RESUMO
In the treatment of complex paraclinoidal and giant cavernous aneurysms, preservation of the patency of the internal carotid artery (ICA) is not always possible, and therapeutic occlusion of the carotid is still an important option for their management. A complete preoperative evaluation of the carotid reserve circulation, including the use of temporary balloon occlusion test and single photon emission computerized tomography (SPECT) should be included in the current paradigms of paraclinoidal and intracavernous aneurysms management. We present a series of fifteen patients with sixteen giant or complex carotid cavernous or ophthalmic aneurysms that were treated following a protocol for our preoperative decision-making analysis. Extracranial to intracranial saphenous vein bypass was reserved to the cases where carotid occlusion would be associated with high risk of ischemic complications and was performed in three patients. Besides the difficulties in dealing with those complex aneurysms, good clinical outcome was possible in our experience with the designed paradigm.
Assuntos
Doenças das Artérias Carótidas/cirurgia , Aneurisma Intracraniano/cirurgia , Adulto , Oclusão com Balão , Doenças das Artérias Carótidas/diagnóstico por imagem , Seio Cavernoso/diagnóstico por imagem , Criança , Terapia Combinada , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios , Tomografia Computadorizada de Emissão de Fóton ÚnicoRESUMO
In the treatment of complex paraclinoidal and giant cavernous aneurysms, preservation of the patency of the internal carotid artery (ICA) is not always possible, and therapeutic occlusion of the carotid is still an important option for their management. A complete preoperative evaluation of the carotid reserve circulation, including the use of temporary balloon occlusion test and single photon emission computerized tomography (SPECT) should be included in the current paradigms of paraclinoidal and intracavernous aneurysms management. We present a series of fifteen patients with sixteen giant or complex carotid cavernous or ophthalmic aneurysms that were treated following a protocol for our preoperative decision-making analysis. Extracranial to intracranial saphenous vein bypass was reserved to the cases where carotid occlusion would be associated with high risk of ischemic complications and was performed in three patients. Besides the difficulties in dealing with those complex aneurysms, good clinical outcome was possible in our experience with the designed paradigm.
No tratamento de aneurismas paraclinoideos complexos e cavernosos gigantes, a preservação da patência vascular nem sempre é possível, e a oclusão terapêutica da carótida ainda é uma opção importante no seu manejo. Uma avaliação pré-operatória completa da reserva circulatória carotídea, incluindo o uso do teste de oclusão temporária por balão associado à tomografia computadorizada por emissão de fóton único (SPECT) podem ser de grande utilidade para definir a opção terapêutica a ser adotada. Nós apresentamos uma série de quinze pacientes com dezesseis aneurismas complexos ou gigantes do segmento oftálmico e cavernoso da artéria carótida, que foram tratados de acordo com determinado protocolo de investigação pré-operatória. Anastomose com enxerto de veia safena entre a carótida extra e intracraniana foi reservada para os casos em que a oclusão carotídea estaria associada a um alto risco de complicações isquêmicas e foi realizado em três pacientes. Apesar das dificuldades em lidar com aneurismas complexos como os aqui relatados, é possível obter um bom resultado clínico nestes pacientes com o paradigma desenhado.
Assuntos
Adulto , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doenças das Artérias Carótidas/cirurgia , Aneurisma Intracraniano/cirurgia , Oclusão com Balão , Terapia Combinada , Doenças das Artérias Carótidas , Seio Cavernoso , Aneurisma Intracraniano , Cuidados Pré-Operatórios , Tomografia Computadorizada de Emissão de Fóton ÚnicoRESUMO
BACKGROUND: Optochiasmatic tuberculomas are very rare lesions. They can occur with concomitant tuberculous meningitis, and pulmonary tuberculosis or as the only manifestation of the disease. The authors present a case of optic pathways tuberculoma with radiologic appearance simulating an optic pathways glioma. CASE DESCRIPTION: We report a case of a 20-year-old man with mental retardation due to anoxic encephalopathy who developed a sudden bilateral amaurosis. He also presented with diabetes insipidus, panhypopituitarism, right proptosis, and chemosis. Computed tomography (CT) and magnetic resonance imaging (MRI) showed an enhancing lesion in the optochiasmatic region extending to both optic nerves, with a mass in the right orbit, mimicking an optic pathways glioma. There was no other evidence of systemic involvement of the tuberculosis. The lesion was explored through a right pterional transylvian approach with opening of the optic canal and orbital roof, and a biopsy and an internal decompression were performed. Histopathological studies demonstrated a granulomatous lesion with central caseous necrosis with acid-fast bacilli. The patient improved after treatment with tuberculostatic drugs, but vision recovery could not be achieved. CONCLUSIONS: Visual compromise in tuberculosis is associated with hydrocephalus, optical neuritis or tuberculomas involving the optic pathways. Reviewing the literature on tuberculomas of the optochiasmatic area, we could not find any other case with such extensive involvement of the optic pathways that was radiologically suggestive of an infiltrating glioma. Histopathological studies remain crucial in the diagnosis of intrinsic expansive processes of the optochiasmatic region.
Assuntos
Doenças do Nervo Óptico/diagnóstico , Doenças do Nervo Óptico/cirurgia , Tuberculoma Intracraniano/diagnóstico , Tuberculoma Intracraniano/cirurgia , Adulto , Diagnóstico Diferencial , Glioma/diagnóstico , Humanos , Imageamento por Ressonância Magnética , Masculino , Neoplasias do Nervo Óptico/diagnósticoRESUMO
We report on a case of endovascular management of pseudoaneurysm of the cavernous segment of the internal carotid artery with covered stent reconstruction. A 36 years-old woman with a history of previous transsphenoidal approach for pituitary macroadenoma and false aneurysma formation was studied in a protocol that included balloon test occlusion and cerebral blood flow evaluation. An endovascular covered stent deployment in the area of the carotid laceration was performed with isolation of the aneurysm from the circulation and maintenance of the carotid flow. Helical angio-CT and cerebral digital subtraction angiography showed the carotid preservation without stenosis in the stented area. In conclusion, endovascular stent reconstruction for post-transsphenoidal carotid artery laceration and false aneurysm is demonstrated as useful technical adjunct in the management strategy and with the potential for carotid sacrifice morbidity avoidance.
Assuntos
Falso Aneurisma/cirurgia , Lesões das Artérias Carótidas/cirurgia , Artéria Carótida Interna/cirurgia , Stents , Acromegalia , Adenoma/cirurgia , Adulto , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/etiologia , Lesões das Artérias Carótidas/diagnóstico por imagem , Lesões das Artérias Carótidas/etiologia , Artéria Carótida Interna/diagnóstico por imagem , Angiografia Cerebral , Feminino , Humanos , Neoplasias Hipofisárias/cirurgia , Complicações Pós-Operatórias/cirurgia , Seio Esfenoidal/cirurgia , Tomografia Computadorizada de Emissão de Fóton ÚnicoRESUMO
We present a case of a 46-year old woman with a ventral epidural angiolipoma at the lumbosacral level with erosion of the sacrum. About ninety cases of spinal angiolipomas have been previously described in the literature, most of them situated on the thoracic region, dorsal to the dural sac. Angiolipomas can be radically excised with a good prognosis even in the presence of bone erosion. We did not find any other angiolipoma at the sacral level surgically explored in the review of the literature.
Assuntos
Angiolipoma/diagnóstico , Sacro , Neoplasias da Coluna Vertebral/diagnóstico , Angiolipoma/cirurgia , Espaço Epidural , Feminino , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Sacro/cirurgia , Neoplasias da Coluna Vertebral/cirurgiaRESUMO
We present a case of a 46-year old woman with a ventral epidural angiolipoma at the lumbosacral level with erosion of the sacrum. About ninety cases of spinal angiolipomas have been previously described in the literature, most of them situated on the thoracic region, dorsal to the dural sac. Angiolipomas can be radically excised with a good prognosis even in the presence of bone erosion. We did not find any other angiolipoma at the sacral level surgically explored in the review of the literature
Assuntos
Feminino , Humanos , Pessoa de Meia-Idade , Angiolipoma/diagnóstico , Sacro , Neoplasias da Coluna Vertebral/diagnóstico , Angiolipoma/cirurgia , Espaço Epidural , Imageamento por Ressonância Magnética , Sacro/cirurgia , Neoplasias da Coluna Vertebral/cirurgiaRESUMO
We report on a case of endovascular management of pseudoaneurysm of the cavernous segment of the internal carotid artery with covered stent reconstruction. A 36 years-old woman with a history of previous transsphenoidal approach for pituitary macroadenoma and false aneurysma formation was studied in a protocol that included balloon test occlusion and cerebral blood flow evaluation. An endovascular covered stent deployment in the area of the carotid laceration was performed with isolation of the aneurysm from the circulation and maintenance of the carotid flow. Helical angio-CT and cerebral digital subtraction angiography showed the carotid preservation without stenosis in the stented area. In conclusion, endovascular stent reconstruction for post-transsphenoidal carotid artery laceration and false aneurysm is demonstrated as useful technical adjunct in the management strategy and with the potential for carotid sacrifice morbidity avoidance
Assuntos
Adulto , Humanos , Feminino , Falso Aneurisma , Lesões das Artérias Carótidas , Artéria Carótida Interna , Stents , Acromegalia , Adenoma , Falso Aneurisma , Lesões das Artérias Carótidas , Artéria Carótida Interna , Angiografia Cerebral , Neoplasias Hipofisárias , Complicações Pós-Operatórias , Seio Esfenoidal , Tomografia Computadorizada de Emissão de Fóton ÚnicoRESUMO
Pituitary tuberculomas are extremely rare lesions, with only few cases described in the literature, usually mistaken as pituitary tumors. Its heterogeneous clinical and imaging profile preclude preoperative diagnosis which ultimately relies on the histopathological examination. We describe a 46 years old woman who presented with an episode of confusion and hypopituitarism with no evidence of systemic tuberculosis. Computed tomography (CT) showed a central calcified and enhancing sellar mass. Magnetic resonance imaging (MRI) showed a sellar mass with suprasellar extension and associated optic chiasm compression. She was submitted a craniotomy for biopsy and resection. A caseous material was found at the center of the lesion involved by a thick wall. Due to the wall adherence to the optic chiasm and the inflammatory aspects of the lesion, subtotal removal was achieved and the patient followed on anti-tuberculous and hormonal replacement therapy. Sellar tuberculomas should be considered in the differential diagnosis of sellar tumors in order to offer appropriate treatment.