Vestibular Schwannomas: Diagnosis and Surgical Treatment

Over the last decades, significant advances in skull base surgery have enabled many neurosurgical centers around the world to perform surgical resection of vestibular schwannomas; otherwise, clinical observation and radiotherapy/radiosurgery can be possible management options. Auditory pattern, the presence of bilateral tumors, tumor size, and neurological symptoms are deeply considered in the decision-making process. In this chapter, we expanded the general discussion of vestibular schwannomas, discussing bases for an accurate diagnose and the technical aspects for the surgical approaches, drilling of internal auditory canal, and its reconstruction as well as the technical nuances when handling very small and large/residual tumors

Syringohydromyelia Associated To Therapeutic Procedures For Severe Forms Of Neurocysticercoses: Case Report.

Syringohydromyelia is defined as a longitudinal dilatation of the central canal of the spinal cord with accumulated cerebrospinal fluid. This condition may cause neurologic deficits when the cavity enlarges and compresses the spinal cord. We present the case of a 33 years-old female with progressive paraparesis caused by syringohydromyelia. This patient underwent previously multiple clinical and surgical treatments for severe form of neurocysticercosis. Surgical decompression of the posterior fossa and syringostomy resolved the neurologic symptoms. The possibility of syringohydromyelia should be considered in the case of patients who have previously undergone surgical and clinical treatment for severe form of neurocysticercosis.62885-

Neurosurgical Tools to Improve Safety and Survival in Patients with Intracranial Tumors: Neuronavigation, MRI, and 5-ALA

This chapter describes the usefulness of surgical technologies such as intraoperative MRI, 5-ALA fluorescence-guided surgery, and neuronavigation as tools to make brain tumor resections safer and more effective. The focuses are practical aspects and the relevant literature regarding the impact of their use in avoidance of complications, improvement in survival rates, and some tips and tricks acquired in the experience of our department. All three strategies have an important role in neuro-oncological surgery. The future probably will prove that the combination of these tools, selected case by case, is the best way to achieve the best results regarding safety and effectiveness

Atypical and Anaplastic Meningiomas: Diagnosis and Treatment

The aim of this chapter is to describe the usefulness of surgical technologies such as neuronavigation, intraoperative MRI, fluorescence-guided surgery and intraoperative monitoring as a tool do make neurosurgical procedures to brain tumors more safe and effective. The main topics to be explored are: history of the specific technique, indications and contra indications, description of the technique, real case examples, pros and cons. The focus on the discussion besides practical aspects is going to be relevant literature regarding impact of their use in avoidance of complications, improve in survival rates, cost-effectiveness, some tips and tricks acquired in the experience of our department

Edema and malignancy in meningiomas

PURPOSE: In recent years there have been many attempts to define a subset of aggressive malignant meningiomas based on histopathology and imaging technologies. The purpose of this study was to evaluate the level of peritumoral edema and its volume using the imaging technologies, computer tomography and magnetic resonance imaging, and correlate these results with the histological WHO classification. Reported causes of tumoral edema and its relationships to the histological characteristics were also reviewed. METHODS: The cases of 55 patients with meningiomas who underwent surgery at the Hospital das Clinicas (Fac Med Univ Sao Paulo) between September 1993 and September 1997 were reviewed. The level of edema according to the classification of Ide et al. (1995) was compared to the histological WHO classification. RESULTS: Classification of the degree of edema was: level 0 edema - 28 cases ; level I edema - 19 cases; level II edema - 8 cases. Histological classification was: benign meningioma - 43 cases; atypical meningiomas - 11 cases; malignant meningioma - 1 case. There was a significant (P = .0089) correlation between the degree of tumoral edema and the histological characteristics. CONCLUSIONS: These results suggest that the degree of edema as revealed by computer tomography and magnetic resonance imaging can be an important clinical predictive factor for the histological grade of the meningioma.OBJETIVO: Nos últimos anos têm-se descrito alguns subtipos de meningiomas de comportamento peculiarmente agressivo. Muitas tentativas têm sido feitas no intuito de estabelecer critérios imagenológicos ou histopatológicos de malignidade. O objetivo desse estudo é avaliar, através de Tomografia Computadorizada e Ressonância Nuclear Magnética o grau de edema peritumoral e seu volume, correlacionando-os com a classificação histológica da OMS. As causas relatadas de edema peritumoral e sua possível correlação histológica foram também revistos. MÉTODOS: Foram estudados 55 casos de meningiomas operados no Hospital das Clinicas (FMUSP) entre Setembro de 1993 e Setembro de 1997. O grau de edema segundo a classificação de Ide et al. (1995) foi comparado com a classificação da OMS. RESULTADOS: Os achados relativos a edema foram: edema grau 0 - 28 pacientes; grau I - 19 pacientes; grau II - 8 pacientes. A classificação histológica demonstrou: meningiomas benignos - 43 casos; meningiomas atípicos - 11 casos meningioma maligno - 1 caso. Demonstrou-se uma correlação significativa (p = 0,0089) entre o grau de edema dos meningiomas e suas características histológicas. CONCLUSÕES: Esses resultados sugerem que o grau de edema avaliado imagenologicamente pela Tomografia Computadorizada e Ressonância Nuclear Magnética pode ser um importante fator preditivo da gradação histológica dos meningiomas

Neurinoma do acústico (schwannoma do vestibular): resultados do tratamento cirúrgico de 240 pacientes operados na posição de decúbito dorsal

OBJECTIVE: To evaluate the result of the surgical treatment of vestibular schwannoma (VS) operated in dorsal decubitus (mastoid position). METHOD: 240 patients with a VS underwent a retrosigmoid craniotomy for tumor resection in dorsal decubitus (mastoid position). The function of 7th and 8th cranial nerves was monitored during surgery and the opened internal auditory canal (IAC) was reconstructed using a vascularized dura flap, muscle and fibrin glue. RESULTS: Complete tumor removal was achieved in 99% of the cases, with a mortality of 1.6%. The facial nerve function was preserved in 85% of cases and hearing in 40% of the patients (with preoperative hearing) with tumors of up 1.5 cm in diameter. The incidence of cerebrospinal fluid leak was 5.8% and meningitis 2.9%. Venous air embolism was registered in 3% of cases; it was not associated to mortality. CONCLUSION: Surgical removal of VS in dorsal position has several advantages; the morbidity and mortality are very low.OBJETIVO: Avaliar o resultado do tratamento cirúrgico de pacientes portadores de schwannoma do vestibular (SV) operados em decúbito dorsal (posição de mastóide). MÉTODO: 240 pacientes foram submetidos a craniotomia retrosigmóide na posição de mastóide. A função do VII e VIII nervos cranianos foi monitorizada durante a cirurgia e a reconstrução da abertura do conduto auditivo interno foi realizada com retalho vascularizado de dura-mater, músculo e cola de fibrina. RESULTADOS: A exérese foi completa em 99% dos casos, com mortalidade de 1,6%. Houve preservação da função do nervo facial em 85% dos casos e da audição em 40% dos pacientes com audição prévia e tumores menores de 1,5 cm. A incidência de fístula liquórica foi 5,8% e meningite 2,9%. Embolia gasosa foi registrada em 3% dos casos, não associada à mortalidade. CONCLUSÃO: O tratamento cirúrgico dos SV utilizando-se a posição de mastóide tem várias vantagens, com baixa morbidade e mortalidade.60560

Dor lombar associada à vértebra de transição lombossacra: dificuldades no diagnóstico e manejo da síndrome de Bertolotti

OBJECTIVE: Bertolotti's syndrome is a spine disorder characterized by the occurrence of a congenital lumbar transverse mega-apophysis in a transitional vertebral body that usually articulates with the sacrum or the iliac bone. It has been considered a possible cause of low back pain. METHOD: We analyzed the cases of Bertolotti's syndrome that failed clinical treatment and reviewed the literature concerning this subject. RESULTS: Five patients in our series had severe low back pain due to the neo-articulation and two of them were successfully submitted to surgical resection of the transverse mega-apophysis. Taking into account the clinical and surgical experience acquired with these cases, we propose a diagnostic-therapeutic algorithm. CONCLUSION: There is still no consensus about the most appropriate therapy for Bertolotti's syndrome. In patients in whom the mega-apophysis itself may be the source of back pain, surgical resection may be a safe and effective procedure.OBJETIVO: A síndrome de Bertolotti é uma desordem congênita da coluna vertebral caracterizada pela ocorrência de uma mega-apófise transversa lombar em uma vértebra de aspecto transicional, que geralmente se articula com o sacro ou com o osso ilíaco. Tal síndrome tem sido considerada possível causa de dor lombar. MÉTODO: Análise dos casos de síndrome de Bertolotti que apresentavam dor lombar sem melhora com tratamento conservador e revisão dos artigos publicados. RESULTADOS: Foram revisados cinco pacientes que não apresentaram melhora com o tratamento clínico, sendo que dois foram submetidos à ressecção cirúrgica da mega-apófise transversa. Considerando a experiência adquirida com estes casos, os autores propõem um algoritmo para diagnóstico e tratamento da Síndrome de Bertolotti. CONCLUSÃO: Ainda não há consenso sobre qual é a terapia mais apropriada para a Síndrome de Bertolotti. Em pacientes em que a mega-apófise parece ser a origem da lombalgia, a ressecção cirúrgica parece ser um procedimento seguro e efetivo.Instituto de Neurologia de Curitiba Department of NeurosurgeryUniversidade Federal de São Paulo (UNIFESP) Department of Neurosurgery/NeurologyUNIFESP, Department of Neurosurgery/NeurologySciEL

Evaluation of a questionnaire on symptom severity and functional status of patients with carpal tunnel syndrome

Este estudo consistiu na avaliação do questionário de Levine et al. (1993) Boston Carpal Tunnel Questionnaire, de avaliação da gravidade dos sintomas e do estado funcional de pacientes com síndrome do túnel do carpo (STC). O questionário consta de uma escala de gravidade dos sintomas – em domínios críticos na STC, como dor, parestesias, adormecimento, fraqueza, sintomas noturnos – e uma escala de estado funcional. Foi aplicado a 30 pacientes diagnosticados com a síndrome, que foram orientados a responder somente sobre a mão mais afetada pela patologia. Na análise dos resultados, não foram encontradas correlações entre a idade dos sujeitos e maior acometimento dos sintomas, nem com a prevalência de mão afetada. O questionário revelou-se consistente, pela estreita correlação entre as duas escalas: onde há maior gravidade dos sintomas, também há maior acometimentofuncional. Com a ressalva de que o questionário não prevê o caso de a mão mais afetada não ser a dominante, é um instrumento de fácil compreensão, adequado para padronizar a avaliação de pacientes com STC, sugerindo-se sua aplicação separadamente para cada mão.This study aimed at assessing the Boston Carpal Tunnel Questionnaire by Levine et al. (1993), a self-administered instrument for evaluating severity of symptoms and functional status in patients with carpal tunnel syndrome (CTS). It is made up of two scales: one on the severity of symptoms – pain, paresthesias, numbness, weakness, nocturnal symptoms – and the other on function impairment. It was answered by 30 patients with CTS, who were guided to answer only about the most affected hand. The analysis of results shows no correlation between age and severity of symptoms, nor between these and the most affected hand (right or left). The questionnaire proved consistent, since a highly positive correlation was found between the two scales: the more severe the symptoms, the worse the functional status. With the objection that it doen’st seem to have foreseen cases in which the dominant hand is not the most affected one, it is an instrument of easy application and understanding, hence suitable to standardize the assessment of CTS symptoms; it is here suggested that it be applied separately for each hand