Universidade Federal de São Paulo (UNIFESP)UNIFESPSciEL

Souza, Heider Lopes de

Arquivos de Neuro-Psiquiatria

Universidade Federal de São Paulo (UNIFESP)Universidade Federal de São Paulo, EPM, São Paulo, BrazilSciEL

Souza, Heider Lopes de [UNIFESP]

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Compression of gasserian ganglion and trigeminal root with balloon in the treatment of trigeminal neuralgia: prospective study of 40 patients

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Heider Lopes de Souza

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Arq Neuropsiquiatr 2001;59(4):981-984THESES*Compressão do gânglio de Gasser e da raiz trigeminal com balão no tratamento da neuralgia do nervo trigêmeo: estudo prospectivode 40 doentes (Resumo). Tese de Doutorado, Universidade Federal de São Paulo (Área de concentração: Neurocirurgia). Orientador:Manoel Jacobsen Teixeira. Co-orientador: Oswaldo Inácio de Tella Júnior.**Address: Avenida Rodrigues Alves 875, 59020-100 Natal RN , Brasil.Forty patients presenting trigeminal neuralgia underwentGasserian ganglion and trigeminal roots compression withFogarty’s balloon are presented. The natural history, theclinical presentation and the demographic aspects of thepatients were similar to that described in the literature.Fifty procedures were performed; 30 patients underwentone compression and nine, two. In one patient the proce-dure was bilateral.The follow-up ranged from six to 48 months. One com-pression was effective in 37 (90.26%) hemifaces and thesecond procedure alleviated pain in nine (100%) patients.There were only minor immediate and late complicationrates. Recurrence of pain occurred in six (15%) patients dur-ing the 48 months follow-up period; four, during the first 24months; one, at the 36th month, and the remainder at the42nd month.Two (5%) patients did not present relief of pain andunderwent a second procedure during the first 24 hoursafter the first one and had total pain relief. Two (5%) otherpatients presented partial pain relief; one did not agreewith the second procedure and the other was operatedsix months after the first surgery.COMPRESSION OF GASSERIAN GANGLION AND TRIGEMINAL ROOT WITH BALLOON IN THE TREATMENT OFTRIGEMINAL NEURALGIA: PROSPECTIVE STUDY OF 40 PATIENTS (ABSTRACT)*. THESIS. SÃO PAULO, 2000.HEIDER LOPES DE SOUZA**Compression time, along with balloon shape and vol-ume were analyzed. The first compression lasted 60 sec-onds and the second, 120 seconds. During the procedure,pear or hourglass shape of the balloon were induced. Thehemifacial numbness was mild in most patients; it wasmoderate but not disagreeable when the compression timewas longer or when the balloon had an hourglass shape.After the second compression all patients presented in-tensification of the hemifacial numbness.It was concluded, then, that the Gasserian ganglioncompression with balloon is efficient, the complicationrate is low and the procedure can be performed underlight general anesthesia, as the cooperation of the pa-tient is not needed. There was a tendency to get betterresults in patients with an hourglass shape balloon achieve-ment. When a pear shape balloon was achieved a motormastigatory deficit and facial numbness were observed.The maximum follow-up period was 48 months and therecurrence rate was 15%.KEY WORDS: pain, trigeminal neuralgia, surgery, bal-loon compression.Myotonic dystrophy (MD), or Steinert’s disease, is amultisistemic disease with the gene localized on chromo-some 19. The muscular involvement is characterized bymyotonia, progressive muscular weakness and atrophy,mainly in the neck, facial and distal muscles of the limbs.These manifestations start at second or third decades oflife. The masseter and temporalis muscles have alreadybeen assessed in these patients by electromyographic andultrasound imaging studies that confirmed their involve-ment. This finding has been associated to the malocclu-MAGNETIC RESONANCE IMAGING OF MASTICATORY MUSCLES AND TEMPOROMANDIBULAR JOINT IN MYO-TONIC DYSTROPHY PATIENTS (STEINERT’S DISEASE) (ABSTRACT)*. THESIS. SÃO PAULO, 2000.EDMAR ZANOTELI **sions and craniofacial abnormalities frequently observedin these patients.The objective of this study was to evaluate the masti-catory muscles by MRI in patients with MD, and the effectof this involvement on temporomandibular joint (TMJ).TMJ images (1.5 T Signa) were done in 15 MD patients,11 males and 4 females, aged 16 to 53 years (medium =31 years). Many dental malocclusions were observed inthese patients, especially Class III and anterior open bite.Three of them referred recurrent TMJ dislocation. TMJ and982 Arq Neuropsiquiatr 2001;59(4)masticatory muscles pain was not observed, and jointsounds were noted in only one patient.The analysis of MR images showed masticatory musclesinvolvement in 13 patients. In eleven, the involvement wasmoderate to intense. The temporalis was the most affectedof the masticatory muscles. The main abnormalities ob-served were increase of muscular tissue signal on T1 andvolumetric reduction of muscles. A unilateral anterior discdisplacement with reduction was seen in one patient, butabnormalities of disk shape were common. Mild osseousabnormalities were frequently observed, including irregu-larities of shape and contours of bone cortical and sclero-sis of bone marrow. In four cases, the condyle moved an-terior to the eminence with the mouth opened fully; and,in two cases, posterior to the eminence.In conclusion, in MD patients, masticatory muscles werefrequently affected. Osseous changes were the most im-portant abnormalities observed on TMJ. A possible expla-nation to this finding is the process of bone remodelingcaused by changing of biomechanic in the jaw due to mas-ticatory muscles involvement.KEY WORDS: myotonic dystrophy, temporomandibu-lar joint, masticatory muscles, magnetic resonance imag-ing.* Ressonância magnética dos músculos da mastigação e da articulação temporomandibular na distrofia miotônica de Steinert (Resumo).Tese de Doutorado, Universidade Federal de São Paulo (Área: Neurologia). Orientador: Acary Souza Bulle Oliveira.** Address: Departamento de Neurologia, Universidade Federal de São Paulo (UNIFESP-EPM), Rua Botucatu, 740, 04023-900 São PauloSP, Brasil. E-mail: zanoteli@terra.com.brCONTRIBUTION TO THE STUDY OF CYSTICERCOSIS: IMMUNOLOGIC TESTS FOR THE DETECTION OF SERUMANTIBODIES (ABSTRACT)*. THESIS. SÃO PAULO, 2001.LÚCIA MARIA BRAGAZZA**Human cysticercosis caused by parasitism with the lar-val phase of Taenia solium is frequent in developing coun-tries. Considering the impact of cysticercosis on publichealth, especially the neurological form, neurocysticercosis(NC), the frequency of anti-cysticercus antibody positivitywas studied in blood samples of subjects from differentgeographic areas distributed as follows: Group from Cássiados Coqueiros, SP (1,863 samples from individuals aged 2to 88 years), Group from Vitória, ES (311 samples frompatients aged 0 to 17 years), Group from Campinas, SP(15 samples from outpatients aged 21 to 69 years). ELISAand immunoblot (WB) with Taenia crassiceps vesicular fluidantigens (ELISA-Tcra and WB-Tcra) were used for antibodydetection.A total of 459 (24.6%) sera reactive to ELISA-Tcra weredetected in the Cássia group, with a greater predominancein the adult age range (p<0.05) and with no significantsex differences (p >0.05). Of these sera, 8.7% (n=40) wereintensely reactive to WB-Tcra. Considering the use of theWB-Tcra test as confirmatory in view of its high specificity,the frequency of anti-cysticercus antibodies in this groupwas 2.1%. When the possible relations between serumreactivity for anti-cysticercus antibodies and the variablesconcerning the sanitary conditions of the population wereanalyzed, the only relevant association was observed forthe variable water source for human consumption, whichdemonstrated a higher frequency of positivity for anti-cysticercus antibodies when the water consumed origi-nated from collective sources (p<0.05), a finding com-patible with the high degree of contamination with fecalcoliforms of these sources (p<0.05).In the Vitória group, 51 (16.4%) sera were reactive toELISA-Tcra, with the 10 to 14 year age range being mostoften involved (p<0.05), and with no sex differences. Ofthese 51 samples, only two (3.9%) were intensely reactiveto WB-Tcra. Considering immunoblot to be specific, wemay conclude that the frequency of antibodies in thisgroup was 0.64%.In the Campinas group, 7 (46.7%) sera were reactiveto ELISA-Tcra and 42.8% of these (n=3) were strongly re-active to WB-Tcra. The three patients reactive to ELISA andWB presented a clinical-laboratory confirmation ofneurocysticercosis.Although ELISA does not present high specificity whenserum samples are assayed, its use with heterologous an-tigen for serologic screening with later confirmation byimmunoblot appears to be a good marker for later epide-miological studies.KEY WORDS: cysticercosis, immunologic tests, diag-nosis, blood serum, cerebrospinal fluid, neurocysticercosis.*Contribuição ao estudo da cisticercose: testes imunológicos para a detecção de anticorpos séricos (Resumo). Tese de Doutorado,Faculdade de Ciências Farmacêuticas de Universidade de São Paulo (Área: Análises Clínicas). Orientadora: Adelaide José Vaz.**Address: Laboratory of Clinical Immunology of the Faculty of Pharmaceutical Sciences of the University of São Paulo, Avenida Profes-sor Lineu Prestes 580 Bloco 17, 05508-900 São Paulo SP, Brasil – c/o Prof. Dr. Adelaide José Vaz. Fax 5511391 32197. E-mail:ajavaz@netpoint.com.brArq Neuropsiquiatr 2001;59(4) 983Refractory epilepsy is a problem of serious conse-quences for the patient, his family and the community.The technological progress provided the diagnosis of agroup of tumors of the brain that are mainly responsiblefor epileptic crises without control, characteristically inchildren and young adults, the cerebral tumor of slowgrowth.Thirty four patients with refractory epilepsy associatedwith cerebral tumor of slow growth were operated be-tween June of 1992 and September of 1997 in the ser-vices of Hospital das Clinicas da Universidade de São Paulo,in the Neurology Institute of São Paulo, and at Hospitalda Restauração of Recife.The patients were divided according pathologic resultsin two groups: Group A - gangliogliomas, with 15 patients(44.1%) and Group B -other tumors, i.c., astrocytomas(12), oligodendrogliomas (5), pleomorphic xantoastrocy-toma (1) and desembryoblastic neuroepithelial tumor (1).Patients of group A showed different clinical behavior,with beginning of the epileptic crises before age of 8 years(p<0.005) and seizures frequency lower than 16 monthly(p<0.002), differentiating with ganglioglioma. The epilep-tic crises of the complex partial type prevailed (88.2%) andthe neurological exam was normal in 67.7% of all patients.Magnetic resonance image showed the tumors in allcases, while the computerized tomography was conside-red normal in 5 patients. The use of contrast did not in-crease the sensibility of the computerized tomography inrelation to magnetic resonance. Group A did not showedema or calcifications in the images, with a smaller capta-tion of contrast in the magnetic resonance when comparedwith group B (20% and 42%). Mass effect was observed in20% of the exams in group A against 52% in group B. Theelectroencephalogram was inexact in just 17.6% of thepatients, without any repercussion on the final result.Electrocorticography, cortical stimulation and stereo-taxy were necessary in the patients’ surgery, increasingthe safety of the resecion of the tumor and of the cerebralcortex generator of epileptic crises. The surgical removalof the tumors was total in 85.3% of the patients. Most ofthem (91.2%) remained without epileptic crises in the fol-low up minimum of 24 months (average of 34.2 months).KEY WORDS: refractory epilepsy, glioma, electro-corticography, cortical stimulation.REFRACTORY EPILEPSY ASSOCIATED WITH CEREBRAL TUMOR OF SLOW GROWTH (ABSTRACT)*. DISSERTA-TION. RECIFE, 1999.PAULO THADEU BRAINER DE QUEIROZ LIMA***Epilepsia refratária associada a tumor cerebral primário de crescimento lento (Resumo).Dissertação de Mestrado, Universidade Federalde Pernambuco (Área: Neuropsiquiatria). Orientador: Luiz Ataíde Júnior.**Address: Rua Jose Clementino 47 / 601, 52050-070 Recife PE, Brasil. E-mail: brainerlima@aol.brMigraine attacks can be initiated, in some patients,under the influence of certain factors (like hormonal, ali-mentary, emotional, sensory) that act upon a reduced painthreshold to precipitate these attacks. Studying the inci-dence of these factors is of importance if we consider thatthey participate in a significant number of migraine epi-sodes. Thus, an approach that takes into account the in-fluence of certain factors in the triggering of migraineshould be included in any therapeutic trial, as an auxiliarymeasure to pharmacologic therapy.To study the distribution of triggers of migraine in aselected population, 100 patients (84 females and 16males, with ages ranging from 10 to 64 years, averaging33.6 years) who fulfilled the diagnostic criteria for migrainewithout aura proposed by the International HeadacheSociety (IHS –1988) were evaluated by means of personalPRECIPITATING FACTORS OF MIGRAINE ATTACKS IN PATIENTS WITH MIGRAINE WITHOUT AURA (ABSTRACT)*.DISSERTATION. NITERÓI, 2000. RICARDO IERUSALIMSCHY **interview. Stress was the most cited trigger, triggering mi-graine in 76%. Afterwards, in descending order of impor-tance, sensorial stimuli (75%), sleep deprivation (49%),hunger (48%), environmental factors (47%), food (46%),menses (39%), fatigue (35%), alcohol (28%), sleep excess(27%), cafeine (22%), physical exertion (20%), head trauma(20%), trips (4%), sexual activity (3%), medications (2%),neck movements (2%), smoking (1%) and the use of alow pillow (1%) were cited. In a comparison made betweentwo groups of patients, there was no evidence of the ac-tion of alcohol as a potentiator for alimentary triggers.We conclude that certain factors seem to play an im-portant role in the triggering of migraine, with stress stand-ing out as the most important one.KEY WORDS: migraine, precipitating factors, migrainetriggers.*Fatores desencadeantes de crises de migrânea em pacientes com migrânea sem aura (Resumo). Dissertação de Mestrado, UniversidadeFederal Fluminense (Área: Neurologia). Orientador: Pedro Ferreira Moreira Filho.**Address: Rua dos Artistas 161 /402, 20511-130 Rio de Janeiro RJ, Brasil.984 Arq Neuropsiquiatr 2001;59(4)CENTRAL NERVOUS SYSTEM PARACOCCIDIOIDOMYCOSIS: ANALYSIS OF 13 CASES WITH IMMUNOFLUORES-CENCE RESEARCH OF GP43 ANTIGEN. (ABSTRACT)*.DISSERTATION. BELO HORIZONTE, 2001.WALTER J. FAGUNDES-PEREYRA**Paracoccidioidomycosis (PCM) is a systemic granulo-matous disease caused by Paracoccidioides brasiliensis,prevalent in Latin America, particularly in Brazil. Centralnervous system (CNS) involvement occur in about 10% ofcases, although such cases are uncommon in the litera-ture.Thirteen cases of neuroparacoccidioidomycosis werestudied emphasizing clinical manifestations, neuroradio-logy and immunology. The 43,000 dalton glycoprotein(gp43) is the main exocellular antigen of P. brasiliensis,which is probably related with fungus virulence. The gp43elicits an efficient antibody response which does not pro-tect again progressive PCM; its secretion and circulationas a free antigen or as immunocomplexs may inhibit “natu-ral killer” cells activity, induce T suppressor cells and pro-mote binding to laminin which may have a role in fungaldissemination; may also carry aggregated molecules withproteolytic activity.The gp43 antigen was investigated by indirect immu-nofluorescence in specimen of brain biopsy containingparacoccidioides granuloma. We studied in vitro the re-sponse of peripheral blood mononuclear cells from pa-tients with PCM presenting with CNS involvement to anti-genic fractions from P. brasiliensis yeast cell lysate (PbAg).The fraction 0 (F0) were obtained using anion-exchangechromatography on a FPLC system. IgG antibodies anti-P.brasiliensis (anti-PbAg and anti-F0) were evaluated in se-rum, plasma and cerebrospinal fluid (CSF). They weremesasured by ELISA and detected by Western Blot.After literature review, 129 cases of neuroparaco-ccidioidomycosis were found, including our 13 patients.The most frequent symptoms were motor deficits (53.8%),cognitive disturbance (53.8%), weight loss (46.1%), head-aches (46.1%) and seizures (46.1%). Computerized tomog-raphy (CT) scans were obtained in all cases and magneticresonance imaging (MRi) was used in one case. Serologyfor HIV was done in ten patients (76.9%), and all the testswere negatives. Granulomatous forms were present in allpatients. Four (30.8%) of them had also meningeal in-volvement (mixed form). The diagnosis was confirmed bythe demonstration of P. brasiliensis in all the cases, twelve(92.3%) by histophathological examination and one (7.7%)in the CSF.Indirect immunofluorescence revealed the presence ofgp43 antigen in all studied cases. ELISA and Western Blotdisclosed IgG antibodies anti-P. brasiliensis (anti-PbAg andanti-F0) in sera and plasma. However, it was not observedin the CSF.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. Fluco-nazole, ketoconazole and itraconazole were each one usedin a different patient as well. Six patients died (46.1%) andseven (53.9%) had satisfatory outcome. The follow-up pe-riod ranged from 2 to 74 (M=30,9) months.In conclusion, the CNS involvement in paracoccidioi-domycosis is more frequent and more serious than thoughtbefore. The clinical manifestations, CT scans and MRi find-ings are not specific of paracoccidioidomycosis. Indirectimmunofluorescence, ELISA and Western Blot can be usedin the detection of P. brasiliensis antigens and antibodieswith satisfatory sensibility. Further studies are still neededaiming at the increase of knowledge about this disease,which has high mortality rates.KEY WORDS: paracoccidiodomycosis, central nervoussystem, gp43 protein.* Paracoccidioidomicose no sistema nervoso central – análise de 13 casos com pesquisa do antígeno gp 43 por imunofluorescência(Resumo). Dissertação de Mestrado, Santa Casa de Belo Horizonte (Área: Medicina). Orientador: Alfredo M. Góes. Co-orientadores: AtosAlves de Sousa e Francisco das Chagas Lima e Silva.** Address: Rua Nossa Senhora da Conceição 402, 31130-240 Belo Horizonte MG, Brasil. E-mail : neurowalter@hotmail.com

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Compression of gasserian ganglion and trigeminal root with balloon in the treatment of trigeminal neuralgia: prospective study of 40 patients

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