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Background: Several approaches are described for giant meningiomas of the anterior skull base. Recently, endonasal endoscopic approaches have been described as a minimally invasive (MI) alternative. However, the extension of dissection of the nose cavity and the risks of CSF leak do not fit in the MI prerogatives. We present an operative video illustrating a MI transcortical approach through a nummular craniotomy for a giant meningioma of the anterior fossa. Case Description: We report an 83-year-old female patient. On neurological examination, she was drowsy and hemiparetic on the left side. MRI scan demonstrated a giant anterior fossa lesion (7.6 × 6.2 × 6 cm). An 1.5 diameter craniotomy was placed in the right frontal region after MRI 3D reconstruction analysis. The first step was to debulk the core of the tumor with the ultrasonic aspirator. An important aspect is that the surgeon needs to rotate its positions around the patient in a 360° fashion for a total resection. The final step was to inspect the surgical cavity with the endoscope to check for any remaining tumor. The patient was discharged home 1 day after the surgery with no new deficits. Conclusion: Giant meningiomas of the anterior fossa are a different entity. When they reach the cortical surface, the surgical approach can be different from the common skull base meningiomas. We demonstrate that a MI transcortical approach can be a safe alternative for giant meningiomas, especially for high-risk patients, as the elderly ones.
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BACKGROUND: Surgical planning for treating brain arteriovenous malformations (bAVMs) is challenging because it entails visualizing 3-dimensional (3D) relationships between the nidus, its feeding and en passage arteries, and draining veins. Surgical experience in developing the capacity to mentally visualize pathological bAVM angioarchitecture could be complemented by this software, and thus potentially lower the steep learning curve for understanding complex bAVM angioarchitecture. We evaluated the clinical application of freely available online 3D reconstruction software in facilitating visualization of AVM angioarchitecture for presurgical planning. METHODS: Preoperative Digital Imaging and Communications in Medicine magnetic resonance imaging/magnetic resonance angiography images of 56 superficial bAVMs from 2013 to 2018 were processed using open-source software Horos. 3D rendered images were compared with the surgical view to evaluate software accuracy and determine its value as a preoperative tool. 3D reconstructed images were compared with intraoperative recordings. RESULTS: A useful image identifying both the main feeding artery and draining vein was achieved in 35 of 56 cases (62.5%). Reconstructions of small AVMs (nidus ≤2 cm) and those located within the temporal or cerebellar cortex were less useful due to soft tissue artifacts. Frontal and parietal lobe lesions had significantly higher rates of identifying feeding arteries and draining veins (P < 0.05). CONCLUSION: Presurgical planning for resection of superficial bAVMs using Horos software allows for a comprehensive 3D analysis of the bAVM angioarchitecture. This technique is most useful for frontal and parietal lobe lesions, and aids the surgeon in formulating an optimal surgical strategy. The 3D reconstruction of the brain surface offers a surgical map not influenced by brain shift.
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Malformações Arteriovenosas Intracranianas/diagnóstico por imagem , Malformações Arteriovenosas Intracranianas/cirurgia , Procedimentos Neurocirúrgicos/métodos , Planejamento de Assistência ao Paciente , Software , Adolescente , Adulto , Idoso , Angiografia Digital , Angiografia Cerebral , Artérias Cerebrais/diagnóstico por imagem , Artérias Cerebrais/cirurgia , Veias Cerebrais/diagnóstico por imagem , Veias Cerebrais/cirurgia , Criança , Pré-Escolar , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Imageamento Tridimensional , Angiografia por Ressonância Magnética , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Adulto JovemRESUMO
BACKGROUND: Although anterior temporal lobectomy may be a definitive surgical treatment for epileptic patients with mesial temporal sclerosis, it often results in verbal, visual, and cognitive dysfunction. Studies have consistently reported the advantages of selective procedures compared with a standard anterior temporal lobectomy, mainly in terms of neuropsychological outcomes. OBJECTIVE: To describe a new technique to perform a selective amygdalohippocampectomy (SAH) through a transpalpebral approach with endoscopic assistance. METHODS: A mini fronto-orbitozygomatic craniotomy through an eyelid incision was performed in 8 patients. Both a microscope and neuroendoscope were used in the surgeries. An anterior SAH was performed in 5 patients who had the diagnosis of temporal lobe epilepsy with mesial temporal sclerosis. One patient had a mesial temporal lesion suggesting a ganglioglioma. Two patients presented mesial temporal cavernomas with seizures originating from the temporal lobe. RESULTS: The anterior approach allowed removal of the amygdala and hippocampus. The image-guided system and postoperative evaluation confirmed that the amygdala may be accessed and completely removed through this route. The hippocampus was partially resected. All patients have discontinued medication with no more epileptic seizures. The patients with cavernomas and ganglioglioma also had their lesions completely removed. One-year follow-up has shown no visible scars. CONCLUSION: The anterior route for SAH is a rational and direct approach to the mesial temporal lobe. Anterior SAH is a safe, less invasive procedure that provides early identification of critical vascular and neural structures in the basal cisterns. The transpalpebral approach provides a satisfactory cosmetic outcome.
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Tonsila do Cerebelo/cirurgia , Túnica Conjuntiva/cirurgia , Endoscopia/métodos , Hipocampo/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Adulto , Idoso , Tonsila do Cerebelo/diagnóstico por imagem , Neoplasias Encefálicas/complicações , Neoplasias Encefálicas/diagnóstico por imagem , Neoplasias Encefálicas/cirurgia , Transtornos Cognitivos/etiologia , Transtornos Cognitivos/cirurgia , Túnica Conjuntiva/diagnóstico por imagem , Craniotomia/métodos , Eletroencefalografia , Epilepsia do Lobo Temporal/complicações , Epilepsia do Lobo Temporal/diagnóstico por imagem , Epilepsia do Lobo Temporal/cirurgia , Feminino , Lobo Frontal/cirurgia , Hemangioma Cavernoso/complicações , Hemangioma Cavernoso/diagnóstico por imagem , Hemangioma Cavernoso/cirurgia , Hipocampo/diagnóstico por imagem , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Although recent technological advances have led to successful endovascular treatment, middle cerebral artery (MCA) aneurysms are still prone to surgery. Because minimally invasive options are limited and possess several functional and cosmetic drawbacks, a transpalpebral approach is proposed as a new alternative. OBJECTIVES: To describe and assess surgical results of the minimally invasive transpalpebral approach in patients with MCA aneurysms. METHODS: The data of 25 patients with unruptured MCA aneurysms from 2013 to 2016 were included in a cohort prospective database. We describe modifications of the approach and technique for MCA aneurysm clipping, in a step-by-step manner. The outcome was based on complications, procedural morbidity and mortality, and clinical and angiographic outcomes. RESULTS: All procedures were successfully performed in a standardized way, and no major complications related to the new approach were observed. Twenty-two patients were discharged the day after surgery (88%). The majority of aneurysms were 5 to 6 mm in diameter (mean, 7 mm; range 4-21 mm). All patients underwent postoperative angiographic control, which showed no significant residual neck. A 3-mo follow-up was sufficient to show no visible scars with excellent cosmetic results. The mean duration of follow-up was 16 mo. CONCLUSION: The transpalpebral approach comes as a minimally invasive, safe, definitive, and cosmetically adequate solution for MCA aneurysms at the present time.
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Craniotomia/métodos , Aneurisma Intracraniano/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Órbita/cirurgia , Adulto , Idoso , Angiografia Digital , Angiografia por Tomografia Computadorizada , Pálpebras/cirurgia , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Neuronavegação , Estudos Prospectivos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
The endoscopic technique has been described as a minimally invasive method for spontaneous hematoma evacuation, as a safe and effective treatment. Nevertheless, to our knowledge, there is no description of a technical report of traumatic intracerebral hematoma removal using the neuroendoscope. A 47-year-old man was admitted sustaining 13 points in Glasgow coma scale with brain computed tomography (CT) scan showing a temporal contusion. Guided by a 3D reconstructed CT, using the program OsiriX®, the posterior limit of the hematoma was identified. A burr hole was placed at the posterior temporal region, and we used the neuroendoscope to assist the hematoma evacuation. The postoperative tomography showed adequate hematoma removal. He was discharged from hospital 48 h after surgery. Two weeks later, he was conscious and oriented temporally. This endoscopic-assisted technique can provide safe removal of traumatic hematomas of the temporal lobe.
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The evaluation of patients in the emergency room department (ER) through more accurate imaging methods such as computed tomography (CT) has revolutionized their assistance in the early 80s. However, despite technical improvements seen during the last decade, surgical planning in the ER has not followed the development of image acquisition methods. The authors present their experience with DICOM image processing as a navigation method in the ER. The authors present 18 patients treated in the Emergency Department of the Hospital das Clínicas of the University of Sao Paulo. All patients were submitted to volumetric CT. We present patients with epidural hematomas, acute/subacute subdural hematomas and contusional hematomas. Using a specific program to analyze images in DICOM format (OsiriX(®)), the authors performed the appropriate surgical planning. The use of 3D surgical planning made it possible to perform procedures more accurately and less invasively, enabling better postoperative outcomes. All sorts of neurosurgical emergency pathologies can be treated appropriately with no waste of time. The three-dimensional processing of images in the preoperative evaluation is easy and possible even within the emergency care. It should be used as a tool to reduce the surgical trauma and it may dispense methods of navigation in many cases.
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Serviço Hospitalar de Emergência , Imageamento Tridimensional/métodos , Neuronavegação/métodos , Procedimentos Neurocirúrgicos/métodos , Software , Adulto , Hematoma/patologia , Hematoma/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Thalamotomies and pallidotomies were commonly performed before the deep brain stimulation (DBS) era. Although ablative procedures can lead to significant dystonia improvement, longer periods of analysis reveal disease progression and functional deterioration. Today, the same patients seek additional treatment possibilities. METHODS: Four patients with generalized dystonia who previously had undergone bilateral pallidotomy came to our service seeking additional treatment because of dystonic symptom progression. Bilateral subthalamic nucleus DBS (B-STN-DBS) was the treatment of choice. The patients were evaluated with the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) and the Unified Dystonia Rating Scale (UDRS) before and 2 years after surgery. RESULTS: All patients showed significant functional improvement, averaging 65.3% in BFMDRS (P = .014) and 69.2% in UDRS (P = .025). CONCLUSIONS: These results suggest that B-STN-DBS may be an interesting treatment option for generalized dystonia, even for patients who have already undergone bilateral pallidotomy.
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Estimulação Encefálica Profunda/métodos , Distúrbios Distônicos/terapia , Palidotomia/métodos , Núcleo Subtalâmico/fisiologia , Adulto , Feminino , Lateralidade Funcional , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto JovemRESUMO
Neurogenic neuroprotection is a promising approach for treating patients with ischemic brain lesions. In rats, stimulation of the deep brain nuclei has been shown to reduce the volume of focal infarction. In this context, protection of neural tissue can be a rapid intervention that has a relatively long-lasting effect, making fastigial nucleus stimulation (FNS) a potentially valuable method for clinical application. Although the mechanisms of neuroprotection induced by FNS remain partially unclear, important data have been presented in the last two decades. A 1-h electrical FNS reduced, by 59%, infarctions triggered by permanent occlusion of the middle cerebral artery in Fisher rats. The acute effect of electrical FNS is likely mediated by a prolonged opening of potassium channels, and the sustained effect appears to be linked to inhibition of the apoptotic cascade. A better understanding of the neuronal circuitry underlying neurogenic neuroprotection may contribute to improving neurological outcomes in ischemic brain insults.
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Infarto Encefálico/prevenção & controle , Núcleos Cerebelares/fisiologia , Estimulação Encefálica Profunda/métodos , Animais , Infarto Encefálico/etiologia , Núcleos Cerebelares/anatomia & histologia , Núcleos Cerebelares/metabolismo , Circulação Cerebrovascular/fisiologia , Modelos Animais de Doenças , Encefalite/etiologia , Encefalite/prevenção & controle , Humanos , Infarto da Artéria Cerebral Média/complicações , Vias Neurais/fisiologia , Lobo Parietal/fisiologiaRESUMO
Aspergilose do sistema nervoso central (SNC) é uma doença rara. O uso de corticosteróides tem elevado o número de casos na atualidade. Trata-se de uma doença com uma elevada taxa de letalidade e deve ser tratada de forma agressiva.Métodos: A literatura foi revisada, sendo identificados 38 casos envolvendo aneurismas cerebrais causadas por Aspergillus.Conclusão: A infecção por Aspergillus é muito rara no mundo, mas sua frequência vem se elevando porque a falha de imunocompetência está crescendo. Não há uma apresentação específica desta doença, tornando o diagnóstico muito difícil.O prognóstico é ruim, portanto a doença deve ser tratada precocemente.
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Humanos , Masculino , Feminino , Aneurisma Infectado , Aspergillus fumigatus , Aneurisma IntracranianoRESUMO
OBJECTIVE: In the majority of cases, the correct treatment of brain lesions is possible only when the histopathological diagnosis is made. Several deep-seated lesions near eloquent areas are not safely approached by the classical neurosurgical procedures. These patients can get benefit by a minimally invasive procedure. METHOD: We present a series of 176 consecutive patients submitted to stereotactic biopsies due to a great variety of brain lesions. RESULTS: Histological diagnosis found in this series: glioma in 40.1% of the patients, other neoplasms in 12.2% and infectious or inflammatory diseases in 29.1 %. The result was inconclusive in 5.2% of the procedures. One patient died (0.6%) and two (1.2%) presented operative complications. The criteria, advantages and risks of the stereotactic biopsies are discussed. CONCLUSION: The efficacy of the method is adequate and morbid-mortality rates were low.