Volume 27 - nº 4 - Outubro / Novembro / Dezembro 2016

  • Volume: 27
  • Número: 4
  • Período: Outubro / Novembro / Dezembro 2016
  • ISSN (versão impressa): 0103-5118
  • e-ISSN (versão online): 2446-6786
  • Editor: Ricardo Ramina - Curitiba/PR

Artigo completo

Nícollas Nunes Rabelo, Vitor Hugo Honorato Pereira, Marco Aurélio Ferrari Sant’Anna, Neiffer Nunes Rabelo, Luiz Antônio Araújo Dias Júnior, Luiz Antônio Araújo Dias, Carlos Umberto Pereira

Anterior communicating artery complex (ACoA) is the most frequent intracranial aneurysms (30%) and the most complex of the anterior circulation, due to variation of architecture, flow and many branches involved. This paper aims to establish anatomical study and clinical manifestations, analyzing a series of cases of AcoA aneurysms. Methods: Articles in PubMed, Scientific Direct were reviewed using as key words, anatomy variations. In addition, AcoA features were analyzed based on our series cases. Results: Most common anatomical variations found in the literature were: plexiform (30%), curling (33%), fenestration (21%), duplication (18%). Clinical features: Fasciobraquial hemiparesis, headache, personality changes, intellectual deficit, anxiety, fear, emotional disturbances, dizziness, agitation, hypokinesia, decreased level of consciousness.
Total of 5-year series of 234 cerebral aneurysms (32 deaths -13.6 %). Analyzing the series, 41 ACoA (18%), with 32 ruptured (78%); 19 deaths (46%); 16 prior hypertension arterial (39%); and a ratio between women and men of 2.25 were found. Conclusion: In our series, we concluded that the ACoA aneurysms are more common in women, the diagnosis is often after rupture and high incidence of death. Probably the anatomical variations, location between bifurcation arteries, A1 characteristics and different direction of the domus, contribute for different outcomes and uncertain clinics. Therefore, to predict the topography of the aneurysm by analyzing only the clinic is difficult.
Key words: Aneurysm complication; Anterior Communicating Artery Aneurysms; Brain Aneurysm Cerebral Aneurysm.

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Moysés Isaac Cohen, Cleomir da Silva Matos, Róbson Luiz Oliveira de Amorim, Wander da Silva Ferreira, Jacob Moysés Cohen, Marcos Jacob Cohen, Sabrina Veloso Avi Cohen, Henrique Oliveira Martins, Ingrid Soani Amaral do Couto, Marcos Robert da Silva Souza, Alcimar Lavareda da Silva Santos Jr

Morning Glory Syndrome is a very rare condition. It is characterized by an enlarged and funnel-shaped optic disc excavated and is associated with other craniofacial anomalies such as hypertelorism, cleft lip, cleft palate, and basal encephalocele. Case Report. A case of a 30 year-old man who came for neurosurgical evaluation after a magnetic resonance imaging (MRI) scan that showed spheno-ethmoidal encephalocele is reported. Conclusions. There is a high association between basal encephalocele, midface abnormalities and Morning Glory Syndrome. A neurosurgical, ophtalmological and endocrinological evaluation must always be done. The patients present with ophtalmic signs and/or strabismus or poor vision. An image study should always be performed to delineate the extent of the lesion and a complete hormone screening should be carried out to exclude pituitary deficiency. 
Key words: Morning Glory Syndrome; Basal encephalocele; Hypertelorism; Midface Abnormalities.

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Rafaella do Rosario Tacla, Murilo Henrique Guedes, Lize Mattiello Oliveira, Luiz Roberto Aguiar

We aimed to verify the reproducibility of the results obtained from previous systematic reviews and meta-analyses, focusing specifically on methodological and technical aspects, such as navigation method, screw insertion technique and spinal region involved to provide a more homogenous analysis. The PubMed database was searched using three terms: “stereotaxic techniques”, “neuronavigation”, and “image-guided surgery,” each associated with other two terms, “pedicle” and “screw”. Data were transferred to Comprehensive Meta-Analysis software, v.3, for statistical analysis. The significance of the pooled odds ratio was determined by the Z test, along with 95% confidence intervals. A funnel plot was used to assess publication bias. The statistical significance was defined as p ≤ 0.05. The meta-analysis yielded an overall odds ratio of 2.9 favouring navigation. The average correct positioning of the screws was 91.8% for navigation, while 82.2% of screws were deemed appropriate in fluoroscopy. The odds ratio obtained for the thoracic and lumbar spines separately was 3.1 and 2.7, respectively. Among the fluoroscopy guided surgeries, 53 complications occurred, whereas only eleven complications were observed among those guided by neuronavigation. This meta-analysis suggests that compared with conventional fluoroscopy technique, neuronavigation allows for more accurate pedicle screw placement.
Key words: Neuronavigation; Fluoroscopy; Arthrodesis; Spine

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Leonardo Gilmone Ruschel, Nick Dorneli de Carvalho, Ricardo Ramina

Intramedullary metastasis is a rare condition, and melanomas consist a minority of these cases which still need more data in literature for a better comprehension. As other intramedullary lesions, they clinically present compressive symptoms in the spinal cord. The golden standard exam for its identification remains the magnetic resonance image (MRi), and the surgical resection for management. Method. Two cases of intramedullary melanoma metastasis were reported with a systematic review of literature on the subject. Discussion. Intramedullary metastases present a higher survival when compared to other primary tumors. In literature, the majority of the cases present a high medullar location, as in our reported cases, and to differentiate a primary tumor from these metastasis there are some signals in image exams to aid the diagnosis. Histologically, no prevalence of type was found in this metastasis, and the clinical evolution in the presented cases was very differentiated, culminating in this paper. Conclusion. In our experience in the selected cases, a microsurgical resection with neuromonitoring aiming to preserve the quality of life and neurological function, followed by radiation and/or chemotherapy showed to be the best management. 
Key words: Intramedullary metastasis; Melanoma; Micruosurgical resection; Neuromonitoring

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Carlos Umberto Pereira, Francisco de Assis Pereira, Debora Moura da Paixão Oliveira, Nicollas Nunes Rabelo

Autonomic dysreflexia is considered a medical emergency. It is a syndrome that occurs in patients with spinal cord injury (SCI) above the level of the sixth thoracic vertebra (T6). It affects about 40% to 90% of patients with SCI above T6. The diagnosis is clinical and presents as main symptoms headache, sweating and piloerection. It is associated with hypertensive crisis and bradycardia. When the diagnosis or treatment is incorrect it may result in serious consequences for the patient. It is important to recognize this syndrome, especially in emergencies where diagnosis has been little recognized, as well as to keep family members and caregivers aware of it.
Key words: Autonomic dysreflexia; Spinal cord injuries; Complications.

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Felipe Constanzo, Mariana Basso Spadoni, Leticia Chaffin Barbosa Peruffo, Ricardo Ramina

Intracranial schwannomas represent 8% of tumors of the cranial compartment. They mostly origin in the vestibular, trigeminal and facial nerves. Trochlear nerve schwannomas are a rare entity, with less than 100 cases in literature, and only 33% with histological confirmation. Case Report: 32 year-old woman, with a 3-month history of left-sided paroxysmal paresthesis, without diplopia or other visual complaints, although she had ambliopia of the ipsilateral eye. Magnetic resonance imaging (MRI) showed a solid-cystic lesion occupying the right ambiens and cerebello-pontine angle cisterns. She underwent microsurgical resection of the lesion, histologically confirmed as schwannoma, and whose origin was found in the cisternal part of the trochlear nerve. After surgery, pre-operative symptoms improved, without new deficits. Literature Review: Pubmed, MEDLINE and Web of Science databases were used, resulting in 94 patients with 95 schwannomas found in literature. From total, 33% had histological confirmation. 42% of the cases underwent surgery, 16% underwent radiosurgery, and 42% were not treated. Gross total resection was obtained 58% of surgically treated patients. Conclusion: Trochlear nerve schwannomas are rare lesions, which should be part of the differential diagnosis of lesion occupying the cerebellopontine cistern.
Key words: Schwannoma; Trochlear nerve; Diplopia.

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Simão Lunière Gonçalves, Mário José Lopes Santacruz, Eurico Manoel Franco Azevedo, Ivan Tramujas da Costa e Silva

Trichilemmal carcinoma is a rare neoplasm first described in 1968. It affects individuals of both sexes with an average age of 50 years. There is a strong association with solar and radiation exposure. Diagnosis is made by histological and immunohistochemical analysis. Surgical treatment is the standard; however the adjuvant treatment is recommended for rare cases with metastasis and recurrence. This is a case report of a patient with atypical evolution of this neoplasm that culminated with intracranial invasion.
Key words: Carcinoma; Cerebellum; Cranial Fossa, Posterior.

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Francisco E. P. Doutel de Andrade, Hugo de Souza, Lygia Câmara, Almir Salgado Maurício, Sérgio P. G. Soeiro, Walter Oliveira Junior, Iogo H. O de Araujo, Fellip Dutra da Silva, Francisco Weldes B. Neves, Maria Izabel Miorin, Marcos Nakajima, Rosana M. Sampaio, José Álvaro B. Pinheiro

The authors presented a case of Glioblastoma (GBM) and right temporal and a case of Pleomorphic Xantoastrocitoma (XAP), both with left temporal cystic degeneration, and conducted a retrospective bibliographic study in order to establish reliable parameters to the decision of the surgical tactics to be employed. GBM Magnetic resonance imaging, in T2 and FLAIR (Fluid Attenuated Invertion Recovery) sequences demonstrated the difference between pasty necrosis and true liquefaction necrosis. The last one allowing a less invasive approach (drainage of the cyst with tumor biopsy), with short-term prognostic efficacy equal or higher. Computed tomography (CT) has not been able to determine this morphological differentiation. In the second case, the CT also just showed solid and non-solid mass differentiation, but it was not enough for the choice of the emergency approach, which was decided on the field.
Key words: Computed tomography; Magnetic resonance imaging; Brain Cystic Glioma; Surgical Approach

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Leonardo Olijnyk, Ademar Mesquita Jr, Geniffer Cardoso, Gustavo dos Santos Raupp, Matheus Ferreira Gomes, Matheus Vanzin Fernandes, Alex Spassim, Carlos Eduardo da Silva

The ocular bobbing (OB) refers to a distinct pattern of spontaneous vertical eye movements that occurs in various diseases of the posterior fossa pathologies. We describe a case of 42-years-old female submitted to epidermoid tumor removal through a subocciptal approach, presenting an OB during the postoperative period.The clinical aspects of the ocular bobbing are reviewed and discussed. There are other presentations or etiologies for OB, therefore differential diagnosis should always be carefully considered.
Key words: Ocular bobbing; Epidermoid tumor; Posterior fossa; Eye movements.

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Alexandre Haddad de Souza, Juan Antonio Castro Flores, Carlos Eduardo Roelke, Felipe Romero Vera, José Carlos Esteves Veiga

Objective. To describe details and technical difficulties observed in the use of this access for the treatment of middle cerebral artery aneurysms. Methods. This is a retrospective study including 15 patients with middle cerebral artery aneurysm operated on using this technique (two ruptured aneurysms and 13 incidental aneurysms). We considered age, gender, laterality of the aneurysm, and whether it was ruptured. We evaluated the surgical corridor (surgical field exposure and ease of handling of the surgical instruments), surgery time, complications, functional and cosmetic results. Results. This access provides adequate exposure of the surgical field, but the restricted working angle makes it difficult to dissect the aneurysm and, especially, to place the definitive clip. Conclusion. The restriction of the working angle may compromise the safety of the surgery. It is important to determine the specific indications for this access, particularly in cases of incidental aneurysms. Key words: Intracranial aneurysm; Supraorbital key-hole approach; Microsurgery .

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Carlos Umberto Pereira, Nicolas Nunes Rabelo, Francisco de Assis Pereira, Debora Moura da Paixão Oliveira, Neiffer Nunes Rabelo

Vítimas de lesões medulares têm sido frequentes em consequência de acidentes automobilísticos, quedas de altura e outras lesões traumáticas geradas pelo crescimento da violência urbana. A lesão medular leva a um importante impacto tanto ao nível físico quanto psicológico e se associa a vários graus de incapacidade que contribui para o comprometimento da qualidade de vida dos pacientes e familiares. 
O TRM cervical pode ocasionar uma série de problemas neurológicos, envolvendo a perda da função sensitiva e motora, disfunção esfincteriana e intestinal, espasticidade, dor neuropática e DISREFLEXIA AUTONÔMICA. As disfunções autonômicas após o TRM cervical são responsáveis pelo aumento da morbidade e mortalidade, tanto na sua fase aguda como na crônica. 
Do ponto de vista terapêutico é necessário intervir precocemente, se possível, para evitar maiores danos tissular, medular e complicações, estabelecendo uma terapêutica medicamentosa que promova neuroproteção. 
O objetivo desta monografia é levar o conhecimento sobre essa afecção a todos os envolvidos no tratamento e na reabilitação dos pacientes vítimas de TRM, principalmente cervical; contribuir para ampliar os conhecimentos dos cuidadores de indivíduos vítimas de TRM cervical e seus familiares, bem como na compreensão e participação da sociedade.

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