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Arquivos de Neuro-Psiquiatria, Volume: 23, Issue: 2, Published: 1965
  • Sôbre o tratamento cirúrgico dos angiomas arterio-venosos intracranianos: estudo da motricidade e da capacidade de trabalho após extirpação total de angiomas artériovenosos situados na região motora

    Tönnis, W.; Walter, W.; Brock, M.

    Abstract in Portuguese:

    De uma casuística maior - 215 angiomas artériovenosos intracranianos, dos quais 118 submetidos à extirpação total - foram selecionados 54 pacientes com angiomas situados na região rolândica, nas regiões temporais e nos territórios limítrofes entre estas zonas e áreas cerebrais vizinhas. Dêsse grupo fôram estudados 22 casos nos quais o angioma artériovenoso estava localizado na região motora. A análise da motricidade e da capacidade de trabalho pós-operatória, após exerese total da lesão, mostrou que a localização da malformação nesta área de elevada importância funcional não aumenta o risco cirúrgico nem agrava o prognóstico. A cifra pré-operatória de perturbações da motricidade aumenta de modo passageiro no período pós-operatório imediato, mas volta a decair aos índices iniciais no período tardio. Qualitativamente, as deficiências motoras após a cirurgia são, em geral, menos intensas do que antes do tratamento. A capacidade integral de trabalho é conservada na maioria dos casos. Apenas uma porcentagem relativamente restrita de pacientes não apresenta integridade funcional completa depois da operação. Na nossa casuística, êste grupo era constituido precisamente por enfêrmos com angiomas de volume superior a 25 cm³. O único registro de invalidez se referiu a paciente que já estava hemiparética ao ser internada. Concluímos que a extirpação total é o método de escolha também no tratamento dos angiomas artériovenosos cerebrais situados em áreas ditas de elevada importância funcional e que eram consideradas inabordáveis sem grandes danos para a capacidade funcional do paciente.

    Abstract in English:

    Among 215 intracranial arteriovenous angiomas (118 submitted to total extirpation) 54 were located in the central region, in the temporal regions an in the transition territories between these and neighbouring cerebral areas. From this group 22 cases have been selected, in which the angioma was seated in the motor area. The study of the motor functions and of the postoperative working capacity in these patients has shown that the localisation of the malformation in this functionally important area does not increase the surgical risk, nor aggravates the prognosis for the patient. The postoperative incidence of motor disfunctions increases reversibly during the immediate postoperative period but later decreases again to the initial values. From the qualitative point of view the motor deficits observed after operation are usually less severe than before treatment. Full working capacity is retained in most cases. Only a relatively low percentage of patients does not display full working capacity after operation. In our casuistic this group was composed precisely of patients with angiomas larger than 25 cc. The only case of invalidity observed was that of a preoperatively already hemiparetic patient. Our conclusion is that total extirpation is the method of choice also for the treatment of those arteriovenous angiomas seated in cerebral areas considered of high functional importance.

    Abstract in de:

    In einer Kasuistik von 215 arteriovenösen Angiomen (118 Totalexstir-pationen) befanden sich die Angiome bei 54 Patienten in der Zentralregion, in den Temporalregionen und in den Übergangsgebieten zwischen diesen und den benachbarten Hirngebieten. Aus dieser Gruppe wurden 22 Fälle aus-gesucht, bei denen das arteriovenõse Angiom in der motorischen Gegend lag. Die Analyse der Motorik und der postoperativen Arbeitsfähigkeit bei diesen Fällen zeigte, dass die Lokalisation der Missbildung in diesem funk-tionell hochwertigen Gebiet das operative Risko nicht erhöht und die Prog nose für den Kranken nicht verschlechtert. Die präoperative Inzidenz von motorischen Ausfällen steigt sofort nach dem Eingriff voriibergehend an, aber sinkt in der katamnestischen Periode wieder auf die Anfangswerte ab. Qualitativ, jedoch, sind die motorischen Ausfälle nach der Operation im Allgemeinen weniger ausgeprägt als vor der Behandlung. Die Arbeitsfähigkeit bleibt in der Mehrzahl der Falle völlig erhalten. Nur ein relativ geringer Prozentsatz der Patienten ist postoperativ nicht võllig arbeitsfähig. In unserem Krankengut stellte sich diese Gruppe gera-de aus Patienten zusammen, deren Angiome ein grösseres Volumen als 25,0 cm³ hatten. Der einzige Fall von Invalidität war eine schon präopera-tiv hemiparetische Patientin. Es wird gefolgert, dass die Totalextirpation die Behandlungsmethode der Wahl darstellt, auch bei arteriovenösen Angiomen, die sich in funktionell hochwertigen Hirnbezirken befinden.
  • Effect of corticotropin on the absorption of vitamin B12 in the subacute combined degeneration of the spinal cord

    Canelas, Horacio M.; Carvalho, Nelson de; Rocha, Arnaldo Gama da

    Abstract in Portuguese:

    Foi estudada a absorção de vitamina B12 em 9 casos de mielose funicular antes e após a administração de ACTH por via intravenosa em um esquema terapêutico com duração variável entre 19 e 43 dias. Em 7 casos foi verificado aumento da absorção. A diferença média de modificação no teste de excreção urinaria de vitamina B12 radioativa situou-se próximo do nível de significancia estatística. Este resultado reforça a indicação do emprego de corticotropina na mielose funicular, pois o hormônio irá atuar tanto sobre o componente alérgico do prccesso desmielinizante, quanto sobre a carência de vitamina B12 resultante do déficit de absorção. Embora o material aqui analisado seja muito pequeno para garantir uma conclusão definitiva, nossos resultados demonstram que, provavelmente, o ACTH age sobre a absorção da vitamina B12 através da mucosa intestinal, e não mediante o aumento de secreção do fator intrínseco ou a mobilização dos depósitos dessa vitamina. In order to study a possible mobilizing effect of ACTH on the radioactive vitamin B12 stores, the intervals between the last urinary excretion test and the test after completion of treatment were analyzed (Table 1). It is easily noticed that in the 7 cases with increase of vitamin B12 absorption these periods were the most varied, lasting from 9 to 62 days. And also in the 2 cases with decrease of absorption the intervals were very dissimilar, namely 15 and 56 days. So, it seems that this effect of ACTH did not play a significant role in the results. Likewise, the time elapsed between the completion of treatment and the repetition of the Schilling's test had no apparent relationship with the results.

    Abstract in English:

    The absortion of vitamin B12 was studied in 9 cases of subacute combined degeneration of the spinal cord before and after the administration of intravenous ACTH in a therapeutic scheme lasting from 19 to 43 days. In 7 cases an increase of absorption was evidenced. The mean difference of change in the urinary excretion test of radioactive vitamin B12 was near the limit of significance. This finding reinforces the indication of the use of corticotropin in subacute combined degeneration of the spinal cord, since the hormone will act both on the allergic component of the demyelinating process and on the deficiency of vitamin B12 absorption. Though the material here analyzed is too small to.warrant a definite conclusion, our results suggest that ACTH influences the vitamin B12 absorption through the intestinal wall, and not by means of an increase of intrinsic factor secretion or a mobilization of vitamin B12 stores.
  • Nerve fibres in isolated segments of dog ulnar nerves after complete brachial plexotomy and periaxilar artery sympathectomy

    Erhart, Eros Abrantes; Rezze, Cecil J.

    Abstract in Portuguese:

    Prosseguindo estudos anteriores que demonstraram a existência de fibras íntegras no segmento distal de nervos com mais de seis meses de secção completa, novas experiências foram efetuadas em cães, desta feita sendo utilizado o nervo ulnar, por causa de suas características morfo-funcionais e topográficas que se enquadravam perfeitamente aos nossos propósitos. A experimentação foi desenvolvida obedecendo a esquematização representada na fig. 1. Os resultados obtidos confirmaram nossos achados anteriores, visto que, mesmo após plexotomia braquial total e simpatectomia periarterial da artéria axilar, continuaram evidentes numerosas fibras nervosas de aspecto normal nos segmentos intermédios e distal do nervo ulnar mantidos em seus leitos conetivos naturais, mas completamente separados entre si e do côto proximal. Essas fibras nervosas, em face da experimentação efetuada, parecem não ser provenientes do côto proximal do nervo ulnar, nem de interco-municações com nervos vizinhos, nem tãopouco de "nervi-vasorum". Há indícios, no entanto, que possivelmente tenham se originado à custa de elementos constituintes de fibras "degeneradas", sob regência conjugada das células de Schwann e do meio ambiente natural. Os trabalhos prosseguem nesse sentido em busca de dados mais concretos. Todavia, desejamos ressaltar que os resultados práticos obtidos até o momento em mais de cento e cinqüenta pacientes, segundo informações de vários colegas que têm dado crédito às nossas pesquisas, vêm demonstrar que muito se poderá fazer em prol da reabilitação de inválidos, através de reconstruções e recuperação funcional de nervos com lesões antigas que infelizmente vinham sendo considerados como irreversíveis e irreparáveis.

    Abstract in English:

    Experiments were performed in adult dogs in order to study our reported observation of normal nerve fibres in the intermediate and distal segments of nerves completely separated from the proximal stump for more than six months. The results obtained confirmed once more our previous observation: there are normal nerve fibres and nerve bundles repopulating the pattern fascicles of the completely separated intermediate and distal segments of the ulnar nerve, although all other nerves of the operated limb, including the proximal stump of the ulnar, show a typical Wallerian degeneration. It seems, therefore, that these fibres of normal appearance must have arisen from a source other than the proximal ulnar nerve stump, neighbour nerves or "Nervi-vasorum". More concrete data about these findings are naturally necessary and our experiments are going on. Even so, as stated before, the practical results obtained up to now in more than one hundred and fifty patients allows us to go on recommending strongly, based on our observations, that proper nerve suture or neurolisys of long-time severed nerves by accident are worth while even after delays of many years.
  • The neuroma-like structure of the long-time severed and isolated nerve stumps

    Erhart, Eros Abrantes; Rezze, Cecil J.

    Abstract in Portuguese:

    Segmentos intermédios e distais de nervos lesados há mais de seis meses, completamente separados entre si e do côto proximal, mas mantidos em seus respectivos leitos conetivos naturais, apresentam-se repopulados por fibras nervosas cuja origem é ainda motivo de discussão e pesquisa. Nas extremidades desses segmentos de nervos existem complexos nódulos, recobertos por tecido cicatricial, portanto, verdadeiras formações neuromatosas.

    Abstract in English:

    The long-time severed and isolated intermediate and distal nerve segments, maintained undisturbed in their connective tissue bed, completely separated from each other and from the proximal stump, are repopulated by nerve-fibres which origin is still unknown. The extremities of such nerve segments present complex nervous nodules capped by fibrous tissue, neuroma-like structures.
  • Neurologic involvement in South American blastomycosis. Pathologic study of 14 cases

    Pereira, Walter C.; Raphael, Açucena; Sallum, Jamil

    Abstract in English:

    Several case reports of involvement of the nervous system by Paracoccidioides brasiliensis have been published, changing thus the concept that the nervous system would no be adequate to the proliferation of this fungus. In the material of the Department of Pathology of the University of São Paulo Medical School, collected up to September 1964, 145 cases of paracoccidioidomycosis were found. In 14 of them there were lesions of the nervous system, giving an incidence of 9,65%. This high incidence contradicts the frequent assumption that the involvement of the nervous system in cases of South American blastomycosis is exceptional. In our material most of the cases of neuroblastomycosis had not systemic lesions, 2 of them having isolated involvement of the nervous system. This fact does not agree with the frequent observation of patients with lesions in all organs but the nervous system. There are no pathophysiologic reasons to explain such contradiction, but it can be assumed that individual conditions, in some cases, make the nervous system vulnerable to the parasite. Of the 14 cases studied, 5 had lesions of the meninges and 9 had gra-nulomata of the brain. Of the 5 cases with meningitis, 3 had an isolated basilar leptomeningitis; in 1 case lesions of the pia-arachnoid of the brain convexity were also found, and in another one the spinal meninges were also involved as well the spinal roots. The granulomata of the brain were isolated in 5 cases and multiple in 4. The most frequent site of the lesions was the cerebral hemispheres (6 cases); in 2 cases the cerebellum was involved; the thalamus, pons and medulla were involved in one case each. This predominance of the hemispheric localization must be related to the larger blood supply of this parte of the nervous system, owing to the hematogenic route followed by the parasite. In our material no lesions of the spinal cord were found. However, no definitive conclusions can be drawn, as there was no systematic study of that parte of the nervous system. From a histopathologic viewpoint the meningeal inflammatory lesions were of the productive type, with a nodular or diffuse distribution. The characteristic cellular elements of this process are the gigantocytes of the Langhans type, the histiocytes, lymphocytes and plasmocytes, the two latter showing a predominant perivascular distribution. In the nodular forms there is a trend to the confluence of the granulomata and focal zones of caseous or gummous necrosis can be found. Arterites also can be found, causing degeneration of the nervous structures. The Paracoccidioides brasiliensis are generally abundantly found either free or phagocyted by histiocytes or gigantocytes. The inflammatory infiltrate grows along the Virchow-Robin's spaces, reaching the outer layers of the nervous parenchyma. The parenchymatous forms present a large central necrotic areas, with the characteristics of caseous or gummous necrosis, surrounded by histiocytes, gigantocytes, lymphocytes and plasmocytes. Fibroblasts and collagenous fibers surround and limit these granulomata of the encephalic parenchyma. Arterites are also observed and seem to play an importante role in the necrotic processes. The fungi are generally abundant, being found especially at the periphery of the necrotic areas or within the inflammatory tissues, free or phagocyted by histiocytes. In the nervous tissue neighboring the granulomata various degrees of degenerative processes of the neurons and glia are observed, as well as hyperplastic reaction of the oligodendroglia, microglia and astroglia. The inflammatory reaction of South American blastomycosis of the nervous system is not specific and, by itself, does not permit the etiologic diagnosis of the process. Only the finding of the parasite, with its characteristic forms, make it possible to establish the cause of the lesion.
  • South American blastomycosis of the brain Report of 9 cases

    Pereira, Walter C.; Raphael, Açucena; Tenuto, Rolando A.; Sallum, Jamil

    Abstract in Portuguese:

    Lesões encefálicas produzidas pelo Paracoccidioides brasiliensis têm sido registradas na literatura com relativa freqüência. Os autores chamam a atenção para a dificuldade diagnóstica dêstes processos que, na quase totali- dade, constituem-se de achados cirúrgicos ou de necropsia. A síndrome de hipertensão intracraniana é a manifestação mais comum, levando quase sempre ao diagnóstico de tumor intracraniano. Os exames complementares, inclusive o líquido cefalorraqueano, são pobres em dados específicos; o encontro do parasita, assim como a positividade das reações de fixação de complemento e de precipitação nesse humor, são raramente verificadas. A natureza da afecção só tem sido suspeitada quando existem lesões paracocci-dióicas conhecidas em outros órgãos. Nove casos de blastomicose sul-americana com localização encefálica são estudados. Sete foram submetidos a intervenções cirúrgicas, dêstes, 3 tiveram boa evolução, sendo os únicos que sobreviveram de tôda a série. Nos três casos foi empregada, em épocas diversas depois da intervenção cirúrgica, anfotericina B pelas vias intravenosa ou intratecal. Os autores consideram a excição cirúrgica dos granulomas encefálicos imprescindível, mormente quando existem sinais de compressão bem localizadas. Após o ato cirúrgico a administração de anfotericina B, pelas vias intravenosa ou intratecal, deve ser prescrita a fim de evitar possíveis recidivas da moléstia.

    Abstract in English:

    The involvement of brain by the Paracoccidioides brasiliensis is rather frequent. Many authors call attention to the difficulty of diagnosis in almost every case, most of them being made through surgery or post mortem examination. The intracranial hypertension syndrome is the most common manifestation, almost always leading to the diagnosis of intracranial tumor. The laboratorial tests, including the spinal fluid examination, are very poor of specific data; the finding of the parasite or a positive test for blastomycosis in this fluid is rarely verified. This disease is only suspected when there are true paracoccidioidal lesions in other organs. Nine cases of South American blastomycosis of brain are reported, seven of which were submitted to surgery. From these seven, three had a fair evolution, beeing the only ones to survive. In the three cases, amphothericin B was used sometime after operation, intravenously or intratecally. The authors are favorable to the surgical management in blastomycosis of brain, whenever reliable localization signs of compression are found. After remotion of the granulomata, amphothericin B must be used in order to avoid recurrence of the disease.
  • Skeletal age in children with cerebral palsy

    Marcondes, Eduardo; Valente, Maria Irmina; Fiore, Francisco F. de; Coelho Neto, Antonio da Silva

    Abstract in Portuguese:

    Os autores estudam a idade óssea de 30 crianças portadoras de paralisia cerebral. Verificaram haver atraso da idade óssea em relação à idade cronológica (mais evidente no sexo masculino), o que não impediu que continuasse a existir regressão entre os dois dados. Relacionando a idade óssea à altura e o pêso, verificaram que as crianças portadoras de paralisia cerebral têm idade óssea superior à esperada, mas só foi possível estabelecer regressão entre idade óssea e altura em crianças do sexo masculino. Estudos de função tireóidea em 10 casos mostraram normalidade em praticamente todos êles. Os dados sugerem: 1) atraso da idade óssea de crianças com paralisia cerebral, proporcional ao atraso somático geral, possivelmente em função da desnutrição que tais crianças apresentam; 2) perturbação das relações de proporcionalidade entre idade óssea e pêso para o sexo masculino e entre idade óssea e pêso e idade óssea e altura para o sexo feminino, possivelmente na dependência da própria paralisia cerebral; 3) a ação desorganizadora da paralisia cerebral não deve depender de um componente de hipotireóidismo; 4) as alterações verificadas são mais intensas no sexo masculino.

    Abstract in English:

    The skeletal age of thirty children with cerebral palsy was studied and related to the chronologic age, height and weight. In 10 cases the thyroid function was evaluated. The results allow the following suggestions: 1) the skeletal age and the somatic development were proportionally delayed and both probably related to the poor nutritional state of the children; 2) the proportionality between skeletal age and weight among the male children, and between the skeletal age and weight as well as height among the female children, were altered; 3) the disorganizing action of the cerebral palsy should not depend on hypothyroidism; 4) the noted alterations are more conspicuous among the male children.
  • Bilateral ventricular and subdural shunt with the Holter valve: a new surgical technique

    Pereira, Walter C.; Almeida, Gilberto M.

    Abstract in Portuguese:

    É relatada uma adaptação da ventrículo-auriculostomia, com válvula de Holter, para casos de bloqueios bilaterais dos orifícios de Monro e de coleções subdurais bilaterais. A técnica consiste na colocação de dois catéteres de borracha siliconiza-da nos ventrículos laterais ou espaços subdurais, mediante trepanações para-medianas na região parietal posterior; êstes catéteres são conectados a uma sonda em forma de T (sonda de Kehr) que, por sua vez, é ligada à uma válvula de Holter, sendo os demais tempos cirúrgicos idênticos aos da ventrículo-auriculostomia convencional. Foram operados, com esta técnica, três pacientes: dois com craniofaringiomas e um com coleção subdural bilateral. Os resultados foram satisfatórios.

    Abstract in English:

    The authors report an adaptation of the ventriculo-auriculostomy, with the Holter valve, for cases of bilateral obstruction of the foramina of Monro and for bilateral subdural fluid collection. Two catheters of silicone are placed into the lateral ventricles or in the subdural spaces, through para-median burr openings made in the posterior parietal area; these catheters are connected to a T-shaped tube (Kehr tube), which in turn is attached to the end of a Holter valve; the other operative stages are the same as in the conventional ventriculo-auriculostomy. With this procedure three patients have been operated on: two with craniopharyngioma and one with bilateral subdural fluid collection. The results were good.
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