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Aspergillosis of the central nervous system is an uncommon infection, mainly occurring in immunocompromised patients. It may be presented in several forms: meningitis, mycotic aneurysms, infarcts and the tumoral form (aspergilloma). The authors report a case of a diabetic patient with cerebral aspergilloma.

A 44-year-old female presented with Duret hemorrhage due to transtentorial herniation by extradural hematoma as a complication after craniotomy for treatment of spontaneous middle cranial fossa cerebrospinal fluid leakage through the oval window. Brain computed tomography revealed linear hemorrhage in the midbrain and the rostral pons. She awoke after 2 weeks in a coma, despite showing ocular bobbing and bilateral intranuclear ophthalmoplegia. She was discharged from the hospital with minimal neurological defects. Duret hemorrhage is usually fatal, but this case shows that early surgical decompression is the most important factor to avoid the worst sequelae.

Objective: Insulin-like growth factor (IGF-I) and IGF binding protein-3 (IGFBP-3) are GH-dependent and their concentrations have been used in the diagnosis of GH deficiency. Recently, the free fraction of IGF-I has received more attention. The aim of the study was to assess the role of free IGF-I in the diagnosis of GH deficiency in adults, and in follow-up during treatment with recombinant human GH (rhGH)., Design and Patients: We studied 24 adult patients with pituitary disease and GH deficiency and 25 matched controls. Nine patients were re-evaluated after 6 months of treatment with rhGH (0.25 U/kg/week)., Measurements: Serum levels of IGF-I, free IGF-I, IGFBP-3 and IGFBP-1 were measured by immunoradiometric assay., Results: Serum free IGF-I levels were significantly lower in the GH deficient group than in the normal group (mean: 0.84 and 1.32 micrograms/l respectively, P = 0.0009). Furthermore, serum IGF-I levels were also lower (mean: 92.24 and 230.47 micrograms/l respectively, P < 0.0001). 63% of patients had serum IGF-I concentration below the normal range. For free IGF-I, 52% of the GH deficient patients showed levels below the lowest value obtained for the normal group. Seventy-five percent of the patients showed at least one of the two determinations below the normal range. The free-total IGF-I ratio was significantly higher (P = 0.025) in GH deficient group (range: 0.19-21.29, mean: 2.53) than in normal controls (range: 0.2-2.15, mean: 0.6). Regarding IGFBP-3 and IGFBP-1 no differences were observed between the two groups. During rhGH treatment the increase in serum total and free IGF-I and IGFBP-3 paralleled the beneficial effects on body composition., Conclusions: Free IGF-I may be another useful method for the diagnosis of GH deficiency, particularly if related to total IGF-I concentration.

Cerebral hemiatrophy or Dyke-Davidoff-Masson syndrome is a condition characterized by seizures, facial asymmetry, contralateral hemiplegia or hemiparesis, and mental retardation. These findings are due to cerebral injury that may occur early in life or in utero. The radiological features are unilateral loss of cerebral volume and associated compensatory bone alterations in the calvarium, like thickening, hyperpneumatization of the paranasal sinuses and mastoid cells and elevation of the petrous ridge. The authors describe three cases. Classical findings of the syndrome are present in variable degrees according to the extent of the brain injury. Pathogenesis is commented.

Meningiomas are benign tumors arisising from arachnoid cells and represent the commonest asymptomatic intracranial tumors. We analysed 69 supratentorial meningiomas managed by the Neurosurgical Tumor Group of the Clinics Hospital of Medicine School of São Paulo University (September 1995 to September 1997). Age, sex, edema degree, tumor site, surgical complications and mortality were studied. Edema degree was defined by radiological methods (CT and MRI). Forty-seven patients were women and average age was 58 years. Type II of edema degree was predominant (38.7%). Twenty-nine patients had parasagital meningiomas and 40 presented convexity tumors. Simpson I resection was obtained in 48 procedures, II in 18 and III in two surgical removals. Nine cases complicated (transitory deficits, 6; permanent deficit, 1; and infection, 2). Death occurred in two patients. Morbity and mortality had relation with age, falx tumors and attempt of radical surgical removal. Edema degree did not modify mortality and morbidity rates.

Neurosurgical treatment of neuropsychiatric illness has evolved considerably since its inception in 1935. The most common psychiatric indications for the procedure, including obsessive-compulsive disorder and major depression, are conceptualized as disorders involving the basal ganglia and limbic system. In this article, the various operations and their contemporary applications are discussed. Neurosurgical treatment represents a viable option in appropriate candidates suffering from severe and otherwise treatment-refractory neuropsychiatric diseases.

Surgery for space occupying lesions of the brain associated with intractable epilepsy represents a special problem because relief of the epilepsy in as much an operative goal as excision of the space occupying lesion itself. This study concerns 32 patients with space occupying lesions and intractable epilepsy who underwent excision of the lesion with acute intraoperative electrocorticography guided resection of the epileptogenic focus. Of the 32 patients, 16 formed a subgroup of gangliogliomas alone. The remaining were mixed lesions, predominantly benign. The duration of seizures in these patients ranged from 2 to 30 years, and the seizure frequency varied from 1 to 300 convulsions per month. The operative procedures included temporal corticectomy, amygdalo-hippocampectomy, and extratemporal corticectomies. Twenty nine patients were in Engel class I postoperatively, and three patients were in Engel class II. The findings with gangliogliomas were also considered in a separate group. This study strongly suggests that the operative procedure under electrocorticography guidance improves seizure outcome in space occupying lesions related intractable epilepsy.

This study discusses the results from the IAP and its lateralizing and prognostic value in patients with temporal lobe epilepsy (TLE) and mesial temporal sclerosis (MTS). Eighteen patients were submitted to the IAP. Fifteen had bitemporal and 3 unitemporal lobe epilepsies. All patients had MTS on MRI and in one there was an unrelated lesion in the contralateral hippocampus. Nine bitemporal patients passed after the injection ipsilateral to the MTS and 4 failed bilaterally. One bitemporal passed bilaterally. Seven of these bitemporal patients passed an injection ipsilateral to MTS and failed on contralateral injection. Two of the unitemporal lobe patients passed the ipsilateral injection and failed the contralateral one. One of the unitemporal lobe patients failed bilaterally the IAP. Overall, 56% of the group disclosed the pass ipsi-/fail contralateral pattern in the IAP. Eight patients were operated, are seizure free and had no additional memory deficit. Many patients with TLE were found to have the pass ipsi-/fail contralateral pattern in the IAP. This might prove to be of lateralizing and prognostic value in such cases.

Surgical procedures near to language related brain regions may cause severe morbidity in relation to speech. Operations performed under local anesthesia and intraoperative cortical mapping may minimize these risks. Six patients with tumors near the Wernicke's area were treated (2 low-grade astrocytomas, 1 ganglioglioma, 1 xanthoastrocytoma, 1 metastasis, 1 glioblastoma). Their clinical presentation consisted of epilepsy (n = 4) and dysphasia (n = 2). The skin and periosteum were infiltrated with local anesthetic and an ample craniotomy was performed. Cortical stimulation with an unipolar electrode was then carried out with concomitant speech testing (mainly comprehension and sequential speech). After mapping, the best surgical approach aiming to avoid the mapped area was elected. In 5 cases the resection was total and in 1, partial (glioblastoma). There was a transitory (10 days) worsening of the pre-operative deficit in 1 case (glioblastoma). In 3 patients, the speech areas were displaced: posteriorly (n = 2) or anteriorly (n = 1). Surgical procedures under local anesthesia are safe and may avoid post-operative language disturbances in patients with tumors near to Wernicke's area.

Nodular intracranial calcifications (NIC) are frequent findings in CT scans of epileptic patients in countries where granulomatous central nervous disease such as neurocysticercosis is endemic. In 34 consecutive epileptic patients with NIC submitted to EEG, CT and CSF analysis, the correlation between the electroclinical localization of the focus and the topography of the NIC was studied. Twenty-nine patients had partial (Group I) and 5 had primarily generalized seizures (Group II). Twenty group I and 1 group II patients showed abnormal EEGs. CSF abnormalities consisted of increased protein content (n = 3) and positive Weinberg's reaction (n = 2). In 2 cases, viable neurocysticercotic vesicles were seen. Twenty-one patients had single NICs. No correlation could be established in group II patients. Within group I, 15 patients had a positive and 14 a negative correlation. Sixty-six percent of the patients with single NICs had negative correlations. These findings strongly suggest that the calcifications themselves are not the epileptogenic lesions in at least 50% of the studied cases.

26 patients with temporal lobe epilepsy clinically documented by several abnormal interictal surface EEGs with typical unitemporal epileptiform activity and a normal CT scan were studied. Interictal 99mTC HMPAO brain SPECT and MRI were performed in all subjects. Abnormalities were shown in 61.5% of MRI (n = 16) and 65.4% of SPECT (n = 17). Hippocampal atrophy associated to a high signal on T2-weighted MRI slices suggesting mesial temporal sclerosis was the main finding (n = 12; 75% of abnormal MRI). MRI correlated well to surface EEG in 50% (n = 13). There was also a good correlation between MRI and SPECT in 30.7% (n = 8). SPECT and EEG were in agreement in 57.7% (n = 15). MRI, SPECT and EEG were congruent in 26.9% (n = 7). These results support the usefulness of interictal brain SPECT and MRI in detecting lateralized abnormalities in temporal lobe epilepsy. On the other hand, in two cases, interictal SPECT correlated poorly with surface EEG. This functional method should not be used isolately in the detection of temporal lobe foci. MRI is more useful than CT as a neuroimaging technique in temporal lobe epilepsy. It may detect small structural lesions and mesial temporal lobe sclerosis which are not easily seen with traditional CT scanning.

The authors studied 58 patients, under 12 years of age, admitted to the Emergency Room of the Sao Paulo University Hospital between September 1987 and November 1991 with the diagnosis of traumatic extradural hematoma. Emphasis was given to the etiology of injury, the time interval from head injury to emergency room evaluation, the clinical features and the outcome after surgical and nonsurgical management. The site of hematoma was defined and correlated with the presence of skull fractures. Computerized tomography is the main diagnostic method, although it is not definitive. Fifteen patients were treated nonsurgically according to rigid clinical and radiological parameters. The overall mortality rate was 3.4%.

Purpose: To study the incidence of cerebellar arteries originating directly from the internal carotid artery, and to discuss the probable embryological origin and clinical implications of this anatomical anomaly., Methods: We reviewed 5500 angiographic studies done at our institution in the last 4 years, searching for these anomalous vessels as well as for other anatomical variants., Results: Eleven cerebellar arteries originating directly from the internal carotid artery and nine embryonic cerebral arteries were found., Conclusion: These arteries are considered persistent trigeminal artery variants and seem to occur as the result of the persistence of a primitive trigeminal artery associated with an incomplete fusion of the longitudinal neural arteries. These anomalous vessels are clinically significant particularly because of their role in endovascular therapeutic and surgical complications and the paradoxical lesions in the cerebellum that occur as a result of carotid disease.

A new form of clinical treatment is proposed for dystonias and torticollis using flunitrazepam (FN), a powerful agonist of all benzodiazepine receptors of GABA neurons. FN has a specific effect in dystonic patients, specially those in which the hypnotic effect of this drug is absent or diminished, thus suggesting the existence of two different neurochemical categories of dystonias.

We successfully treated by nonsurgical methods 15 children with laminar epidural hematomas (EH), with minimal neurological symptoms and no signs of brain herniation. These EH were discovered 30 minutes to 5 days after head injury. The majority were localized in the parietal region. All children recovered without surgery from 2 to 12 days after hospitalization and all had evidence on CT scan of spontaneous clot reabsorption. We discuss the criteria for patient selection for this kind of treatment on EH in children.

The cases of two children with traumatic extradural hematoma with an early normal CT scan are reported. Consciousness impairment occurred in them respectively 20 and 60 hours after admission, and CT at this occasion evidenced extradural hematoma. Serial neurological examinations are recommended for children with large traumatic cephalohematoma associated or not to skull fracture and in whom an initial early CT was normal, since they can lately develop extradural hematoma.

In a 33 years-old epileptic woman with a traumatic impact to the vertex, clinical and radiological studies (skull X-R, CT and MRI) disclosed an extensive callosal section under the topography of the falx, associated to fronto-basal contusions. There was a significant improvement in the epileptic syndrome. No interhemispheric disconnection syndrome could be determined, which is compatible with the posterior regions of the corpus callosum having been spared. This is, to the best of our knowledge, the most extensive callosal injury documented by MRI to date.

Pre-surgical evaluation of epileptic patients consists of neurological examination, intensive electroencephalographic (EEG) monitoring and anatomical studies (CT and MRI). Functional methods such as PET and SPECT imaging are now used more frequently. We have studied pre-operatively 15 adult epileptic patients (8 female, 7 male) using a rotational scintillation camera interfaced to a dedicated computer. The tomographic images were obtained 15 minutes after intravenous injection of 99mTc-HMPAO. All had MRI scanning and intensive EEG monitoring which generally included seizure recording. Five patients had progressive lesions (3 meningiomas, 2 astrocytomas). In 10 patients, neuroradiological studies did not show the presence of progressive lesions (2 normal scans and 8 cases with inactive lesions). Two patients with meningioma showed hypoperfusion at the lesion site while the third patient had a marked hyperperfusion which might correlate with the clinical diagnosis of epilepsia partialis continua. In the astrocytoma patients SPECT scans showed hypoperfusion at the lesion site. Data obtained from the 10 patients without progressive CNS lesions showed: (a) in 4, SPECT findings correlated well with the anatomical findings; (b) in 5 instances, SPECT was able to disclose additional functional deficits; (c) in one case, there was no SPECT correlate of a discrete anatomical lesion. In 5 of these cases with no progressive lesions (n = 10) SPECT findings were useful as a complementary tool in determining the clinical or surgical management of these patients. Despite the small number and heterogenicity of the present sample, SPECT seems to be an useful tool as part of the clinical workup of epileptic patients who are candidates for epilepsy surgery.

A 32 years old woman who had postural limbic and primarily generalized tonic-clonic seizures since the age of 11 presented to us with a CT image strongly suggestive of a mesial meningioma near the right cingulum. Her ictal EEG pattern was characterized by regular 1.5-2.0 Hz sharp and slow wave complexes. A right craniotomy was performed under general anesthesia and intraoperative electroencephalographic and electrocorticographic recordings were obtained by means of scalp steel electrodes and modified cerebellar stimulation electrodes, respectively. These recordings demonstrated that surface spikes were often independent from the electrocorticographically recorded ones. Before tumor excision, electrical stimulation of the peritumoral mesial cortex resulted in an increase in the epileptic activity. The stimulation of the cavity left after tumor excision led to a prolonged electrographic seizure and neurophysiological procedures were stopped. Post-operatively, the patient has remained seizure free for 6 months and her EEG was normal. The pre-, intra- and postoperative findings in this case suggest that the gliotic peritumoral mesial cortex was at least involved in the epileptogenic process.

Two acromegalic patients with severe headache, persisting after pituitary adenomectomy followed by radiotherapy in one, were treated with the somatostatin analogue SMS 201-995. Both had been resistant to conventional headache therapy and experienced dramatic and rapid relief after the first injection of the analogue. This result persisted with long-term treatment of the drug. Although the mechanism of action of SMS 201-995 in pain remains unclear, the rapid and efficacious analgesic effect of this compound may be one more indication for its use in pituitary tumors associated with cephalalgias.

A 30 year old woman with primary hypothyroidism due to an ectopic (sublingual) thyroid, with a pituitary tumour invasive to the sphenoidal sinus presented with hyperprolactinaemia, amenorrhoea and galactorrhoea not corrected by long-term thyroid replacement. High basal TSH and TRH hyperresponsiveness were suppressed by thyroid therapy. After transsphenoidal removal of the tumour the Prl returned to normal. Light microscopy including differential staining and immunocytochemistry demonstrated that the tumour was composed of TSH cells. Ultrastructurally the adenoma cell contained small granules (90-150 nm) as described in TSH cells. This case provides evidence that a TSH cell adenoma probably arising from protracted overstimulation secondary to thyroid deficiency can induce hyperprolactinaemia. This did not appear to be produced directly by the adenoma nor was there any evidence of compression of the pituitary stalk.

The authors have studied psychiatrically, pre and post-operatively, a series of 31 cases operated upon for temporal lobe epilepsy. They have concluded that medically uncontrollable limbic epilepsy is associated in its physiopathological substrate to: pathological irritability, affective tenacity, impulsiveness, epileptic cognitive dysfunction and abstraction deficiencies of intellectual process. The high incidence of these events in the patients studied demonstrate the existence of a causal relationship between these abnormalities and the limbic epilepsy. Unilateral temporal lobectomies have been demonstrated to be very efficient for the control of epileptic seizures, whose frequency was remarkably reduced post-operatively. The operation resulted in a major reduction of the psychiatric manifestations of pathological irritability, impulsiveness, epileptic cognitive dysfunction and the instability of abstraction capacity produced by affective impacts. Affective tenacity was ill affected by the surgical procedure, although a favourable effect was noticed. The presence of bilateral temporal foci did not decrease the efficacy of the surgical intervention, nor its effect on the seizures or the effect of surgery on the studied psychopathological changes.

Several studies on epidemiology of epilepsy were carried out in different parts of the world. However, the majority of their data was collected from hospitals, clinics, individual physicians and or small communities. Although these studies have contributed to our knowledge as to the risk factors of epilepsy, some of them have prevented us from further generalization, since the prevalence rates of the phenomena were not known for the entire population where from they were derived. Latin America has remained without epidemiological data, specially prevalence rates, for many years. A house-to-house survey was programmed by the Brazilian League of Epilepsy in the urban area of S. Paulo City the third largest cosmopolitan city in the world: 13 million inhabitants in 1980. A significant sample of 2011 houses was chosen by statistical means. A total of 7603 interviews were performed by 50 senior medical students and nurses, and 388 persons were considered suspect and further referred to our University Hospital for other studies; 348 of these were examined, and in 91 the diagnosis of epilepsy was confirmed, thus producing a prevalence rate 11.9 per 1000.

Corpus callosum stimulation produced by chronically implanted electrodes, placed either by craniotomy or stereotactically, failed to control refractory generalized epilepsy in humans and also in experimentally produced penicillin epilepsy in cats. However, the patients that suffered craniotomy, frontal lobe retraction or pneumoencephalograms, without callosal section, showed remarkable improvement of their seizure condition due to these unspecific manipulation effects. Stereotactic anterior callosotomy emerged as a sequel of these functional neurosurgical findings, and as an alternative procedure to preclude undesirable neuropsychological and neurological side effects of split brain syndrome and of brain retraction, associated to conventional callosotomy. Ten patients with various disabling convulsive disorders have undergone this new operation, which showed to be less traumatic and better tolerated than open callosotomy.

A series of modified gyratory bayonets instruments is described. They have the advantage to allow any adjustable position within a 360 degree rotation angle, during the various surgical steps of transphenoidal surgery, thus keeping the surgeon's hand always at the same position.

The author presents a survey of his experience with the use of benzoin as an aid to prevent and to treat wound complications as: CSF leakage ruptured meningoceles, prevention of leakage and wound infections, during the use of external cranial drainage, indwelling catheters or implanted cannulas and electrodes. A few other handy uses are also mentioned.

This article is a corrollary of a previously published anatomical study of the anterior cerebral artery. The authors propose a method to obtain a computer model of the anterior cerebral artery, based on a combined system of stereotaxic coordinates and a specially developed computer program. The graphic analysis, thus obtained, is projected on a model atlas brain and an ideal diagram of this anatomical structure is obtained. Forty anatomical specimens were used for this study.