RESUMO
An 18-year-old boy with refractory epilepsy and aggressiveness associated to a hypothalamic hamartoma was submitted to a stereotactically guided lesion by thermocoagulation. The target was based on magnetic resonance (MR) images merged with computed tomography scan images taken on the day of surgery while patient was on a stereotactic frame. In order to reveal structures not discernible in MR images, the Schaltenbrand digital brain atlas was merged onto the patient's images. Target and trajectory of the depth electrode were chosen based on three-dimensional imaging reconstructions. A surgical plan was devised to disconnect the hypothalamic hamartoma from the hypothalamus, medial forebrain bundle, fasciculus princeps, and dorsal longitudinal fasciculus. Our target was placed at the inferior portion of the posterolateral component of the hamartoma, bordering the normal hypothalamus. The patient evolved with marked lessening of aggressiveness. Seizure frequency was reduced from several seizures per day to less than one tonic-clonic seizure during sleep per month and only two episodes suggestive of partial complex seizures during daytime. These results have remained consistent over a 24-month postoperative follow-up. Functional neuroanatomy of hypothalamic connections involved in seizure propagation and aggressive behavior was reviewed.
Assuntos
Hamartoma/cirurgia , Doenças Hipotalâmicas/cirurgia , Transtornos Mentais/prevenção & controle , Procedimentos Neurocirúrgicos , Radiocirurgia , Convulsões/prevenção & controle , Adolescente , Anticonvulsivantes/uso terapêutico , Resistência a Medicamentos , Eletrodos Implantados , Eletroencefalografia , Hamartoma/complicações , Hamartoma/psicologia , Humanos , Doenças Hipotalâmicas/complicações , Doenças Hipotalâmicas/psicologia , Processamento de Imagem Assistida por Computador , Imageamento por Ressonância Magnética , Masculino , Transtornos Mentais/etiologia , Convulsões/etiologia , Tomografia Computadorizada de Emissão de Fóton ÚnicoRESUMO
OBJECTIVE: Use of the gray matter overlying the anterior portions of the occipitotemporal and rhinal sulci as an intraoperative landmark for locating the temporal horn during amygdalohippocampectomies approached by the superior or lateral surface of the temporal lobe. METHODS: The presence of occipitotemporal and rhinal sulci was analyzed in the magnetic resonance imaging scans of 165 patients who subsequently underwent mesial temporal resections, focusing on coronal slices up to 4 cm from the temporal pole. These sulci were used during surgery to locate the temporal horn in 150 surgeries. Five adult cadaveric heads whose vessels were perfused with colored silicone were used for photography. RESULTS: These sulci are the principal sulci of the anterior basal temporal lobe. They were present in 154 out of 165 and 165 out of 165 patients, respectively. When approaching mesial temporal structures from the superior or lateral surface of the temporal lobe, dissection is initially performed through the white matter toward the floor of the middle fossa until the gray matter overlying an anterior basal sulcus is encountered. Dissection continues medially and superiorly from the top of the gray matter until the temporal horn is entered. CONCLUSION: Gray matter overlying these sulci leads toward the anterior portion of the floor of the temporal horn and constitutes a landmark for locating the temporal horn. However, only the rhinal sulcus was always present. When both are present, the gray matter overlying the occipitotemporal sulcus is a reliable landmark. These landmarks are most suitable for mesial temporal resections without significant displacement of the temporal horn.
Assuntos
Tonsila do Cerebelo/anatomia & histologia , Tonsila do Cerebelo/cirurgia , Hipocampo/anatomia & histologia , Hipocampo/cirurgia , Neurônios/citologia , Procedimentos Neurocirúrgicos/métodos , Lobo Temporal/anatomia & histologia , Lobo Temporal/cirurgia , Craniotomia/métodos , Humanos , Cuidados Intraoperatórios/métodos , Imageamento por Ressonância MagnéticaRESUMO
Thymic hyperplasia has been described after the resolution of hypercortisolism from several etiologies, causing great diagnostic dilemmas. We describe a case where the catheterization of the thymic vein was essential for the differential diagnosis of a thymic enlargement in an adrenalectomized patient with ACTH-dependent Cushing's syndrome. The patient was a 48-year-old female with clinical and laboratorial data suggesting Cushing's disease. She underwent a transsphenoidal surgery with no tumor visualization and no remission of the syndrome. Histopathological studies disclosed a normal pituitary. She underwent a bilateral adrenalectomy and 8 months later a chest CT showed an increase of left thymic lobe, which was previously non-existent. After a negative (111)In-pentetreotide scintigraphy, the patient underwent simultaneous and bilateral catheterism of the petrosus sinuses and catheterization of the thymic and inominate veins and no ACTH gradient was shown among the sites of collection. She did not undergo thoracotomy and a follow-up was established. During the evolution, there was a spontaneous regression of the thymic lesion 38 months after the diagnosis. The ACTH gradient during the catheterization of thymic vein was essential for the differential diagnosis of the thymic enlargement tumor after hypercortisolism resolution in ACTH-dependent Cushing's syndrome, especially in this case, where the ACTH source was occult, thus avoiding an invasive surgical procedure for a benign entity with spontaneous resolution.
Assuntos
Síndrome de Cushing/tratamento farmacológico , Timo/patologia , Hormônio Adrenocorticotrópico/biossíntese , Cateterismo , Síndrome de Cushing/complicações , Feminino , Humanos , Hiperplasia , Pessoa de Meia-Idade , Timo/irrigação sanguínea , Neoplasias do Timo/complicações , Neoplasias do Timo/diagnósticoAssuntos
Tronco Encefálico/lesões , Corpos Estranhos/cirurgia , Traumatismos Cranianos Penetrantes/cirurgia , Adulto , Angiografia Digital , Tronco Encefálico/patologia , Tronco Encefálico/cirurgia , Angiografia Cerebral , Corpos Estranhos/diagnóstico , Traumatismos Cranianos Penetrantes/diagnóstico , Humanos , Processamento de Imagem Assistida por Computador , Imageamento por Ressonância Magnética , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Reoperação , Tomografia Computadorizada por Raios XRESUMO
Postoperative fever is a usual source of concern among caregivers and patients' family given that it may reflect a wide range of complications. The objective of this paper was to outline the expected postoperative temperature variation after hemispherectomies, and to establish factors that affect this curve. From 1987 to 2003, 30 patients were hemispherectomized in our institution. Among them, 24 patients without clinical diagnosis of infection were selected for this study. Postoperative axillary temperature from each patient was recorded over 10 days. Data was initially analyzed for all 24 patients and, later, for subgroups by (1) surgical technique (functional hemispherectomy, anatomical hemispherectomy, and hemispherotomy) and (2) hemispheric volume of the causative pathology (groups with large, moderately atrophic, and severely atrophic hemispheres). There was a trend of temperature elevation (p=0.06) over the first 4 days in all patients where 14 subjects recorded values over 38.5 degrees C, and 3 over 39.0 degrees C. Temperature curves from subgroups undergoing different techniques presented no statistical differences. However, the group including causative pathologies with larger hemispheres had a higher temperature curve when compared to patients with severely atrophic hemispheres (p<0.05). Our findings support the view that fever is an predictable event after hemispherectomies and causative pathologies with larger hemispheres present higher postoperative temperatures.
Assuntos
Febre/etiologia , Hemisferectomia , Complicações Pós-Operatórias/etiologia , Antibioticoprofilaxia , Hemisferectomia/métodos , Humanos , Infecção da Ferida Cirúrgica/prevenção & controleRESUMO
OBJECT: The use of decompressive craniectomy has experienced a revival in the previous decade, although its actual benefit on patients' neurological outcome remains the subject of debate. A better understanding of the intracranial pressure dynamics, as well as of the metabolic and hemodynamic brain processes, may be useful in assessing the effect of this surgery on the pathophysiology of the swollen brain. The aim of this study was to use transcranial Doppler (TCD) ultrasonography to examine the hemodynamic changes in the brain after decompressive craniectomy in patients with head injury, in addition to examining the relationship between such hemodynamic changes and the patient's neurological outcome. METHODS: Nineteen patients presenting with traumatic brain swelling and cerebral herniation syndrome who had undergone decompressive craniectomy with dural expansion were studied prospectively. The TCD ultrasonography measurements were performed bilaterally in both the middle cerebral artery (MCA) and in the distal portion of the cervical internal carotid artery (ICA) immediately prior to and after surgical decompression. After surgery, the mean blood flow velocity (BFV) rose to 175 +/- 209% of preoperative values in the MCA of the operated side, while rising to 132 +/- 183% in the contralateral side; the difference between the mean BFV increase in in the MCA of both the decompressed and the opposite side reached statistical significance (p < 0.05). The mean BFV of the extracranial ICA increased to 91 +/- 119% in the surgical side and 45 +/- 60% in the opposite side. Conversely, the MCA pulsatility index (PI) values decreased, on average, to 33 +/- 36% of the preoperative value in the operated side and to 30 +/- 34% on the opposite side; the MCA PI value reductions were significantly greater in the decompressed side when compared with the contralateral side (p < 0.05). The PI of the extracranial ICA reduced, on average, to 37 +/- 23% of the initial values in the operated side and to 24 +/- 34%, contralaterally. No correlation was verified between the neurological outcome and cerebral hemodynamic changes seen on TCD ultrasonography. CONCLUSIONS: Decompressive craniectomy results in a significant elevation of cerebral BFV in most patients with traumatic brain swelling and transtentorial herniation syndrome. The increase in cerebral BFV may also occur in the side opposite the decompressed hemisphere; the cerebral BFV increase is significantly greater in the operated hemisphere than contralaterally. Concomitantly, PI values decrease significantly postoperatively, mainly in the decompressed cerebral hemisphere, indicating reduction in cerebrovascular resistance.
Assuntos
Edema Encefálico/diagnóstico por imagem , Edema Encefálico/cirurgia , Encéfalo/irrigação sanguínea , Ultrassonografia Doppler Transcraniana , Adolescente , Adulto , Lesões Encefálicas/complicações , Artéria Carótida Interna , Descompressão Cirúrgica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média , Estudos Prospectivos , Fluxo Sanguíneo RegionalRESUMO
Anatomical hemispherectomy has been used for the treatment of seizures since 1938. However, it was almost abandoned in the 1960s after reports of postoperative fatalities caused by hydrocephalus, hemosiderosis, and trivial head traumas. Despite serious complications, the remarkable improvement of patients encouraged authors to carry out modifications on anatomical hemispherectomy in order to lessen its morbidity while preserving its efficacy. The effort to improve the technique generated several original procedures. This paper reviews current techniques of hemispherectomy and proposes a classification scheme based on their surgical characteristics. Techniques of hemispherectomy were sorted into two major groups: (1) those that remove completely the cortex from the hemisphere and (2) those that associate partial cortical removal and disconnection. Group 1 was subdivided into two subgroups based on the integrity of the ventricular cavity and group 2 was subdivided into three subgroups depending on the amount and location of the corticectomy. Grouping similar techniques may allow a better understanding of the distinctive features of each one and creates the possibility of comparing data from different authors.
Assuntos
Epilepsia/cirurgia , Hemisferectomia/métodos , Causas de Morte/tendências , Hemisferectomia/classificação , Hemisferectomia/tendências , Mortalidade Hospitalar , Humanos , Complicações Pós-Operatórias/mortalidade , Fatores de RiscoRESUMO
BACKGROUND: The purpose of this article was to assess if high-risk, mildly head-injured patients with normal CT scan present an outcome similar to the group with "low-risk MHI." METHODS: A total of 379 hospital charts of inpatients with Glasgow Coma Scale scores of 13, 14, and 15 were reviewed. Information regarding age, fGCS, trauma mechanism, cranial CT scan findings, hospital course, and follow-up using the GOS were obtained from all patients. RESULTS: Patients were separated in 3 groups: fGCS 13 (46 patients), fGCS 14 (138 patients), and fGCS 15 (195 patients). The groups with different scores on fGCS did not differ regarding CT scan abnormalities, surgical treatment, or outcome. Patients were also separated in 2 groups based on CT scan findings: 266 patients had CT interpreted as abnormal and 113 had CT interpreted as normal. The 2 groups differed statistically regarding surgical treatment and scores on GOS (P < .05). There was no statistically significant difference between the 2 groups regarding sex, trauma mechanism, fGCS, or age. CONCLUSIONS: Our findings support the idea that a normal cranial CT scan in patients with fGCS scores of 13 or higher ascertain a low-risk MHI outcome and, therefore, such patients must be included in this category of traumatic brain injury. On the other hand, patients with cranial CT scan abnormalities should be included in the group with moderate head injury.
Assuntos
Traumatismos Craniocerebrais/diagnóstico por imagem , Escala de Coma de Glasgow , Tomografia Computadorizada por Raios X , Adulto , Traumatismos Craniocerebrais/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
OBJECTIVE: The objective of this paper is to evaluate factors of surgical morbidity from different techniques of hemispherectomy with emphasis on causative pathology. PATIENTS AND METHODS: Thirty patients underwent hemispherectomy in our institution from 1987 to 2003, two presented with Sturge-Weber Syndrome (SWS), sixteen with Rasmussen's Syndrome (RS), eight with established hemispheric lesions (EHL), and four with cortical development malformations (CDM). Six surgeons operated on three patients using anatomical hemispherectomies (AH), 11 patients using functional hemispherectomy (FH), and 16 patients employing hemispherotomy (HT). Surgical technique and causative pathology were studied independently as factors of morbidity in hemispherectomy. RESULTS: Overall mean surgical time was 11:50+/-3:20 h and increased proportionately in pathologies with larger hemispheres. Blood transfusion was particularly influenced by the approach adopted by our team of anesthesiologists, independently of technique or pathology. Pathology was the most important factor related to hydrocephalus as two out of four patients with CDM needed ventriculoperitoneal shunt whilst none with EHL or SWS. Four patients undergoing HT and one FH presented residual bridges connecting the hemispheres, three were reoperated and are seizure free. Two patients with CDM did not improve their seizures worthwhile with surgery and other two (one with RS and other with CDM) were waiting a second procedure due to incomplete inter-hemispheric disconnection. Five patients presented infection and one died after developing meningoencephalitis. CONCLUSION: Hemispherectomies are procedures where pathology and surgical technique interact narrowly. Therefore, in order to study surgical morbidity or outcome, both pathology and technique have to be analyzed independently.
Assuntos
Córtex Cerebral/patologia , Córtex Cerebral/cirurgia , Epilepsia/cirurgia , Hemisferectomia/mortalidade , Hemisferectomia/métodos , Adolescente , Adulto , Fatores Etários , Córtex Cerebral/fisiopatologia , Criança , Pré-Escolar , Epilepsia/fisiopatologia , Feminino , Hemisferectomia/efeitos adversos , Humanos , Hidrocefalia/etiologia , Hidrocefalia/fisiopatologia , Lactente , Masculino , Meningoencefalite/etiologia , Seleção de Pacientes , Hemorragia Pós-Operatória , Fatores de Tempo , Derivação VentriculoperitonealRESUMO
OBJECTIVE: This paper reports the use of dexmedetomidine in three epileptic patients with cavernous angiomas that underwent awake surgery in order to map their speech areas. METHOD: Loading dose of dexmedetomidine varied from 1 microg/Kg/h to 3 microg/Kg/h over 20 minutes and maintenance dose from 0.4 microg/Kg/h to 0.8 microg/Kg/h. RESULTS: There was no occurrence of hemodynamic instability, convulsions or respiratory depression. Patients tolerated well the procedure. CONCLUSION: Dexmedetomidine was useful for awake craniotomy as it decreased patients level of consciousness but did not produce agitation. Laryngeal mask was not necessary to keep air ventilation.