Aneurismas intracranianos incidentais n?o rotos de circula??o cerebral anterior : impacto da microcirurgia nas fun??es cognitivas e comportamentais

Made available in DSpace on 2015-04-14T13:35:28Z (GMT). No. of bitstreams: 1 438016.pdf: 4635938 bytes, checksum: 2a705e22808f50de4476ad4bf483ebc6 (MD5) Previous issue date: 2012-03-12BACKGROUND : Recent technological advances in neuroimaging modalities, associated with increased prevalence of cerebrovascular diseases in general, have resulted in more frequent incidental detection of unruptured intracranial aneurysms. When opting for therapeutic intervention, it is a consensus that most lesions can be treated with acceptably low morbidity and mortality rates, regardless of the method performed. Recently, some studies have suggested that changes in cognitive status could be a form of complication attributable to microsurgical treatment. However, to the present date, no study had behavioral analysis or evaluation of cognitive functions with a term greater than 12 months postoperatively. This pioneering study contributes to the pursuit of new knowledge on these topics.AIMS : To evaluate the impact of microsurgical treatment on cognitive and behavioral functions in patients with incidental unruptured intracranial aneurysms of anterior cerebral circulation.METHOD : A within-subjects clinical trial was performed including 40 patients submitted to microsurgical clipping for unruptured intracranial aneurysms of the anterior cerebral circulation through left or right pterional approach. Subjects were evaluated in three stages: preoperative period, three months and three years after surgery. The cognitive and behavioral tests applied were: Mini Mental State Examination, Wechsler Adult Intelligence Scale III, Wechsler Memory Scale III, Boston Naming Testing, Stroop Test, Verbal Fluency Test and FrSBe (Frontal Systems Behavior Scale). Traditional epidemiological and outcome parameters were also analyzed. Paired Student?s t test and analysis of variance (ANOVA), followed by post-hoc test of Bonferroni were used for statistical purposes. Results were considered significant when P ≤ 0.05.RESULTS : Among the 40 patients of the study, feminine gender predominated (87.5%) and the mean age was 54.1 years. The topographic distribution of treated aneurysms was: internal carotid artery (45%), middle cerebral artery (45%), and anterior communicating artery (10%). Five patients had multiple aneurysms. Aneurysm?s sizes ranged between 3 and 15 mm (mean: 5.67 mm). The aneurysms were xviii completely excluded by clipping in 95% of cases. Neurologic complications occurred on 7.5% of the cases and there were no deaths. The cognitive and behavioral tests showed no worsening in the performance of patients after microsurgical intervention in the short or long term. Clinical and demographic characteristics (gender, age, education and risk factors for cerebrovascular disease) were not predictive variables for cognitive or behavioral changes. Surgical approach, surgeons` learning curve, topography, multiplicity and size of aneurysms did not interfere with the results of the tests as well.CONCLUSION : Microsurgical clipping in patients with unruptured intracranial aneurysms did not alter the behavioral and cognitive functions in the short or long term. The intervention had a very high efficacy, associated to a low morbidity and mortality rates and a very good functional outcome.Recentes avan?os tecnol?gicos nas modalidades de imagem, associados ao aumento da preval?ncia das doen?as cerebrovasculares em geral, t?m contribu?do para uma maior detec??o incidental dos aneurismas intracranianos n?o rotos. Quando se opta pela interven??o terap?utica, ? consenso na literatura que a maioria das les?es pode ser tratada com baixas taxas de morbimortalidade independentemente do m?todo adotado. Alguns recentes estudos sugeriram que altera??es do estado cognitivo poderiam ser uma forma de complica??o associada ao tratamento microcir?rgico. Todavia, at? o momento, nenhuma pesquisa apresentou an?lise das fun??es comportamentais ou avalia??o cognitiva com prazo superior a 12 meses de p?s-operat?rio. O presente trabalho visa contribuir pioneiramente para a busca de conhecimentos nesses dom?nios.OBJETIVO : Avaliar o impacto do tratamento microcir?rgico nas fun??es cognitivas e comportamentais em pacientes com aneurismas intracranianos incidentais n?o rotos de circula??o cerebral anterior.M?TODO : Ensaio cl?nico com controle intra-grupo, envolvendo 40 sujeitos com aneurismas intracranianos incidentais n?o rotos de circula??o cerebral anterior submetidos ? clipagem microcir?rgica por via pterional direita ou esquerda. Os pacientes foram avaliados em tr?s momentos: no per?odo pr?-cir?rgico, tr?s meses e tr?s anos ap?s a interven??o. Os testes cognitivos e comportamentais usados foram: o Miniexame do Estado Mental, a Escala de Intelig?ncia para Adultos de Wechsler III, a Escala de Mem?ria de Wechsler III, o Teste de Nomea??o de Boston, o Teste Stroop, o Teste de Flu?ncia Verbal e o Teste FrSBe (Escala de Personalidade Frontal). Par?metros comuns de epidemiologia e evolu??o tamb?m foram analisados. An?lise estat?stica foi realizada com o teste t de Student e a an?lise de vari?ncia (ANOVA), seguida do teste de post-hoc de Bonferroni. Os resultados foram considerados significativos quando P ≤ 0,05.RESULTADOS : Entre os 40 pacientes da amostra, houve predom?nio do g?nero feminino (87,5%) e a m?dia de idade geral foi 54,1 anos. A distribui??o topogr?fica dos aneurismas tratados foi: art?ria car?tida interna (45%), art?ria cerebral m?dia (45%) e art?ria comunicante anterior (10%). Cinco pacientes apresentaram aneurismas m?ltiplos. O tamanho variou entre 3 e 15 mm (m?dia: 5,67 mm). Os aneurismas foram totalmente exclu?dos pela clipagem em 95% dos casos. Complica??es neurol?gicas ocorreram em 7,5% dos pacientes e n?o houve ?bitos. Os testes cognitivos e comportamentais n?o mostraram piora no desempenho dos pacientes ap?s a interven??o microcir?rgica a curto ou a longo prazo. Caracter?sticas cl?nicas e demogr?ficas (g?nero, idade, escolaridade e fatores de risco para doen?a cerebrovascular) n?o foram vari?veis preditivas para altera??o cognitiva ou comportamental. Abordagem cir?rgica, curva de aprendizado dos cirurgi?es, topografia arterial, multiplicidade e tamanho dos aneurismas tamb?m n?o interferiram nos resultados dos testes aplicados.CONCLUS?O : Em pacientes com aneurismas intracranianos incidentais n?o rotos de circula??o cerebral anterior, o tratamento microcir?rgico n?o alterou as fun??es cognitivas e comportamentais a curto ou a longo prazo. O tratamento microcir?rgico apresentou efic?cia muito alta, associada a baixa taxa de morbimortalidade e a ?tima recupera??o funcional

Intracranial intrasellar kissing carotid arteries: case report Artérias carótidas intracranianas intra-selares "que se beijam": relato de caso

Intracranial "kissing" carotid arteries are a rare variant of the carotid arteries, where both internal carotid arteries deviate medially and touch each other near the midline within the sphenoid sinus or the sphenoid bone, including the sella. This anomaly is particularly important since it may cause or mimic pituitary disease and also may complicate transsphenoidal surgery. We report a rare case of intracranial intrasellar kissing carotid arteries in a 57-years-old woman that was submitted to a computed tomography angiography during investigation of a sudden headache, and to discuss the clinical relevance of this radiological finding.Artérias carótidas intracranianas "que se beijam" representam rara variação da anatomia arterial, onde ambas as artérias carótidas internas desviam-se medialmente e tocam-se próximo à linha media dentro do seio esfenoidal ou do osso esfenóide, incluindo a sela túrcica. Essa anomalia é particularmente importante, pois pode causar ou simular doença pituitária e ainda pode complicar uma cirurgia transesfenoidal. Relatamos um raro caso de artérias carótidas intracranianas "que se beijam" em mulher de 57 anos, a qual foi investigada por angiotomografia por quadro de cefaléia súbita. Discutimos a relevância clínica desse achado radiológico

Primary meningeal Burkitt-type lymphoma presenting as the first clinical manifestation of acquired immunodeficiency syndrome Linfoma de Burkitt primitivo da meninge como primeira manifestação clínica da síndrome da imunodeficiência adquirida

The purpose of this study is to report a rare case of primary meningeal high grade Burkitt-type lymphoma presenting as the first clinical manifestation of acquired immunodeficiency syndrome. A 38-year-old Caucasian man, with a negative past medical history, sought treatment after experiencing global headache for five days. CT-Scan revealed a right front-temporo-parietal hyperdense subdural expansive mass. A craniotomy was performed and a hard white subdural was microsurgically dissected. Some hours after the surgery, the patient developed hemispheric cerebral edema and intracranial hypertension syndrome. Decompressive craniotomy was performed and the patient had an excellent recovery. Screening blood tests diagnosed human immunodeficiency virus infection. Further investigation ruled out systemic diseases. Eleven days after the initial surgery, the patient developed an acute respiratory failure and sepsis, dieing on that day. Pathological studies diagnosed Burkitt-type lymphoma.O objetivo desse estudo é relatar um caso de linfoma de Burkitt de alto grau primitivo da meninge, que se apresentou como primeira manifestação clínica da síndrome de imunodeficiência adquirida. Um homem branco, de 38 anos, previamente hígido, referia cefaléia holocraniana há cinco dias. A TC de crânio evidenciou coleção hiperdensa subdural na região fronto-temporo-parietal direita. Após craniotomia fronto-temporal direita, um tumor branco e rígido de localização subdural foi microcirurgicamente ressecado. Algumas horas após, o paciente apresentou edema cerebral hemisférico e hipertensão intracraniana, tendo sido submetido à craniotomia descompressiva com excelente melhora clínica. Testes sorológicos evidenciaram infecção por vírus da imunodeficiência humana. Investigações complementares afastaram outras doenças sistêmicas. Onze dias após a primeira cirurgia, o paciente apresentou insuficiência respiratória aguda e sepse, evoluindo para o óbito. Análise histopatológica evidenciou linfoma de Burkitt