reported involuntary left hemiface contractions in 2001 (aged 50). In 2007, right hemifacial symptoms appeared, without spasm remission during sleep. Botulinum toxin type A application produced partial temporary improvement. Left microvascular decompression (MVD) was performed in August 2013, followed by right MVD in May 2014, with excellent results. Follow-up in March 2016 showed complete cessation of spasms without medication. RESULTS: The literature confirms nine BHFS cases bilaterally treated by MVD, a definitive surgical option with minimal complications. Regarding HFS pathophysiology, ectopic firing and ephaptic transmissions originate in the root exit zone (REZ) of the facial nerve, due to neurovascular compression (NVC), orthodromically stimulate facial muscles and antidromically stimulate the facial nerve nucleus; this hyperexcitation continuously stimulates the facial muscles. These activated muscles can trigger somatosensory afferent skin nerve impulses and neuromuscular spindles from the trigeminal nerve, which, after transiting the Gasser ganglion and trigeminal nucleus, reach the somatosensory medial posterior ventral nucleus of the contralateral thalamus as well as the somatosensory cortical area of the face. Once activated, this area can stimulate the motor and supplementary motor areas (extrapyramidal and basal ganglia system), activating the motoneurons of the facial nerve nucleus and peripherally stimulating the facial muscles. CONCLUSIONS: We believe that bilateral MVD is the best approach in cases of BHFS.

Surgical treatment of the intracranial pial arteriovenous fistula.

BACKGROUND: Pial arteriovenous fistula (PAVF) is a rare vascular condition comprising of one or more arterial vessels that are in direct communication with the draining veins. The condition is also characterized by the absence of a nidus. Due to high blood flows, varicose systems adjacent to the fistula appear. The key characteristic of the arteriovenous direct transition is that it offers a treatment option in which interruption of the blood flow can occur without removing the entire lesion. This study presents two cases of PAVF. CASE DESCRIPTION: The first case is of a 59-year-old male with lesions in the frontal region, fed by a branch of the right anterior cerebral artery and drained by the frontal basal vein to the sphenoparietal sinus. The second case is of a 3-year-old child with a lesion in the right anterior frontal lobe, fed by a branch of the right middle cerebral artery, which drains into the Trolard vein and was associated with large a venous varix. CONCLUSION: PAVF is a disease characterized by its rarity, and knowledge of PAVF's clinical presentation is of vital importance in early diagnosis. The treatment of the condition consists of an occlusion of the supply vessel, which can be done by endovascular, microsurgical, or both procedures. Both the cases were successfully treated by microsurgical procedure.

E-learning for neurosurgeons: Getting the most from the new web tools.

As open access resource, the role of Internet has been increasing in our professional life. There are several emergent new tools that can facilitate and make it more efficient to get accurate and reliable information. In this article, we discuss how we can manage to get the most from these new instruments, like blogs, Facebook, Twitter, and LinkedIn, in order to improve clinical practice. With good sense and some caution, these can turn to be of valuable help in our careers.

Efficacy and safety of a porcine collagen sponge for cranial neurosurgery: a prospective case-control study.

OBJECTIVE: The use of dural grafts is very useful when primary dural closure cannot be achieved. Our primary objective was to study the incidence of postoperative cerebrospinal fluid leak, including fistula and pseudomeningocele, and postoperative infection by comparing autologous material and a new collagen graft. MATERIALS AND METHODS: A prospective nonrandomized study with a new collagen-based product derived from porcine cells (Peridry) was performed. It was used for dural replacement in 50 patients who underwent a variety of neurosurgical procedures requiring the use of a dural graft. These results were compared with a control group of 50 patients who were treated with autologous duraplasty material. The follow-up period was 3 months. RESULTS: Postoperative overall cerebrospinal fluid fistula occurred in 6% of both groups. No patient in the collagen group developed any sort of infection. One patient in the control developed osteomyelitis in the bone flap. CONCLUSION: The new collagen-based product derived from porcine cells (Peridry), compared with an autologous tissue, is safe, effective, easy to use, as well as time saving in cranial neurosurgery.

Skin closure in vascular neurosurgery: A prospective study on absorbable intradermal suture versus nonabsorbable suture.

BACKGROUND: The craniotomy performed with minimal hair removal and closure with intradermal suture alone is an option in neurosurgical procedures, which can help faster psychological recovery of the patient, as it allows a better cosmetic result. This study is aimed at evaluating if such method is safe and effective, compared with continuous skin sutures with 2-0 nylon. METHODS: We analyzed the sutures in 117 patients undergoing craniotomies for cerebral aneurysm clipping. In the case group (n = 49), closure of the scalp was performed only with intradermal absorbable sutures using wire Monocryl(®) 2-0. In the control group (n = 68), closure was performed with continuous suture using 2-0 nylon. RESULTS: The case group was composed of 49 patients in whom just intradermal suture was performed. One (2.2%) patient developed wound infection and was given proper medical treatment. No cases of dehiscence or cerebrospinal fluid leaks were observed. The control group was composed of 68 patients in whom the skin was closed with 2-0 nylon continuous suture. Three (5.3%) patients developed wound infection and were given proper medical treatment. There were no cases of wound dehiscence. The overall infection rate in the control group was 4%. There was no statistically significant difference in the number of wound infections between the two groups (P = 0.73). CONCLUSION: The closure with intradermal suture alone in craniotomies is as safe as the traditional skin closure with nylon sutures, besides eliminating the need for suture removal and providing a cosmetic advantage.

Blogs for neurosurgeons.

Blogs are useful tools to research and to disseminate information. As they allow people who do not have specific knowledge on the building of sites to post content on the internet, they turned out to be very popular. In the past years, there has been a rapid expansion of blogs on several subjects and nowadays there are over 156 million blogs online. Neurosurgery was not out of this wave, and several blogs related to it can be found on the internet. The objective of this paper is to describe, in general, the functions of a blog and to provide initial guidance for the creation and the adequate use of neurosurgical blogs. Some interesting blogs and their features are also listed as examples.

Meningioangiomatosis without neurofibromatosis simulating encephalitis in neuroimaging.

BACKGROUND: Meningioangiomatosis (MA) is a rare entity characterized by a focal lesion that affects the leptomeninges and the cerebral cortex. CASE DESCRIPTION: We describe a case of a 32-year-old man diagnosed with MA not associated with hamartomatous lesions or with type 2 neurofibromatosis. Magnetic resonance images (MRI) showed an extensive parieto-occipital lesion and another right frontal lesion, initially suggestive of encephalitis. A biopsy of the meninges and brain was performed via a right parieto-occipital craniotomy. The histopathologic diagnosis, complemented by immunohistochemical studies, was MA. CONCLUSION: Diagnosis of MA is very difficult based only on images, therefore lesions compromising the brain cortex, associated or not with calcifications, should be further examined through biopsy so as to have a precise diagnosis.

Importance of recognizing sentinel headache.

BACKGROUND: Sentinel headache (SH) is a kind of secondary headache and is characterized as sudden, intense, and persistent, preceding spontaneous subarachnoid hemorrhage (SAH) by days or weeks. METHODS: Eighty-nine consecutive patients with a diagnosis of spontaneous SAH were evaluated following admission to the Neurosurgical Service at Santa Casa Hospital, Belo Horizonte, between December 2009 and December 2010. RESULTS: Out of the 89 patients, 64 (71.9%) were women. Mean age was 48.9 years (SD ± 13.4, ranging from 18 to 85 years). Twenty-four patients (27.0%) presented SH, which occurred, in average, 10.6 days (SD ± 13.5) before a SAH. No statistically significant differences were observed between the presence of SH and gender, arterial hypertension and migraine (P > 0.05), Glasgow Comma Scale (GCS) and World Federation of Neurological Surgeons (WFNS) scale at admission. CONCLUSION: The prevalence of SH was 27% in this study but no related factors were identified. Therefore, further clarification of this important entity is required so as to facilitate its recognition in emergency services and improve the prognosis of patients with cerebral aneurysms.

Papillary tumor of the pineal region.

Tumors of the pineal region are rare in adulthood, accounting for approximately 1% of intracranial neoplasms in this age range. Papillary tumor of the pineal region (PTPR) was first described by Jouvet et al. in 2003. In 2007, PTPR was included by the World Health Organization as a distinct entity in their new classification of central nervous system tumors. We report a case of PTPR, and undertake a literature review of this rare neuroepithelial neoplasm. Patients with PTPR need long-term follow up, and new cases should be well documented so that we can gain a better understanding of this neoplasm.

Gliomatosis cerebri: diagnostic considerations in three cases.

Clinical symptoms and radiologic characteristics of gliomatosis cerebri (GC) are non-specific and the condition may be confused with other central nervous system diseases. We report three patients with GC; all the three patients had involvement of more than three lobes and the deep white matter, as well as bilateral involvement. Differentiation of GC from other neurologic diseases involving diffuse white matter may be difficult. However, the diagnosis can be based on the combination of radiologic and histopathologic features.

Bilateral malignant metastases to the internal auditory canal: radiosurgical management.

Malignant melanomas constitute 1-8% of all malignant tumors and are the third most common tumor to metastasize to the central nervous system. However, metastases to the cerebellopontine angle (CPA) are rare, accounting for only 0.2 to 0.7% of the lesions identified in this location Case Report. A 62-year-old white man with a history of melanoma of the back, who had had all lesions completely excised, was reportedly tumor-free for 6 years. The patient presented bilateral metastatic CPA melanoma. Left side tumor was treated with surgery with partial resection (lost hearing) and radisorugery. Right side lesion was treated with radiosurgery and hearing preserved for 8 months, tumor controlled for 12 months, until death due to leptomeningeal carcinomatosis after 13 months of radiosurgey. The patient underwent intensity-modulated stereotactic radiosurgery using BrainLab Iplan 4.1 for both IAC lesions, the dose was 18Gy prescribed to the 80% isodose line delivered by 11 fields. The patient presented no post-radiosurgery neurological complications. Conclusion: In patients with lesions in the CPA, a diagnosis of melanoma should be included, particularly in cases with rapid progression of symptoms. Therefore, radiosurgery is a viable treatment option since the hearing can be preserved and tumor control achieved.

Clinical experience with a novel bovine collagen dura mater substitute.

BACKGROUND: Dural substitutes are used to achieve a watertight closure in situations where adequate closure is not possible .This study was conducted to evaluate the efficacy and safety of use a new collagen matrix dural substitute ( Duradry, Tecnodry, Belo Horizonte MG) in repair or expansion of cranial and spinal dura-mater. METHODS: 30 patients operated on between March and September 2008, were studied. Surgical logs were reviewed for sex, age, diagnosis, location of the graft, technique and presence of fistula or infection. The patients were followed-up for at least 3 months, and the presence of complications as cerebrospinal leakage, infection, aseptic meningitis, hydrocephalus, pseudomeningocele were analysed. RESULTS: Only one patient presented with CSF fistula. No patients presented with wound infections, hydrocephalus, pseudomeningocele, meningitis, brain abscesses or signs of toxicity related to the material. CONCLUSIONS: The new dural substitute used in this study is effective and safe, and the initial results are similar to those of other dural substitutes reported in the literature.

[Central nervous system paracoccidioidomycosis: analysis of 13 cases]. / Paracoccidioidomicose do sistema nervoso central: análise de 13 casos.

Paracoccidioidomycosis (PCM) is a systemic granulomatous disease caused by Paracoccidioides brasiliensis, prevalent in Latin America, particularly in Brazil. Central nervous system (CNS) involvement occur in about 10% of cases. Thirteen patients with PCM involving CNS were studied considering clinical manifestation, neuroradiology and treatment modalities. Age ranged from 30 to 71 years-old (M=47.1+/-11.6 Me=46). There were eleven men and two women. The most frequent symptoms were motor deficits (53.8%), cognitive disturbance (53.8%), weight loss (46.1%), headaches (46.1%) and seizures (46.1%). The diagnosis was confirmed by the demonstration of P. brasiliensis. Granulomatous forms were present in all patients. Four (30.8%) of them had also meningeal involvement (mixed form). Computerized tomography (CT) scans were obtained in all cases and magnetic resonance imaging (MRI) was used in one case. Serology for HIV was done in ten patients (76.9%), and all the tests were negatives. Amphotericin B was used in twelve patients (92.3%), one of them by intraventricular infusion. In eight patients (61.5%), trimethopim and sulfamethoxazole were used, and, in two (15.4%), sulfadiazine and pirimetamine. Fluconazole, ketoconazole and itraconazole were each one used in a different patient as well. Six patients died (46.1%) and seven (53.9%) had satisfatory outcome. The follow-up period ranged from 2 to 74 (M=30.9) months. In conclusion, the CNS involvement in paracoccidioidomycosis is more frequent and more serious than thought before. The clinical manifestations, CT scans and MRI findings are not specific of paracoccidioidomycosis.

Monitoring of activated coagulation time in carotid endarterectomy.

BACKGROUND: The objective of the present study was to evaluate the efficacy of monitoring activated coagulation time (ACT) during carotid endarterectomy (CEA) in reducing surgical risks and complications. METHODS: A total of 175 consecutive patients who had CEA between July 2002 and January 2004 were studied. Activated coagulation time was monitored during the procedure in all patients. The results were compared with the data reported in the literature, and with those obtained in 2 previous series, totaling 1924 patients treated at the same service before the use of ACT. RESULTS: Only 4 of the 175 patients had cerebral ischemia, with 3 of them almost completely recovering during hospitalization. Significant morbidity was 0.6% and mortality was 0.6%. No statistically significant difference in the incidence of cerebral ischemia or death was observed between symptomatic and asymptomatic patients. In the 2 previous series used for comparison, operated by the same author, we found 0.7% and 0.8% of significant morbidity and 1.4% and 2.6% of mortality, respectively. Most series in the literature have shown a higher significant morbidity than the present one, mainly in symptomatic patients. The incidence of hematoma in the present series was 5.7%, only 3 (1.7%) of them being significant. No increase in the frequency of hematomas was observed in cases where heparin was not reversed or in those using a shunt. In the 2 other previous series, the incidence of hematomas was 1.5% and 3.6%. CONCLUSIONS: Activated coagulation time monitoring during CEA was effective in evaluating the level of heparinization of patients during surgery and the immediate postoperative period. The comparison of the present series with the literature and with the previous series of the same service, before the use of ACT, permits also to conclude that the control of the level of heparinization seems to reduce the risk of perioperative and immediate postoperative ischemia. In addition, ACT monitoring also seems to be effective in diminishing the risk of postoperative cervical hematoma.