An economic study of neuro-oncological patients in a large developing country: a cost analysis

BACKGROUND

Neuro-oncological patients require specialized medical care. However, the data on the costs incurred for such specialized care in developing countries are currently lacking. These data are relevant for international cooperation.

OBJECTIVE

The present study aimed to estimate the direct cost of specialized care for an adult neuro-oncological patient with meningioma or glioma during hospitalization in the largest philanthropic hospital in Latin America.

METHODS

The present observational economic analysis describes the direct cost of care of neuro-oncological patients in Santa Casa de São Paulo, Brazil. Only adult patients with a common primary brain tumor were included.

RESULTS

Due to differences in the system records, the period analyzed for cost estimation was between December 2016 and December 2019. A group of patients with meningiomas and gliomas was analyzed. The estimated mean cost of neurosurgical hospitalization was US$4,166. The cost of the operating room and intensive care unit represented the largest proportion of the total cost. A total of 17.5% of patients had some type of infection, and 66.67% of these occurred in nonelective procedures. The mortality rate was 12.7% and 92.3% of all deaths occurred in emergency procedures.

CONCLUSIONS

Emergency surgeries were associated with an increased rate of infections and mortality. The findings of the present study could be used by policymakers for resource allocation and to perform economic analyses to establish the value of neurosurgery in achieving global health goals.

Slip Clip after successful microsurgery of a blister aneurysm: Should bypass always be the first option?

Blood Blister-like aneurysms are intracranial non-saccular aneurysms with higher rupture risk due to its fragile wall. Diagnosis is performed in the acute phase of a subarachnoid hemorrhage. There are several treatment options based on reconstructive or deconstructive techniques. This paper aims to discuss the limitations of microsurgery clipping for a ruptured blister aneurysm. We report on a case of a female patient presented with a Fisher III subarachnoid hemorrhage. Cerebral angiography revealed an internal carotid artery blister aneurysm. Initially microsurgery clipping was successfully performed. However, after a few days the patient presented new subarachnoid hemorrhage. The new cerebral angiography showed growth of the previously clipped aneurysm, with displacement of the clip from the position adjacent to the artery. High-flow bypass was performed obtaining definitive treatment. This is a definitive approach for blister aneurysms. If microsurgery clipping is chosen, a strict follow-up is required due to the dynamic nature of this lesion and the chance of re-bleeding even after successfully clipping.

The Use of Osirix for Surgical Planning Using Cranial Measures and Region of Interest Tools: Technical Note

Background:

During the surgery for intrinsic brain lesions, it is important to plan the proper site of the craniotomy and to identify the relations with the gyri and superficial veins. This might be a challenge, especially in small subcortical lesions and when there is a distortion of the cortical anatomy.

Materials and Methods:

Using the free computer software Osirix, we have created a 3-dimensional reconstruction of the head and cerebral showing the gyri and superficial veins. With the aid of some tools, it is possible to create a colored image of the lesion and also to calculate the distance between the areas of interest and some easily identifiable structure, making it easier to plan the site of the craniotomy identify the topography of the lesion.

Results:

The reconstructions were compared to the intraoperative view. We found this technique to be useful to help identify the gyri and cortical veins and use them to find the lesions. The use of a region of interest to show better the lesion under the cortical surface and in the three-dimensional reconstruction of the head was also helpful.

Conclusions:

This is a low-cost and easy technique that can be quickly learned and performed before every surgery. It helps the surgeon to plan a safe craniotomy and lesionectomy.

Intracranial aneurysm and arachnoid cyst: just a coincidence? A case report

CONTEXT

Presence of an arachnoid cyst and a non-ruptured intracystic brain aneurysm is extremely rare. The aim of this paper was to describe a case of a patient with an arachnoid cyst and a non-ruptured aneurysm inside it. Clinical, surgical and radiological data were analyzed and the literature was reviewed.

CASE REPORT

A patient complained of chronic headache. She was diagnosed as having a temporal arachnoid cyst and a non-ruptured middle cerebral artery aneurysm inside it. Surgery was performed to clip the aneurysm and fenestrate the cyst.

CONCLUSIONS

This report raises awareness about the importance of intracranial vascular investigation in patients with arachnoid cysts and brain hemorrhage.

Cryptococcoma mimicking a brain tumor in an immunocompetent patient: case report of an extremely rare presentation

CONTEXT

Central nervous system (CNS) infectious diseases have high prevalence in developing countries and their proper diagnosis and treatment are very important for public health planning. Cryptococcus neoformans is a fungus that may cause several CNS manifestations, especially in immunocompromised patients. Cryptococcal meningitis is the most common type of involvement. Mass-effect lesions are uncommon: they are described as cryptococcomas and their prevalence is even lower among immunocompetent patients. The aim here was to report an extremely rare case of cryptococcoma causing a mass effect and mimicking a brain tumor in an immunocompetent patient. The literature on CNS cryptococcal infections was reviewed with emphasis on cryptococcomas. Clinical, surgical and radiological data on a female patient with this rare presentation of cryptococcoma mimicking a brain tumor are described.

CASE REPORT

A 54-year-old female patient presented to the emergency department with a rapid-onset progressive history of confusion and completely dependency for basic activities. Neuroimaging showed a left occipital lesion and neurosurgical treatment was proposed. From histopathological evaluation, a diagnosis of cryptococcoma was established. She received clinical support with antifungals, but despite optimal clinical treatment, her condition evolved to death.

CONCLUSIONS

Cryptococcal infections have several forms of presentation and, in immunocompetent patients, their manifestation may be even more different. Cryptococcoma is an extremely rare presentation in which proper surgical and clinical treatment should be instituted as quickly as possible, but even so, there is a high mortality rate.

Analysis of direct costs of decompressive craniectomy in victims of traumatic brain injury

ABSTRACT Background: Decompressive craniectomy is a procedure required in some cases of traumatic brain injury (TBI). This manuscript evaluates the direct costs and outcomes of decompressive craniectomy for TBI in a developing country and describes the epidemiological profile. Methods: A retrospective study was performed using a five-year neurosurgical database, taking a sample of patients with TBI who underwent decompressive craniectomy. Several variables were considered and a formula was developed for calculating the total cost. Results: Most patients had multiple brain lesions and the majority (69.0%) developed an infectious complication. The general mortality index was 68.8%. The total cost was R$ 2,116,960.22 (US$ 661,550.06) and the mean patient cost was R$ 66,155.00 (US$ 20,673.44). Conclusions: Decompressive craniectomy for TBI is an expensive procedure that is also associated with high morbidity and mortality. This was the first study performed in a developing country that aimed to evaluate the direct costs. Prevention measures should be a priority.

Simultaneous meningioma and brain metastasis from renal cell carcinoma - a rare presentation. Case report

CONTEXT:

Brain metastases are the most common tumors of the central nervous system. Because of their high frequency, they may be associated with rare situations. Among these are tumor-to-tumor metastasis and an even a rarer situation called simultaneous brain tumors, which are more related to primary tumors of the reproductive and endocrine systems.

CASE REPORT:

A 56-year-old male patient with a history of renal cell carcinoma (which had previously been resected) presented with a ventricular lesion (suggestive of metastatic origin) and simultaneous olfactory groove lesion (probably a meningioma). First, only the ventricular lesion was dealt with, but after a year, the meningothelial lesion increased and an occipital lesion appeared. Therefore, both of these were resected in a single operation. All the procedures were performed by the same neurosurgeon. The patient evolved without neurological deficits during the postoperative period. After these two interventions, the patient remained well and was referred for adjuvant treatment.

CONCLUSIONS:

This study provides the first description of an association between these two tumors. Brain metastases may be associated with several lesions, and rare presentations such as simultaneity with meningioma should alert neurosurgeons to provide the best oncological treatment.

Facial paralysis due to Ramsay Hunt syndrome - A rare condition

Summary Ramsay Hunt syndrome (or herpes zoster oticus) is a rare complication of herpes zoster in which reactivation of latent varicella zoster virus infection in the geniculate ganglion occurs. Usually, there are auricular vesicles and symptoms and signs such otalgia and peripheral facial paralysis. In addition, rarely, a rash around the mouth can be seen. Immunodeficient patients are more susceptible to this condition. Diagnosis is essentially based on symptoms. We report the case of a diabetic female patient who sought the emergency department with a complaint of this rare entity.

Retroauricular pain caused by Eagle syndrome: A rare presentation due to compression by styloid process elongation

Summary Eagle syndrome is a rare condition presenting with retroauricular pain (usually as main symptom) associated with dysphagia, headache, neck pain on rotation and, much rarelier, stroke. This occurs due to styloid process elongation. Sometimes, there is also styloid ligament calcification, which can cause compression of nerves and arteries and the symptoms above. Treatment can be conservative with pain modulators (e.g. pregabalin) or infiltrations (steroids or anesthetics drugs). In refractory cases, surgical approach aiming to reduce the size of the styloid process can be performed. We present a rare case of Eagle syndrome (documented by computed tomography) with good response to clinical treatment.

Surgical treatment of neurocysticercosis. Retrospective cohort study and an illustrative case report

CONTEXT AND OBJECTIVE:

Neurocysticercosis is prevalent in developing countries and manifests with several neurological signs and symptoms that may be fatal. The cysts may be parenchymal or extraparenchymal and therefore several signs and symptoms may occur. Depending on their location, neurosurgical procedures may be required, sometimes as emergencies. The aim here was to review 10-year statistics on all surgical neurocysticercosis cases at a large public tertiary-level hospital.

DESIGN AND SETTING:

Retrospective cohort at a large public tertiary-level hospital.

METHODS:

All surgical neurocysticercosis cases seen between July 2006 and July 2016 were reviewed. Parenchymal and extraparenchymal forms were considered, along with every type of surgical procedure (shunt, endoscopic third ventriculostomy and craniotomy). The literature was reviewed through PubMed, using the terms "neurocysticercosis", "surgery", "shunt" and "hydrocephalus".

RESULTS:

37 patients underwent neurosurgical procedures during the study period. Most were male (62.16%) and extraparenchymal cases predominated (81%). Patients aged 41 to 50 years were most affected (35.13%) and those 20 years or under were unaffected. Ventricular forms were most frequently associated with hydrocephalus and required permanent shunts in most cases (56.57%).

CONCLUSIONS:

The treatment of neurocysticercosis depends on the impairment: the parenchymal type usually does not require surgery, which is more common in the extraparenchymal form. Hydrocephalus is a frequent complication because the cysts often obstruct the cerebrospinal flow. The cysts should be removed whenever possible, to avoid the need for permanent shunts.

Cerebral aneurysms associated with human immunodeficiency virus in adults: literature review and new perspectives

INTRODUCTION

the treatment of human immunodeficiency virus (HIV) infection has been decreasing patient morbidity and mortality by opportunistic infections and, thus, survival has increased. This new reality has been changing the spectrum of diseases affecting such patients.

OBJECTIVE

to discuss the association between HIV and the emergence of aneurysmal brain injuries.

METHOD

it was performed a literature review using medical database. The following descriptors were searched: "Intracranial Aneurysms and HIV", "Intracranial Aneurysms and Acquired Immunodeficiency Syndrome," "aneurysm and brain and HIV".

RESULTS

after performed a literature review, it was observed that the relationship between HIV infection and the formation of aneurysms appears to be real, however, it still lacks data to confirm the pathophysiology of this condition and its best treatment.

CONCLUSION

there are new signs and symptoms that should be studied and researched relating HIV with other changes not previously known.

Retroclival Pneumocephalus Associated with Bilateral Abducens Palsy in a Child

Traumatic brain injury (TBI) is less common in children than in adults. Posterior fossa lesions are even more uncommon, but, when present, are usually epidural hematomas. These lesions, even when small, may have a bad outcome because of the possibility of compression of the important structures that the infratentorial compartment contains, such as the brainstem and cranial nerves, and the constriction of the fourth ventricle, causing acute hydrocephalus. Although unusual, posterior fossa lesions are increasingly being diagnosed because of the better quality of and easier access to cranial tomography. In this paper, we report a case of a 12-year-old male patient who had suffered a TBI and presented with several pneumocephali, one of them in the retroclival region, causing a mass effect and then compression of the sixth cranial nerve which is the most susceptible to these injuries. We discuss these traumatic posterior fossa lesions, with an emphasis on retroclival pneumocephalus, not yet described in the literature in association with bilateral abducens palsy. In addition, we discuss associated lesions and the trauma mechanism.

[Davidenkow syndrome. A rare peripheral neuropathy]

A different and rare type of atrophy with a predominant pattern in scapulo-peroneal distribution was described by Davidenkow in 1939. The syndrome was characterized by some researchers as a variant of Charcot-Marie-Tooth disease, however Davidenkow noticed that clinical and laboratorial manifestations did not corroborate exactly with this hypothesis. We describe a case of a female patient, 39 years-old, clinical picture similar to the syndrome described by Davidenkow, presenting scapulo-peroneal atrophy. Her first symptoms had appeared when she was 24, initially with proximal motor weakness in the upper limbs. This patient did not have family history of myopathy or neuropathy. Several tests were performed to exclude other syndromes that could be included in the differential diagnosis, by testing gene mutation, in addition to the physical examination and electromyography. The large spectrum of neuromuscular diseases makes difficult the diagnosis of Davidenkow's syndrome which always should be considered in the differential diagnosis.

Closed head injury in rats: histopathological aspects in an experimental weight drop model

PURPOSE

To study histopathological findings due to a model of closed head injury by weight loss in rats.

METHODS

A platform was used to induce closed cranial lesion controlled by weight loss with a known and predefined energy. 25 male Wistar rats (Rattus novergicus albinus) were divided in five equal groups which received different cranial impact energy levels: G1, G2, G3 and G4 with 0.234J, 0.5J, 0.762J and 1J respectively and G5 (Sham). Under the effect of analgesia, the brain of each group was collected and prepared for histopathological analysis by conventional optic microscopy.

RESULTS

It was observed greater number of injured neurons in animals of group 4, however neuronal death also could be noticed in animals of group 5. Intraparenchymal hemorrhages were more frequent in animals of group 4 and the cytotoxic brain swelling and vascular congestion were more intense in this group

CONCLUSION

The histopathological analysis of these findings allowed to observe typical cranial trauma alterations and these keep close relation with impact energy.