Arq Neuropsiquiat r 2001;59(4):981-984
THESES
* Compressão do gânglio de Gasser e da raiz t rigeminal com balão no t rat ament o da neuralgia do nervo t rigêmeo: est udo prospect ivo de 40 doent es (Resumo). Tese de Dout orado, Universidade Federal de São Paulo (Área de concent ração: Neurocirurgia). Orient ador: M anoel Jacobsen Teixeira. Co-orient ador: Osw aldo Inácio de Tella Júnior.
* * Address: Avenida Rodrigues Alves 875, 59020-100 Nat al RN , Brasil. Forty patients presenting trigeminal neuralgia underw ent Gasserian ganglion and trigeminal roots compression w it h Fogart y’s balloon are present ed. The natural history, the clinical presentation and the demographic aspects of the patients w ere similar to t hat described in t he lit erat ure. Fift y procedures w ere performed; 30 patients underw ent one compression and nine, tw o. In one patient the proce-dure w as bilat eral.
The follow -up ranged from six t o 48 mont hs. One com-pression w as effective in 37 (90.26%) hemifaces and t he second procedure alleviat ed pain in nine (100%) pat ient s. There w ere only minor immediat e and lat e complicat ion rat es. Recurrence of pain occurred in six (15%) patients dur-ing the 48 months follow-up period; four, durdur-ing the first 24 months; one, at the 36th month, and the remainder at the 42nd month.
Tw o (5%) pat ient s did not present relief of pain and underw ent a second procedure during t he first 24 hours aft er t he first one and had t ot al pain relief. Tw o (5%) ot her pat ient s present ed part ial pain relief; one did not agree w it h t he second procedure and t he ot her w as operat ed six mont hs aft er t he first surgery.
COM PRESSION OF GASSERIAN GANGLION AND TRIGEM INAL ROOT W ITH BALLOON IN THE TREATM ENT OF TRIGEM INAL NEURALGIA: PROSPECTIVE STUDY OF 40 PATIENTS (ABSTRACT)* . THESIS. SÃO PAULO, 2000.
HEIDER LOPES DE SOUZA* *
Compression t ime, along w it h balloon shape and vol-ume w ere analyzed. The first compression last ed 60 sec-onds and t he second, 120 secsec-onds. During t he procedure, pear or hourglass shape of t he balloon w ere induced. The hemifacial numbness w as mild in most pat ient s; it w as moderate but not disagreeable w hen the compression time w as longer or w hen t he balloon had an hourglass shape. Aft er t he second compression all pat ient s present ed in-t ensificain-t ion of in-t he hemifacial numbness.
It w as concluded, t hen, t hat t he Gasserian ganglion compression w it h balloon is efficient , t he complicat ion rat e is low and t he procedure can be performed under light general anest hesia, as t he cooperat ion of t he pa-t ienpa-t is nopa-t needed. There w as a pa-t endency pa-t o gepa-t bepa-t pa-t er results in patients w ith an hourglass shape balloon achieve-ment . When a pear shape balloon w as achieved a mot or mast igat ory deficit and facial numbness w ere observed. The maximum follow -up period w as 48 mont hs and t he recurrence rat e w as 15%.
KEY W ORDS: pain, t rigeminal neuralgia, surgery, bal-loon compression.
M yot onic dyst rophy (M D), or St einert ’s disease, is a mult isist emic disease w it h t he gene localized on chromo-some 19. The muscular involvement is charact erized by myot onia, progressive muscular w eakness and at rophy, mainly in t he neck, facial and dist al muscles of t he limbs. These manifest at ions st art at second or t hird decades of life. The masset er and t emporalis muscles have already been assessed in t hese pat ient s by elect romyographic and ult rasound imaging st udies t hat confirmed t heir involve-ment . This finding has been associat ed t o t he
malocclu-M AGNETIC RESONANCE Imalocclu-M AGING OF malocclu-M ASTICATORY malocclu-M USCLES AND TEmalocclu-M POROmalocclu-M ANDIBULAR JOINT IN malocclu-M YO-TONIC DYSTROPHY PATIENTS (STEINERT’S DISEASE) (ABSTRACT)* . THESIS. SÃO PAULO, 2000.
EDM AR ZANOTELI * *
sions and craniofacial abnormalit ies frequent ly observed in t hese pat ient s.
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m ast icat ory m uscles pain w as not observed, and joint sounds w ere not ed in only one pat ient .
The analysis of M R images show ed masticatory muscles involvement in 13 pat ient s. In eleven, t he involvement w as moderate to intense. The temporalis w as the most affected of t he mast icat ory muscles. The main abnormalit ies ob-served w ere increase of muscular t issue signal on T1 and volumet ric reduct ion of muscles. A unilat eral ant erior disc displacement w it h reduct ion w as seen in one pat ient , but abnormalit ies of disk shape w ere common. M ild osseous abnormalit ies w ere frequent ly observed, including irregu-larit ies of shape and cont ours of bone cort ical and
sclero-sis of bone marrow. In four cases, t he condyle moved an-t erior an-t o an-t he eminence w ian-t h an-t he mouan-t h opened fully; and, in t w o cases, post erior t o t he eminence.
In conclusion, in MD patients, masticatory muscles w ere frequently affected. Osseous changes w ere t he most im-port ant abnormalit ies observed on TM J. A possible expla-nation to this finding is the process of bone remodeling caused by changing of biomechanic in the jaw due to mas-ticatory muscles involvement .
KEY W ORDS: myot onic dyst rophy, t emporomandibu-lar joint , mast icat ory muscles, magnet ic resonance imag-ing.
* Ressonância magnét ica dos músculos da mast igação e da art iculação t emporomandibular na dist rofia miot ônica de St einert (Resumo). Tese de Dout orado, Universidade Federal de São Paulo (Área: Neurologia). Orient ador: Acary Souza Bulle Oliveira.
* * Address: Depart ament o de Neurologia, Universidade Federal de São Paulo (UNIFESP-EPM ), Rua Bot ucat u, 740, 04023-900 São Paulo SP, Brasil. E-mail: zanot eli@t erra.com.br
CONTRIBUTION TO THE STUDY OF CYSTICERCOSIS: IM M UNOLOGIC TESTS FOR THE DETECTION OF SERUM ANTIBODIES (ABSTRACT)* . THESIS. SÃO PAULO, 2001.
LÚCIA M ARIA BRAGAZZA* *
Human cyst icercosis caused by parasit ism w it h t he lar-val phase of Taenia solium is frequent in developing coun-t ries. Considering coun-t he impaccoun-t of cyscoun-t icercosis on public healt h, especially t he neurological form, neurocyst icercosis (NC), t he frequency of ant i-cyst icercus ant ibody posit ivit y w as st udied in blood samples of subject s from different geographic areas distributed as follow s: Group from Cássia dos Coqueiros, SP (1,863 samples from individuals aged 2 t o 88 years), Group from Vit ória, ES (311 samples from pat ient s aged 0 t o 17 years), Group from Campinas, SP (15 samples from out pat ient s aged 21 t o 69 years). ELISA and immunoblot (WB) w ith Taenia crassiceps vesicular fluid ant igens (ELISA-Tcra and WB-Tcra) w ere used for ant ibody det ect ion.
A t ot al of 459 (24.6%) sera react ive t o ELISA-Tcra w ere det ect ed in t he Cássia group, w it h a great er predominance in t he adult age range (p< 0.05) and w it h no significant sex differences (p > 0.05). Of t hese sera, 8.7% (n= 40) w ere int ensely react ive t o WB-Tcra. Considering t he use of t he WB-Tcra t est as confirmat ory in view of it s high specificit y, t he frequency of ant i-cyst icercus ant ibodies in t his group w as 2.1%. When t he possible relat ions bet w een serum react ivit y for ant i-cyst icercus ant ibodies and t he variables concerning t he sanit ary condit ions of t he populat ion w ere analyzed, t he only relevant associat ion w as observed for
t he variable w at er source for human consumpt ion, w hich demonst rat ed a higher frequency of posit ivit y for ant i-cyst icercus ant ibodies w hen t he w at er consumed origi-nat ed from collect ive sources (p< 0.05), a finding com-pat ible w it h t he high degree of cont aminat ion w it h fecal coliforms of t hese sources (p< 0.05).
In t he Vit ória group, 51 (16.4%) sera w ere react ive t o ELISA-Tcra, w it h t he 10 t o 14 year age range being most oft en involved (p< 0.05), and w it h no sex differences. Of t hese 51 samples, only t w o (3.9%) w ere int ensely react ive t o WB-Tcra. Considering immunoblot t o be specific, w e may conclude t hat t he f requency of ant ibodies in t his group w as 0.64%.
In t he Campinas group, 7 (46.7%) sera w ere react ive t o ELISA-Tcra and 42.8% of t hese (n= 3) w ere st rongly re-act ive t o WB-Tcra. The t hree pat ient s rere-act ive t o ELISA and WB p resen t ed a clin ical-lab o rat o ry co n f irm at io n o f neurocyst icercosis.
Alt hough ELISA does not present high specificit y w hen serum samples are assayed, it s use w it h het erologous an-t igen for serologic screening w ian-t h laan-t er confirmaan-t ion by immunoblot appears t o be a good marker for lat er epide-miological st udies.
KEY W ORDS: cyst icercosis, immunologic t est s, diag-nosis, blood serum, cerebrospinal fluid, neurocyst icercosis.
* Cont ribuição ao est udo da cist icercose: t est es imunológicos para a det ecção de ant icorpos séricos (Resumo). Tese de Dout orado, Faculdade de Ciências Farmacêut icas de Universidade de São Paulo (Área: Análises Clínicas). Orient adora: Adelaide José Vaz.
Arq Neuropsiquiat r 2001;59(4) 983
Ref ract ory epilepsy is a problem of serious conse-quences for t he pat ient , his family and t he communit y. The t echnological progress provided t he diagnosis of a group of t umors of t he brain t hat are mainly responsible for epilept ic crises w it hout cont rol, charact erist ically in children and young adult s, t he cerebral t umor of slow grow t h.
Thirt y four pat ient s w it h refract ory epilepsy associat ed w it h cerebral t umor of slow grow t h w ere operat ed be-t w een June of 1992 and Sepbe-t ember of 1997 in be-t he ser-vices of Hospit al das Clinicas da Universidade de São Paulo, in t he Neurology Inst it ut e of São Paulo, and at Hospit al da Rest auração of Recife.
The pat ient s w ere divided according pat hologic result s in tw o groups: Group A - gangliogliomas, w ith 15 pat ient s (44.1%) and Group B -ot her t umors, i.c., ast rocyt omas (12), oligodendrogliomas (5), pleomorphic xant oast rocy-t oma (1) and desembryoblasrocy-t ic neuroepirocy-t helial rocy-t umor (1). Patients of group A show ed different clinical behavior, w ith beginning of the epileptic crises before age of 8 years (p< 0.005) and seizures frequency low er than 16 monthly (p< 0.002), differentiating w ith ganglioglioma. The
epilep-tic crises of the complex partial type prevailed (88.2%) and the neurological exam w as normal in 67.7% of all patients. M agnet ic resonance image show ed t he t umors in all cases, w hile t he comput erized t omography w as conside-red normal in 5 pat ient s. The use of cont rast did not in-crease t he sensibilit y of t he comput erized tomography in relat ion t o magnet ic resonance. Group A did not show edema or calcificat ions in t he images, w ith a smaller capta-tion of contrast in the magnet ic resonance w hen compared w it h group B (20% and 42%). Mass effect was observed in 20% of the exams in group A against 52% in group B. The electroencephalogram w as inexact in just 17.6% of t he pat ient s, w it hout any repercussion on t he final result .
Elect rocort icography, cort ical st imulat ion and st ereo-t axy w ere necessary in ereo-t he paereo-t ienereo-t s’ surgery, increasing t he safet y of t he resecion of t he t umor and of t he cerebral cort ex generat or of epilept ic crises. The surgical removal of t he t umors w as t ot al in 85.3% of t he pat ient s. M ost of t hem (91.2%) remained w it hout epilept ic crises in t he fol-low up minimum of 24 mont hs (average of 34.2 mont hs).
KEY W ORDS: ref ract ory epilepsy, gliom a, elect ro-cort icography, ro-cort ical st imulat ion.
REFRACTORY EPILEPSY ASSOCIATED W ITH CEREBRAL TUM OR OF SLOW GROW TH (ABSTRACT)* . DISSERTA-TION. RECIFE, 1999.
PAULO THADEU BRAINER DE QUEIROZ LIM A* *
* Epilepsia refrat ária associada a t umor cerebral primário de cresciment o lent o (Resumo).Dissert ação de M est rado, Universidade Federal de Pernambuco (Área: Neuropsiquiat ria). Orient ador: Luiz At aíde Júnior.
* * Address: Rua Jose Clement ino 47 / 601, 52050-070 Recif e PE, Brasil. E-mail: brainerlima@aol.br
M igraine at t acks can be init iat ed, in some pat ient s, under t he influence of cert ain fact ors (like hormonal, ali-ment ary, emot ional, sensory) t hat act upon a reduced pain t hreshold t o precipit at e t hese at t acks. St udying t he inci-dence of t hese fact ors is of import ance if w e consider t hat t hey part icipat e in a significant number of migraine epi-sodes. Thus, an approach t hat t akes int o account t he in-fluence of cert ain fact ors in t he t riggering of migraine should be included in any t herapeut ic t rial, as an auxiliary measure t o pharmacologic t herapy.
To st udy t he dist ribut ion of t riggers of migraine in a select ed populat ion, 100 pat ient s (84 f em ales and 16 males, w it h ages ranging from 10 t o 64 years, averaging 33.6 years) w ho fulfilled the diagnostic criteria for migraine w it hout aura proposed by t he Int ernat ional Headache Societ y (IHS –1988) w ere evaluat ed by means of personal
PRECIPITATING FACTORS OF M IGRAINE ATTACKS IN PATIENTS W ITH M IGRAINE W ITHOUT AURA (ABSTRACT)* .
DISSERTATION. NITERÓI, 2000.
RICARDO IERUSALIM SCHY * *
int erview. St ress w as t he most cit ed t rigger, t riggering mi-graine in 76%. Aft erw ards, in descending order of impor-t ance, sensorial simpor-t imuli (75%), sleep deprivaimpor-t ion (49%), hunger (48%), environment al fact ors (47%), food (46%), menses (39%), fat igue (35%), alcohol (28%), sleep excess (27%), cafeine (22%), physical exertion (20%), head trauma (20%), t rips (4%), sexual act ivit y (3%), medicat ions (2%), neck movement s (2%), smoking (1%) and t he use of a low pillow (1%) w ere cited. In a comparison made betw een tw o groups of patients, there w as no evidence of the ac-tion of alcohol as a potentiator for alimentary triggers.
We conclude t hat cert ain fact ors seem t o play an im-portant role in the triggering of migraine, w ith stress stand-ing out as t he most import ant one.
KEY W ORDS: migraine, precipit at ing fact ors, migraine t riggers.
* Fat ores desencadeant es de crises de migrânea em pacient es com migrânea sem aura (Resumo). Dissert ação de M est rado, Universidade Federal Fluminense (Área: Neurologia). Orient ador: Pedro Ferreira M oreira Filho.
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CENTRAL NERVOUS SYSTEM PARACOCCIDIOIDOM YCOSIS: ANALYSIS OF 13 CASES W ITH IM M UNOFLUORES-CENCE RESEARCH OF GP43 ANTIGEN. (ABSTRACT)* .DISSERTATION. BELO HORIZONTE, 2001.
WALTER J. FAGUNDES-PEREYRA* *
Paracoccidioidomycosis (PCM ) is a syst emic granulo-mat ous disease caused by Paracoccidioides brasiliensis, prevalent in Lat in America, part icularly in Brazil. Cent ral nervous syst em (CNS) involvement occur in about 10% of cases, alt hough such cases are uncommon in t he lit era-t ure.
Thirt een cases of neuroparacoccidioidomycosis w ere st udied emphasizing clinical manifest at ions, neuroradio-logy and immunoneuroradio-logy. The 43,000 dalt on glycoprot ein (gp43) is t he main exocellular ant igen of P. brasiliensis, w hich is probably relat ed w it h fungus virulence. The gp43 elicit s an efficient ant ibody response w hich does not pro-t ecpro-t again progressive PCM ; ipro-t s secrepro-t ion and circulapro-t ion as a free antigen or as immunocomplexs may inhibit “ natu-ral killer” cells act ivit y, induce T suppressor cells and pro-mot e binding t o laminin w hich may have a role in fungal disseminat ion; may also carry aggregat ed molecules w it h prot eolyt ic act ivit y.
The gp43 ant igen w as invest igat ed by indirect immu-nofluorescence in specimen of brain biopsy cont aining paracoccidioides granuloma. We st udied in vit ro t he re-sponse of peripheral blood mononuclear cells from pa-t ienpa-t s w ipa-t h PCM presenpa-t ing w ipa-t h CNS involvemenpa-t pa-t o anpa-t i-genic fract ions from P. brasiliensis yeast cell lysat e (PbAg). The fract ion 0 (F0) w ere obt ained using anion-exchange chromat ography on a FPLC syst em. IgG ant ibodies ant i-P.
brasiliensis (ant i-PbAg and ant i-F0) w ere evaluat ed in se-rum , plasm a and cerebrospinal f luid (CSF). They w ere mesasured by ELISA and det ect ed by West ern Blot .
Af t er lit erat ure review, 129 cases of neuroparaco-ccidioidomycosis w ere found, including our 13 pat ient s. The most frequent sympt oms w ere mot or deficit s (53.8%), cognit ive dist urbance (53.8%), w eight loss (46.1%), head-aches (46.1%) and seizures (46.1%). Comput erized t
omog-raphy (CT) scans w ere obt ained in all cases and magnet ic resonance imaging (M Ri) w as used in one case. Serology for HIV w as done in t en pat ient s (76.9%), and all t he t est s w ere negat ives. Granulomat ous forms w ere present in all pat ient s. Four (30.8%) of t hem had also meningeal in-volvement (mixed form). The diagnosis w as confirmed by t he demonst rat ion of P. brasiliensis in all t he cases, t w elve (92.3%) by histophathological examination and one (7.7%) in t he CSF.
Indirect immunofluorescence revealed t he presence of gp43 ant igen in all st udied cases. ELISA and West ern Blot disclosed IgG ant ibodies ant i-P. brasiliensis (ant i-PbAg and ant i-F0) in sera and plasma. How ever, it w as not observed in t he CSF.
Amphotericin B w as used in tw elve patients (92.3%), one of t hem by int ravent ricular infusion. In eight pat ient s (61.5%), t rimet hopim and sulfamet hoxazole w ere used, and, in t w o (15.4%), sulfadiazine and pirimet amine. Fluco-nazole, ket oconazole and it raconazole w ere each one used in a different pat ient as well. Six patients died (46.1%) and seven (53.9%) had sat isfat ory out come. The follow -up pe-riod ranged from 2 t o 74 (M = 30,9) mont hs.
In conclusion, t he CNS involvement in paracoccidioi-domycosis is more frequent and more serious than thought before. The clinical manifest at ions, CT scans and M Ri find-ings are not specific of paracoccidioidomycosis. Indirect immunofluorescence, ELISA and West ern Blot can be used in t he det ect ion of P. brasiliensis ant igens and ant ibodies w it h sat isfat ory sensibilit y. Furt her st udies are st ill needed aiming at t he increase of know ledge about t his disease, w hich has high mort alit y rat es.
KEY W ORDS: paracoccidiodomycosis, cent ral nervous syst em, gp43 prot ein.
* Paracoccidioidomicose no sist ema nervoso cent ral – análise de 13 casos com pesquisa do ant ígeno gp 43 por imunofluorescência (Resumo). Dissert ação de M est rado, Sant a Casa de Belo Horizont e (Área: M edicina). Orient ador: Alfredo M . Góes. Co-orient adores: At os Alves de Sousa e Francisco das Chagas Lima e Silva.
