Volume 27 - nº 2 - abril / maio / junho 2016

  • Volume: 27
  • Número: 2
  • Período: abril / maio / junho 2016
  • ISSN (versão impressa): 0103-5118
  • e-ISSN (versão online): 2446-6786
  • Editor: Ricardo Ramina - Curitiba/PR

Artigo completo

Gustavo Simiano Jung, Ricardo Ramina, Erasmo Barros da Silva Jr, Maurício Coelho Neto

Atypical and anaplastic meningiomas (WHO grade II and III) are uncommon tumors with poorer prognosis than benign meningiomas. They represent a small and heterogeneous subgroup of meningiomas that has more aggressive biological nature and higher frequency of recurrence. Treatment of these tumors remains challenging and recurrence is common even after gross total resection. We report five year experience of an experienced neurosurgical center (INC) reviewing treatment options and predictor of treatment outcomes for malignant meningiomas.
Key words: Anaplastic meningioma; Atypical meningioma; Prognostic factor

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Leticia Marissol de Souza Francisco, Maick Willen Fernandes Neves, Telmo Augusto Barba Belsuzari, Paulo Henrique Pires de Aguiar, João Flavio de Araújo Mattos

Introduction: Pituitary adenomas are benign tumors that are classified into functioning and nonfunctioning adenomas. The diagnosis is based on the clinical picture and MRI. The first-choice treatment is usually surgery. Objective: We aimed to evaluate the hormonal complications in the postoperative period of pituitary adenomas resection. Methods: Using the databases PubMed, MedLine, and Scielo, the terms “pituitary adenoma” and “postoperative” were investigated and 11 publications were selected, written in English and Portuguese between 2007 and 2016 to evaluate hormonal complications in the postoperative period of pituitary adenomas resection. Results: Nonfunctioning tumors were more frequent and occurred along with hypopituitarism, mainly affecting the gonadotrophic axis. Among the functional adenomas, prolactinomas were more common. The rate of postoperative hypopituitarism varied from 1.29% to 21.2% and the diabetes insipidus rate was from 5.1% to 15.7%. Hypopituitarism or panhypopituitarism, adrenal insufficiency, growth hormone deficiency and diabetes insipidus occurred in the postoperative period. Conclusion: Nonfunctioning adenomas are more common and present hypopituitarism. Prolactinomas and somatotrophinomas are the most frequent tumors among functioning adenomas; hypopituitarism is a frequent complication due to the compression and destruction of the pituitary gland, which may be the result of the surgical manipulation itself. Diabetes insipidus is another common surgical complication.
Key words: Postoperative; Pituitary Adenoma; Diabetes insipidus; Panhypopituitarism.

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Juliano Nery Navarro, Renato Andrade Chaves, Tatiana Peres Vilasboas Alves, Francisco de Assis Ulisses Sampaio Junior, Mariano Ebram Fiore, Bartolomeu Souto Queiroz Quidute

Background: Cerebrospinal fluid shunting is the most commonly performed surgical procedure in the management of hydrocephalus. Although frequently performed, this procedure is not free of complications. Case description: We report a case of non-described shunt migration, in which the ventricle-peritoneal catheter, at the mediastinum level, crosses to the contralateral side. Conclusion: When we are faced with complications after ventriculoperitoneal shunt surgeries, we should consider unusual or even unpredictable possibilities.
Key words: Ventriculoperitoneal shunt; Complications; Migration; Hydrocephalus

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Juliano Nery Navarro, Renato Andrade Chaves, Tatiana Peres Vilasboas Alves, Francisco de Assis Ulisses Sampaio Junior, Bartolomeu Souto Queiroz Quidute

Postlaminectomy Syndrome and Failed Back Surgery Syndrome are diseases described in the literature that contemplate the persistence of low back pain in patients submitted to lumbar spine surgeries. We report a case of a patient in the postoperative period of Lumbar Arthrodesis, who develops lumbosciatalgia after initial improvement of symptoms, coming from an unusual condition.
Key words: Failed Back Surgery Syndrome; Postlaminectomy Syndrome; Postoperative pain

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Alejandra Jaume, Daniel Wilson, Matías Negrotto, Ignacio Aramburu, Roberto Crosa, Mariana Romero

Introduction: Cerebral vascular malformations have an incidence of 6%, and are classified in many ways depending on topography, morphology, and / or demographics. With respect to the latter division, these malformations can be classified into malformations nonproliferative or proliferative type. Proliferative lesions are divided into: Moya-Moya (M-M), proliferative cerebral angiopathy (ACP), and hemangiomas. Materials and Methods: First a case of a patient who was assisted in the Endovascular Neurological Center, where he researches and diagnosis of vascular proliferative lesion, being operated to treat your intraventricular hemorrhage with hydrocephalus occurs. From this illustrative case an update on this pathology was performed. Discussion: The APC is a rare malformation, with a frequency of 3.4% and the M-M has a higher incidence in Japan (3: 100,000). Both have more frequent in females, but the APC usually occurs at age 22, while the M-M presentation has two peaks, one at 5 and one to 40 years. Usually this type of proliferative lesions present clinically as strokes (CVA) of ischemic cause. The study gold standard for the diagnosis of these malformations is cerebral angiography. APCs are malformations of large size may occupy a lobe or entire hemisphere, with countless vessels extending between neurons and normal white substance. In most cases treatment is intended to improve circulation hypoperfusion in order to prevent further ischemic events. Conclusion: It is important to diagnose this type of injury time, as well as differentiate proliferative angiopathy or Moya moya, other types of malformations, as it has implications for treatment and prognosis.
Key words: Vascular malformation; Proliferative lesions; Ischemic; Endovascular treatment; Surgery; Prognosis

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Vinicius Ricieri Ferraz, João Luiz Vitorino Araújo, Alexandros Theodoros Panagopoulos, Guilherme Brasileiro de Aguiar, José Carlos Esteves Veiga

Introduction: Lung cancer, breast cancer, renal cell cancer, gastrointestinal carcinoma, and melanoma are common sources of cerebral metastasis. Brain metastasis from malignant gynecological tumors are considered rare. According to the literature, fewer than 3% of all brain metastases originate from gynecological lesions. The primary mechanism of metastatic spread from genital tract cancers to the brain is through the hematogenous rout. The endometrial carcinoma metastasis to the brain is a very rare event. The objective of this study is to describe this rare event and conduct a brief review of the literature. Case description: We report on a unique case of a cystic endometrial adenocarcinoma metastasis treated by neurosurgical procedure. The patient underwent “en bloc” tumor resection guided by neuronavigation and there were no complications during surgery. After discharge, she underwent whole brain radiation therapy, currently makes quarterly outpatient follow-up and showed no signals of tumor recurrence. Conclusion: In this article we present a case of cystic brain metastasis from an endometrial adenocarcinoma that was successfully treated by neurosurgery tumoral resection. To our knowledge, this condition has not been reported previously in the literature.
Key words: Brain Neoplasms; Endometrial Carcinoma; Neurosurgery; Oncology

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Leonardo Carmo Kawakame da Silva, Rodrigo Eiji Nakagawa, Luis Alencar Biurrum Borba, Johnni Oswaldo Zamponi Júnior, Tiago Gonçalves Rosa, Matheus de Quadros Ribeiro

Background: Intramedullary intradural tumors are rare lesions that correspond to about 2-4% of CNS neoplasms and 8-10% of spinal cord tumors. The most common tumor type is ependymoma, followed by astrocytomas and hemangioblastomas, the symptoms are insidious and nonspecific being the pain the most common complaint. The diagnosis is made by MRI and by means of the anatomopathological examination, and the recommended treatment is surgical resection. Objective: To characterize the patients in relation to mean age, gender frequency, tumor type, topographic location more frequent, degree of resection of the lesion, preoperative neurological status of the patient and prognosis in the post-surgery. Methods: Retrospective review, from 2005 to 2016, of medical records of adult patients undergoing surgery for intramedullary tumors was performed. The ethics committee approved this study. Data were collected regarding demographics, clinical and radiological characteristics and surgical details. The modified McCormick scale was used to assess patients’ neurologic status on admission, discharge and follow-up. The Chi-square test was used to evaluate the association between qualitative variables. Values of p <0.05 were considered as statistically significant. Results: Thirty-six cases were reviewed. The mean age was 51.04 ± 17.05 years, while the mean follow-up was 12 months (range: 0.25-112 months). The most commonly histological type of lesion found was ependymoma (n = 18; 50%), followed by astrocytoma (n = 11, 30.55%) and hemangioblastoma (n = 5; 13.88%). The cervical region was the most commonly involved (n = 17; 47.22%), followed by the lumbar (n = 11; 30.55%) and thoracic (n = 8; 22.22%) regions. Total resection was obtained in 27 cases (75%). The preoperative McCormick grade was significantly associated with the follow-up McCormick grade (p value = 0.002). Five patients proceeded to postoperative radiation therapy. Twenty-eight patients (77.78%) had progression-free survival at the last follow-up. Preoperative neurological status was associated with a better postoperative McCormick score at p<0.05. Conclusion: Preoperative neurological status and the degree of surgical resection of the lesion were significant predictive factors of better postoperative outcomes in patients submitted to intramedullary intradural tumors at a reference hospital in Southern Brazil. The histological type of the lesion did not present significant results in relation to the patients’ survival.
Key words: Intramedullary intradural tumor; Spinal cord tumors; Intramedullary ependymomas; Intramedullary astrocytomas

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Ivam Sousa Barbosa Júnior, Satyaki Navinchandra, Rômulo Alberto Silva Marques, Rodrigo Alves de Carvalho Cavalcante, Vladimir Arruda Zaccariotti, Osvaldo Vilela Filho

Cancer pain is one of the main stigmas on oncologic patients. Long considered irreversible and irremediable, forcing patients to live with it through their lifetime. The surgical treatment of cancer pain has ablative and non-ablative options, including rostral mesencephalic reticulotomy. We described a 08 cases series of oncologic patients who underwent midbrain rostral reticulotomy for intractable pain treated at Brazilian midwest reference center of oncology, Araújo Jorge Hospital. The results were compared with literature review to demonstrate that the efficacy of the main articles published are reproducible in a safe way, resulting in improvement in the quality of life, the pain perception, as well as the suffering related to complex, mixed characteristics (neuropathic / nociceptive) oncologic pain related to skull, face, neck, and scapular girdle, refractory to the conservative treatment as recommended by WHO`s pain scale. Our experience when compared with literature has shown that stereotactic rostral reticulotomy is a very valid method for the treatment of chronic oncologic pain syndrome, even when the predominance of pain is neuropathic or even in deafferentation pain.
Key words: Rostral reticulotomy; Mesencephalotomy; Oncologic pain; Intractable pain.

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Moisés Ricardo da Silva, Carlos Alberto de Barros Perino, Jeferson Santiago, Tereza Lais Menegucci Zutin

Objective: To determine the degree of knowledge of a population regarding the disease, aiming to promote actions of continuing education to the population. Material and method: Cross-sectional, exploratory study with a quantitative approach that investigates the frequency of headache in a population attending to Family Healthcare Unit (FHU) in a municipality in the interior of São Paulo state. This study was conducted by the medical students from the University of Marília. A semi-structured questionnaire containing 21 objective questions was used as instrument. The questionnaire was elaborated based on the data obtained within the International Classification of Headache and the sample was calculated according to the statistical methodology for the cross-sectional study. Results: We interviewed 104 individuals. The addressed questions were: 1) knowledge about pathophysiology; 2) risk factors; 3) immediate conduct; and 4) signs and symptoms. It was verified that, in relation to physiopathology, the population does not know to adequately distinguish the headaches episodes. Risk factors were well identified. As for signs, symptoms and sequelae, a low level of knowledge was found, involving signs and symptoms that are absent in pathological conditions. Conclusion: Due to the wide range of signs and symptoms of headache, the average population has difficulty to recognize and associate them with brain disorders. The results related to signs and symptoms, pathophysiology and conducts showed an unsatisfactory level in the study, evidencing the need for actions of continuing education to the population.
Key words: Headache; International Classification of Headache; Epidemiology

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Willian Costa Baia Junior, Moisés Ricardo da Silva, Daniel Santos Sousa, Marcelo Neves Linhares

Objective: To evaluate the effectiveness of neurofeedback in improving neurocognitive and psychiatric disorders in adults surgically treated for brain tumor. Methods: Double-blind, randomized and placebo-controlled study intending to investigate whether neurofeedback improves neurocognitive and mental functioning in adults who received surgical treatment for brain tumor. Thirty-seven survivors of brain tumor who underwent neurosurgery with complaints of neurocognitive deficits, depressive symptoms and worse quality of life were selected. Results: Individuals surgically treated for brain tumor showed improvement in their memory skills and attention after performing treatment with neurofeedback. The group undergoing treatment with neurofeedback showed a significant increase. There was an improvement in cognitive abilities after treatment with neurofeedback. Indexes of measurement of quality of life showed increase. Study participants showed a decrease in depressive symptoms after performing treatment with neurofeedback. Conclusion: This study showed that neurofeedback is effective in treating cognitive deficits, depressive symptoms and changes in quality of life secondary to brain tumors. Future studies with brain electrophysiological monitoring and functional magnetic resonance imaging are needed to establish and register possible changes in brain physiology offered by training with neurofeedback.
Key words: Neurofeedback; Brain neoplasms; Cognitive neuroscience; Neurosurgery; Depression.

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Fernanda Vieira Moraes, Sandra de Fátima Barboza Ferreira, Ângela Maria Costa de Souza, Denise Sisterolli Diniz

Introduction: TMS is said to be an effective technique for motor and cognitive rehabilitation for acquired neurological lesions. This study aims to evaluate the effect of TMS in the cognition of patients after stroke. Methods: This prospective, longitudinal and interventional study was approved by the Ethics Committee (Protocol No. 54977216.3.0000.5078) and included 16 stroke victims aged from 24 to 74 years. The Montreal Cognitive Assessment (MoCA) test was used before and after the stimulation sessions and TMS was administered according to treatment protocols for a motor goal, with inhibitory (1 hz) TMS stimulation over the right and left primary motor cortex; and according to protocol for the prefrontal cortex involved in humor processing, with stimulation (10 hz) of the left dorsolateral prefrontal cortex, and inhibitory (1 hz) stimulation of the right dorsolateral prefrontal cortex. The patients underwent fifteen treatment sessions, on average. Results: Memory subtests showed improvement, and average and standard deviation values for the pre- and post-intervention periods were [2.06 (1.6) and 3.5 (1.5)], respectively. In terms of total performance, MoCA results were [18.7(3.4) and 21.1(4.03)]. Student’s t test indicated p=0.006 for performance differences in memory and p=0.003 for total performance. Conclusion: TMS was shown to be effective in achieving cognitive rehabilitation after strokes, most notably in terms of the recovery of mnemonic functions.
Key words: Neuromodulation; Transcranial Magnetic Stimulation; MoCA. Stroke; Cognitive rehabilitation.

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Jonathan Watanabe Rodriguez, Ricardo Hiroshi Murashita Fujiki, Raysa Moreira Aprígio, Ivan Matos, Allan Zimmermann, Samuel Simis, Sylvine Carrondo Cottin, Marcos Vinicius Calfat Maldaun, Paulo Henrique Pires de Aguiar

Introduction: Dystonia can be defined as a neurological disorder characterized by involuntary movements with spasmodic contractions. Deep brain stimulation (DBS) is considered highly effective in critically selected and evaluated patients. The greater effectiveness of DBS is demonstrated mainly in cases of clinical and pharmacological treatment of refractory cervical dystonia. Objective: This paper aims to review the literature comparing the results of the DBS at Globus Pallidus internus (GPi), analyzing the results obtained in the treatment of focal and segmental dystonia. Methods: We searched at MEDLINE database for articles describing DBS for dystonia using keywords. Results: We identified 308 articles involving studies in the treatment of dystonia with the GPi DBS. After applying filters in “MEDLINE” database, 48 articles were excluded, remaining 260 eligible articles. Subsequently, a thorough review of the articles published on this platform was carried out. Conclusions: it is pointed out that patients with primary dystonia are more benefited by DBS when electrodes are inserted in the ventromedial portion of the GPi with acceptable adverse effects rates. A better prognosis of these patients depends on an individualized interdisciplinary follow-up in the pre and postoperative period.
Key words: Deep Brain Stimulation; Globus pallidus; Dystonia; Analysis.

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Rayanne Pereira Mendes, Katriny Guimarães Couto, Emilly Cristina Tavares, Laura Divina Souza Soares, Yasmin Fagundes Magalhães, Nágila Pereira Mendes

Introduction: Gliomas are brain tumors of high mortality in adults and high prevalence in children. The good prognosis depends on previous diagnosis, precise staging, complete resection and post-treatment recurrence correction correction. PET scans are promising tools for this purpose and this work aims to address their efficacy. Method: The Pubmed and Virtual Health Library were used as the database to select articles that best attend to the topic: nuclear markers for assessment of glioma. Results: MET-C¹¹ presented sensitivity and specificity of 70-80%. The use of FET-F18 for glioma has a sensitivity of 95% and a specificity of 91%. FDOPA-F18 has a sensitivity of 81% and specificity of 84%. FGD-F18 has accuracy, sensitivity and specificity for generally very limited gliomas, which are 80, 70 and 97% respectively. 68Ga-PRGD2 shows superior efficacy to FGD and maximum capacity in differentiating tumor grade. Conclusion: The best method for the identification of glioma is PET-FET and the most accurate in the differentiation of tumor grade or RGD-PET. The others cited have diagnostic value superior to Magnetic Resonance (MRi) for glioma.
Key words: Glioma; FGD; MET; PRGD2; FET.

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Matheus de Andrade Bannach, Mariana Lima Caetano, Caio Átila Saloio, José Édison da Silva Cavalcante, Helioenai de Sousa Alencar

Introduction: Intracerebral Aneurysms are important causes of morbidity and mortality, with mortality rate of up to 50%. Endovascular coiling was introduced as an alternative to surgical clipping, and has shown better results with a reduction in morbidity and mortality risk of 6-9%. Objective: To characterize the two types of treatment for intracerebral aneurysms within Brazilian scenario, and to compare the results with the international literature. Methods: An analytic observational study using data from the SIH / DATASUS (National Health Information System) in the period of 2010-2015. Results: The total number of hospitalizations decreased, with a 38.3% decrease in clipping and 18.4% in embolizations. The mean value of embolization was significantly higher, however, presenting a downward trend (R$ 22,011.37 in 2010 to R$ 15,607.18 in 2015), while the value of microsurgery increased (R$ 7,022.31 to R$ 8,645.28, respectively). Microsurgery was a risk factor for death (p-value <0.01). Conclusion: It has been shown that the international trend of transition from clipping to embolization did not occur in Brazil. The cost of embolization is much higher. For the authors, the death outcome contrasts with literature due to confounding factors that act within limitations of the study.
Key words: Aneurysm; Clipping; Embolization; Mortality.

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Ivam Sousa Barbosa Júnior, Antônio Jorge Barbosa de Oliveira, Paulo Augusto Souza de Lara Leão, Marcelle Rehem Machado, Alexandre Raváglia de Oliveira

Introduction: Late abdominal perforation due to Peritoneal Ventricle Derivations (PVD), with migration of the catheter tip is a very rare situation. Incidence estimated from 0.01 to 1% of all complications. Methods: retrospective study and literature review. Case Report: A case of DVP production in a 29-year-old female patient, asymptomatic from a neurological, abdominal or infectious point of view is presented. Incidental finding in upper gastrointestinal endoscopy (UGE). Removal of the intragastric portion of PVD by UGE and exteriorization of the distal catheter without infection of the shunt. Conclusions: Perforations of abdominal viscera related to PVD are potentially severe. We present, therefore, a case without late complications of abdominal or liquorical infections. In the medical literature researched, we found no asymptomatic case like this.
Key words: Ventriculoperitoneal shunt; Complication; Asymptomatic gastric perforation.

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Tiago Silva e Carvalho, Gerival Vieira Júnior, Thiago Vinícius Muniz Santana, Lucídio Duarte Souza Filho, Jarbas Carvalhais Reis, Fabrício Nery Marques, Ramon Souza Lago, Weverson José Teodoro Lacerda, Marco Túlio Reis, Lucas Ramos Lima

Introduction: Arachnoid cysts (AC) represent 1% of intracranial masses, and the intrasellar location occurs in only 3% of these cysts. Because it is a rare pathology with more common differential diagnoses (pituitary adenoma, craniopharyngioma, Rathke’s pouch cyst), its management still raises doubts. Case report: 53 year-old patient with complaints of visual scotomas, holocranial headache, vertigo and visual and auditory hallucinations. Magnetic resonance imaging (MRI) of the brain showed cystic lesion in the topography of the sella turcica with compression of the optic pathways. The patient was submitted to an endoscopic transsphenoidal surgery. After cyst fenestration, a communication between the cyst and the suprasellar subarachnoid space was observed. The cyst was obliterated with fat and the reconstruction included a pedicled nasoseptal flap. The patient did not present cerebrospinal fluid leak (CSF) in the postoperative period. There was a significant improvement in headache and visual changes. The control MRI showed regression of the compression on the optical pathways. Discussion: Symptomatic intrasellar AC requires surgical management. The treatment can be performed through transcranial and transsphenoidal approaches. The endonasal endoscopic approach is the most commonly used nowadays. There is still debate about the best option to address these lesions. Removal of the entire cyst is possible, but increases the manipulation of the pituitary gland and the risk of hormonal dysfunction. Another option is to open the cyst and obliterate it with fat, with minimal manipulation of the pituitary gland and lower risk of CSF leak. We present a case treated with obliteration of the cyst with a satisfactory outcome.
Key words: Intrasellar arachnoid cyst; Endonasal endoscopic approach; Transsphenoidal endoscopic surgery.

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