RESUMO
Owing to their invasive character, extreme vascularity, and critical location, glomus jugulare tumors present a formidable challenge. Techniques have been developed for safe and successful removal of even giant glomus paragangliomas.1-3 Preoperative evaluation including genetic, hormonal, and multiplicity workup4 has enhanced the safety of surgical management, as did modern preoperative embolization by eliminating excessive blood loss.5 Despite these advancements, surgical outcomes of glomus jugulare remain haunted by cranial nerve dysfunction such as facial nerve palsies and hearing loss, with lower cranial nerves dysfunction being the most morbid. These can be avoided by technical maneuvers to preserve the cranial nerves. The external ear canal is not closed to maintain conductive hearing. The facial nerve is not transpositioned and kept inside a bony protective canal. Cranial nerves IX, X, and XI are the most vulnerable because they pass through the jugular foramen ventral to the venous bulb wall. They are preserved by intrabulbar dissection that maintains a protective segment of the venous wall over the nerves. By mastering the anatomy of the upper neck, meticulous dissection is performed to preserve the course of IX, X, XI, and XII.6,7 Ligation of the jugular vein is delayed until the tumor is totally isolated to avoid diffuse bleeding.7 We present the case of a 60-yr-old woman with a glomus jugulare tumor with intradural, extradural, and cervical extension. The technical nuances of cranial nerves preservation are demonstrated. The patient consented to the procedure and publication of her images. Images at 2:12, 2:50, and 3:09 from Al-Mefty and Teixeira,6 with permission from JNSPG.
Assuntos
Doenças do Nervo Facial , Tumor do Glomo Jugular , Glomo Jugular , Nervos Cranianos/cirurgia , Nervo Facial/cirurgia , Feminino , Glomo Jugular/patologia , Tumor do Glomo Jugular/diagnóstico por imagem , Tumor do Glomo Jugular/cirurgia , Humanos , Pessoa de Meia-IdadeRESUMO
INTRODUCTION: The cerebellopontine angle (CPA) is a subarachnoid space in the lateral aspect of the posterior fossa. In this study, we propose a complementary analysis of the CPA from the cerebellopontine fissure. METHODS: We studied 50 hemi-cerebelli in the laboratory of neuroanatomy and included a description of the CPA anatomy from the cerebellopontine fissure and its relationship with the flocculus and the 5th, 6th, 7th, and 8th cranial nerves (CN) origins. RESULTS: The average distance from the 5th CN to the mid-line (ML) was 19.2 mm, 6th CN to ML was 4.4 mm, 7-8 complex to ML was 15.8 mm, flocculus to ML was 20.5 mm, and flocculus to 5th CN was 11.5 mm, additionally, and the diameter of the flocculus was 9.0 mm. The angle between the vertex in the flocculus and the V CN and the medullary-pontine line was 64.8 degrees. DISCUSSION: The most common access to the CPA is through the retrosigmoid-suboccipital region and this approach can be done with the help of an endoscope. The anatomy of origins of neural structures tends to be preserved in cases of CPA lesions. CONCLUSION: Knowledge of the average distances between the neural structures in the cerebellar-pontine fissure and the angular relationships between these structures facilitates the use of surgical approaches such as microsurgery and endoscopy.
Assuntos
Ângulo Cerebelopontino/anatomia & histologia , Mapeamento Encefálico , Ângulo Cerebelopontino/cirurgia , Cerebelo/anatomia & histologia , Cerebelo/cirurgia , Nervos Cranianos/anatomia & histologia , Nervos Cranianos/cirurgia , Endoscopia/métodos , Humanos , Bulbo/anatomia & histologia , Bulbo/cirurgia , Microcirurgia/métodos , Procedimentos Neurocirúrgicos/métodos , Ponte/anatomia & histologia , Ponte/cirurgiaRESUMO
BACKGROUND: Paragangliomas of the head and neck are neuroendocrine tumors. They have a low incidence (0.6%), are generally benign, have a poorly defined etiology, and multiple factors have been associated with their origin. Humans and other species living at high altitudes (>2000 m above sea level) are subjected to a relatively chronic hypoxia and there is a high prevalence of the development of carotid body hyperplasia and eventually paragangliomas. This disease is usually seen in patients in their 50s and in their 30s if there is a family history. CLINICAL CASE: We present the case of a 16 year-old female with acute pharyngitis and growing tumor located on the left side of the neck, without symptoms. A duplex Doppler ultrasound showed a solid nodular lesion on the left carotid bifurcation. A left lateral cervicotomy was performed, finding a highly vascularized tumor of 4 × 3 × 3 cm involving the common carotid from its middle third, the internal carotid up to the cranial base, and the external carotid to its upper third, and intimately related to the trachea, esophagus and cervical spine. The tumor was completely resected and the histopathological analysis corroborated the presence of paragangliomas. CONCLUSIONS: The publication of this case is relevant and of clinical interest due to the uncommon age of presentation and the fact that it should be considered as a diagnostic possibility.
Antecedentes: los paragangliomas de cabeza y cuello son tumores neuroendocrinos de baja incidencia (0.6%), en su mayor parte benignos, en cuyo origen se han involucrado múltiples factores. Los seres humanos y otras especies que viven a grandes alturas (por arriba de 2000 metros sobre el nivel del mar) son propensos a sufrir hipoxia crónica relativa, hiperplasia del cuerpo carotídeo y, eventualmente, paragangliomas. Este padecimiento aparece en la quinta década de la vida y en la tercera, en caso de presentación familiar. Caso clínico: se comunica el caso de una adolescente de 16 años de edad que un año antes tuvo faringitis aguda con tumor localizado en la cara lateral izquierda del cuello, de crecimiento gradual, sin ningún síntoma. El ultrasonido Doppler dúplex de cuello mostró una lesión nodular sólida sobre el trayecto de la bifurcación carotídea izquierda. Fue intervenida quirúrgicamente mediante cervicotomía lateral izquierda, en la cual se encontró una tumoración de aproximadamente 4 × 3 × 3 cm, sumamente vascularizada, que afectaba la carótida común desde su tercio medio, la carótida interna hasta la base del cráneo y la carótida externa hasta el tercio superior, con íntima relación con la tráquea, el esófago y la columna cervical. La tumoración se resecó en su totalidad, el estudio histopatológico corroboró los paragangliomas. Conclusiones: la edad de presentación es poco común, por lo que se considera relevante y de interés clínico comunicar este caso, toda vez que debe considerarse como posibilidad diagnóstica.
Assuntos
Tumor do Corpo Carotídeo/patologia , Adolescente , Idade de Início , Altitude , Artérias Carótidas/patologia , Tumor do Corpo Carotídeo/classificação , Tumor do Corpo Carotídeo/diagnóstico por imagem , Tumor do Corpo Carotídeo/epidemiologia , Tumor do Corpo Carotídeo/cirurgia , Doença Crônica , Doenças dos Nervos Cranianos/etiologia , Nervos Cranianos/patologia , Nervos Cranianos/cirurgia , Suscetibilidade a Doenças , Feminino , Humanos , Hipóxia/complicações , Invasividade Neoplásica , Faringite/complicações , Complicações Pós-Operatórias/etiologia , Base do Crânio/patologia , Tomografia Computadorizada Espiral , Carga Tumoral , UltrassonografiaRESUMO
In one series of experiments, heart frequency (f (H)), blood pressure (P (a)), gill ventilation frequency (f ( R )), ventilation amplitude (V (AMP)) and total gill ventilation (V (TOT)) were measured in intact jeju (Hoplerythrinus unitaeniatus) and jeju with progressive denervation of the branchial branches of cranial nerves IX (glossopharyngeal) and X (vagus) without access to air. When these fish were submitted to graded hypoxia (water PO(2) approximately 140, normoxia to 17 mmHg, severe hypoxia), they increased f ( R ), V (AMP), V (TOT) and P (a) and decreased f (H). In a second series of experiments, air-breathing frequency (f (RA)), measured in fish with access to the surface, increased with graded hypoxia. In both series, bilateral denervation of all gill arches eliminated the responses to graded hypoxia. Based on the effects of internal (caudal vein, 150 microg NaCN in 0.2 mL saline) and external (buccal) injections of NaCN (500 microg NaCN in 1.0 mL water) on f (R), V (AMP), V (TOT), P (a) and f (H) we conclude that the O(2) receptors involved in eliciting changes in gill ventilation and associated cardiovascular responses are present on all gill arches and monitor the O(2) levels of both inspired water and blood perfusing the gills. We also conclude that air breathing arises solely from stimulation of branchial chemoreceptors and support the hypothesis that internal hypoxaemia is the primary drive to air breathing.
Assuntos
Células Quimiorreceptoras/fisiologia , Peixes/fisiologia , Brânquias/fisiologia , Frequência Cardíaca/fisiologia , Hipóxia/fisiopatologia , Consumo de Oxigênio/fisiologia , Mecânica Respiratória/fisiologia , Animais , Pressão Sanguínea/efeitos dos fármacos , Pressão Sanguínea/fisiologia , Brasil , Nervos Cranianos/cirurgia , Denervação , Brânquias/citologia , Frequência Cardíaca/efeitos dos fármacos , Reflexo/fisiologia , Mecânica Respiratória/efeitos dos fármacos , Cianeto de Sódio/farmacologia , Taquicardia/fisiopatologia , Fatores de TempoRESUMO
The localization, distribution and orientation of O(2) chemoreceptors associated with the control of cardio-respiratory responses were investigated in the neotropical, Hoplias lacerdae. Selective denervation of the cranial nerves (IX and X) was combined with chemical stimulation (NaCN) to characterize the gill O(2) chemoreceptors, and the fish were then exposed to gradual hypoxia to examine the extent of each cardio-respiratory response. Changes in heart rate (f(H)) and ventilation amplitude (V(amp)) were allied with chemoreceptors distributed on both internal and external surfaces of all gill arches, while ventilation rate (f) was allied to the O(2) chemoreceptors located only in the internal surface of the first gill arch. H. lacerdae exposed to gradual hypoxia produced a marked bradycardia (45%) and 50% increase in V(amp), but only a relatively small change in f (32%). Thus, the low f(R) response yet high V(amp) were in accord with the characterization of the O(2) chemoreceptors. Comparing these results from H. lacerdae with hypoxia-tolerant species revealed a relationship existent between general oxygenation of the individual species environment, its cardio-respiratory response to hypoxia and the characterization of O(2) chemoreceptors.
Assuntos
Adaptação Fisiológica/genética , Fenômenos Fisiológicos Cardiovasculares , Células Quimiorreceptoras/fisiologia , Peixes/fisiologia , Oxigênio/fisiologia , Fenômenos Fisiológicos Respiratórios , Animais , Pressão Sanguínea/fisiologia , Nervos Cranianos/cirurgia , Denervação , Brânquias/irrigação sanguínea , Brânquias/efeitos dos fármacos , Brânquias/inervação , Frequência Cardíaca/fisiologia , Especificidade de Órgãos , Cianeto de Sódio/farmacologia , Especificidade da Espécie , Estresse Fisiológico/fisiologiaRESUMO
Petroclival meningiomas are technically challenging lesions. They have a tendency to grow slowly, involve cranial nerves and compress the brainstem and basilar artery, pushing them to the opposite side. Their natural history is marked by clinical deterioration and fatal outcome. They were once considered inoperable lesions; decades ago, mortality rates were higher than 50%. The authors describe 15 petroclival meningiomas treated surgically between 1995 and 2007. The main approaches used were combined anterior petrosectomy and retrosigmoid (3 cases), retrosigmoid (8 cases), and pre-sigmoid and subtemporal (4 cases). The mortality rate was 13.5% due to surgical bed hematoma and brain ischemia. The post-operative complications were hydrocephalus in 2 cases, cerebrospinal fluid leak in 2 cases and infection of surgical flap in one case. Limiting factors for surgical removal are tumor consistency, encasement of brainstem perforators and pre-operative clinical status.
Assuntos
Neoplasias Meníngeas/complicações , Neoplasias Meníngeas/cirurgia , Meningioma/complicações , Meningioma/cirurgia , Procedimentos Neurocirúrgicos/métodos , Osso Petroso/cirurgia , Adulto , Nervos Cranianos/patologia , Nervos Cranianos/cirurgia , Craniotomia/efeitos adversos , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Neoplasias Meníngeas/mortalidade , Meningioma/mortalidade , Pessoa de Meia-Idade , Exame Neurológico , Procedimentos Neurocirúrgicos/efeitos adversos , Osso Petroso/patologia , Complicações Pós-Operatórias , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE: In most complete brachial plexus injuries, at least 1 root still is available for grafting. We report on the results obtained with reconstruction of the brachial plexus using short sural nerve grafts that connect nonavulsed roots to the anterior, posterior, or both divisions of the upper trunk. METHODS: We prospectively studied 22 young adults with complete brachial plexus palsy who had surgical repair an average of 5 months after trauma. Sural nerve grafts connected the C5 root to the anterior division and the C6 root to the posterior division of the upper trunk. When the C6 root was not available, the posterior division of the upper trunk was repaired by means of a nerve transfer. In all cases except one, the suprascapular nerve was repaired via a nerve transfer. Outcomes were assessed an average of 35 months after surgery, focusing on recovery of muscle strength, categorized using the Medical Research Council scale. We compared the results obtained after a single root graft, either C5 (n = 11) or C6 (n = 1), with those observed after double root grafting (i.e., C5 + C6; n = 9). The single case of 3 roots available for grafting was excluded for this comparative study. RESULTS: With grafting of the anterior division of the upper trunk, 17 of the 22 patients (n = 15) regained useful pectoralis major and biceps function of at least M3. Grafting the anterior and the posterior divisions of the upper trunk resulted in 18 of the 22 patients (n = 18) recovering shoulder abduction-adduction and either elbow flexion or extension. In only 5 cases (5 of 22 patients), however, was shoulder abduction-adduction achieved with concomitant recovery of both elbow flexion and extension. Grafting the posterior division of the upper trunk did not enhance the recovery of shoulder abduction, but it did restore elbow extension in approximately 6 of the 9 patients. In terms of muscle strength, an average of 2.3 muscles scored M3 or M4 in the single-root group, compared with 3.1 in the C5/C6 group (p < .05). The relative probability of recovering elbow flexion and shoulder adduction did not differ between patients with 1 versus 2 root grafts. The results of nerve transfers to the posterior division and of forearm muscle reinnervation were poor. CONCLUSIONS: Grafting the divisions of the brachial plexus ensured multiple function reconstruction in 18 of the 22 patients (n = 18). However, only 5 of 22 patients (n = 4) experienced restoration of elbow flexion and extension. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.
Assuntos
Neuropatias do Plexo Braquial/cirurgia , Plexo Braquial/cirurgia , Transferência de Nervo/métodos , Nervo Sural/transplante , Acidentes de Trânsito , Adolescente , Adulto , Plexo Braquial/lesões , Neuropatias do Plexo Braquial/etiologia , Nervos Cranianos/cirurgia , Feminino , Humanos , Masculino , Movimento/fisiologia , Contração Muscular/fisiologia , Força Muscular/fisiologia , Estudos Prospectivos , Recuperação de Função Fisiológica/fisiologia , Extremidade Superior/inervação , Extremidade Superior/fisiopatologia , Adulto JovemRESUMO
We report the surgically treated case of a 21-year-old caucasian male harboring a cavernous hemangioma of the right internal auditory canal encasing the seventh and eighth cranial nerves complex. Only 18 cases of cavernous hemangiomas of this location have been previously reported. The clinical features, the differential diagnosis and the treatment are discussed.
Assuntos
Neoplasias da Orelha/patologia , Orelha Interna/patologia , Hemangioma Cavernoso/patologia , Adulto , Nervos Cranianos/patologia , Nervos Cranianos/cirurgia , Neoplasias da Orelha/cirurgia , Hemangioma Cavernoso/cirurgia , Humanos , Imageamento por Ressonância Magnética , Masculino , Invasividade Neoplásica , Tomografia Computadorizada por Raios XRESUMO
Relata-se o caso de homem de 21 anos, leucoderma, portador de angioma cavernoso do meato acústico interno direito envolvendo o complexo VII e VIII nervos cranianos tratado cirurgicamente. Apenas 18 casos de angiomas cavernosos dessa localização foram relatados na literatura. São comentados os aspectos clínicos, o diagnóstico diferencial e o tratamento.
Assuntos
Adulto , Humanos , Masculino , Neoplasias da Orelha/patologia , Orelha Interna/patologia , Hemangioma Cavernoso/patologia , Nervos Cranianos/patologia , Nervos Cranianos/cirurgia , Neoplasias da Orelha/cirurgia , Hemangioma Cavernoso/cirurgia , Imageamento por Ressonância Magnética , Invasividade Neoplásica , Tomografia Computadorizada por Raios XRESUMO
The optimal management for patients with cavernous sinus meningiomas is to evacuate tumor without causing mortality or morbidity. The records of 16 patients, including 11 women and 5 men ranging in age from 31 to 63 years, underwent surgical treatment for this condition were reviewed. Completeness of tumor resection, cranial nerve morbidity, complications, mortality, the internal carotid artery encasement and outcome were studied. Total removal was achieved in six patients. Of ten patients who underwent subtotal resection there was one death and four were sent to radiotherapy. Morbidity was 24% for cranial nerves controlling extraocular motor function; trigeminal nerve function did not improve after surgical treatment. Symptomatic recurrence occurred in two patients who underwent subtotal tumor resection and in one who underwent complete tumor resection. The average follow-up period was of 26 months. According to our findings, we conclude: 1) the resectability of meningiomas of cavernous sinus depends on the degree of internal carotid artery involvement; 2) total resection of meningiomas confined in cavernous sinus is rare; 3) morbidity of the cranial nerves is significant; 4) subtotal resection is an effective mean to obtain control of the disease.