Paracoccidioidomicose do sistema nervoso central: análise de 13 casos

Paracoccidioidomycosis (PCM) is a systemic granulomatous disease caused by Paracoccidioides brasiliensis, prevalent in Latin America, particularly in Brazil. Central nervous system (CNS) involvement occur in about 10% of cases. Thirteen patients with PCM involving CNS were studied considering clinical manifestation, neuroradiology and treatment modalities. Age ranged from 30 to 71 years-old (M=47.1 +/- 11.6 Me=46). There were eleven men and two women. the most frequent symptoms were motor deficits (53.8%), cognitive disturbance (53.8%), weight loss (46.1%), headaches (46.1%) and seizures (46.1%). the diagnosis was confirmed by the demonstration of P. brasiliensis. Granulomatous forms were present in all patients. Four (30.8%) of them had also meningeal involvement (mixed form). Computerized tomography (CT) scans were obtained in all cases and magnetic resonance imaging (MRI) was used in one case. Serology for HIV was done in ten patients (76.9%), and all the tests were negatives. Amphotericin B was used in twelve patients (92.3%), one of them by intraventricular infusion. in eight patients (61.5%), trimethopim and sulfamethoxazole were used, and, in two (15.4%), sulfadiazine and pirimetamine. Fluconazole, ketoconazole and itraconazole were each one used in a different patient as well. Six patients died (46.1%) and seven (53.9%) had satisfatory outcome. the follow-up period ranged from 2 to 74 (M=30.9) months. in conclusion, the CNS involvement in paracoccidioidomycosis is more frequent and more serious than thought before. the clinical manifestations, CT scans and MRI findings are not specific of paracoccidioidomycosis.Clin Neurol & Neurocirurgia Santa Casa Belo Horiz, Belo Horizonte, MG, BrazilMestre Med Santa Casa Belo Horizonte, Belo Horizonte, MG, BrazilUNIFESP, Escola Paulista Med, São Paulo, BrazilServ Neurocirurg Santa Casa, Belo Horizonte, MG, BrazilUniv Fed Minas Gerais, Dept Bioquim & Imunol, Inst Ciencias Biol, Belo Horizonte, MG, BrazilPrograma Pos Grad Santa Casa, Belo Horizonte, MG, BrazilUNIFESP, Escola Paulista Med, São Paulo, BrazilWeb of Scienc

Motor cortex electric stimulation for the treatment of neuropathic pain

OBJECTIVE: Motor cortex stimulation (MCS) is considered to be an effective treatment for chronic neuropathic pain. The aim of the present study was to assess the efficacy of MCS for treating neuropathic pain. METHOD: 27 patients with chronic neuropathic pain were operated. Electrodes were implanted with the use of an stereotactic frame. Electrophysiological evaluations (motor stimulation and somatosensory evoked potentials) were performed, with guidance by means of three-dimensional reconstruction of magnetic resonance images of the brain. 10 patients (37%) presented central neuropathic pain (post-stroke pain) and 17 others (63%) presented peripheral neuropathic pain (brachial plexus avulsion, phantom limb pain or trigeminal pain). RESULTS: In 15 patients (57.7%) the pain relief was 50% or more; while in ten patients (38.5%), more than 60% of the original pain was relieved. No differences were found in relation to central and peripheral neuropathic pain (p=0.90), pain location (p=0.81), presence of motor deficit (p=0.28) and pain duration (p=0.72). No major complications were observed. CONCLUSION: MCS was efficient for treating patients presenting chronic central or peripheral neuropathic pain

Manejo da hipertensão arterial na isquemia cerebral aguda Management of arterial hypertension in patients with acute ischemic stroke

OBJETIVO: Avaliar o nível de conhecimento dos médicos, através de sua conduta, em paciente com quadro de hipertensão arterial na fase aguda da isquemia cerebral. Também comentamos as principais condutas nesta fase, com ênfase na tensão arterial (TA). MÉTODO: Foram entrevistados 120 médicos da clínica médica e da cirurgia geral, em dez dos maiores Hospitais de Belo Horizonte, em 1997. Todos responderam a um questionário contendo um caso clínico de paciente hipertenso leve, admitido com quadro de isquemia cerebral e tensão arterial de 186x110 mmHg. Os profissionais deveriam optar por reduzir, aumentar ou manter a TA. RESULTADOS: Dos entrevistados, 38 (31,7%) responderam que reduziriam os níveis tensionais, 82 (68,3%) optaram pela manutenção e nenhum aumentaria (p<0,05). Estes índices foram iguais nas duas especialidades. Já em relação ao tempo de formado, observou-se que aqueles com mais de 10 anos de graduação, apresentaram maior tendência a redução da TA (p<0,05), quando comparado aos mais jovens. CONCLUSÃO: A redução da TA prejudica a perfusão cerebral, podendo aumentar a área isquêmica ("zona de penumbra"). Concluimos que, apesar de estar a maioria dos médicos ciente da conduta recomendada no manejo da hipertensão arterial na fase aguda dos quadros isquêmios cerebrais 31,7% ainda é uma taxa elevada de médicos despreparados para o atendimento emergencial de isquemia cerebral, considerando os prejuízos trazidos ao paciente em decorrência da conduta inadequada. Talvez o desenvolvimento de unidades especializadas no atendimento desses pacientes ("stroke units") possa melhorar tais índices.<br>PURPOSE: We aimed with study to assess the current clinical practice about the management of high blood pressure in patients in the acute phase of ischemic stroke. We also comment some topics of ischemic stroke treatment. METHODS: A case report of a patient admitted 8 hours after onset of ischemic stroke and with blood pressure of 186x110 mmHg was presented to 120 surgeons and clinician. They were asked to decide the best therapeutic option: to increase, decrease or maintenance blood pressure. RESULTS: Thirty-eight physicians (31,7%) considered decreasing blood pressure the best therapeutics, 82 (68,3%) considered maintenance and none decided to increase it (p < 0.05). There was no difference between the two specialties conduct. The physicians, with more than 10 years of graduation, had a tendency to decrease the blood pressure (p <0.05). CONCLUSION: The maintenance of blood pressure may present a sufficient blood support to compensate brain flow. A high percentage of the physicians (31,7%) do not know about the current concepts of therapeutics considering hypertension in acute ischemic stroke. The development on special units to treat these patients ("stroke units") may eventually decrease the morbimortality rates of ischemic stroke

Ganglioglioma da região da pineal: relato de caso Ganglioglioma of the pineal region: case report

Os gangliogliomas são neoplasias mistas, compostas de elementos gliais e neuronais, extremamente raros na região da glândula pineal. Na presente revisão da literatura foram encontrados oito casos publicados. Apresentamos o caso de paciente de 14 anos, masculino, com ganglioglioma da região da pineal, tratado cirurgicamente, com exérese total da lesão por via suboccipital transtentorial. O estudo histológico mostrou tratar-se de ganglioglioma grau I, confirmado por imuno-histoquímica. Conclui-se que tais tumores são raros e que se deve optar pela cirurgia, objetivando a exérese total. Quando isso não for possível, ou no caso de recorrência, o paciente deve ser acompanhado clínica e radiograficamente, considerando-se a radioterapia como tratamento complementar.<br>Ganglioglioma are tumors presenting neoplastic glial cells and nerve cells, very rarely found in the pineal region. Only eight cases have been previously published in the literature. We present the case of a 14 years-old male patient with a ganglioglioma of the pineal region. The patient was treated surgically by a suboccipital transtentorial approach with complete removal. Histopathologic specimens with immunostainning revealed a ganglioglioma grade I. We conclude that these tumors are rare and should be treated surgically aiming total remove. If it is not possible or in case of recorrence the patient should be followed and radiotheraphy could be considered