Cysticercosis of the central nervous system: I. Surgical treatment of cerebral cysticercosis. A 23 years experience in the hospital das clínicas of Ribeirão Preto Medical School
Cisticercose do sistema nervoso central: I. Tratamento cirúrgico da cisticercose cerebral. Experiência de 23 anos no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto
Benedicto Oscar ColliI; Nelson MartelliII; João Alberto Assirati Jr.III; Hélio Rubens MachadoIV; Cármine Porcelli SalvaraniV; Valéria Paula SassoliV; Sylvio de Vergueiro ForjazVI
IDivision of Neurosurgery, Department of Surgery, Ribeirão Preto Medical School (FMRP), University of São Paulo (USP): M.D., PH.D., Associated Professor and Head of the Division of Neurosurgery
IIDivision of Neurosurgery, Department of Surgery, Ribeirão Preto Medical School (FMRP), University of São Paulo (USP): M.D. PH.D.., Assistant Professor
IIIDivision of Neurosurgery, Department of Surgery, Ribeirão Preto Medical School (FMRP), University of São Paulo (USP): M.D., Assistant Physician (Neurosurgeon)
IVDivision of Neurosurgery, Department of Surgery, Ribeirão Preto Medical School (FMRP), University of São Paulo (USP): M.D., Ph.D., Associated Professor
VDivision of Neurosurgery, Department of Surgery, Ribeirão Preto Medical School (FMRP), University of São Paulo (USP): M.D. Resident
VIDivision of Neurosurgery, Department of Surgery, Ribeirão Preto Medical School (FMRP), University of São Paulo (USP): M.D., Ph.D., Professor of Neurosurgery
SUMMARY
Cysticercosis is the most frequent parasitosis of the nervous system and nowadays it is widespread through the world. Despite the development of anticysticercal drugs (praziquantel and albendazole), their efficacy is more marked in cases with parenchymal active cysts and they do not prevent complications such as hydrocephalus. Thus, many patients with neurocysticercosis require surgical intervention, generally of palliative nature, but that may occasionally produce a cure. The clinical outcome of 180 patients with cerebral cysticercosis who underwent srugical treatment form 1970 to 1993 was analised. Surgical treatment was performed to control increased ICP in 177 patients and due to local compression of cranial nerves or brainstem in five. Some patients had more than one surgical procedure, totalizing 287 interventions. Increased intracranial pressure (ICP) was caused by hydrocephalus in 91%, by intracranial mass lesion (tumoral form) in 6.2% and by pseudotumor cerebri (pseudotumoral form) in 2.8% of the case. Based on the pathophysiological mechanisms of intracranial hypertension identified through conventional CT-scan, ventriculography, cisternotomograpy, ventriculotomography and MRI, different surgical approaches were indicated. Patients with tumoral form were submitted to direct approach and cyst removal and generally they had benefits from this procedure. Patients with pseudotumoral form whose clinical treatment failure underwent decompressive craniectomies and had a poor outcome (40% of good results). Direct removal of ventricular/ cisternal cysts and/or ventriculoatrial/peritoneal shunting (VA/VPS) was performed in patients with hydrocephalus. Removal of free ventricular cysts in patients who had no ependimitis/arachnoiditis generally allowed a good outcome. Patients with adherent cysts and inflammatory process nedeed a VA/VPS posteriorly and the outcome was not so good. One hundred thirty-two patients were submitted to VA/VPS (109 as the first procedure and 23 after another surgical treatment). The VA/VPS was effective to control increased ICP, despite many complications observed mainly during the two first postoperative years. After this period the surviving patients generally had a better outcome. The patients submitted to cyst removal due to local compression of cranial nerves/brainstem generally had good results. Based on the experience acquired with the management of these patiens we present our recent policy for the treatment of patients with neurocisticercosis.
Key words: cerebral cysticercosis, hydrocephalus, intracranial pressure, surgical treatment.
RESUMO
A neurocisticercose é a parasitose mais frequente do sistema nervoso e hoje em dia é encontrada em todo o mundo. Apesar do advento de drogas anticisticerco (praziquantel e albendazol), sua eficácia é comprovada apenas nos cistos ativos parenquimatosos. Além disso, essas drogas não previnem complicações como a hidrocefalia. Portanto, número considerável de pacientes requer intervenções cirúrgicas, geralmente paliativas, mas que excepcionalmente podem ser curativas. Foram analisadas as evoluções clínicas de 180 pacientes com cisticercose cerebral tratados cirurgicamente no período de 1970 a 1993. A cirurgia foi indicada para controlar a hipertensão intracraniana (HIC) em 177 pacientes e para remover compressão local de nervos cranianos ou do tronco cerebral em 5 pacientes. Vários pacientes foram submetidos a mais de um procedimento cirúrgico totalizando 287 cirurgias. A HIC intracraniana foi causada por hidrocefalia em 91% dos casos, por processo expansivo (forma tumoral) em 6,2% e por pseudotumor (forma pseudotumoral) em 2,8%. Baseadas nos mecanismos fisiopatológicos da HIC identificados por tomografia computadorizada, ventriculografia, cisternotomografia, ventriculotomografia e/ou ressonância nuclear magnética, diferentes abordagens cirúrgicas foram indicadas. Pacientes com a forma tumoral foram submetidos a exérese dos cistos com boa evolução. Pacientes com a forma pseudotumoral que não melhoraram com tratamento clínico foram submetidos a craniectomia descompressiva e os resultados obtidos não foram bons. Exérese de cistos ventriculares ou cisternais e/ou DVA/DVP foram indicadas em pacientes com hidrocefalia. Os pacientes com cistos livres que não apresentavam aracnoidite/ependimite geralmente tiveram boa evolução e aqueles com cistos aderidos e/ou processo inflamatório necessitaram posteriomente de DVA/DVP e suas evoluções não foram tão boas. Cento e trinta e dois pacientes foram submetidos a DVA/DVP (109 como primeiro tratamento e 23 após outro tratamento cirúrgico). O controle da HIC com a DVA/DVP foi efetivo apesar do grande número de pacientes de complicações observadas durante os 2 primeiros anos pós-operatórios. Após este período, os sobreviventes geralmente tiveram boa evolução. Os pacientes submetidos à exérese de cistos que causavam compressão local apresentaram boa evolução. Baseados na experiência adquirida no manuseio desses pacientes apresentamos nossa conduta atual no tratamento dos pacientes com neurocisticercose.
Palavras-chave: cisticercose cerebral, hidrocefalia, hipertensão intracraniana, tratamento cirúrgico.
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REFERENCES
See next paper (Part II of this study)
Aceite: 26-setembro-1993.
This paper will be presented ate the X International Congress of Neurological Surgery, Acapulco (México), October, 1993.
Dr. Benedicto Oscar Colli - Department of Surgery HCFMRP Campus Universitário USP - 14048-900 Ribeirão Preto, SP - Brasil.
Publication Dates
-
Publication in this collection
19 Jan 2011 -
Date of issue
June 1994
