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This manuscript presents the quantification and correlation of three aspects of Alzheimer's Disease evolution, including structural, biochemical, and cognitive assessments. We aimed to test a novel structural biomarker for neurodegeneration based on a cortical folding model for mammals. Our central hypothesis is that the cortical folding variable, representative of axonal tension in white matter, is an optimal discriminator of pathological aging and correlates with altered loadings in Cerebrospinal Fluid samples and a decline in cognition and memory. We extracted morphological features from T1w 3T MRI acquisitions using FreeSurfer from 77 Healthy Controls (age = 66 ± 8.4, 69% females), 31 Mild Cognitive Impairment (age = 72 ± 4.8, 61% females), and 13 Alzheimer's Disease patients (age = 77 ± 6.1, 62% females) of recruited volunteers in Brazil to test its discriminative power using optimal cut-point analysis. Cortical folding distinguishes the groups with reasonable accuracy (Healthy Control-Alzheimer's Disease, accuracy = 0.82; Healthy Control-Mild Cognitive Impairment, accuracy = 0.56). Moreover, Cerebrospinal Fluid biomarkers (total Tau, A β 1-40, A β 1-42, and Lipoxin) and cognitive scores (Cognitive Index, Rey's Auditory Verbal Learning Test, Trail Making Test, Digit Span Backward) were correlated with the global neurodegeneration in MRI aiming to describe health, disease, and the transition between the two states using morphology. [ABSTRACT FROM AUTHOR]

Metagenomic next-generation sequencing (mNGS) methodology serves as an excellent supplement in cases where diagnosis is challenging to establish through conventional laboratory tests, and its usage is increasingly prevalent. Examining the causes of infectious diseases in the central nervous system (CNS) is vital for understanding their spread, managing outbreaks, and effective patient care. In a study conducted in the state of São Paulo, Brazil, cerebrospinal fluid (CSF) samples from 500 patients with CNS diseases of indeterminate etiology, collected between 2017 and 2021, were analyzed. Employing a mNGS approach, we obtained the complete coding sequence of Pegivirus hominis (HPgV) genotype 2 in a sample from a patient with encephalitis (named IAL-425/BRA/SP/2019); no other pathogen was detected. Subsequently, to determine the extent of this virus's presence, both polymerase chain reaction (PCR) and/or real-time PCR assays were utilized on the entire collection. The presence of the virus was identified in 4.0% of the samples analyzed. This research constitutes the first report of HPgV detection in CSF samples in South America. Analysis of the IAL-425 genome (9107 nt) revealed a 90% nucleotide identity with HPgV strains from various countries. Evolutionary analyses suggest that HPgV is both endemic and extensively distributed. The direct involvement of HPgV in CNS infections in these patients remains uncertain. [ABSTRACT FROM AUTHOR]

Cryptococcosis in HIV-negative patients can be an opportunistic or endemic disease. There are no published studies on the use of the finger-prick whole blood (point-of-care) cryptococcal antigen lateral flow assay (CrAg LFA) for diagnosing cryptococcosis in HIV-negative patients. We conducted a case series study of HIV-negative patients with cryptococcosis in two centers in São Paulo, Brazil. The objectives were to identify the sensitivity of a finger-prick whole blood CrAg LFA and to describe the main characteristics of this population. We identified 30 HIV-negative patients with cryptococcosis [19 (63%), male; median age, 47 years]. Ten (33%) patients were immunosuppressed, ten (33%) had other comorbidities, and ten (33%) were apparently immunocompetent and without comorbidities. The distribution of the sites of cryptococcosis was as follows: the central nervous system, 90% (n = 27); pulmonary, 43% (n = 13); and other extrapulmonary sites, 40% (n = 12). The sensitivity of the finger-prick whole blood CrAg LFA for the diagnosis of cryptococcosis was 97% (29/30). Among 26 participants with cryptococcal meningitis, the sensitivity of testing cerebrospinal fluid was as follows: CrAg latex agglutination, 77% (20/26); CrAg LFA, 96% (25/26); and culture, 81% (21/26). Culture speciation identified Cryptococcus gattii in 16 (62%) cases, and all had a positive finger-prick whole blood CrAg LFA. This test presented high sensitivity to the diagnosis of cryptococcosis in HIV-negative patients, including those caused by C. gattii. [ABSTRACT FROM AUTHOR]

We report a case of COVID-19-associated meningoencephalitis with a fatal outcome in a male patient with concomitant influenza A, who had been hospitalized at the beginning of 2022, in the Northeastern region of Brazil. He died due to cardiopulmonary arrest after developing status epilepticus on the third day of hospitalization. The SARS-CoV-2 RNA was detected in cerebrospinal fluid and Influenza A was detected in the nasopharyngeal swab. Meningoencephalitis due to COVID-19 is a rare manifestation and physicians must be aware of this complication, mainly during the pandemic. In viral co-circulation situations, the possibility of respiratory coinfections should be remembered. [ABSTRACT FROM AUTHOR]

Yellow fever virus (YFV) is the causative agent of yellow fever (YF), a hemorrhagic and viscerotropic acute disease. Severe YF has been described in approximately 15-25% of YF patients, with 20-50% of severe YF cases being fatal. Here we analyzed cerebrospinal fluid (CSF) samples collected during the YF outbreak in Brazil in 2018, aiming to investigate CNS neuroinvasion in fatal YFV cases. YFV RNA was screened by RT-qPCR targeting the 3'UTR region of the YFV genome in CSF. CSF samples were tested for the presence of anti-YFV IgM and neutralizing antibodies, coupled with routine laboratory examinations. Among the 13 patients studied, we detected anti-YFV IgM in CSF from eight patients and YFV RNA in CSF from five patients. YFV RNA genomic load in CSF samples ranged from 1.75x103 to 5.42x103 RNA copies/mL. We genotyped YFV from three CSF samples that grouped with other YFV samples from the 2018 outbreak in Brazil within the South-American I genotype. Even though descriptions of neurologic manifestations due to wild type YFV (WT-YFV) infection are rare, since the last YF outbreak in Brazil in 2017-2018, a few studies have demonstrated WT-YFV RNA in CSF samples from YF fatal cases. Serological tests indicated the presence of IgM and neutralizing antibodies against YFV in CSF samples from two patients. Although the presence of viral RNA, IgM and neutralizing antibodies in CSF samples could indicate neuroinvasiveness, further studies are needed to better elucidate the role of YFV neuroinvasion and possible impacts in disease pathogenesis. [ABSTRACT FROM AUTHOR]

Severe neurological complications following arbovirus infections have been a major concern in seasonal outbreaks, as reported in the Northeast region of Brazil, where the same mosquito transmitted Zika (ZIKV), Dengue (DENV), and Chikungunya (CHIKV) viruses. In this study, we evaluated the levels of 36 soluble markers, including cytokines, chemokines, growth factors, and soluble HLA-G (Luminex and ELISA) in: i) serum and cerebrospinal fluid (CSF), during the acute phase and two years after the infection (recovery phase, only serum), ii) the relationship among all soluble molecules in serum and CSF, and iii) serum of infected patients without neurological complications, during the acute infection. Ten markers (sHLA-G, IL-10, IL-22, IL-8, MIP-1α, MIP-1β, MCP-1, HGF, VEGF, and IL-1RA) exhibited differential levels between the acute and recovery phases, with pronounced increases in MIP-1α (P <0.0001), MCP-1 (P <0.0001), HGF (P = 0.0001), and VEGF (P <0.0001) in the acute phase. Fourteen molecules (IL-1β, IL-2, IL-3, IL-4, IL-5, IL-6, IL-7, IL-9, IL-13, IL-15, IL-17A, IFN-α, TNF, and G-CSF) exhibited distinct levels between arbovirus patients presenting or not neurological complications. IL-8, EGF, IL-6, and MCP-1 levels were increased in CSF, while RANTES and Eotaxin levels were higher in serum. Soluble serum (IL-22, RANTES, Eotaxin) and CSF (IL-8, EGF, IL-3) mediators may discriminate putative risks for neurological complications following arbovirus infections. Neurological complications were associated with the presence of a predominant inflammatory profile, whereas in non-complicated patients an anti-inflammatory profile may predominate. Mediators associated with neuroregeneration (EGF and IL-3) may be induced in response to neurological damage. Broad spectrum immune checkpoint molecules (sHLA-G) interact with cytokines, chemokines, and growth factors. The identification of soluble markers may be useful to monitor neurological complications and may aid in the development of novel therapies against neuroinflammation. [ABSTRACT FROM AUTHOR]

Zika virus (ZIKV) has been detected in blood, urine, semen, cerebral spinal fluid, saliva, amniotic fluid, and breast milk. In most ZIKV infected individuals, the virus is detected in the blood to one week after the onset of symptoms and has been found to persist longer in urine and semen. To better understand virus dynamics, a prospective cohort study was conducted in Brazil to assess the presence and duration of ZIKV and related markers (viral RNA, antibodies, T cell response, and innate immunity) in blood, semen, saliva, urine, vaginal secretions/menstrual blood, rectal swab and sweat. The objective of the current manuscript is to describe the cohort, including an overview of the collected data and a description of the baseline characteristics of the participants. Men and women ≥ 18 years with acute illness and their symptomatic and asymptomatic household contacts with positive reverse transcriptase-polymerase chain reaction test for ZIKV in blood and/or urine were included. All participants were followed up for 12 months. From July 2017 to June 2019, a total of 786 participants (284 men, 502 women) were screened. Of these, 260 (33.1%) were enrolled in the study; index cases: 64 men (24.6%), 162 (62.3%) women; household contacts: 12 men (4.6%), 22 (8.5%) women. There was a statistically significant difference in age and sex between enrolled and not enrolled participants (p<0.005). Baseline sociodemographic and medical data were collected at enrollment from all participants. The median and interquartile range (IQR) age was 35 (IQR; 25.3, 43) for men and 36.5 years (IQR; 28, 47) for women. Following rash, which was one of the inclusion criteria for index cases, the most reported symptoms in the enrollment visit since the onset of the disease were fever, itching, arthralgia with or without edema, non-purulent conjunctivitis, headache, and myalgia. Ten hospitalizations were reported by eight patients (two patients were hospitalized twice) during follow up, after a median of 108 days following symptom onset (range 7 to 266 days) and with a median of 1.5 days (range 1 to 20 days) of hospital stay. A total of 4,137 visits were performed, 223 (85.8%) participants have attended all visits and 37 (14.2%) patients were discontinued. [ABSTRACT FROM AUTHOR]

Human enteroviruses (EV) are the most common cause of aseptic meningitis worldwide. Data on EV viral load in cerebrospinal fluid (CSF) and related epidemiological studies are scarce in Brazil. This study investigated the influence of EV viral load on CSF parameters, as well as identifying the involved species. CSF samples were collected in 2018-2019 from 140 individuals at The Hospital das Clínicas, São Paulo. The EV viral load was determined using real-time quantitative polymerase chain reaction, while EV species were identified by 5'UTR region sequencing. Median viral load was 5.72 log 10  copies/mL and did not differ by subjects' age and EV species. Pleocytosis was observed in 94.3% of cases, with the highest white blood cell (WBC) counts in younger individuals. Viral load and WBC count were correlated in children (p = 0.0172). Elevated lactate levels were observed in 60% of cases and correlated with the viral load in preteen-teenagers (p = 0.0120) and adults (p = 0.0184). Most individuals had normal total protein levels (70.7%), with higher in preteen-teenagers and adults (p < 0.0001). By sequencing, 8.2% were identified as EV species A and 91.8% as species B. Age-specific variations in CSF characteristics suggest distinct inflammatory responses in each group., (© 2024 Wiley Periodicals LLC.)

Cerebral toxoplasmosis is the most common cause of focal brain lesion in people living with HIV (PLWH) and usually causes multifocal encephalitis with little or no meningeal involvement. Classically, only subtle cerebrospinal fluid (CSF) abnormalities are described. There are no prior case reports in the literature on eosinophilic meningitis associated with cerebral toxoplasmosis in PLWH. We report on an HIV-positive man from Brazil who presented to the emergency department with headache, nausea, vomiting, and hemiparesis. He had a T-CD4+ lymphocyte count of 145 cells/mm3, and antiretroviral failure was identified. Brain computed tomography showed a contrast-enhancing lesion with mild mass effect and trimethoprim–sulfamethoxazole and dexamethasone were started. Examination of CSF showed 194 cells/mm3 (74% eosinophils, 18% lymphocytes, 4% monocytes, and 2% neutrophils), protein = 83 mg/dL, and glucose = 49 mg/dL. Detection of Toxoplasma gondii on CSF by polymerase chain reaction confirmed the diagnosis of cerebral toxoplasmosis. An exhaustive laboratorial investigation excluded other possible etiologies. After 14 days, the patient showed complete resolution of neurological and CSF alterations and substantial improvement in the brain lesion and was discharged home. We suggest that eosinophilic meningitis should be included in the spectrum of manifestations of HIV-related cerebral toxoplasmosis, especially in countries with high prevalence of toxoplasmosis in the general population. [ABSTRACT FROM AUTHOR]

Background and Aims: Syphilis and stroke are high prevalent diseases in south Brazil and estimates of concomitance and possible role of syphilis in acute stroke are lacking. Our aims are to estimate the prevalence of syphilis and neurosyphilis (NS) in a cohort of tertiary stroke center. Methods: We reviewed all hospital records of stroke/transitory ischemic attack (TIA) using International Classification of Diseases, 10th revision, at discharge, frequency of syphilis screen, serology positivity, cerebrospinal fluid (CSF) analysis, and prevalence of NS in this stroke population applying CDC criteria. Results: Between 2015 and 2016, there were 1,436 discharges for cerebrovascular events and in 78% (1,119) of these cases, some syphilis screening was performed. We have found a frequency of positive serology for syphilis of 13% (143/1,119), and higher stroke severity was the main determinant for non-screening. Applying standard NS criteria, 4.7% (53/1,119) cases with CSF analysis had NS diagnosis: 8 based on CSF-Venereal Disease Research Laboratory (VDRL) positive and 45 based on abnormal CSF white cells or protein, but CSF VDRL negative. NS VDRL positive cases were younger, had higher serum VDRL title, had more frequent HIV infection, and received NS treatment more often. Demographic and clinical characteristics were not different between NS VDRL negative and non-NS cases. Conclusion: Positive syphilis serology is frequent in patients with acute stroke/TIA in our region. Acute post-stroke CSF abnormalities make the diagnosis of NS difficult in the context of CSF VDRL negative. [ABSTRACT FROM AUTHOR]

Zika virus (ZIKV) is a mosquito-transmitted flavivirus that caused a public health emergency in the Americas when an outbreak in Brazil became linked to congenital microcephaly. Understanding how ZIKV could evade the innate immune defenses of the mother, placenta, and fetus has become central to determining how the virus can traffic into the fetal brain. ZIKV, like other flaviviruses, evades host innate immune responses by leveraging viral proteins and other processes that occur during viral replication to allow spread to the placenta. Within the placenta, there are diverse cell types with coreceptors for ZIKV entry, creating an opportunity for the virus to establish a reservoir for replication and infect the fetus. The fetal brain is vulnerable to ZIKV, particularly during the first trimester, when it is beginning a dynamic process, to form highly complex and specialized regions orchestrated by neuroprogenitor cells. In this review, we provide a conceptual framework to understand the different routes for viral trafficking into the fetal brain and the eye, which are most likely to occur early and later in pregnancy. Based on the injury profile in human and nonhuman primates, ZIKV entry into the fetal brain likely occurs across both the blood/cerebrospinal fluid barrier in the choroid plexus and the blood/brain barrier. ZIKV can also enter the eye by trafficking across the blood/retinal barrier. Ultimately, the efficient escape of innate immune defenses by ZIKV is a key factor leading to viral infection. However, the host immune response against ZIKV can lead to injury and perturbations in developmental programs that drive cellular division, migration, and brain growth. The combined effect of innate immune evasion to facilitate viral propagation and the maternal/placental/fetal immune response to control the infection will determine the extent to which ZIKV can injure the fetal brain. [ABSTRACT FROM AUTHOR]

Introduction: Hydrocephalus is a common complication among neurological patients whose treatment in acute cases is done through an external ventricular drain catheter which allows monitoring and controlling intracranial hypertension. This study aimed at describing the knowledge retention by nurses after an educational intervention on nursing care for an external ventricular drain. Materials and Methods: A quasi-experimental study with nurses at an adult intensive care unit was conducted in which knowledge retention on the topic was evaluated at different three times: before, one week and three months after training. Results: After one week, significant retention was observed but not after three months, given that after this period the question success rate was significantly low with respect to the previous phases. Participants' performance was better in those questions related to system management. Discussion: Time is a factor that interferes with learning since studies show that knowledge at three months significantly decreases and is almost completely gone after six months and a year. Practical behaviors based on assistance guidelines have better retention among professionals, underlining that it is easier to learn technical skills that are associated with professional experience. Conclusions: A significant knowledge retention was observed among professionals in the first week after training but not after three months. [ABSTRACT FROM AUTHOR]

Purpose: Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an immune-mediated disease of the central nervous system (CNS). The aim of this study was to describe the variability of clinical presentation in anti-NMDAR encephalitis, treatment and outcomes in a case series of children and adolescents.Methods: Retrospectively analyse patients diagnosed with anti-NMDAR encephalitis, from 2010 to 2018.Results: The study population consisted of nine children with anti-NMDAR encephalitis from southern Brazil, six females and three males, aged 5 months to 16 years (mean 5 years). The time of follow-up varied between 1 and 7 years, with a mean of 3 years. The most frequent first manifestation consisted of seizures. All patients described had psychiatric symptoms and a wide spectrum of neurologic findings. Five patients had unilateral symptoms. Magnetic resonance imaging and electroencephalogram were normal in most patients. Cerebrospinal fluid pleocytosis occurred in five patients. All patients were administered immunoglobulin and/or steroids. Seven patients (78%) required cyclophosphamide and/or rituximab. Almost half of the patients fully recovered from all symptoms.Conclusions: A wide variety of symptoms were observed in this study and, although unilateral symptoms are rarely reported in the literature, a high frequency was observed among Brazilian children. Alternatives to first-line therapy should be considered in patients with clinical suspicion, even if they have not had a good response with first-line therapy. [ABSTRACT FROM AUTHOR]

While studying aseptic meningitis in Salvador, Brazil, we diagnosed anicteric leptospirosis in 1.7% (5/295) of patients hospitalized for aseptic meningitis. Leptospirosis-associated meningitis patients had lower mean cerebrospinal fluid cell counts and protein than other-cause aseptic meningitis (p<0.05). Clinicians must consider leptospirosis-associated meningitis in appropriate clinical-epidemiologic contexts. [ABSTRACT FROM AUTHOR]

Background: HTLV-1 infection is endemic in Brazil. About 1 to 2% of the Brazilian population is estimated to be infected, but most infected HTLV-1 individuals do not know about their own infection, which favors the continuity of sexual and vertical virus transmission. In addition, HTLV-1 associated central nervous system diseases and their pathophysiologic mechanisms are not fully understood. This study aimed to evaluate the correlation of spinal cord metabolism, viral and inflammatory profiles with features of neurological presentation in HTLV-1 infected individuals. Methodology: This is a cross-sectional study of a cohort including 48 HTLV-1 infected individuals clinically classified as asymptomatic-AG (N = 21), symptomatic-SG (N = 11) and HAM/TSP-HG (N = 16) and a nested case-control study with HTLV-1 infected individuals-HIG (N = 48) and HTLV-1 non infected controls-CG (N = 30) that had their spinal cord analysed by Positron Emission Tomography with 18F-Fluordeoxyglucose (18F-FDG PET/CT). HTLV-1 infected individuals had 18F-FDG PET/CT results analyzed with clinical and demographic data, proviral load, cytokines and chemokines in the blood and cerebrospinal fluid (CSF). Principal Findings: 18F-FDG PET/CT showed hypometabolism in the thoracic spinal cord in HTLV-1 infected individuals. The method had an accuracy of 94.4% to identify HAM/TSP. A greater involvement of the thoracic spinal cord was observed, although hypometabolism was also observed in the cervical spinal cord segment in HTLV-1 infected individuals. Individuals with HAM/TSP showed a pro-inflammatory profile in comparison to asymptomatic and symptomatic groups, with a higher level of Interferon-inducible T-cell alpha chemoattractant (ITAC/CXCL11), IL-6, IL-12p70 in the plasma; and ITAC, IL-4, IL-5, IL-8 (CXCL8) and TNF-alpha in the CSF. Using regression, thoracic spinal cord SUV (standardized uptake value) and CSF ITAC level were identified as the HAM/TSP predictors in the multivariate model. Conclusions: 18F-FDG PET/CT imaging showed spinal cord hypometabolism in most HTLV-1 infected individuals, even in the asymptomatic HTLV-1 group. Thoracic spinal cord hypometabolism and CSF-ITAC levels were identified predictors of HAM/TSP. Significance: Our findings suggested that in most HTLV-1 infected individuals there was compromise of central nervous system (CNS) structures despite of the lack of clinical symptoms. To explain the found hypometabolism, the role of microcirculatory and metabolic factors in the pathogenesis of neurological diseases associated with HTLV-1 infection must be further investigated. It is paramount to evaluate the central nervous function and to compare the performance among HTLV-1 infected individuals considered asymptomatic to the uninfected controls. [ABSTRACT FROM AUTHOR]

Background: During 2015–16 Brazil experienced the largest epidemic of Zika virus ever reported. This arthropod-borne virus (arbovirus) has been linked to Guillain-Barré syndrome (GBS) in adults but other neurological associations are uncertain. Chikungunya virus has caused outbreaks in Brazil since 2014 but associated neurological disease has rarely been reported here. We investigated adults with acute neurological disorders for Zika, chikungunya and dengue, another arbovirus circulating in Brazil. Methods: We studied adults who had developed a new neurological condition following suspected Zika virus infection between 1st November 2015 and 1st June 2016. Cerebrospinal fluid (CSF), serum, and urine were tested for evidence of Zika, chikungunya, and dengue viruses. Results: Of 35 patients studied, 22 had evidence of recent arboviral infection. Twelve had positive PCR or IgM for Zika, five of whom also had evidence for chikungunya, three for dengue, and one for all three viruses. Five of them presented with GBS; seven had presentations other than GBS, including meningoencephalitis, myelitis, radiculitis or combinations of these syndromes. Additionally, ten patients positive for chikungunya virus, two of whom also had evidence for dengue virus, presented with a similar range of neurological conditions. Conclusions: Zika virus is associated with a wide range of neurological manifestations, including central nervous system disease. Chikungunya virus appears to have an equally important association with neurological disease in Brazil, and many patients had dual infection. To understand fully the burden of Zika we must look beyond GBS, and also investigate for other co-circulating arboviruses, particularly chikungunya. [ABSTRACT FROM AUTHOR]

Information regarding resistance and virulence traits of meningitis-causing enterobacteria in hospital environment remains scarce. The aim of this study was to characterize virulence and acquired resistance genes of carbapenem-resistant and/or 3rd to 4th generation cephalosporin-resistant Klebsiella pneumoniae isolated from the cerebrospinal fluid of inpatients. Antimicrobial susceptibility testing was performed by disk diffusion. The string test was performed to identify hypermucoviscous phenotype. Galleria mellonella infection model was used to evaluate the virulence profile of the isolates. Screening for virulence determinants and acquired resistance genes were performed by PCR. The bla CTX-M and/or bla KPC and/or rmtG were detected in all the isolates. Genetic virulence determinants, including mrkD, entB, iroD, fecIRA, uge, wabG, fimH, ureA, ybtS, and clb were detected in the majority of multidrug-resistant K. pneumoniae isolates. One isolate presented hypermucoviscous phenotype, and several isolates showed enhanced virulence in G. mellonella infection model. The combination of the virulence genes found here seems to support not only the known virulence genetic context among nosocomial infections-causing K. pneumoniae but also the role that clb and ybtS may play in K. pneumoniae virulence. [ABSTRACT FROM AUTHOR]

Background: Although serogroup 20 is not part of any conjugate pneumococcal vaccine, its serotype 20A, but not 20B, belongs to the polysaccharide 23-valent formula. Little is known about its clinical, laboratorial and epidemiological characteristics.Methods: The purpose of this study was to evaluate the bacterial genotypes (by PFGE and MLST), clinical characteristics of patients (from review of medical records) and antimicrobial susceptibility of serogroup 20 isolates which were recovered from patients with invasive pneumococcal disease (IPD) from 2007 to 2012. Subtyping to determine 20A and 20B types was also performed by sequencing the genes of the cps locus.Results: Sixteen isolates were genotyped and were highly related. All pneumococci were resistant to tetracycline and 31 % were non-susceptible to trimethoprim/sulfamethoxazole. Penicillin MIC ranged from 0.004 to 1 μg/mL and non-susceptibility (MIC ≥ 0.12 μg/mL) was observed in 5/16 isolates (31 %). All isolates belonged to subtype 20B. Most patients were male with a median age of 62 years and presented at least one underlying disease (mostly respiratory conditions). All isolates belonged to ST8889 and to a unique PFGE clone.Conclusions: A high clonal occurrence of serotype 20B pneumococci recovered from patients with IPD in Brazil was observed. As a non-PCV10 serotype, selective pressure may be responsible for this unusual occurrence of serogroup 20. However, temporal variation effect should not be underestimated; therefore it is an issue that warrants continued monitoring. [ABSTRACT FROM AUTHOR]

Objective: Our objective was to describe and compare the occurrence of neurological outcomes and neurosyphilis in people living with HIV with incident syphilis and no neurological symptoms who underwent early screening for asymptomatic neurosyphilis (ANS) or regular clinical management without a lumbar puncture., Methods: This was a retrospective cohort study in a single referral centre of Sao Paulo, Brazil. Patients with incident syphilis diagnosed between January 2000 and August 2016 and meeting the adapted criteria for ANS investigation suggested by Marra et al. (CD4 + T-cell counts ≤350 cells/mm³ and/or venereal disease research laboratory test results ≥1:16) were identified. Those with no neurological symptoms and immediately referred for lumbar puncture were categorized as group 1, and those not referred for cerebrospinal fluid collection were categorized as group 2. We compared the occurrence of neurological symptoms and neurosyphilis diagnoses between the groups using incidence rates and Kaplan-Meier curves., Results: We included 425 participants with a median follow-up of 6 years. The incidence rate of neurological symptoms was 36.5/1000 person-years in group 1 and 40.6/1000 person-years in group 2 (incidence rate ratio [IRR] 0.90; 95% confidence interval [CI] 0.57-1.39; p = 0.62). The incidence rate of neurosyphilis was 15.0 cases/1000 person-years in group 1 and 6.7 cases/1000 person-years in group 2 (IRR 2.26; 95% CI 0.93-5.68; p = 0.05)., Conclusions: We found no statistically significant differences between groups in the incidence rates of neurological symptoms and neurosyphilis. Our findings support the current guidelines, which suggest a less invasive approach regarding ANS investigation among people living with HIV with incident syphilis., (© 2022 British HIV Association.)

• Arboviruses are considered the third most common cause of viral neurological infections in brazil. • CHIKV, DENV and OROV are an important etiology for neurological infections in midwestern brazil. • Two mutations in CHIKV-ECSA genomes from the state of mato grosso were identified in 2019: nsP2:T31I and nsP3: A388V. • ECSA genotype of CHIKV is one of the most important arbovirus for public health in brazil. • Genome sequencing lead to the identification of microorganisms that may cause neurological infections. Neurological viral infection is frequently associated to enterovirus, herpesvirus and arboviruses. These infections may cause severe clinical outcomes, long lasting sequelae or death. Few studies have addressed viral neurological infections etiology in Brazil. Identification of viruses in the cerebral spinal fluid (CSF) of human neurological infections suspected of viral etiology during January and May 2019 in Midwestern Brazil. Clinical, laboratory and epidemiological information was gathered from medical records. In addition, an aliquot of the sampled CSF was subjected to viral RNA/DNA extraction, randomic dscDNA amplification by PCR, DNA purification and Ilumina HiSeq 2500 sequencing. Six viral genomes belonging to Chikungunya virus (CHIKV) East-Central-South African (ECSA) genotype (10.834–11.804 nt in length) confirmed lately by RT-PCR for CHIKV envelope were present in all six liquor samples. These genomes present two mutations, nsP2:T31I and nsP3:A388V, shared with other Mato Grosso State strains from 2019, not present in sequences of the virus from previous years obtained in the State. One case was a triple co-infection also confirmed through RT-PCR, with Dengue virus serotype 4 genotype II (NS5; 874 nt) and Oropouche virus genotype IA (segment S; 302 nt). CSF was clear and colorless (5/6 patients), with >10% of lymphomononuclear cells (6/6), 1–99 erythrocytes/mm3 (5/6), glucose levels >50 mg/dl (4/5) e > 10 mg/dl of proteins (4/4). One patient evolved to death, and another, a newborn, presented sequelae after recovery. Despite herpesviruses and enteroviruses are frequent etiologies of neurological infections, the casuistic here reported was associated to arboviruses already known to be responsible for acute febrile illness outbreaks in the state of Mato Grosso, Midwestern Brazil. [Display omitted] [ABSTRACT FROM AUTHOR]

SUMMARY Aims Depression is a highly prevalent disorder in the elderly and one of the risk factors for developing dementia. The present study involves patients with Alzheimer's disease (AD), geriatric major depressive disorder (MDD) and cognitively healthy controls aiming to compare baseline cerebrospinal fluid (CSF) biomarkers. Methods The study included 52 patients with more than 60 years of age with a diagnosis of MDD, AD, and healthy controls. All individuals underwent a medical history, physical, and neurologic examination, laboratory tests and neuropsychological assessment to rule out any clinical diseases or disorders. Measurement of CSF P-tau181, T-tau, and Aβ42 was performed using commercial assays (ELISA). Results CSF Aβ42 levels of depressed patients and normal controls were significantly higher than in AD. There was not any significant difference in measures of P-tau among the groups. T-tau, however, showed to be significantly different among the groups, with higher measures in AD group. Higher levels of P-tau were observed in four MDD patients compared with controls. Conclusion CSF Aβ42, T-tau, and P-tau levels may differentiate between AD and depression in a Brazilian sample. [ABSTRACT FROM AUTHOR]

Abstract: Following routine childhood vaccination against Haemophilus influenzae type b (Hib) disease in Brazil in 1999, passive laboratory surveillance reported increasing numbers of non-b serotypes and nontypeable H. influenzae (NTHi) from meningitis cases. To characterize this increase, we analyzed data on 3910 H. influenzae isolated from cerebrospinal fluid or blood from meningitis cases that were sent to the national reference laboratory for serotyping from 1990 to 2008. Hib accounted for 98% of H. influenzae meningitis isolates received during 1990–1999 versus 59% during 2000–2008, while non-b serotypes increased from 1% to 19% and NTHi increased from 2% to 22% of H. influenzae isolates received during the two periods. Higher proportions of non-b serotypes and NTHi than Hib were isolated from blood rather than cerebrospinal fluid. Estimated incidence rates for H. influenzae meningitis for Sao Paulo state remained below 1 case per million population during 2000–2008, although annual incidence of NTHi meningitis (mean, 0.03 cases per 100,000 population) increased in several age groups. Changes in surveillance for H. influenzae following introduction of Hib conjugate vaccine likely contributed to increased numbers of non-b and nontypeable H. influenzae meningitis isolates received at the national reference laboratory. [Copyright &y& Elsevier]

Abstract: This study investigated the genetic characteristics of Toxoplasma gondii samples collected from 62 patients with toxoplasmosis in Sao Paulo State, Brazil. DNA samples were isolated from blood, cerebrospinal fluid and amniotic fluids of 25 patients with cerebral toxoplasmosis and AIDS, two patients with acute toxoplasmosis, 12 patients with ocular toxoplasmosis, six newborns with congenital toxoplasmosis and 17 pregnant women with acute infection. Diagnosis of toxoplasmosis was based in clinical, radiological and laboratory features. Genotyping was performed using multilocus PCR–RFLP genetic markers including SAG1, SAG2, 5′- and 3′-SAG2, alt.SAG2, SAG3, BTUB, GRA6, C22-8, c29-2, L358, PK1 and Apico. Among the 62 clinical samples, 20 (32%) were successfully genotyped at eight or more genetic loci and were grouped to three distinct genotypes. Eighteen samples belonged to ToxoDB Genotype #65 and the other two samples were identified as ToxoDB Genotypes #6 and #71, respectively ( http://toxodb.org/toxo/). Patients presenting Genotypes #6 and #71 had severe and atypical cerebral toxoplasmosis, characterized by diffuse encephalitis without extensive brain lesions. These results indicate that T. gondii Genotype #65 may have a high frequency in causing human toxoplasmosis in Sao Paulo State, Brazil. This unusual finding highlights the need to investigate the possible association of parasite genotypes with human toxoplasmosis. [Copyright &y& Elsevier]

Neurocysticercosis (NCC) is a common central nervous system (CNS) infection caused by Taenia solium metacestodes. Depression is present in 53-85% of the NCC patients. The present study was aimed to evaluate the correlation of signs of NCC activity (evolution phase of NCC cysts and CSF characteristics) with depression. The study group consisted of 65 patients subdivided into two groups: NCC with epilepsy (48) and NCC without epilepsy []. Depression was assessed and quantified by the Hamilton Rating Scale for Depression (HRSD-21) and compared with CSF inflammatory characteristics (increase of WBCs and total protein) and presence of calcifications or cysts. There was no difference between the scores of depression in the group with CNS calcifications or cysts. CSF signs of active disease, specifically increase of CSF TP, were significantly more frequent in patients with mild depression and in non-depressant patients. The depression scores were inversely proportional to the CSF TP levels in the groups with depression. Although immunological factors could be associated with the development of depression, the data above lead us to make assumptions about the association of other factors such as genetic predisposition, or social and cultural factors. [ABSTRACT FROM AUTHOR]

Real-time (RT)-PCR increases diagnostic yield for bacterial meningitis and is ideal for incorporation into routine surveillance in a developing country. We validated a multiplex RT-PCR assay for Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae in Brazil. Risk factors for being culture-negative, RT-PCR positive were determined. The sensitivity of RT-PCR in cerebrospinal fluid (CSF) was 100% (95% confidence limits, 96.0%-100%) for N. meningitidis, 97.8% (85.5%-99.9%) for S. pneumoniae, and 66.7% (9.4%-99.2%) for H. influenzae. Specificity ranged from 98.9% to 100%. Addition of RT-PCR to routine microbiologic methods increased the yield for detection of S. pneumoniae, N. meningitidis, and H. influenzae cases by 52%, 85%, and 20%, respectively. The main risk factor for being culture negative and RT-PCR positive was presence of antibiotic in CSF (odds ratio 12.2, 95% CI 5.9-25.0). RT-PCR using CSF was highly sensitive and specific and substantially added to measures of meningitis disease burden when incorporated into routine public health surveillance in Brazil. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To evaluate the etiology of viral meningitis and encephalitis in adults and adolescents living in areas affected by dengue. Methods: Over two years, adults and adolescents with diagnoses of viral encephalitis or meningitis were selected for study in Brazil. PCRs for dengue, enterovirus, HSV1 and 2 and cytomegalovirus were performed in CSF samples. Serum and CSF samples were tested for the presence of anti-dengue IgM antibodies. Results: The etiologies of encephalitis and meningitis were determined in 70% of cases (30/47). Dengue was the leading cause of encephalitis (47%) with normal CSF cellularity in 75% of these patients. HSV1 was found in 17.6% of the cases, two of which had mild encephalitis. Enterovirus was the most common cause of meningitis (50%), followed by HSV1 (15%), cytomegalovirus and dengue (10%, each). Conclusions: We identified the viral agents causing encephalitis and meningitis in a higher proportion of cases than has been reported in other studies. Dengue was the most frequent cause of encephalitis, which surpassed HSV. In endemic areas, dengue should be investigated as an important cause of encephalitis. Normal CSF cellularity should not exclude dengue encephalitis. Enterovirus is known to be the leading cause of meningitis in children, but here we found it was also the main cause of the disease in adults. HSV1 should be investigated in patients with mild forms of encephalitis and meningitis. [Copyright &y& Elsevier]

Neurological disorders caused by Cytomegalovirus (CMV) in patients with Acquired Immunodeficiency Syndrome (AIDS) are rarely reported in the Highly Active Antiretroviral Therapy (HAART) period. The objective of this study was to describe the main clinical and laboratory features of patients with CMV-related neurological complications in HIV-infected patients admitted to a referral center in São Paulo, Brazil. CMV disease requires the identification of the virus in the cerebrospinal fluid (CSF) using Polymerase Chain Reaction (PCR). Thirteen cases were identified between January, 2004 and December, 2008. The median age of patients was 38 years and nine (69%) were men. At admission all patients were aware of their HIV status and only four (31%) patients were on HAART. Patients who were not on antiretroviral therapy before admission received HAART while inpatients. CMV disease was the first AIDS-defining illness in eight (62%) patients. The neurologic syndromes identified were diffuse encephalitis (n = 7; 62%), polyradiculopathy (n = 7; 54%), focal encephalitis (rhombencephalitis) (n = 1; 8%), and ventriculo-encephalitis (n = 1; 8%). Seven (54%) patients presented extra-neural CMV disease and four (31%) had retinitis. The median of CD4+ T-cell count was 13 cells/µL (range: 1-124 cells/µL). Overall in-hospital mortality was 38%. Eight patients used ganciclovir or foscarnet (in-hospital mortality: 50%) and five patients used ganciclovir and foscarnet (in-hospital mortality: 20%). None of the patients fulfilled the diagnosis criteria of immune reconstitution inflammatory syndrome. Four patients were lost to follow-up, and three patients presented immune recovery and discontinued secondary prophylaxis. Although infrequent, distinct neurological syndromes caused by CMV continue to cause high mortality among AIDS patients. Survival depends upon the use of effective antiviral therapy against CMV and the early introduction of HAART. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate the epidemiological, clinical and laboratorial profile of patients with Baggio-Yoshinari Syndrome (BYS), who underwent internment at the Instituto de Infectologia Emilio Ribas in São Paulo, Brazil, during the period from July 1990 to July 2006. BYS is a new Brazilian tick-borne disease caused by Borrelia burgdorferi sensu lato microorganisms that resembles features of Lyme disease (LD), except for its epidemiological, clinical and laboratorial particularities. From 60 patients' records with positive serology to B. burgdorferi done by ELISA and Western-blotting methods, 19 cases were diagnosed as having BYS, according to criteria adopted at LIM-17 HCFMUSP, the Brazilian Reference Laboratory for the research of BYS. The other 41 remaining patients displayed miscellaneous infections or auto-immune processes. The beginning of symptoms in BYS group varied from one day to six years, from the onset of the disease. Four of 19 patients were included in acute disease stage, and 15 in latent. General unspecific symptoms were identified in almost all cases, with high frequencies of fever (78.9%) and lymphadenomegaly (36.8%). Six patients had skin lesions (31.5%); six arthralgia or arthritis (31.5%) and eight neurological symptoms (42%). Interestingly, two patients showed antibodies directed to B. burgdorferi exclusively in cerebrospinal fluid. Since BYS is a new emergent Brazilian zoonosis and its diagnosis is sometimes complex, all the new knowledge about BYS must be scattered to Brazilian Medical specialists, aiming to teach them how to diagnose this amazing tick-borne disease and to avoid its progression to chronic irreversible sequels. [ABSTRACT FROM AUTHOR]

Summary: Cerebral toxoplasmosis among individuals with AIDS may be difficult to diagnose and needs to be differentiated from other neurological diseases. A validation study was performed on real-time PCR for detecting the B1 gene of Toxoplasma gondii in the blood and cerebrospinal fluid (CSF) of AIDS patients with cerebral toxoplasmosis. The study included 135 AIDS patients divided into two groups: Group I comprised 85 patients with neurotoxoplasmosis; and Group II comprised 50 patients with non-toxoplasmic neurological diseases. Real-time PCR on blood showed a sensitivity of 1.5%, specificity of 100.0%, positive predictive value (PPV) of 100.0% and negative predictive value (NPV) of 36.5%. CSF testing produced better results, with a sensitivity of 35.3%, specificity of 100.0%, PPV of 100.0% and NPV of 44.7%. The group presenting with pleocytosis and four or more encephalic lesions was associated with greater CSF positivity on PCR. In conclusion, real-time PCR on blood was not useful for diagnosis. CSF testing showed low sensitivity but high specificity. Greater numbers of lesions and greater CSF cellularity may improve the sensitivity of the method. [Copyright &y& Elsevier]

Background: Cerebrospinal fluid (CSF) leak of the anterior skull base is an abnormal communication between the subarachnoid space and the nasal cavity or the paranasal sinus. Its presence increases the incidence of complications, as meningitis, with risk of sequelae. The early and correct diagnosis of the CSF leaks is important to perform surgical treatment as soon as possible. The CSF detection in nasal fluids could be made through the beta2-transferrin (beta2Tr) immunoelectrophoretic test, an expensive and cumbersome immunologic test, not available to the majority of the Brazilian hospitals. Recently, the detection of beta-trace protein (betaTP) for identification of CSF leaks has been described. The literature suggests there may be similar sensitivity and specificity to tests of beta2Tr, because betaTP is also a specific brain protein and it is present in CSF in high concentrations. The majority of Brazilian hospitals have the nephelometric equipment for betaTP detection. This study was designed to determine threshold values for betaTP concentrations in nasal cavity secretions as a predictor of CFS leak. Methods: Nasal secretions were collected from patients with suspicion of CSF leak and from healthy volunteers. Pure CSF samples were used. A nephelometric assay was used to determine the betaTP concentration in samples. Results: Values between 0.244 and 0.496 mg/L were determined for the cutoff. Conclusion: Beta-trace concentrations above 0.496 mg/L are highly suggestive of the presence of CSF in examined nasal secretion. Positive predictive value and negative predictive value were 100%. BetaTP nephelometric test can predict the side of the CSF leak. [ABSTRACT FROM AUTHOR]

The article aims to describe clinical and laboratory features of human immunodeficiency infection (HIV)-infected patients with neurosyphilis in tertiary referral center in Sao Paulo, Brazil. The authors employ a retrospective study of 27 consecutive cases of HIV-infected patients with a positive venereal diseases research laboratory (VDRL) in cerebrospinal fluid (CSF). Discussion on the results of the study is provided. Moreover, the study concludes that most patients had early and asymptomatic neurosyphilis, and more than one third had early syphilis.

Summary: Objective: To evaluate the presence of JC virus DNA in CSF samples from Brazilian AIDS patients with focal lesions of CNS white matter without mass effect compatible with progressive multifocal leukoencephalopathy (PML). Methods: CSF samples from AIDS patients with neurological symptoms and a CT scan showing focal lesions of CNS white matter without mass effect suggestive of PML, and from AIDS and non-AIDS patients with non-PML neurological diseases were tested for JC virus DNA by PCR. The primers used to amplify the T antigen region of the JC virus resulted in a 173-bp fragment. The presence of the JC virus was confirmed by digestion of the PCR product using BamH1. Results: The PCR for JCV DNA was negative in 119/120 non-PML CSF samples (specificity =99.2%). Of 56 CSF samples from AIDS patients with focal lesions of CNS white matter without mass effect, JCV DNA was positive in 48.2% (27/56). In 23/29 (79.3%) JCV DNA-negative cases, other causes for the encephalitic lesions were found. No JCV DNA-positive cases showed other diagnoses. Conclusions: The prevalence of JCV DNA by PCR in CSF samples from Brazilian AIDS patients with focal brain lesions, without mass effect was 48.2%. In these patients, a negative JCV PCR is highly suggestive of other neurological conditions. [Copyright &y& Elsevier]

Four patients with leukoencephalopathy with vanishing white matter from three unrelated Brazilian families are reported. In all cases the initial symptoms occurred in the three first years of life. In three cases the onset was acute and at least in two patients the involvement of the white matter preceded the clinical symptoms. Only cerebellar and pyramidal signs were present and persisted throughout the evolution. An episodic course with worsening of the symptoms during febrile illnesses was noted in one patient. In three patients a significant deceleration of the head growth was noted. In one family, brother and sister were affected but the twin brother of the boy was free from the disease. In another family, the patient had a sister who died at 13 years of age from an identical disease not diagnosed at that time. In one family, the parents were first cousins. In all patients, serial magnetic resonance imaging and magnetic resonance spectroscopy showed the characteristic picture of the involvement of the white matter with increasing signal intensity close to that of the cerebrospinal fluid. [Copyright &y& Elsevier]

The article discusses a study that investigated the prevalence of dengue neurologic cases in patients with suspected viral meningitis/meningoencephalitis in a dengue-endemic area in Brazil's Ceará State. The observation of clinical signs that involve the central nervous system in dengue patients is considered. Cerebrospinal fluid was analyzed, showing positive results and a greater likelihood of identifying positive fluid in patients who died. The study's results reinforce the idea of testing patients with neurologic manifestations for dengue virus in dengue-endemic areas.

Ilheus virus is an arbovirus with the potential for central nervous system involvement. Accurate diagnosis is a challenge due to similar clinical symptoms and serologic cross-reactivity with other flaviviruses. Here, we describe the first documented case of a fatal outcome following the identification of Ilheus virus in the cerebrospinal fluid (CSF) of a patient with cerebral encephalitis in Brazil. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the use of cerebrospinal fluid (CSF) ferritin levels in the diagnosis of purulent meningitis (PM)., Method: We studied 81 children between 28 days and 12 years of age who presented with clinical suspicion of meningitis to the emergency department. CSF ferritin levels were measured and compared between diagnostic groups (PM, aseptic meningitis (AM) and no meningitis)., Results: The median age was 24 (IQR 8-69) months. There were 32 patients with AM (39%), 23 with PM (28%) and 26 with no meningitis (32%). Median CSF ferritin was 4.2 ng/mL (IQR 3.0-6.5), 52.9 ng/mL (IQR 30.7-103 ng/mL) and 2.4 ng/mL (IQR 2-4), respectively. CSF ferritin was higher in children with PM compared with AM (p<0.001) or no meningitis (p<0.001). There was no difference between AM and no meningitis., Conclusion: CSF ferritin may be a useful biomarker to discriminate PM in children with clinical symptoms of this disease., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Flaviviruses are agents of a major emerging human public health issue and members of this genus have been associated with central nervous system (CNS) infections. In Brazil, a country endemic for some arboviruses, the most clinically relevant neurotropic flaviviruses include Dengue virus and Zika virus. Flaviviruses cause diseases ranging from mild or sub-clinical infections to severe cases as CNS infections. There is a lack of data about the incidence of flaviviruses in the CNS of children in Brazil. In this review, we provide a general overview of several flaviviruses that cause CNS infections in Brazilian children and explore the importance of epidemiological surveillance of CNS infections in cases of flavivirus infections. [ABSTRACT FROM AUTHOR]

We report a 3-year-old child who was hospitalized because of severe manifestations of the central nervous system. The child died after 6 days of hospitalization. Analysis of postmortem cerebrospinal fluid showed the presence of yellow fever virus RNA. Nucleotide sequencing confirmed that the virus was wild-type yellow fever virus.

The aim of this study was to describe atypical cerebrospinal fluid (CSF) alterations in tuberculous meningitis (TBM) and to analyse the differences in outcome between patients with typical and atypical profiles. We did a retrospective study during the period of 2000 to 2005 including the cases of TBM assisted in a referral centre for infectious diseases in Rio de Janeiro State, Brazil. Neutrophilic plecytosis at the first spinal tap was found in 32.4% of TBM patients, who had a worse outcome when compared with those patients with typical CSF profiles. One factor that might have a major impact was the delay in starting empirical treatment (27.5 versus 11.6 days).We conclude that, in cases with clinical and epidemiological data compatible with TBM but with an atypical CSF profile, empirical treatment should be considered if CSF culture and direct examination for bacteria are negative. [ABSTRACT FROM AUTHOR]

Background: Neurological involvement during influenza infection has been described during epidemics and is often consistent with serious sequelae or death., Objective: To investigate the etiologic agent involved in myelopathy post influenza-like syndrome., Study Design: This investigation focuses on virus isolation from the cerebrospinal fluid (CSF) collected from a 19-year-old male student presenting with clinical diagnosis of myelopathy post influenza-like syndrome. To achieve this goal, different cell cultures and molecular methodologies were carried out., Results: Influenza virus A(H3N2) strain was isolated in MDCK cell culture; virus particles were observed under electron microscopy. Phylogenetics analyses showed that the Brazilian influenza A(H3N2) strains were closely related to the A/Perth/16/2009-like., Conclusion: This study demonstrates that influenza virus A(H3N2) strain was the cause of illness of the students. According to the Brazilian influenza virus sentinel surveillance data A/Perth/16/2009-LIKE (H3N2) strain has predominated during the 2010 influenza virus season in Brasília-DF., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Analysis on cerebrospinal fluid (CSF) in neurological diagnosis has always been considered to be a strong point among the main complementary examinations in Brazil. The present paper reviews the main events in the history of CSF in the neurological sciences, with emphasis on the founders of several CSF schools in our country from the beginning of the 20th century to the present time.

The Cerebrospinal Fluid (CSF) Scientific Department of the Brazilian Academy of Neurology (SD-BAN) suggests the use of consent inform for patients submitted to lumbar puncture. It should be explained to the patients the possible complications related to CSF puncture. The laws related to the research in human beings have also been discussed by the CSF SD-BAN.

200 cervical lateral punctions (CLP) were performed in comatose patients without psychomotor trouble proving this new system to be an alternative for suboccipital punction. This procedure was successful in 90% of the cases. Low importance venous accidents happened but they did not bring any injury or serious consequences to the patients or to cerebrospinal fluid examination results. Vertebral artery injury was not observed. Punctions in corpses showed us that this artery is one cm far from the needle trajectory during the realization of the CLP.