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Publicações | 2017

Intraoperative Ultrasonography for Definition of Less Invasive Surgical Technique in Patients with Chiari Type I Malformation.

Brock RS, Taricco MA, de Oliveira MF, de Lima Oliveira M, Teixeira MJ, Bor-Seng-Shu E. World Neurosurg. 2017 May;101:466-475.  

Abstract:

 

INTRODUCTION:

Chiari malformation type I (CM) is the main congenital malformation disease of the craniovertebral junction. The ideal surgical treatment is still controversial. Invasive procedures inside the cerebrospinal fluid (CSF) space and associated with dural repair are considered the gold standard; however, less invasive surgery with isolated bone decompression without dural opening may be possible in selected patients. Our study evaluates the efficacy of intraoperative CSF flow measurement with ultrasonography (USG) as a determining parameter in the selection of these patients.

 

METHODS:

We analyzed prospectively 49 patients with CM operated on at the Hospital das Clínicas, College of Medicine, University of São Paulo. Patients underwent decompressive surgery with or without opening of the dura mater after intraoperative USG measuring flow rate. A value of 3 cm/second was considered a cutoff. Quality of life before and after surgery and the improvement of neck pain and headache were evaluated.

 

RESULTS:

Among 49 patients enrolled, 36 patients (73%) had CSF flow >3 cm/second and did not undergo duraplasty. In 13 patients (27%) with initial flow <3 cm/second, dural opening was performed together with duraplasty. All patients improved when preoperative and postoperative scores were compared, and all clinical parameters evaluated did not differ between both surgical groups. Patients submitted to bone decompression alone had a lower complication rate.

 

CONCLUSIONS:

Intraoperative USG with measurement of CSF allows the proper selection of patients with CM for less invasive surgery with bone decompression without duraplasty.

Brazilian Academy of Neurology (2006 - 2016). 

Coelho FM, Castro LH, Fukujima MM, Adoni T, Rieder CRM, Bichuetti DB, Prado GFD, Gagliardi RJ. ArqNeuropsiquiatr. 2017 Sep;75(9):635-638.

Abstract:

 

Brazil is a heterogeneous country with continental dimensions. The diferente characteristics of cultural, socioeconomic, and demographic status of the population drive different strategies for neurological care. This knowledge helps the understanding of the current scenario with the consequent possibility of preparing for future challenges. We used data from annual internal forms of the Brazilian Academy of Neurology (BAN) since 2006 and the survey for all BAN members (3,240) in 2016. The geographic distribution of BAN members in Brazil follows the demographic concentration of the population. Participation of members from big cities was the most prevalent, 18.7% of participants were Young neurologists, and 36.7% of neurologists had more than of 20 years of neurological practice. The improvement of knowledge of neurological practice in Brazil will be useful for BAN leadership in planning future actions. The BAN must make an effort to aggregate a greater number of neurologists, offering updating support contributing to health policies to disseminate neurological care in Brazil.

Abstract:

 

OBJECTIVE:

Vitamin D has taken center stage in research and treatment of multiple sclerosis (MS). The objective of the present study was to assess the sérum vitamin D levels of a large population of patients with MS and controls living in a restricted tropical area.

 

METHODS:

Data from 535 patients with MS and 350 control subjects were obtained from 14 cities around the Tropic of Capricorn.Results: The mean serum 25-OH vitamin D level was 26.07 ± 10.27 ng/mL for the control subjects, and 28.03 ± 12.19 ng/mL for patients with MS. No correlation was observed between vitamin D levels and the disability of patients over the disease duration.

 

CONCLUSION:

At least for the region around the Tropic of Capricorn, serum levels of vitamin D typically are within the range of 20 to 30 ng/mL for controls and patients with MS.

Orbital Compartment Syndrome After Frontotemporal Craniotomy: Case Report and Review of Literature.

Pahl FH, de Oliveira MF, Dal Col Lúcio JE, Souza E Castro EF. World Neurosurg. 2018 Jan;109:218-221. 

Abstract:

 

INTRODUCTION:

Orbital compartment syndrome (OCS) is a rare condition characterized by increased intraorbital pressure and hypoperfusion of critical neural structures. It is usually associated with external ophthalmoplegia. We report a case of postoperative OCS following a frontotemporal craniotomy and review pertinent literature.

 

CASE DESCRIPTION:

A 3-year-old female patient presented with a 3-year history of refractory epilepsy and diagnosis of right frontobasal cortical dysplasia. She underwent an elective frontotemporal craniotomy to allow resection of dysplastic cortex. The intraoperative period was uneventful. Postoperatively, following removal of operating fields, we noticed proptosis and right periorbital swelling. A diagnosis of orbital compartment syndrome was made. At the pediatric intensive care unit, the patient underwent an emergency right lateral canthotomy with wide inferior and superior cantholysis. Nowadays she is in the fourth month of postoperative follow-up. There is still slight and almost indistinguishable exophthalmos, but her extrinsic eye movement ranges and reaction to light are normal.

 

DISCUSSION:

OCS is a rare ophthalmologic emergency characterized by an acute rise in orbital pressure and may result in complete irreversible blindness if not rapidly treated. The frontotemporal or "pterional" craniotomy exposure requires a myocutaneous flap to be retracted anteriorly and inferiorly near the orbit. There may be orbital compression due to this flap leading to potential harmful complications. Attention to factors such as direct ocular pressure from skin flaps, congestion from head positioning, and adequate intraoperative eye protection may reduce the risk or allow faster management.

Abstract:

 

METHODS:

Series of cases collected from Brazilian centers.Results: We studied 13 cases of patients presenting with progressive histories of neurological dysfunction caused by SS-CNS. The most frequent clinical findings in these patients were progressive gait ataxia, hearing loss, hyperreflexia and cognitive dysfunction. The diagnoses of SS-CNS were made seven months to 30 years after the disease onset. Conclusion: SS-CNS is a rare disease that may remain undiagnosed for long periods. Awareness of this condition is essential for the clinician.

Abstract:

METHODS:

Thirty cases, previously treated according to the new algorithm, were presented to four spine surgeons who were questioned about their personal suggestion for treatment, and the treatment suggested according to the application of the algorithm. After four weeks, the same questions were asked again to evaluate reliability (intra- and inter-observer) using the Kappa index. Results: The reliability of the treatment suggested by applying the algorithm was superior to the reliability of the surgeons' personal suggestion for treatment. When applying the upper cervical spine injury treatment algorithm, an agrément with the treatment actually performed was obtained in more than 89% of the cases.

 

CONCLUSION:

The system is safe and reliable for treating traumatic upper cervical spine injuries. The algorithm can be used to help surgeons in the decision between conservative versus surgical treatment of these injuries.

Microsurgical treatment of basilar tip aneurysms: is it still acceptable? 

Pahl FH, Oliveira MF, Rotta JM. Arq Neuropsiquiatr. 2017 Oct;75(10):697-702.

Abstract:

 

OBJECTIVE:

Basilar tip aneurysms (BTAs) have a complex anatomy, making them difficult to treat. We describe our surgical results for BTAs.

 

METHODS:

From 2004 to 2015 (12 years), a total of 25 small BTAs and two giant BTAs were treated in the Hospital do Servidor Público Estadual de São Paulo.

 

RESULTS:

In 23 patients harboring aneurysms positioned anteriorly or straight, all aneurysms were clipped (complete exclusion in all on follow-up angiography). In two patients with posteriorly positioned aneurysms, there was residual neck. All patients submitted to surgical treatment of small aneurysms presented with late Glasgow Outcome Scale scores of 4 or 5. Two patients with giant aneurysms died.

 

CONCLUSION:

Surgical treatment of these lesions may be accomplished with quite high success rates and low morbidity.

The Timed Up and Go Test as a Diagnostic Criterion in Normal Pressure Hydrocephalus.

Mendes GAS, de Oliveira MF, Pinto FCG. World Neurosurg. 2017 Sep;105:456-461.

Abstract:

 

INTRODUCTION:

Normal-pressure hydrocephalus (NPH) is a disease characterized by gait disturbance, urinary incontinence, and dementia. Our objectives were to define an average value of the test for the population, check the specificity and test sensitivity as evaluation criteria and diagnostic testing, and correlate with other already used more frequently.

 

METHODS:

A study conducted at the Neurosurgery Division of the Hospital do Servidor Público Estadual de São Paulo in which a group of 30 patients with NPH was submitted to the Mini-Mental State Test Examination, Time Up and Go (TUG), test and Japanese scale for NPH before the Tap Test 3 hours and 72 hours after the Tap Test. After being subjected to ventriculoperitoneal shunt, patients were evaluated 3 months, 6 months, and 12 months after surgery. A control group was used composed of 30 individuals of the same age and who had no diagnosis of NPH who were submitted to the TUG test to determine an average, which was compared with that of patients with NPH.

 

RESULTS:

TUG did not show good correlation with other tests used, but there was excellent specificity (0.967) and sensitivity (0.933) for cut-off value of 16.5 seconds for the diagnosis of NPH.

 

CONCLUSIONS:

TUG is a good test for the diagnosis of NPH because there is very good specificity and sensitivity, with a mean value of 16.5 seconds as the cut-off.

The number of burr holes and use of a drain do not interfere with surgical results of chronic subdural hematomas.

Heringer LC, Sousa UO, Oliveira MF, Nunes AS, Alves KA, Zancanaro ML, Botelho RV. Arq Neuropsiquiatr. 2017 Nov;75(11):809-812.

Abstract:

 

Burr hole evacuation has been the most frequently-used procedure for the treatment of chronic subdural hematomas (CSDH).

 

OBJECTIVE:

To evaluate whether the use of a drain and/or the number of burr holes for treatment of CSDH modifies the rates of recurrence and complications. METHODS: A retrospective review of 142 patients operated on because of CSDH, between 2006 and 2015, analyzing recurrence and complications of the use of one or two burr holes with or without the use of a drain.

 

RESULTS:

Thirty-seven patients had bilateral CSDH (26%) and 105 (73.9%) patients had unilateral CSDH. Twenty-two (59.4%) patients were given a drain and 15 (40.6%) were not. A total number of recurrences occurred in 22 (15.5%) patients and the total number of complications was in six (4.2%) patients. Mean follow-up time was 7.67 months.

 

CONCLUSIONS:

The number of burr holes and the use of the drain did not alter the rates of recurrence and complications in the treatment of CSDH.

Effect of kyphoplasty in the treatment of osteoporotic vertebral fractures compared to vertebroplasty - Overview of systematic reviews.

Botelho RV, Diniz JM, Sousa UO, Mudo ML, Oliveira MF. Arquivos Brasileiros de Neurocirurgia/Brazilian Neurosurgery. Arq Bras Neurocir 2017; 36(04):217-224. 

Abstract:

 

INTRODUCTION:

Vertebroplasty and kyphoplasty are possible options for vertebral augmentation after osteoporotic fractures. Both are percutaneous techniques with specific advantages and disadvantages. Our aim is to compare the clinical and radiological results of these two procedures.

 

METHODS:

An overview of published systematic reviews in the literature on the effects of kyphoplasty compared with vertebroplasty was performed.

 

RESULTS:

After short and long follow-up, the kyphoplasty group had lower pain scores on the visual analogue scale (VAS), lower scores in the Oswestry Disability index (ODI), greater restoration of the vertebral body height and lower kyphosis angle in the immediate postoperative period. There was less leakage of cement to the vertebral canal and extraspinal spaces.

Malignant transformation of low-grade gliomas in patients undergoing adjuvant therapy.

Rotta JM, de Oliveira MF, Reis RC, Botelho RV. Acta Neurol Belg. 2017 Mar;117(1):235-239.

Abstract:

 

Low-grade gliomas (LGG) comprise nearly 15-20 % of all central nervous system glial tumors. Several factors have been recognized as playing role in LGG malignant transformation (MT). A breakthrough analysis of a multidisciplinary group pointed that temozolomide may play a role in MT of LGGs. We analyzed the prevalence of MT in LGG patients submitted to adjuvant therapy (AT). We analyzed the medical charts of 43 patients with LGG submitted to surgery or biopsy and attending at Hospital do Servidor Público Estadual de São Paulo (São Paulo, Brazil), consecutively diagnosed from 1995 to 2013. 43 patients (24 women and 19 men) were evaluated, with mean age of 45.3 years. According to histology, 30 were astrocytomas (70 %), 12 (27 %) were oligodendrogliomas, and 1 (3 %) were mixed glioma. Mean follow-up time was 4.2 years with the standard deviation of 2.1. Twenty-eight patients did not receive adjuvant therapy and 15 received adjuvant therapy. From 43 patients with complete follow-up, 21 (48 %) experienced malignant transformation. Among such patients, nine were users of AT. Forty-eight percent of patients presented MT, being 60 % in the AT group and 42.8 % without AT. Our analysis revealed a high prevalence of MT in patients undergoing AT, higher than in patients without AT.

Abstract:

 

A 65-year-old right-handed businessman presented with a 3-month history of worsening muscle twitching and painful proximal muscle spasms, excessive sweating, constipation, cold hands, and a burning sensation in his feet. He had lost 10 kg and his wife reported that he seemed to have hallucinations during sleep. He had no relevant family or alcohol history, and was an ex-smoker with a 10 pack-year history. 

Abstract:

 

INTRODUCTION:

Epidermoid tumors represent approximately 0.3 to 1.8% of all intracranial brain tumors. Only 1.5% of all intracranial epidermoid cysts (ECs) invade the brain and secondary epilepsy is extremely rare. Since August 2014, a 59-year-old male smoker had been presenting bad smell feelings, totaling four episodes with sudden onset and duration of 2 minutes. On September 2014, after a  sense of smell episode, it evolved into loss of contact and automatic movements followed by generalized tonic-clonic movements. The brain magnetic resonance imaging revealed an extensive subtemporal lesion affecting anterior, middle, and  posterior fossa with invasion of the choroidal fissure and projection to the temporal horn of the lateral ventricle. Pretemporal craniotomy with combined approaches, transsylvian and subtemporal, allowed for the excision of a White keratinized and softened lesion suggestive of EC. Discussion  The optimal surgical strategy in individuals with ECs and seizures is not established. The evaluation of the cause and risk-benefit must be held to choose the appropriate surgical strategy: lesionectomy, lobectomy, or amygdalohippocampectomy. In this case, a lesionectomy was performed due to an absence of evidence of involvement of hippocampus and amygdala. Conclusion  Epilepsy secondary to ECs is a rare association. Lesionectomy can be an option with good results without increasing the morbidity.

VIM thalamotomy in the treatment of Holmes' tremor secondary to HIV-associated midbrain lesion: a case report.

Oliveira JO Jr, Jorge Cecilio SA, Fernandes Oliveira M, Takahashi LR, Galassi AR, Holanda VM, Rotta JM. J Neurosurg Sci. 2017 Oct;61(5):544-546. 

Abstract:

 

Holmes' tremor (rubral tremor, cerebellar outflow tremor) is characterized by rest, intention and postural tremor, often localized to one upper extremity, associated with ipsilateral dysmetria and dysdiadochokinesia. We describe a case of successful treatment of Holmes' tremor with unilateral nucleus ventralis intermedius (VIM) thalamotomy. The subject is a 43-year-old woman with unremarkable previous medical history. She presented with complete left hemiparesis in the context of human immunodeficiency syndrome and the magnetic resonance image disclosed a contrast-enhancing lesion in right brain peduncle, in topography of red nucleus. She developed a progressive rest, intention and postural tremor in left upper limb. She was submitted to a stereotactic biopsy and the tremor became worse. She performed awake right VIM thalamotomy, with immediate complete resolution of tremor. There were no complications after procedure, and the result is stable after six months. We highlight the role of thalamotomy in cases like ours, once patient recovered well and, due to HIV, will need further neuroimage studies to evaluate neurologic complications of HIV. Deep brain stimulation in such cases may interfere with coming neuroimage quality and may act like a foreign body.

Retrograde endovascular approach for treating unruptured basilar apex aneurysms: report of 2 cases and review of literature.

Rotta MAC, Dias GMS, Rezende AL, Pahl FH, Oliveira M.F., Rotta JM. Arq Bras Neurocir 2017; 36(02): 128-132. 

Abstract:

 

BACKGROUND:

Treatment of target lesions when parent vessels are injured or diseased may be quite difficult. Moret et al have proposed an endovascular technique based on retrograde transcirculation approach through communicating vessels. Methods We report on the first Brazilian experience with retrograde endovascular approach, to the best of our knowledge. Results The two cases illustrate difficult anterograde approach techniques to treat basilar apex aneurysms. In the first case, tortuosity and angulation of both vertebral arteries associated to stenosis did not allow an anterograde approach. In the second case, after a SAH of a basilar apex aneurysm treated more than a decade ago with bilateral vertebral artery trapping, the patient underwent a retrograde approach. Conclusion For this approach, follow-up data are still lacking and complications are usually more common than in anterograde approach. Nevertheless, in select cases, it may be applied by experienced hands with acceptable risks when no other treatment option (surgical or endovascular) is available. 

Revisiting retrograde ventriculosinus shunt as an alternative for treating hydrocephalus in children.

Oliveira MF, Teixeira MJ, Oliveira ML, Bor-Seng-Shu E, Pinto FCG. Arq Bras Neurocir 2017; 36(02): 108-116.

Abstract:

 

INTRODUCTION:

Retrograde ventriculosinus shunt (RVSS) is a useful option in the daily routine of neurosurgeons dealing with hydrodynamics. The objective of this manuscript is to review the main data about RVSS. Methods We performed a critical review. The keywords used were hydrocephalus, shunt, venous sinus, ventriculosinus shunt, retrograde ventriculosinus shunt, and sagittal sinus. The search was performed in the Medline (Pubmed) and EMBASE databases. Results Van Canneyt et al (2008) and Pinto et al (2016) performed experimental studies confirming the effectiveness of RVSS. El Shafei et al (1985, 1987, 2001) authors reported several cases treated with efficacy and few complications. Oliveira et al (2015, 2016) compared RVSS and ventriculoperitoneal shunt (VPS) in the treatment of hydrocephalus after myelomeningocele repair in infants, with similar functional results. Oliveira et al (2015, 2016) also described the applicability of RVSS in situations when VPS is not feasible, or when the peritoneum is not useful. Discussion Retrograde ventriculosinus shunt is a safe and more physiological option, which requires the use of less prosthetic material. It is feasible and applicable. Especially in children, it generates a normotensive state after shunting, allowing centrifugal head growth, once there is no intracranial hypotension due to overdrainage, which may reflect in long-term better psychomotor development. Conclusions The surgical technique of RVSS is feasible. The clinical results are comparable with those of the VPS.

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