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Cavernomas são hamartomas que podem acometer qualquer ponto do neuro-eixo. São malformações vasculares com maior ou menor potencial de sangramento ao longo da vida, em função de determinadas variáveis. Podem ter como origem fatores genéticos, tema de diversas pesquisas recentes, embora a maioria seja esporádica. Com o avanço da tecnologia de neuroimagem atual, a incidência de diagnósticos casuais vem aumentando. Quando há repercussão clínica, geralmente se dá por hemorragia, crise convulsiva, ou por crescimento e efeito expansivo.

A acrania é uma malformação congênita rara que cursa com ausência parcial ou total do crânio de fetos humanos. Está associada frequentemente com anencefalia e é, via de regra, fatal em curtíssimo prazo. Existem alguns marcadores pré-natais, sendo a ultrassonografia o exame diagnóstico padrão-ouro. Os autores revisam aspectos relacionados a epidemiologia, fisiopatologia, diagnóstico ultrassonográfico, diagnóstico diferencial entre malformações cefálicas e manejo obstétrico da doença.

Paciente feminina, 24 anos, apresentando, há 9 anos, cefaléia crônica recorrente e crises convulsivas sensíveis ao tratamento clínico com fenitoína e fenobarbital, evoluindo com períodos de amnésia transitória. A tomografia computadorizada (TC) demonstrou lesão cística e superficial em lobo temporal esquerdo, tendo sido submetida à craniotomia temporoparietal, com ressecção parcial da lesão. O exame histopatológico de rotina evidenciou cédulas ora fusiformes de núcleo alongado ora redondas ou ovaladas com núcleo único ou convoluto; pleomorfismo nuclear, células gigantes multinucleadas bizarras, conteúdo lipídico e fibras reticulínicas variáveis foram evidenciados. A análise imunohistoquímica pela técnica da avidina-biotina-peroxidase evidenciou positividade para GFAP, proteína S100 e sinaptofisina, confirmando o diagnóstico de astrocitoma xantopleomórfico. A paciente avoluiu com a melhor das crises tônico-clônicas, contudo, cinco meses após, a TC evidenciou presença de recidiva tumora. A paciente foi submetida à nova ressecção tumoral, não havendo posterior recidiva.

Low- and high-frequency stimulation (LFS and HFS, respectively) have been, reported to modify seizure characteristics in rats. We here report effects of hippocampal LFS and HFS, applied at two or four sites in fully kindled rats.Rats were kindled through a hippocampal tetrode until the fully kindled state. Animals with, stable afterdischarge (AD) threshold were randomly assigned to 5 groups; stimulation at 1Hz (LFS) or, 130Hz (HFS) was continuously applied for 7 days at 2 or 4 intrahippocampal sites; a control, group received no stimulation. Four-contact stimulation was performed in a rotating fashion. Stimulation effects on AD threshold, AD duration and behavioral seizures were assessed.Four-contact LFS consistently increased AD threshold for a period of 2 days to 2 weeks, whereas 4-contact HFS significantly decreased AD duration 24hours following the stimulation period. No significant AD modification was observed with either 2-contact stimulation paradigms. No, behavioral alteration occurred in any group.These findings suggest that effects of hippocampal stimulation depend on frequency and topography of stimulus application. LFS and HFS had anti-epileptic effect on afterdischarges when applied in a rotating pattern. This supports concepts on patterned stimulation to result in desynchronization and anti-kindling effects.

Object The goal of this paper is to analyze the extension and relationships of glomus jugulare tumor with the temporal bone and the results of its surgical treatment aiming at preservation of the facial nerve. Based on the tumor extension and its relationships with the facial nerve, new criteria to be used in the selection of different surgical approaches are proposed. Methods Between December 1997 and December 2007, 34 patients (22 female and 12 male) with glomus jugulare tumors were treated. Their mean age was 48 years. The mean follow-up was 52.5 months. Clinical findings included hearing loss in 88%, swallowing disturbance in 50%, and facial nerve palsy in 41%. Magnetic resonance imaging demonstrated a mass in the jugular foramen in all cases, a mass in the middle ear in 97%, a cervical mass in 85%, and an intradural mass in 41%. The tumor was supplied by the external carotid artery in all cases, the internal carotid artery in 44%, and the vertebral artery in 32%. Preoperative embolization was performed in 15 cases. The approach was tailored to each patient, and 4 types of approaches were designed. The infralabyrinthine retrofacial approach (Type A) was used in 32.5%; infralabyrinthine pre- and retrofacial approach without occlusion of the external acoustic meatus (Type B) in 20.5%; infralabyrinthine pre- and retrofacial approach with occlusion of the external acoustic meatus (Type C) in 41%; and the infralabyrinthine approach with transposition of the facial nerve and removal of the middle ear structures (Type D) in 6% of the patients. Results Radical removal was achieved in 91% of the cases and partial removal in 9%. Among 20 patients without preoperative facial nerve dysfunction, the nerve was kept in anatomical position in 19 (95%), and facial nerve function was normal during the immediate postoperative period in 17 (85%). Six patients (17.6%) had a new lower cranial nerve deficit, but recovery of swallowing function was adequate in all cases. Voice disturbance remained in all 6 cases. Cerebrospinal fluid leakage occurred in 6 patients (17.6%), with no need for reoperation in any of them. One patient died in the postoperative period due to pulmonary complications. The global recovery, based on the Karnofsky Performance Scale (KPS), was 100% in 15% of the patients, 90% in 45%, 80% in 33%, and 70% in 6%. Conclusions Radical removal of glomus jugulare tumor can be achieved without anterior transposition of the facial nerve. The extension of dissection, however, should be tailored to each case based on tumor blood supply, preoperative symptoms, and tumor extension. The operative field provided by the retrofacial infralabyrinthine approach, or the pre- and retrofacial approaches, with or without closure of the external acoustic meatus, allows a wide exposure of the jugular foramen area. Global functional recovery based on the KPS is acceptable in 94% of the patients.

Background Among the many complications of SAH, one of the most important is vasospasm. Several treatment alternatives have been proposed for this condition, with far-from-ideal results being obtained. Magnesium sulfate recently returned to the scene (with still unproven benefit) as an adjuvant in the treatment of vasospasm. Methods Seventy-two patients diagnosed with SAH by aneurysm rupture were submitted to microsurgery craniotomy and subdivided in 2 groups. Group 1, formed by 48 patients, received prophylactic hypervolemic and hemodilution therapy in addition to nimodipine. Group 2, composed of 24 patients, received the same treatment of group 1 with the addition of magnesium sulfate in continuous infusion from 120 to 150 mg a day, keeping serum magnesium levels close to double normal values. Results Age was 49 ± 12.6 years. Ratio of female to male was 3.16:1. Most patients were admitted in a Hunt-Hess grade 2 (46.4%) and Fisher grade 3 (52.8%). Anterior communicating artery aneurysms were the most common in location (38.8%). Both groups were compared, and there was no statistical difference related to age, sex, and Glasgow, Fisher, or Hunt-Hess admission grades. No statistical difference in vasospasm incidence was found between the two groups. However, in group 1, vasospasm was correlated with a longer hospitalization time (P = .0003), different from group 2, in which patients with vasospasm receiving magnesium sulfate required less hospitalization time. Conclusion Magnesium did not seem to interfere in vasospasm frequency but apparently acted favorably in decreasing morbidity and length of hospital stay.

Spinal extradural meningeal cysts are typically formed by a thin fibrotic membranous capsule, macroscopically similar that of an arachnoid membrane, filled by cerebro spinal fluid and related to a nerve root or to the posterior midline. Ventral location is extremely rare and when it occurs they usually cause spinal cord herniation through the ventral dural gap. A 61 year-old man who began with a two years long history of insidious tetraparesis, spasticity and hyperreflexia in lower extremities, and flaccid atrophy of upper limbs, without sensory manifestations, is presented. Investigation through magnetic resonance imaging demonstrated an extensive spinal ventral extradural cystic collection from C6 to T11. The lesion was approached through a laminectomy and a cyst-peritoneal shunt was introduced. The cyst reduced in size significantly and the patient is asymptomatic over a 48 months follow-up. This is the first reported case of a spontaneous ventral extradural spinal meningeal cyst causing cord compression. Cyst-peritoneal shunt was effective in the treatment of the case and it should be considered in cases in which complete resection of the cyst is made more difficult or risky by the need of more aggressive surgical maneuvers. Cistos meníngeos extradurais espinhais são formados tipicamente por estreita cápsula membranosa fibrótica, macroscopicamente semelhante a uma membrana de aracnóide, repleta de líquor e relacionada com uma raiz nervosa ou com a linha média posterior. Eles são extremamente raros em posição anterior e, quando ocorrem, habitualmente causam herniação da medula espinhal pela falha dural ventral. O caso de um homem de 61 anos de idade que iniciou com tetraparesia, espasticidade e hiperreflexia em membros inferiores, e flacidez com hipotrofia nos membros superiores, sem manifestação sensitiva, é apresentado. A investigação com ressonância magnética demonstrou extensa coleção cística extradural ventral à medula de C6 a T11. A lesão foi abordada diretamente via laminectomia com introdução de derivação cisto-peritoneal, reduzindo o cisto e tornando o paciente assintomático com um seguimento de 48 meses. Este é o primeiro caso relatado de cisto meníngeo extradural ventral espontâneo causando compressão medular. A derivação cisto-peritoneal se mostrou eficaz no tratamento do caso e deve ser considerada em situações em que a ressecção completa do cisto esteja impossibilitada, ou dificultada pela necessidade de manobras cirúrgicas mais agressivas e arriscadas.

Cerebellar hemorrhage is listed among the potential complications following neurosurgical pro ce dures. In this scenario it is usually reported as a rare condition. However, it seems that epilepsy surgery pa tients are somewhat more prone to this kind of complication, compared to other surgical groups. Head po si tioning, excessive cerebral spinal fluid draining and the excision of non-expanding encephalic tissue (or combinations among the three) are likely to be cause underlying remote cerebellar hemorrhage. Out of the 118 ATL/AH performed at our institution, between 1996 and 2002, we identified 3 (2.5%) patients pre sen ting with cerebellar hemorrhage. We report on such cases and review the literature on the topic.

Gliosarcoma (GSa) is a rare primary central nervous system neoplasm (CNS) characterized by biphasic histological pattern with both glial and sarcomatous components. Our objective is to describe the clinical, morphological and immunohistochemical features of four cases of GSa and to discuss its pathogenetic mechanisms. The male:female ratio was 3:1. The mean age was 39 years, ranging from 19 to 48. Headache was the commonest clinical symptom. All patients underwent craniotomy with microsurgery and total resection of the tumor. Diagnosis was suspected due to microscopic architecture and confirmed by detection of reticulin fibers through histochemical techniques. Immunohistochemical analysis was positive for p53 in both glial and sarcomatous cells in all four cases. EGFR was focally positive in glial cells in one case. Our findings support monoclonal origin of GSa involving the TP53 tumor-suppressor gene. However, alternative pathways cannot be ruled out.

Cavernomas são malformações vasculares que frequentemente acometem a substância branca dos hemisférios cerebrais e tronco encefálico. São angiograficamente ocultas e têm como principal método diagnóstico a ressonância magnética, em que tipicamente se observa nas sequências ponderadas em T2, um halo perilesional hipointenso devido a deposição de hemossiderina no tecido adjacente. A localização ventricular é considerada rara, e suas características de imagem na ressonância magnética diferem, podendo não apresentar tal halo. Apresentamos dois casos nos quais o diagnóstico foi feito somente com exame histopatológico, devido a ausência dos critérios de imagem que permitiriam a suspeita de tal lesão. Os cavernomas devem ser incluidos no diagnóstico diferencial dos processos expansivos intraventriculares, sendo a ressecção cirurgica completa a melhor modalidade de tratamento para estas lesões.

Entre 1993 e 1999 foram estudados 44 pacientes que preencheram requisitos protocolares de seguimento adequado e que foram submetidos à ressecção de processo expansivo extramedular intradural. Os pacientes eram constituídos por 43,2% de mulheres e por 56,8% de homens. A média da idade foi 32,9 anos. A localização da lesão foi mais comum na região torácica, com 45,5% dos casos, seguida da lombar com 18,2%. A extensão tumoral variou de 1 a 7 segmentos vertebrais, com uma média de 2,5 níveis. O schwanoma foi o tipo histológico mais comum com 65,9%, seguido dos meningiomas com 20,5%. Houve 2 casos de neurofibroma e 1 caso de paraganglioma, cisto neuroentérico, metástase e schwanoma maligno. A evolução foi de melhora em 56,8%, estabilidade em 31,8% e de piora em 11,4%. Não houve mortalidade relacionada ao procedimento cirúrgico. Todos os casos de piora tiveram ressecção total e eram localizados no segmento torácico. A ressecção total é a modalidade ideal de tratamento cirúrgico. No entanto, no nível torácico, onde predominam as peculiaridades de irrigação da medula, a morbidade cirúrgica pode ser mais elevada (p=0,014). Between 1993 and 1999, 44 patients submitted to resection of an expansible intradural extramedullary lesion who filled protocol requirements of appropriate follow up were studied. Patients were constituted by 43.2% female and 56.8% male. The mean age was 32.9 years old. Lesion most common location was at the thoracic spine, with 45.5% of the cases, followed by the lumbar level with 18.2%. Tumor extension varied from 1 to 7 vertebral segments, with an average of 2.5 levels. Schwannoma, with 65,9% of the cases, was the most frequent lesion, followed by meningioma with 20.5%. There were 2 cases of neurofibroma and 1 case of paraganglioma, neuroenteric cyst, metastasis and malignant schwannoma. The evolution was of improvement in 56.8%, stability in 31.8% and of worsening in 11.4%. There was no mortality related to the surgical procedure. All cases of worsening had total resection and they had lesions located in the thoracic segment. Total resection is the ideal modality of surgical treatment. However, at the thoracic level, where the peculiarities of spine irrigation prevail, surgical morbidade may be higher (p=0.014).

Pituitary abscesses are potentially life-threatening lesions if not appropriately diagnosed and treated. The authors have operated on more than five hundred cases of pituitary tumors and only one represented a case of pituitary abscess. A 35-year-old woman was investigated for chronic frontal headache. CT scan showed a cystic sellar lesion with ring enhancement after contrast injection leading to an initial diagnosis of pituitary adenoma. She underwent a sublabial transsphenoidal approach to the pituitary gland. After dural opening, purulent material was obtained and no tumor or other associated lesion was detected. There was no evidence of current or previous septicemic illness, meningitis, cavernous sinus thrombosis or sinus infection. Cultures were negative. She was put on antibiotics and discharged after 4 weeks. Nowadays, 10 years after treatment, she is doing well, with no anterior pituitary hormone deficit. MRI shows a partially empty sella without residual lesion and the pituitary stalck is in the midline. The early diagnosis and adequate treatment of this life-threatening lesion may result in excellent prognosis. Abscessos pituitários são lesões potencialmente graves se não diagnosticadas e tratadas de maneira apropriada. Os autores têm mais de 500 casos de tumores pituitários operados e apenas um único caso de abscesso pituitário. Uma mulher de 35 anos foi investigada por cefaléia frontal crônica. A tomografia computadorizada de crânio mostrou uma lesão selar cística com captação de contraste levando à hipótese diagnóstica inicial de adenoma hipofisário. A paciente foi submetida a um acesso sublabial transesfenoidal para a hipófise. Após abertura dural, foi encontrado material purulento sem sinal de tumor ou outra lesão associada. Não havia evidência de doença séptica prévia ou atual, meningite, trombose de seio cavernoso ou sinusite. Culturas foram negativas. A paciente foi submetida a tratamento com antibióticos e recebeu alta após 4 semanas. Atualmente, após 10 anos do tratamento, encontra-se sem déficit hormonal hipofisário anterior. Sua ressonância magnética de crânio mostra uma sela parcialmente vazia sem lesão residual, com o talo hipofisário na linha média. O diagnóstico e tratamento adequado desta lesão potencialmente grave pode resultar em excelente prognóstico.

Os meningiomas correspondem de 1% a 4% das neoplasias intracranianas primárias em pacientes pediátricos; a incidência nesta população aumenta de acordo com a faixa etária. Não há predominância quanto ao sexo, ao contrário do que acontece na população adulta onde predominam no sexo feminino. Relatamos dois casos de meningioma em crianças, discutindo os aspectos clínicos, radiológicos e histológicos desta entidade. O primeiro paciente é do sexo masculino, com 2 anos de idade e apresentava com crises convulsivas há 4 meses. Os exames de imagem revelaram uma lesão expansiva de 20 mm na região parieto-occipital direita, a qual foi totalmente ressecada. Os exames histológico e imunohistoquímico definiram o diagnóstico de meningioma. Atualmente, 17 meses após a cirurgia, o paciente encontra-se bem, sem evidências de recidiva tumoral. O segundo paciente é do sexo feminino, com 11 anos, e queixava-se de cefaléia frontal há 2 anos. Os exames radiológicos demonstraram presença de lesão expansiva de 5 cm em região frontal direita. Realizou-se craniotomia frontal com ressecção total do tumor. O diagnóstico histológico foi de meningioma. Atualmente, 20 meses após a cirurgia, encontra-se sem evidência de recidiva tumoral. Os autores discutem ainda o tratamento e prognóstico dos meningiomas pediátricos ressaltando que apesar de incomuns, estes devem fazer parte do diagnóstico diferencial de lesões intracranianas expansivas nesta faixa etária. Meningiomas correspond to 1% - 4% of primary intracranial tumors in pediatric group, with their incidence raising according to age. There is not gender prevalence, in spite of some authors describe a male tendency opposed to female one in adulthood. At present study we describe two cases of pediatric meningiomas reviewing clinical, radiological and histological aspects of these lesions. The authors review also treatment options and prognosis of childhood meningiomas. A two-year-old boy was admitted with seizures. Computerized tomography showed a right parietal lesion, which was totally resected. Histological features were compatible with meningioma. After 17 months the child is doing well, with no deficits or seizures. The second case is a 12-year-old girl, with a headache complain. During investigation, a CT revealed a right frontal lesion. She was operated under a right frontal craniotomy with total tumor resection. Nowadays she is asymptomatic, 20 months after surgery. Despite meningiomas in pediatric group are uncommon; they should be included in differential diagnosis list of expansive intracranial lesions of childhood.

A ocorrência de um angioma cavernoso epidural primário é incomum, constituindo aproximadamente 4% de todos os tumores epidurais espinhais, entretanto o número de relatos desta entidade tem aumentado nos últimos anos, provavelmente devido aos melhores recursos diagnósticos. Relatamos o caso de um paciente com um angioma cavernoso epidural puro em nível espinhal de L1-L2 , que apresentava quadro clínico de compressão medular lenta e progressiva, com piora importante recente. A ressonância magnética de coluna lombosacra demonstrou lesão hipo e isointensa em T1 e hiperintensa em T2. O paciente foi submetido a tratamento cirúrgico com boa recuperação neurológica. Os achados clínicos, de imagem, anátomo-patológicos e de tratamento desta patologia são analisados e discutidos.

BACKGROUND Focal intracranial infections caused by Salmonella species are uncommon. The authors report a case of multiple brain abscesses caused by Salmonella typhi . CASE DESCRIPTION A 2-month-old girl was admitted to the hospital because of diarrhea, vomiting, fever, and poor feeding. Neurological examination revealed cervical hyperextension and absence of sucking and Moro reflexes. During the next 20 hours she developed complex partial seizures with secondary generalization and alternated irritability with drowsiness. Investigation showed hemoglobin 6.3 g/dl; white blood cell count of 19500/mm 3 with a marked shift to the left. The analysis of the cerebrospinal fluid revealed white cell count of 1695/mm 3 , lymphocytes 61%, protein 300 mg/dl and glucose 6 mg/dl. The patient was treated for acute gastroenterocolitis, sepsis, and meningitis. Blood culture taken on the day of admission showed Gram-negative bacilli, later identified as S. typhi . Computed tomography scan demonstrated a lesion in the right parietal lobe compatible with a brain abscess. Follow-up computed tomography after 7 days showed several other lesions with the same features. Surgical drainage of the right parietal lesion was performed on the 13th day, through a burr hole. The patient was discharged 5 weeks after admission without neurological deficit. CONCLUSION Bacteremia, sepsis, and meningitis are relatively common in children with Salmonella infection but intracranial abscesses are very rare. Surgical drainage combined with prolonged antibiotic therapy (drug of choice: chloramphenicol) is the best treatment for Salmonella brain abscesses. The possibility of intracranial infection should be considered in patients with Salmonellosis and neurological dysfunction.

A cirurgia para tratamento da doença discal lombo-sacra pode cursar com complicações severas, iatrogênicas incluindo-se as neurológicas, vasculares, entéricas, ureterais e disfunção sexual podendo levar o paciente à morte dependendo da extensão da lesão. Abramovitz relata que as complicações vasculares do acesso posterior para o tratamento hérnia discal lombo-sacra ocorrem em menos de 0,1% dos casos As lesões vasculares podem manifestar-se de maneira imediata como hemorragia arterial levando a choque hipovolêmico no per ou pós-operatório imediato, devendo ser diagnosticadas e tratadas prontamente. Sinais precoces de hemorragia retroperitoneal se manifestam na vigência de lesões traumáticas, sendo os pseudoaneurismas e as fístulas arteriovenosas diagnosticados tardiamente, semanas ou mesmo após anos. Descrevemos o caso de uma paciente de 39 anos que foi submetida a tratamento cirúrgico de hérnia discal no espaço L4-L5, à direita, em outro serviço. Devido ao fato de persistirem os sintomas dolorosos, foi encaminhada ao nosso serviço. Na investigação a ressonância magnética mostrou lesão paravertebral sugestiva de abscesso. A angiografia aorto-ilíaca revelou a presença de pseudoaneurisma na artéria ilíaca comum esquerda, o qual foi reparado cirurgicamente com sucesso. Discutimos os mecanismos das lesões vasculares e as precauções para evitá-las.

O tumor disembrioplástico neuroepitelial (TDN) é entidade tumoral relativamente nova que foi descrita pela primeira vez por Daumas-Duport et al. em 1988 e foi incorporado à classificação de tumores cerebrais da Organização Mundial da Saúde em 1993. Os autores apresentam o primeiro caso de TDN relatado na literatura latino-americana. Trata-se de paciente de sexo feminino, com 16 anos, que começou a ter crises convulsivas tipo parciais complexas com generalização secundária aos cinco anos de idade. Usou diversas drogas anti-convulsivas mas nunca obteve total controle clínico das crises epiléticas. O exame físico era normal e não havia alterações neurológicas focais ou de cognição. O exame por ressonância nuclear magnética do crânio mostrou tumor no lobo temporal esquerdo. A paciente foi submetida a craniotomia e a ressecção tumoral foi completa. Os cortes histológicos apresentavam proliferação neuroglial atípica condizente ao TDN. O estudo imunohistoquímico pela técnica de avidina-biotina peroxidase revelou positividade para proteína glial fibrilar ácida e proteína S 100 no componente astrocitário e enolase neurônio específica e sinaptofisina no componente neuronal. Dysembryoplastic neuroepithelial tumor (DNT) is a relatively new neuroepithelial neoplasm that was first described by Daumas-Duport et al. in 1988. It was incorporated in the revised World Health Organization classification of brain tumors in 1993. The authors present the first case of DNT reported in the Latin-American literature. A 16-year-old woman had been found at age of five years to have complex partial seizures accompanied by secondary generalization. She was treated with various anti-epileptic drugs but always with incomplete control of seizures activity. Neurological examination was normal. Magnetic resonance imaging demonstrated a lesion in the left temporal lobe. She underwent a craniotomy with complete resection of the tumor. Histological study showed atypical neuroglial proliferation characteristic of DNT. Monoclonal antibody immunostaining for glial fibrillary acidic protein and S-100 protein confirmed the glial component, and neuronal specific enolase and synaptophysin emphasized the neuronal component.

A total of 42 patients were submitted to a clinical, behavioural and neuropsychological evaluation with the objective of eventual surgical treatment of epilepsy refractory to the usual clinical therapies. Prolonged video-EEG monitoring, MRI hippocampal volume measurement, lateralization of speech and memory using the amobarbital (Wada) test were used. Of 18 operated cases, 12 were submitted to temporal lobectomy, with a follow-up of 6-30 months; 8 patients had significant improvement in seizures control; 2 patients had partial improvement in seizure frequency and intensity; 2 patients had no improvement in seizure control. One patient underwent right frontal lobectomy with total remission of seizures and 5 had callosotomy with varying degrees of success. There was no mortality. Morbidity included one subdural hematoma, one transient hemiparesis, one episode of mania, one lobar pneumonia and frequent immediately post-operative muscular tension headaches. These early results indicate good results of temporal lobectomy patients investigated through a non-invasive presurgical evaluation. No total, 42 pacientes foram submetidos a avaliação clínica, comportamental e neuropsicológica com o objetivo de eventual tratamento cirúrgico de epilepsia refratária aos tratamentos clínicos usuais. Monitorização de vídeo-EEG digital prolongado, avaliação do volume hipocampal por RM, lateralização de fala e memória pelo teste do Amobarbital (teste de Wada) foram utilizados. Dos 18 pacientes operados 12 foram submetidos a lobectomia temporal, com seguimento de 6-30 meses (média 17 meses), sendo que 8 encontram-se com melhora significativa do controle de crises, 2 com melhora parcial e em 2 não foi observada mudança substancial na intensidade e frequência de crises. Uma paciente foi submetida a lobectomia frontal direita com remissão total de crises. Cinco pacientes foram submetidos a calosotomia com graus variáveis de sucesso. Não houve mortalidade. A morbidade incluiu um hematoma subdural, uma hemiparesia transitória, um episódio de mania, uma pneumonia lobar e cefaléia tensional muscular frequente no pós-operatório imediato. Estes resultados preliminares indicam uma boa resposta do tratamento cirúrgico de epilepsia em um novo centro, com pacientes selecionados através de monitorização não invasiva.

Prospective Experimental study in which we created a bony defect in the mastoids of rats and filled it up with hydroxyapatite to evaluate bone regeneration, to solve the problems of open cavities after mastoidectomies that frequently present with otorrhea, infection, granulation tissue and hearing loss. OBJECTIVE: The aim was to evaluate bone regeneration in defects created in the mastoids of rats, using hydroxyapatite, to see how much of the cavity we could reduce. MATERIAL AND METHODS: Twelve rats Wistar-Furth were used. A 0.5 x 0.5 cm bone defect was created in both temporal bones of the rats, and filled with 15 micrograms of hydroxyapatite. The left side was used as control. The animals were slaughtered 40 days afterwards and histology analyses were carried out. RESULTS: In the hydroxyapatite group, the new bone growth involved an area of 68.53% of the total; and in the control group it was only of 15.97%. DISCUSSION AND CONCLUSIOn: It was observed a very good hydroxyapatite integration to the temporal bone in this experimental model. The microscopic results were superior with the use of hydroxyapatite when compared to the control group. It is a safe method and easy to apply to solve the problems of open cavities with chronic discharge and difficult to clean. Estudo experimental prospectivo utilizando ratos que foram submetidos à realização de defeito ósseo em mastoide para avaliar o grau de regeneração óssea após preenchimento com hidroxiapatita de cálcio sintética, para resolver o problema das cavidades abertas pós-mastoidectomia que frequentemente se apresentam com secreção, tecido de granulação, otorreia e perda de audição. OBJETIVO: Avaliar a regeneração óssea em defeitos criados em mastoides de ratos, utilizando hidroxiapatita cáustica, avaliando quanto a cavidade mastoidea criada pode ser diminuída, por meio de microscopia óptica. MATERIAL E MÉTODO: Foram utilizados 12 ratos Wistar. Foi criado um defeito ósseo de 0,5cm x 0,5cm no osso temporal de todos os animais bilateralmente com broca. Padronizou-se à direita o preenchimento do defeito com 15 microgramas de hidroxiapatita, e à esquerda o não preenchimento como controle. A eutanásia foi realizada no 40º pós-operatório e procedeu-se à análise histológica. RESULTADOS: No grupo hidroxiapatita, a neoformação óssea perfez uma área correspondente a 68,53%, no grupo controle 15,97% (p=0,0022). CONCLUSÃO: Observou-se a integração satisfatória da hidroxiapatita nesse modelo experimental. Pode ser um método de fácil aplicação para resolver o problema das cavidades abertas.

We report the case of a young woman who presented with cerebrospinal fluid (CSF) rhinorrhea due to an undiagnosed and untreated pituitary adenoma. The tumor had extended well beyond sella turcica and caused bony erosion. The patient initially refused surgery and was treated with bromocriptine and a radiation therapy. CSF leakage did not improved and she was submitted to surgery by the transsphenoidal approach with removal of a tumor mass located in sphenoid sinus and sellar region. Origin of the leak was localized and repaired with fascia lata and a lumbar subarachnoid drain was left in place for 5 days. After 4 years she has normal serum PRL levels and no rhinorrhea. The management, complications and mechanisms involved in this rare condition are discussed.

The goal of this paper is to analyze the extension and relationships of glomus jugulare tumor with the temporal bone and the results of its surgical treatment aiming at preservation of the facial nerve. Based on the tumor extension and its relationships with the facial nerve, new criteria to be used in the selection of different surgical approaches are proposed.Between December 1997 and December 2007, 34 patients (22 female and 12 male) with glomus jugulare tumors were treated. Their mean age was 48 years. The mean follow-up was 52.5 months. Clinical findings included hearing loss in 88%, swallowing disturbance in 50%, and facial nerve palsy in 41%. Magnetic resonance imaging demonstrated a mass in the jugular foramen in all cases, a mass in the middle ear in 97%, a cervical mass in 85%, and an intradural mass in 41%. The tumor was supplied by the external carotid artery in all cases, the internal carotid artery in 44%, and the vertebral artery in 32%. Preoperative embolization was performed in 15 cases. The approach was tailored to each patient, and 4 types of approaches were designed. The infralabyrinthine retrofacial approach (Type A) was used in 32.5%; infralabyrinthine pre- and retrofacial approach without occlusion of the external acoustic meatus (Type B) in 20.5%; infralabyrinthine pre- and retrofacial approach with occlusion of the external acoustic meatus (Type C) in 41%; and the infralabyrinthine approach with transposition of the facial nerve and removal of the middle ear structures (Type D) in 6% of the patients.Radical removal was achieved in 91% of the cases and partial removal in 9%. Among 20 patients without preoperative facial nerve dysfunction, the nerve was kept in anatomical position in 19 (95%), and facial nerve function was normal during the immediate postoperative period in 17 (85%). Six patients (17.6%) had a new lower cranial nerve deficit, but recovery of swallowing function was adequate in all cases. Voice disturbance remained in all 6 cases. Cerebrospinal fluid leakage occurred in 6 patients (17.6%), with no need for reoperation in any of them. One patient died in the postoperative period due to pulmonary complications. The global recovery, based on the Karnofsky Performance Scale (KPS), was 100% in 15% of the patients, 90% in 45%, 80% in 33%, and 70% in 6%.Radical removal of glomus jugulare tumor can be achieved without anterior transposition of the facial nerve. The extension of dissection, however, should be tailored to each case based on tumor blood supply, preoperative symptoms, and tumor extension. The operative field provided by the retrofacial infralabyrinthine approach, or the pre- and retrofacial approaches, with or without closure of the external acoustic meatus, allows a wide exposure of the jugular foramen area. Global functional recovery based on the KPS is acceptable in 94% of the patients.

The kindling phenomenon is classically investigated in epileptology research. The present study aims to provide further information about hippocampal kindling through computational processing data. Adult Wistar rats were implanted with dorsal hippocampal and frontal neocortical electrodes to perform the experiment. The processing data was obtained using the Spike2 and Matlab softwares. An inverse relationship between the number of "wet dog shakes" and the Racine's motor stages development was found. Moreover it was observed a significant increase in the afterdischarge (AD) duration and its frequency content. The highest frequencies were, however, only reached at the beginning of behavioral seizures. During the primary AD, fast transients (ripples) were registered in both hippocampi superimposed to slower waves. This experiment highlights the usefulness of computational processing applied to animal models of temporal lobe epilepsy and supports a relevant role of the high frequency discharges in temporal epileptogenesis.

Cervical uterine cancer (CUC) spreads locally (pelvis and paraortic lymphnodes) or distantly (lungs, liver and bones). Metastasis to central nervous system (CNS) are rare. There are about 80 cases reported in the literature. Outcome is poor and survival varies from 3 to 6 months. Three cases of CNS metastasis from CUC are reported, one infratentorial and two supratentorials in location. In one patient, the initial manifestation was due to the cerebral lesion, a feature re p o rted for the first time. All cases were treated by surg e ry, radiotherapy and/or chemotherapy. Clinical findings and treatment options of these rare lesions are reviewed._________________________________________________________________________________________ RESUMO: Tumores do cólo uterino se disseminam por contigüidade ou via hematogênica (pulmão, fígado e ossos). Metástases para sistema nervoso central são incomuns. Apenas cerca de 80 casos são citados na literatura. Manifestações clínicas são devidas à hipertensão intracraniana e a déficits focais. A sobrevida varia de 3 a 6 meses. Três casos são relatados sendo um infratentorial e dois supratentoriais. No primeiro , o diagnóstico da metástase antecedeu o da lesão uterina. No segundo, houve 5 anos sem recidiva após a cirurgia, fato este inédito. O tratamento foi cirurgia, radioterapia e/ou quimioterapia. A discussão enfatiza manejo multidisciplinar destas raras lesões.

Chondrosarcomas are malignant tumors that rarely grow inside the spinal canal. Prognosis depends on histological features, patient's age and surgical margins free from tumor. Response to radio and chemotherapy is poor. Ideal treatment consists of total " en-block" resection, not always achievable due to limitation of location, compromise of stability and risk of inducing neurological deficits. Two cases of spinal chondrosarcoma causing cord compression are reported, located in the cervical and thoracic spine. Microsurgical technique consisted of initial debulking followed by removal of margins until limits free from tumor were obtained. Total resection was accomplished and neurological function improved in both cases. Follow-up has been seven and one year respectively, with no evidence of recurrence and preserved neurological functions. Association between chondrosarcoma and estrogen-dependent tumor has been confirmed in this report. Although " en-block" resection of a chondrosarcoma should be tried whenever possible, tumor fragmentation should be considered in difficult cases, as in the present report, in which a long period free from recurrence with good quality of life can be obtained. Os condrosarcomas são tumores malignos, raramente localizados no interior do canal espinhal, com prognóstico dependente do grau histológico do tumor, idade do paciente e margens cirúrgicas livres. Esses tumores apresentam pouca resposta à radio e quimioterapia. O tratamento ideal consiste em ressecção tumoral em bloco, condição particularmente difícil em se tratando de tumores causando compressão medular, devido à localização da lesão, comprometimento da estabilidade axial e necessidade da manutenção ou recuperação da integridade da função neurológica do paciente. Relatamos dois casos de condrossarcomas causando compressão medular, um na coluna cervical e outro na torácica, submetidos a cirurgia com esvaziamento tumoral seguido de remoção das margens, atingindo-se ressecção total e melhora das funções neurológicas em ambos os casos. Um paciente se encontra há 7 anos e outro há 1 ano livre de recorrências, ambos com funções neurológicas preservadas. Associação entre condrosarcoma e tumor dependente de estrógeno é confirmada clinicamente pelo presente estudo. Embora uma ressecção em bloco dos condrossarcomas deva ser tentada quando possível, deve-se considerar uma ressecção com fragmentação tumoral em casos específicos, podendo-se atingir, como demonstrado nos presentes casos, períodos livres de recorrência e longo tempo de sobrevida.

Between 1993 and 1999, 44 patients submitted to resection of an expansible intradural extramedullary lesion who filled protocol requirements of appropriate follow up were studied. Patients were constituted by 43.2% female and 56.8% male. The mean age was 32.9 years old. Lesion most common location was at the thoracic spine, with 45.5% of the cases, followed by the lumbar level with 18.2%. Tumor extension varied from 1 to 7 vertebral segments, with an average of 2.5 levels. Schwannoma, with 65,9% of the cases, was the most frequent lesion, followed by meningioma with 20.5%. There were 2 cases of neurofibroma and 1 case of paraganglioma, neuroenteric cyst, metastasis and malignant schwannoma. The evolution was of improvement in 56.8%, stability in 31.8% and of worsening in 11.4%. There was no mortality related to the surgical procedure. All cases of worsening had total resection and they had lesions located in the thoracic segment. Total resection is the ideal modality of surgical treatment. However, at the thoracic level, where the peculiarities of spine irrigation prevail, surgical morbidade may be higher (p=0.014).

Cavernomas are vascular malformations that typically affect the white matter of cerebral hemispheres and brain stem. They are angiographically occult lesions that depend on magnetic resonance imaging (MRI) for their diagnosis, presenting a hypointense perilesional ring caused by hemossiderin deposition as seen in T2 sequences. The ventricular location is rare, and image features may differ. We present two cases with diagnosis made only by histopathologic examination, due to a lack of classic image findings. Cavernous hemangiomas must be included in the differential diagnosis of intraventricular tumors, and total surgical resection is the treatment of choice. Perilesional ring as demonstrated by MRI, must not be expected when dealing with such lesions.

The authors describe a case of paraganglioma of the sellar region in a young female patient with loss of vision and headache. She presented with amaurosis, depression, anxiety and amenorrhea. Clinical and radiological impression was that it was a meningioma or pituitary adenoma. She received bromocriptine with no reduction of the lesion. She developed panhypopituitarism, but with normal levels of prolactin. It was resected and histological examination revealed nests of large cells with moderate nuclear pleomorphism, vesicular nuclei with occasional nucleoli. There were rare mitotic figures, but no necrosis. Immunohistochemistry was positive for synaptophysin, chromogranin A, and neuron-specific enolase with a few sustentacular cells positive for S100. The Ki67 proliferation was 1-2%. All pituitary hormonal antibodies were negative as well as GFAP, AE1/AE3, p53 and EMA. Paragangliomas affecting the sellar region are extremely rare and might be due to the presence of remnants of paraganglionic tissue or abnormal migration. The patient's post-operative diabetes insipidus remains under medical control.

Entre 1993 e 1999, foram analisados 35 pacientes submetidos a microcirurgia para remoção de tumor intramedular nos Serviços de Neurocirurgia do Hospital Nossa Senhora das Graças e do Hospital de Clínicas de Curitiba - PR. A população foi composta por 68,6% de pacientes do sexo masculino; a média de idade era de 32,9 anos. A localização tumoral mais frequente foi torácica em 40% dos casos, seguida pela região cervical e cervicotorácica em 25,7%. Ao exame neurológico realizado entre 6 a 12 meses do pós-operatório, 42,9% dos pacientes demonstraram melhora, 34,3% permaneceram estáveis e 22,9% dos casos apresentaram piora. A ressecção foi total em 57,2% dos casos e subtotal em 37,1%. Em 5,7% dos pacientes, foi realizada apenas biópsia para diagnóstico. O grau de ressecção completa foi maior nos ependimomas (13 de 17 casos) e menor nos astrocitomas (5 de 12 casos). Entretanto, o grau de ressecção e o tipo histológico não interferiram na morbidade pós-operatória. Fatores como sexo, idade e tamanho do tumor também não demonstraram importância na evolução após a cirurgia. A localização torácica do tumor foi associada a maior morbidade cirúrgica (p=0,021).

O neurocitoma central foi descrito pela primeira vez na literatura em 1982 por Hassoun e colaboradores como tumor bem diferenciado de origem neuronal. O tumor geralmente localiza-se no sistema ventricular, afetando adultos jovens e geralmente cursando com hipertensão intracraniana secundária à hidrocefalia obstrutiva. O diagnóstico diferencial com outros processos intraventriculares como oligodendroglioma é realizado através de métodos imuno-histoquímicos. Raros casos de neurocitoma central associados com hemorragia têm sido descritos na literatura. Descrevemos um caso de neurocitoma central de uma paciente de 35 anos com apresentação atípica. A paciente havia procurado o hospital com quadro súbito de cefaléia, vômitos e rigidez de nuca, sugerindo a presença de hemorragia subaracnóidea. A ressonância magnética demonstrou volumosa massa no ventrículo lateral direito cujos perfis histológico e imuno-histoquímico eram condizentes com neurocitoma central, a ressecção cirúrgica foi realizada com sucesso, embora a paciente tenha evoluído para um quadro de ventriculite no pós-operatório. Salientamos a importância do estabelecimento do neurocitoma central como diagnóstico diferencial de pacientes com hemorragia intraventricular e discutimos as opções de tratamento para este tumor incomum. Central neurocytoma was first described by Hassoun et al. in 1982 as a well-differentiated tumor from neuronal origin. This tumor typically occurs in young adults, localized in the ventricular system. It usually presents as intracranial hypertension due to obstructive hydrocephalus. The differential diagnosis should be done with others intraventricular tumors as oligodendroglioma, subependymoma and choroidal plexus papilloma. There are few cases of central neurocytoma presented by intraventricular hemorrhage in the literature. We report a case of 35 year-old woman, who presented with obstructive hydrocephalus due to intraventricular hemorrhage within the tumor. MRI revealed a tumor localized in the right lateral ventricle. Histopathological and immunohystochemical analysis confirmed the diagnosis of central neurocytoma. We review options for the treatment of this entity as well reinforce the inclusion of central neurocytoma as a differential diagnosis for intraventricular hemorrhage.