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BACKGROUND: After a case of stroke, intracranial pressure (ICP) must be measured and monitored, and the gold standard method for that is through an invasive technique using an intraventricular or intraparenchymal device. However, The ICP can also be assessed through a non-invasive method, comprised of the measurement of the optic nerve sheath diameter (ONSD) through ultrasound (US). OBJECTIVE: To evaluate the ICP of patients who underwent wide decompressive craniectomy after middle cerebral artery (MCA) infarction via preoperative and postoperative ONSD measurements. METHODS: A total of 17 patients, aged between 34 and 70 years, diagnosed with malignant MCA infarction with radiological edema and mid-line shift, who underwent decompressive surgery, were eligible. From the records, we collected data on age, sex, preoperative and postoperative Glasgow Coma Scale (GCS) scores, National Institutes of Health Stroke Scale (NIHSS) score, the degree of disability in the preoperative period and three months postoperatively through the scores on the Modified Rankin Scale (MRS), and the preoperative and postoperative midline shift measured by computed tomography (CT) scans of the brain. RESULTS: Preoperatively, the mean GCS score was of 8 (range: 7.7-9.2), whereas it was found to be of 12 (range 10-14) on the first postoperative day (p = 0.001). The mean preoperative NIHSS score was of 21.36 ± 2.70 and, on the first postoperative day, it was of 5.30 ± 0.75 (p < 0.001). As for the midline shift, the mean preoperative value was of 1.33 ± 0.75 cm, and, on the first postoperative day, 0.36 ± 0.40 cm (p < 0.001). And, regarding the ONSD, the mean preoperative measurement was of 5.5 ± 0.1 mm, and, on the first postoperative day, it was of 5 ± 0.9 mm (p < 0.001). CONCLUSION: The ocular US measurement of the ONSD for the preoperative and postoperative monitoring of the ICP seems to be a practical and useful method.

ANTECEDENTES: Após um acidente vascular cerebral (AVC), a pressão intracraniana (PIC) deve ser medida e monitorada, e o método padrão-ouro para isso é um procedimento invasivo por meio de um dispositivo intraventricular ou intraparenquimal. No entanto, a PIC também pode ser avaliada por um método não invasivo, composto da medida do diâmetro da bainha do nervo óptico (DBNO) por ultrassom (US). OBJETIVO: Avaliar a PIC de pacientes submetidos a craniectomia descompressiva ampla após infarto da artéria cerebral média (ACM) por meio das medidas do DBNO nos períodos pré e pós-operatório. MéTODOS: Um total de 17 pacientes, com idades entre 34 e 70 anos, diagnosticados com infarto maligno da ACM com edema radiológico e deslocamento da linha média, e que foram submetidos a cirurgia descompressiva, eram elegíveis. A partir dos prontuários, coletamos informações relativas à idade, gênero, pontuações pré e pós-operatória na Escala de Coma de Glasgow (ECG), pontuação na escala de AVC dos National Institutes of Health (NIH), o grau de incapacidade no pré-operatório e após três meses da operação pelas pontuações na Escala de Rankin Modificada (ERM), e o desvio da linha média no pré e pós-operatório medido por tomografia computadorizada (TC) cerebral. RESULTADOS: No pré-operatório, a pontuação média na ECG foi de 8 (variação: 7,7­9,2), e, no primeiro dia do pós-operatório, 12 variação 10­14) (p = 0,001). A pontuação média na escala dos NIH foi de 21,36 ± 2,70 no pré-operatório, e de 5,30 ± 0,75 no primeiro dia de pós-operatório (p < 0,00 1). Quanto ao desvio da linha média, no pré-operatório ele teve uma média de 1,33 ± 0,75 cm, e de 0,36 ± 0,40 cm no primeiro dia de pós-operatório (p < 0,001). E o DBNO apresentou uma média pré-operatória de 5,5 ± 0,1 mm, e de 5 ± 0,9 mm no primeiro dia de pós-operatório (p < 0,001). CONCLUSãO: A mensuração ocular do DBNO por US para o monitoramento da PIC no pré e no pós-operatório parece ser um método prático e útil.

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ABSTRACT Purpose: To describe an innovative animal model of eye transplantation used in rabbits. Methods: six Dutch-belted male rabbits were submitted to lateral orbitotomy in the right eye, wide retrobulbar anatomy exposure, dissection of the structures, identification and distal section of the optic nerve followed by anastomosis either by vicryl (group 1) or fibrin glue (group 2). Electroretinography recording was performed before the section of the optic nerve and every 30 seconds after, to monitor the function of retina. Left eye was used as control group. Results: After optic nerve resection and anastomosis, stable ERG amplitude of the right eye was lost after 302 seconds in group 1 and after 296 seconds on group 2. Left eye kept longer stable ERG amplitude curves. Conclusions: The animal model of whole eye transplantation was effective in describing a novel technique to be used in rabbits, with success of the anatomic procedure. Further studies will clarify the best anastomosis methods and maintenance of function of the receptor organ. Translational relevance: this animal model of whole eye transplantation provides a novel perspective for blind patients and the research models, since we describe a novel mammal animal model. This model can be used as basis of a human model of whole eye transplantation in future studies.

RESUMO Objetivo: Descrever uma técnica cirúrgica inovadora para transplante de olho em um modelo animal em coelhos. Métodos: Seis coelhos machos com Dutch Belted foram submetidos à orbitotomia lateral do olho direito, com ampla exposição da anatomia retrobulbar, dissecção do cone muscular, exposição e secção distal do nervo óptico seguida de anastomose por vicryl (Grupo 1) ou cola de fibrina (Grupo 2). O registro da eletrorretinografia foi realizado antes da secção do nervo óptico e a cada 30 segundos após, para monitorar a função da retina. O olho esquerdo foi usado como grupo controle. Resultados: Após a ressecção do nervo óptico, a estabilidade da amplitude da eletrorretinografia foi perdida no olho direito após 302 segundos no Grupo 1 e após 296 segundos no Grupo 2. O olho esquerdo manteve eletrorretinografia estável por períodos mais longos. Conclusão: O modelo animal de transplante total de olho foi eficaz em descrever uma nova técnica cirúrgica para ser utilizada em laboratório com coelhos, com sucesso do procedimento anatômico. Novos estudos esclarecerão os melhores métodos de anastomose e manutenção da função do órgão receptor.

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BACKGROUND: Carotid-ophthalmic aneurysms arise from the internal carotid artery between the distal dural ring and the origin of the posterior communicating artery. The surgical treatment of these aneurysms usually requires anterior clinoidectomy. However, this procedure is not without complications. In the present report, we have described optic nerve mobilization after optic foraminotomy as an alternative to anterior clinoidectomy to clip superior carotid-ophthalmic aneurysms. METHODS: We have reported the cases of 3 patients with superior carotid-ophthalmic aneurysms who had undergone surgical clipping. Instead of an anterior clinoidectomy, the optic nerve was mobilized after performing optic foraminotomy. The optic canal was carefully unroofed with a 3-mm, high-speed, diamond drill under constant cold saline irrigation to avoid thermal damage to the optic nerve. After incision of the falciform ligament and optic sheath, the optic nerve was gently mobilized with a No. 6 Penfield dissector, facilitating aneurysmal neck exposure and clipping through a widened opticocarotid triangle. RESULTS: The postoperative course was uneventful for all 3 patients, without any added visual defect. Optic nerve mobilization allowed us to safely widen the opticocarotid triangle and dissect the aneurysm off the optic nerve, without the need for clinoidectomy. This alternative technique permitted, not only early decompression of the optic nerve, but also dissection of the arachnoid between the inferior surface of the optic nerve and the superior surface of the ophthalmic-carotid artery and aneurysm dome. CONCLUSIONS: Optic nerve mobilization after optic foraminotomy proved to be a safe and relatively easy technique for exposing and treating superior carotid-ophthalmic aneurysms.

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Even though intracranial meningiomas commonly invade the optic canals, true optic nerve sheath meningiomas are extremely rare. They are insidious lesions that frequently grow in 4 stages, leading to progressive visual loss.1-4 Frequently, management includes observation for asymptomatic patients, and fractioned stereotactic radiotherapy with progressive visual loss.1,3 However, surgery is avoided due to the risk of perioperative visual loss.2-4 However, many of these cases present in the early stage of tumor growth, where an arachnoidal plane is still present, and vision can be saved by microsurgical tumor resection.2 Here we present the case of a 33-yr-old female presenting with a 3-wk history of blurred vision. Neuroimaging depicted an enhancing lesion along both optic nerves consistent with bilateral optic nerve sheath meningioma. Neuroophthalmological examination showed inferior cut of visual field bilaterally, more extensive on the left eye. Acuity was 20/20 on both eyes. Microsurgical resection of the tumor was performed through left supraorbital craniotomy, with the goal of eliminating intracranial extension and stabilizing visual function.5 The optic canal was unroofed with diamond bit drill under copious irrigation. A remarkable improvement of her visual field was observed with maintenance of acuity at 20/20 on follow-up. As the patient is attempting pregnancy, she is closely monitored without radiation. Surgery can be offered as a primary treatment of optic nerve sheath meningiomas, especially in early stages, with likely preservation and, in some cases, improvement of visual function.6 The patient consented to the procedure and the use of image. Images at 1:46 and 3:48 reprinted from Al-Mefty O, Operative Atlas of Meningiomas. 1998: Raven Press; Philadelphia, PA, with permission from LWW. Image at 2:57 reprinted from Rassi et al2; © Anil Can, 2018, used with permission. Image at 9:27 in public domain/age.

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Interleukin-2 (IL-2) is a classical pro-inflammatory cytokine known to display neuroprotective roles in the central nervous system including the retina. In the present study, we investigate the molecular targets involved in the neurotrophic effect of IL-2 on retinal ganglion cells (RGC) after optic nerve axotomy. Analysis of retrograde labeling of RGC showed that common cell survival mediators, as Trk receptors, Src, PI3K, PKC, and intracellular calcium do not mediate the neurotrophic effect of IL-2 on RGC. No involvement of MAPK p38 was also observed. However, other MAPKs as MEK and JNK appear to be mediating this IL-2 effect. Our data also indicate that JAK2/3 are important intracellular proteins for the IL-2 effect. Interestingly, we demonstrate that the IL-2 effect depends on dopamine D1 receptors (D1R), the cAMP/PKA pathway, interleukin-10 (IL-10), and NF-κB, suggesting that RGC survival induced by IL-2 encompasses a molecular network of major complexity. In addition, treatment of retinal cells with recombinant IL-10 or 6-Cl-pb (D1R full agonist) was able to increase RGC survival similar to IL-2. Taken together, our results suggest that after optic nerve axotomy, the increase in RGC survival triggered by IL-2 is mediated by IL-10 and D1R along with the intracellular pathways of MAPKs, JAK/STAT, and cAMP/PKA.

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OBJECTIVES: The current study aims to increase awareness of the falciform ligament and its anatomical and surgical relationships, for the benefit of the neurosurgeon. PATINENTS AND METHODS: Twenty-four sides from twelve Caucasian cadaveric heads (all fresh-frozen) were used in this study. The length and thickness of the falciform ligament were recorded. The relationship of the falciform ligament to the optic nerve was also observed and documented. Finally, the force needed to avulse the falciform ligament was recorded. RESULTS: In all specimens, the ligament was identified as a continuation of the outer dural layer, forming a roof at the entrance of the optic canal. The mean medial-to-lateral length, anteroposterior length, and thickness of the falciform ligament were 7.97 mm, 2.12 mm, and 0.26 mm, respectively. The mean distance from the medial attachment of the ligament to the midline was 5.54 mm. For the undersurface of the falciform ligament, the optic nerve occupied the middle third in 50.0 %, the lateral third in 44.4 %, and the medial third in 5.6 % of sides. The mean optic nerve diameter at the entrance of the optic canal was 4.20 mm. The mean failure force was 2.47 N. CONCLUSION: The anatomical measurements and relationships provided in this description of the falciform ligament serve as a tool for surgery selection and planning, as well as an aid to improving microsurgical techniques, with the final goal being better patient outcomes.

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BACKGROUND: Several diseases that involve the optic canal or its contained structures may cause visual impairment. Several techniques have been developed to decompress the optic nerve. OBJECTIVE: To describe minimally invasive extradural anterior clinoidectomy (MiniEx) for optic nerve decompression, detail its surgical anatomy, present clinical cases, and established a proof of concept. METHODS: Anatomic dissections were performed in cadaver heads to show the surgical anatomy and to show stepwise the MiniEx approach. In addition, these surgical concepts were applied to decompress the optic nerve in 6 clinical cases. RESULTS: The MiniEx approach allowed the extradural anterior clinoidectomy and a nearly 270° optic nerve decompression using the no-drill technique. In the MiniEx approach, the skin incision, dissection of the temporal muscle, and craniotomy were smaller and provided the same extent of exposure of the optic nerve, anterior clinoid process, and superior orbital fissure as that usually provided by standard techniques. All patients who underwent operation with this technique had improved visual status. CONCLUSIONS: The MiniEx approach is an excellent alternative to traditional approaches for extradural anterior clinoidectomy and optic nerve decompression. It may be used as a part of more complex surgery or as a single surgical procedure.

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Abstract Introduction: Endoscopic orbital surgery is a nascent field and new tools are required to assist with surgical planning and to ascertain the limits of the tumor resectability. Objective: We purpose to utilize three-dimensional radiographic reconstruction to define the theoretical lateral limit of endoscopic resectability of primary orbital tumors and to apply these boundary conditions to surgical cases. Methods: A three-dimensional orbital model was rendered in 4 representative patients presenting with primary orbital tumors using OsiriX open source imaging software. A 2-Dimensional plane was propagated between the contralateral nare and a line tangential to the long axis of the optic nerve reflecting the trajectory of a trans-septal approach. Any tumor volume falling medial to the optic nerve and/or within the space inferior to this plane of resectability was considered theoretically resectable regardless of how far it extended lateral to the optic nerve as nerve retraction would be unnecessary. Actual tumor volumes were then superimposed over this plan and correlated with surgical outcomes. Results: Among the 4 lesions analyzed, two were fully medial to the optic nerve, one extended lateral to the optic nerve but remained inferior to the plane of resectability, and one extended both lateral to the optic nerve and superior to the plane of resectability. As predicted by the three-dimensional modeling, a complete resection was achieved in all lesions except one that transgressed the plane of resectability. No new diplopia or vision loss was observed in any patient. Conclusion: Three-dimensional reconstruction enhances preoperative planning for endoscopic orbital surgery. Tumors that extend lateral to the optic nerve may still be candidates for a purely endoscopic resection as long as they do not extend above the plane of resectability described herein.

Resumo Introdução: A cirurgia orbital endoscópica é um campo emergente e são necessárias novas ferramentas para auxiliar no planejamento cirúrgico e determinar os limites da ressecabilidade tumoral. Objetivo: Usar a reconstrução radiográfica tridimensional para definir o limite lateral teórico de ressecabilidade endoscópica de tumores orbitais primários e aplicar essas condições de limites a casos cirúrgicos. Método: Um modelo orbital tridimensional foi aplicado a quatro pacientes representativos com tumores orbitais primários utilizando o software de imagem de fonte aberta OsiriX. Um plano bidimensional foi propagado entre a narina contralateral e uma linha tangencial ao eixo longo do nervo óptico que reflete a trajetória de uma abordagem transeptal. Qualquer volume de tumor situado medialmente ao nervo óptico e/ou dentro do espaço inferior a esse plano de ressecabilidade foi teoricamente considerado ressecável, independentemente de quão longe ele se estendia até o nervo óptico, pois a retração do nervo seria desnecessária. Os volumes reais do tumor foram então sobrepostos sobre esse plano e correlacionados com os resultados cirúrgicos. Resultados: Entre as quatro lesões analisadas, duas eram totalmente mediais ao nervo óptico, uma se estendia lateralmente ao nervo óptico, mas permaneceu inferior ao plano de ressecabilidade, e uma se estendia lateralmente ao nervo óptico e superior ao plano de ressecabilidade. Conforme previsto pelo modelo tridimensional, uma ressecção completa foi obtida em todas as lesões, exceto uma, que transgrediu o plano de ressecabilidade. Nenhuma nova diplopia ou perda de visão foi observada em qualquer paciente. Conclusão: A reconstrução tridimensional melhora o planejamento pré-operatório para a cirurgia orbital endoscópica. Os tumores que se estendem lateralmente ao nervo óptico podem ainda ser candidatos à ressecção puramente endoscópica, desde que não se estendam além do plano de ressecabilidade aqui descrito.

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INTRODUCTION: Endoscopic orbital surgery is a nascent field and new tools are required to assist with surgical planning and to ascertain the limits of the tumor resectability. OBJECTIVE: We purpose to utilize three-dimensional radiographic reconstruction to define the theoretical lateral limit of endoscopic resectability of primary orbital tumors and to apply these boundary conditions to surgical cases. METHODS: A three-dimensional orbital model was rendered in 4 representative patients presenting with primary orbital tumors using OsiriX open source imaging software. A 2-Dimensional plane was propagated between the contralateral nare and a line tangential to the long axis of the optic nerve reflecting the trajectory of a trans-septal approach. Any tumor volume falling medial to the optic nerve and/or within the space inferior to this plane of resectability was considered theoretically resectable regardless of how far it extended lateral to the optic nerve as nerve retraction would be unnecessary. Actual tumor volumes were then superimposed over this plan and correlated with surgical outcomes. RESULTS: Among the 4 lesions analyzed, two were fully medial to the optic nerve, one extended lateral to the optic nerve but remained inferior to the plane of resectability, and one extended both lateral to the optic nerve and superior to the plane of resectability. As predicted by the three-dimensional modeling, a complete resection was achieved in all lesions except one that transgressed the plane of resectability. No new diplopia or vision loss was observed in any patient. CONCLUSION: Three-dimensional reconstruction enhances preoperative planning for endoscopic orbital surgery. Tumors that extend lateral to the optic nerve may still be candidates for a purely endoscopic resection as long as they do not extend above the plane of resectability described herein.

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