Jugular Foramen Paragangliomas.

Paragangliomas are the most common tumors at jugular foramen and pose a great surgical challenge. Careful clinical history and physical examination must be performed to adequately evaluate neurological deficits and its chronologic evolution, also to delineate an overview of the patient performance status. Complete imaging evaluation including MRI and CT scans should be performed, and angiography is a must to depict tumor blood supply and sigmoid sinus/internal jugular vein patency. Screening for multifocal paragangliomas is advisable, with a whole-body imaging. Laboratory investigation of endocrine function of the tumor is necessary, and adrenergic tumors may be associated with synchronous lesions. Preoperative prepare with alpha-blockage is advisable in norepinephrine/epinephrine-secreting tumors; however, it is not advisable in exclusively dopamine-secreting neoplasms. Best surgical candidates are young otherwise healthy patients with smaller lesions; however, treatment should be individualized each case. Variations of infratemporal fossa approach are employed depending on extensions of the mass. Regarding facial nerve management, we avoid to expose or reroute it if there is preoperative function preservation and prefer to work around facial canal in way of a fallopian bridge technique. If there is preoperative facial nerve compromise, the mastoid segment of the nerve is exposed, and it may be grafted if invaded or just decompressed. A key point is to preserve the anteromedial wall of internal jugular vein if there is preoperative preservation of lower cranial nerves. Careful multilayer closure is essential to avoid at most cerebrospinal fluid leakage. Residual tumors may be reoperated if growing and presenting mass effect or be candidate for adjuvant stereotactic radiosurgery.

Kappa and beta-casein alleles in dairy zebu cattle.

The kappa (CSN3) and beta-casein (CSN2) genes are intensively genotyped in dairy cattle for selection purposes. This information is also generated and disseminated for Zebu breeds adapted to tropical climates. The objective of this work was to gather information on the genotypes for the CSN3 and CSN2 genes in three breeds (Gyr, Guzerat and Sindhi), and to verify the genotypic frequencies in the populations. The genotype AA and allele A frequencies are high for the CSN3 gene, without changes in values over the years, possibly indicating a small gene participation in traits under selection. In addition, the A2A2 frequencies are high for the CSN2 gene (<∼0.80). It is recommended to verify the association and contribution of CSN3 genotypes in productive traits for these breeds. The potential of A2 milk production by these genetic groups is also confirmed.

Largest neurosurgical social media group and its impact on communication and research.

BACKGROUND: The use of social media to communicate and disseminate knowledge has increased exponentially, especially in the field of neurosurgery. 'Neurosurgery cocktail' (NC) was developed by a group of young neurosurgeons as a means of sharing didactic materials and clinical experiences via social media. It connects 35.000 neurosurgeons worldwide on multiple platforms, primarily Facebook and Twitter. Given the rising utilization of social media in neurosurgery, the popularity of NC has also increased since its inception. In this study, the authors surveyed the social media analytics of NC for both Facebook and Twitter. Besides, we reviewed the literature on the use of social media in neurosurgery. METHODS: Facebook and Twitter metrics were extracted through each respective platform's analytics tools from December 2020 (earliest available date for data analysis) through January 2021. A literature search was conducted using PubMed (MEDLINE) and Scopus databases. RESULTS: On Facebook, as of January 2021, the group had a total of 25.590 members (87.6% male), most commonly (29%) between 35 and 44 years of age with over 100 countries were represented. As of January 2021, they had amassed 6457 followers on Twitter. During the last 28 d between December 2020 and January 2021, the account published 65 tweets that garnered a total of 196,900 impressions. Twelve articles were identified in our literature review on the use of social media within the neurosurgical community. CONCLUSIONS: NC is one of the most widely utilized neurosurgical social media resources available. Sharing knowledge has been broadened thanks to the recent social media evolution, and NC has become a leading player in disseminating neurosurgical knowledge.

Delayed diagnosis of intracranial aneurysm in pediatrics: the risk of misdiagnosis-a case report.

BACKGROUND: Aneurysms in the pediatric population are uncommon, requiring a high index of suspicion for diagnosis. We report a case of a child with head trauma and delayed diagnosed cerebral aneurysm. METHODS: A 2-year-old girl was brought to the emergency room with seizures. Head imaging showed acute intraventricular hemorrhage, hydrocephalus, and paraclinoid aneurysm of the right internal carotid artery. She had been hospitalized elsewhere 1 month prior for traumatic brain injury after falling to the ground with subarachnoid and intraventricular hemorrhage and good recovery, but without diagnosis of aneurysm. RESULTS: The child was treated with aneurysm embolization and ventriculoperitoneal shunt, being discharged asymptomatic. CONCLUSION: Most primary intraventricular hemorrhage in pediatric population has identifiable etiology. A high rate of clinical suspicion, associated with a low threshold for vascular neuroimaging studies for children with spontaneous or atypical intracranial hemorrhage allow accurate diagnosis, appropriate treatment, and improved outcome.

Simultaneous cochlear implantation as a therapeutic option in vestibular schwannoma surgery: case report.

Hearing loss is the most common symptom of vestibular schwannomas (VSs). The management of these lesions includes observation, radiosurgery, and microsurgical resection. Hearing preservation and rehabilitation are the major challenges after the tumor treatment. A 43-year-old man with previous left-sided profound hearing loss and tinnitus presented with a 2-mm left-sided intracanalicular VS. The decision was made to perform a simultaneous cochlear implantation (CI) and microsurgical resection of the tumor. The patient did well postoperatively, with significant improvement of tinnitus, sound localization, and speech recognition in noise. Previous reports of simultaneous CI and VS resection in patients with neurofibromatosis type 2 and sporadic VS in the only hearing ear have been described. The role of CI in patients with VS and normal contralateral hearing has been recently described, showing positive outcomes due to the binaural benefits. Tinnitus also can be treated by the implantation of the cochlear device. The simultaneous microsurgical removal of VS and implantation of a cochlear device is a feasible approach in patients with unilateral hearing loss and severe tinnitus.

The transcondylar approach to craniocervical meningiomas.

Surgical removal of foramen magnum meningiomas poses great challenges due their deep location within the central skull base and their proximity to vital neurovascular structures. This video depicts the operative nuances of surgical management for a 59-year-old female who presented with a right-sided spinocranial meningioma. Simpson Grade I resection was achieved through a right transcondylar approach. The patient's postoperative period was unremarkable, and she was discharged home on postoperative Day 5 for periodic follow-up. The transcondylar approach safely exposes the craniocervical junction at the anterior aspect of the neuraxis and still allows the surgeon to access the tumor through a parallel plane, with minimum morbidity. The video can be found here: https://youtu.be/P0-kXjAkw9U .

Microsurgical management of a high-grade brain arteriovenous malformation in the central lobe after unsuccessful radiosurgery.

The recommendation for the great majority of high-grade brain arteriovenous malformations (bAVMs) is observation, except for those patients with recurrent hemorrhages, progressive neurological deficits, steal-related symptoms, or AVM-related aneurysms, for whom intervention should be considered. These are general recommendations, and the decision should be made on an individual basis. Surgical resection of an AVM in the central lobe may cause postoperative sensorimotor deficits since this anatomical region includes the pre- and postcentral gyri on the lateral surface and the paracentral lobule on the medial surface. The authors present a patient with a ruptured high-grade bAVM in the central lobe who underwent previous surgery for hematoma evacuation and previous radiosurgery, and whose indication for reoperation was proposed based on progressive hemiparesis. Microsurgical resection was possible after a wide frontoparietal craniotomy, which made all the nidus borders accessible. This case illustrates the anatomy and surgical technique for large nidus AVMs in eloquent areas, showing that complete microsurgical resection is possible with good clinical outcome. The video can be found here: https://youtu.be/Cpd1PK6BLIM .

Direct variable cost of the topical treatment of stages III and IV pressure injuries incurred in a public university hospital.

AIM: to estimate the direct variable costs of the topical treatment of stages III and IV pressure injuries of hospitalized patients in a public university hospital, and assess the correlation between these costs and hospitalization time. MATERIALS AND METHODS: Forty patients of both sexes who had been admitted to the São Paulo Hospital, São Paulo, SP, Brazil, from 2011 to 2012, with pressure injuries in the sacral, ischial or trochanteric region were included. The patients had a total of 57 pressure injuries in the selected regions, and the lesions were monitored daily until patient release, transfer or death. The quantities and types of materials, as well as the amount of professional labor time spent on each procedure and each patient were recorded. The unit costs of the materials and the hourly costs of the professional labor were obtained from the hospital's purchasing and human resources departments, respectively. Spearman's correlation coefficient and the Mann-Whitney and Kruskal-Wallis tests were used for the statistical analyses. RESULTS: The mean topical treatment costs for stages III and IV PIs were significantly different (US$ 854.82 versus US$ 1785.35; p = 0.004). The mean topical treatment cost of stages III and IV pressure injuries per patient was US$ 1426.37. The mean daily topical treatment cost per patient was US$ 40.83. There was a significant correlation between hospitalization time and the total costs of labor and materials (p < 0.05). There was no significant difference between hospitalization time periods for stages III and IV pressure injuries (40.80 days and 45.01 days, respectively; p = 0.834). CONCLUSION: The mean direct variable cost of the topical treatment for stages III and IV pressure injuries per patient in this public university hospital was US$ 1426.37.

Cranioplasty with Direct Revascularization in Hemorrhagic Moyamoya Disease: 2-Dimensional Operative Video.

Moyamoya disease is a progressive nonatherosclerotic stenosis of the terminal segments of the arteries of the Circle of Willis. Hemorrhagic presentation is a life-threatening condition, associated with an increased risk of rebleeding and ischemic events.1-7 We present the case of a 65-year-old woman with a right intracerebral hemorrhage who underwent emergency hematoma evacuation without bone flap replacement (Video 1). The investigation confirmed the diagnosis of Moyamoya disease and demonstrated hypoperfusion of the right cerebral hemisphere. Late angiography depicted no transdural collaterals through the bone defect and demonstrated preservation of the superficial temporal artery (STA). Next, it was chosen to perform 1-stage cranioplasty with direct revascularization. We detached the temporal fascia from the muscle and created a window through the fascia to give STA passage in a corridor through the temporal muscle until the brain's surface. Vascular anastomosis was performed with an interrupted suture line employing a 10-0 nylon thread. Flow within the right middle cerebral artery was retrograde, coming from branches of the posterior cerebral artery, and the end-to-side anastomosis was placed to orientate the STA flow in the same direction as in the middle cerebral artery. We used a custom-made titanium plate for the cranioplasty and gave enough room inferiorly for the course of STA. In the end, we sutured the temporal fascia to the titanium plate for a better cosmetic result. To avoid additional unnecessary procedures, the performance of direct revascularization during the cranioplasty is feasible and deserves additional investigation as a tool to prevent new hemorrhagic or ischemic events. Informed consent was obtained from the patient for the procedure and publication of this operative video.

Bipolar, high-voltage, long-duration pulsed radiofrequency ablation of the Gasserian ganglion for the treatment of trigeminal neuralgia in a patient with a cardiac implantable electronic device: illustrative case.

BACKGROUND: One of the common methods of treating trigeminal neuralgia (TN) nowadays is radiofrequency therapy. However, it has serious limitations in patients with a cardiac pacemaker because of electromagnetic interference. Therefore, it is crucial to select optimal radiofrequency ablation parameters to make this procedure safe with favorable outcomes for such patients. OBSERVATIONS: In this study, the authors present a case of a 70-year-old man with a history of cardiac pacemaker dependency and previous microvascular decompression with complaints of severe, constant facial pain. After reprogramming the cardiac implantable electronic device (CIED), the authors performed bipolar, high-voltage, long-duration pulsed radiofrequency therapy (PRFT) of the Gasserian ganglion under electrocardiography and pulse rate control in the pre-, intra-, and postoperative periods. There were no cardiovascular or neurological complications after PRFT. The patient reported relief of pain after the procedure, and at the 9-month follow-up, he was pain-free. LESSONS: This clinical case demonstrates that the use of bipolar, high-voltage PRFT for TN treatment in patients with a CIED can be safe and effective, provided that the rules and pacemaker instructions are followed. It is necessary to use ablative treatment with caution and to guide the patient in collaboration with a cardiac surgeon and an anesthesiologist resuscitator.

Liquid biopsy and tumor DNA/RNA detection in the cerebrospinal fluid of patients diagnosed with central nervous system glioma - A review article.

Background: Gliomas are the most common primary malignant neoplasms of the central nervous system and their characteristic genetic heterogeneity implies in a prominent complexity in their management. The definition of the genetic/molecular profile of gliomas is currently essential for the classification of the disease, prognosis, choice of treatment, and it is still dependent on surgical biopsies, which in many cases become unfeasible. Liquid biopsy with detection and analysis of biomarkers such as deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) from the tumor and circulating in the bloodstream or cerebrospinal fluid (CSF) has emerged as a minimally invasive alternative to aid in diagnosis, follow-up, and response to treatment of gliomas. Methods: Through a systematic search in the PubMed MEDLINE, Cochrane Library, and Embase databases, we reviewed the evidence on the use of liquid biopsy to detect tumor DNA/RNA in the CSF of patients diagnosed with central nervous system gliomas. Results: After a systematic review applying all inclusion and exclusion criteria, as well as a double review by independent authors, 14 studies specifically addressing the detection of tumor DNA/RNA in the CSF of patients diagnosed with central nervous system glioma were selected in the final analysis. Conclusion: Sensitivity and specificity of liquid biopsy in CSF are still very variable depending on factors such as the diagnostic method, collection timing, biomarker (DNA and RNA), tumor type, extension and volume of the tumor, collection method, and contiguity from neoplasm to CSF. Despite the technical limitations that still exist and prevent the routine and validated use of liquid biopsy in CSF, the growing number of studies around the world is increasingly improving this technic, resulting in promising prospects for its use in diagnosis, evolutionary follow-up, and response to the treatment of complex diseases such as central nervous system gliomas.

Transmastoid/Infralabyrinthine Approach to the Jugular Foramen: 2-Dimensional Operative Video.

INDICATIONS CORRIDOR AND LIMITS OF EXPOSURE: This approach is intended for tumors centered in the jugular foramen with extensions between intracranial and extracranial spaces, possible spread to the middle ear, and variable bony destruction. 1,2. ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT: Jugular foramen paragangliomas are complex lesions that usually invade and fill related venous structures. They present complex relationships with skull base neurovascular structures as internal carotid artery, lower cranial nerves (CNs), middle ear, and mastoid segment of facial nerve. In this way, it is essential to perform an adequate preoperative vascular study to evaluate sinus patency and the tumor blood supply, besides a computed tomography scan to depict bone erosion. ESSENTIAL STEPS OF THE PROCEDURE: Mastoidectomy through an infralabyrinthine route up to open the lateral border of jugular foramen, allowing exposure from the sigmoid sinus to internal jugular vein. Skeletonization of facial canal without exposure of facial nerve is performed and opening of facial recess to give access to the middle ear in way of a fallopian bridge technique. 2-10. PITFALLS/AVOIDANCE OF COMPLICATIONS: If there is preoperative preservation of lower CN function, it is important to not remove the anteromedial wall of the internal jugular vein and jugular bulb. In addition, facial nerve should be exposed just in case of preoperative facial palsy to decompress or reconstruct the nerve. VARIANTS AND INDICATIONS FOR THEIR USE: Variations are related mainly with temporal bone drilling depending on the extensions of the lesion, its source of blood supply, and preoperative preservation of CN function.Informed consent was obtained from the patient for the procedure and publication of his image.Anatomy images were used with permission from:• Ceccato GHW, Candido DNC, and Borba LAB. Infratemporal fossa approach to the jugular foramen. In: Borba LAB and de Oliveira JG. Microsurgical and Endoscopic Approaches to the Skull Base. Thieme Medical Publishers. 2021.• Ceccato GHW, Candido DNC, de Oliveira JG, and Borba LAB. Microsurgical Anatomy of the Jugular Foramen. In: Borba LAB and de Oliveira JG. Microsurgical and Endoscopic Approaches to the Skull Base. Thieme Medical Publishers. 2021.

Usefulness of Intraoperative ultrasound for cortical dysplasia type I treatment - A single-center experience.

Background: Focal cortical dysplasias (FCD) cause a subgroup of malformations of cortical development that has been closely linked to cause drug intractable epilepsy. Attaining adequate and safe resection of the dysplastic lesion has proved to be a viable option to archive meaningful seizure control. Of the three types of FCD (types I, II, and III), type I has the least detectable architectural and radiological abnormalities. This makes it challenging (preoperatively and intraoperatively) to achieve adequate resection. Intraoperatively, ultrasound navigation has proven an effective tool during the resection of these lesions. We evaluate our institutional experience in surgical management of FCD type I using intraoperative ultrasound (IoUS). Methods: Our work is a retrospective and descriptive study, where we analyzed patients diagnosed with refractory epilepsy who underwent IoUS-guided epileptogenic tissue resection. The surgical cases analyzed were from January 2015 to June 2020 at the Federal Center of Neurosurgery, Tyumen, only patients with histological confirmation of postoperative CDF type I were included in the study. Results: Of the 11 patients with histologically diagnosed FCD type I, 81.8% of the patients postoperatively had a significant reduction in seizure frequency (Engel outcome I-II). Conclusion: IoUS is a critical tool for detecting and delineating FCD type I lesions, which is necessary for effective post-epilepsy surgery results.

Proteomics reveals differentially regulated pathways when comparing grade 2 and 4 astrocytomas.

Astrocytic tumors are known for their high progression capacity and high mortality rates; in this regard, proteins correlated to prognosis can aid medical conduct. Although several genetic changes related to progression from grade 2 to grade 4 astrocytoma are already known, mRNA copies do not necessarily correlate with protein abundance and therefore could shadow further comprehension about this tumor's biology. This motivates us to seek for complementary strategies to study tumor progression at the protein level. Here we compare the proteomic profile of biopsies from patients with grade 2 (diffuse, n = 6) versus grade 4 astrocytomas (glioblastomas, n = 10) using shotgun proteomics. Data analysis performed with PatternLab for proteomics identified 5,206 and 6,004 proteins in the 2- and 4-grade groups, respectively. Our results revealed seventy-four differentially abundant proteins (p < 0.01); we then shortlist those related to greater malignancy. We also describe molecular pathways distinctly activated in the two groups, such as differences in the organization of the extracellular matrix, decisive both in tumor invasiveness and in signaling for cell division, which, together with marked contrasts in energy metabolism, are determining factors in the speed of growth and dissemination of these neoplasms. The degradation pathways of GABA, enriched in the grade 2 group, is consistent with a favorable prognosis. Other functions such as platelet degranulation, apoptosis, and activation of the MAPK pathway were correlated to grade 4 tumors and, consequently, unfavorable prognoses. Our results provide an important survey of molecular pathways involved in glioma pathogenesis for these histopathological groups.

Clinical and anatomical analysis of the epileptogenic spread patterns in focal cortical dysplasia patients.

Background: Focal cortical dysplasia (FCD) is one of the main causes of intractable epilepsy, which is amendable by surgery. During the surgical management of FCD, the understanding of its epileptogenic foci, interconnections, and spreading pathways is crucial for attaining a good postoperative seizure free outcome. Methods: We retrospectively evaluated 54 FCD patients operated in Federal Center of Neurosurgery, Tyumen, Russia. The electroencephalogram findings were correlated to the involved brain anatomical areas. Subsequently, we analyzed the main white matter tracts implicated during the epileptogenic spreading in some representative cases. We prepared 10 human hemispheres using Klinger's method and dissected them through the fiber dissection technique. Results: The clinical results were displayed and the main white matter tracts implicated in the seizure spread were described in 10 patients. Respective FCD foci, interconnections, and ectopic epileptogenic areas in each patient were discussed. Conclusion: A strong understanding of the main implicated tracts in epileptogenic spread in FCD patient remains cardinal for neurosurgeons dealing with epilepsy. To achieve meaningful seizure freedom, despite the focal lesion resection, the interconnections and tracts should be understood and somehow disconnected to stop the spreading.

Two-Stage Pulsatile Human Placenta Model for Microvascular Anastomosis Training in Neurosurgery.

OBJECTIVE: The development of microsurgical skills is crucial for neurosurgical education. The human placenta is a promising model for practicing vascular anastomosis due to its similarities with brain vessels. We propose a 2-stage model for training in extracranial-to-intracranial anastomosis using the placenta. METHODS: Initially, we propose practicing anastomosis in 2 adjacent placentas. Once successful, the procedure advances to a more challenging configuration that employs a 3-dimensionally printed skull with a window simulating a pterional craniotomy. It is positioned an intracranial placenta and an extracranial one, and the latter has a prominent vessel exposed toward the side of the craniotomy. Both placentas have one artery and vein cannulated in the umbilical cord, and we present an artificial placental circulation system for microvascular training that regulates pulsation and hydrodynamic pressure while keeping veins engorged with a pressurized bag. To verify anastomosis patency, we utilize sodium fluorescein and iodine contrast. RESULTS: The 2-stage model simulated several aspects of microvascular anastomosis. Our perfusion system allowed for intraoperative adjustments of hydrodynamic pressure and pulsation. Using iodine contrast and fluorescein enabled proper evaluation of anastomosis patency and hydrodynamic features. CONCLUSIONS: Training in the laboratory is essential for developing microsurgical skills. We have presented a model for microvascular anastomosis with artificial circulation and postoperative imaging evaluation, which is highly beneficial for enhancing the learning curve in microvascular procedures.

Microsurgical Resection of Trigeminal Schwannoma via Anterior Petrosal Approach: 2-Dimensional Operative Video.

Trigeminal schwannomas are complex lesions that may be related to many critical neurovascular structures. We present the case of a 59-year-old male presenting a history of left-sided trigeminal neuralgia. Preoperative imaging demonstrated a mass highly suggestive of a trigeminal schwannoma, and microsurgical resection was indicated considering the progressive symptomatology and important mass effect (Video 1). A middle fossa route including an anterior petrosectomy was chosen. The patient was placed supine with the head rotated to the contralateral side, and an arcuate incision was performed. A V-shaped zygomatic osteotomy was done to mobilize the temporalis muscle more inferiorly and better expose the middle fossa floor. Following craniotomy, peeling of the dura propria from the lateral wall of cavernous sinus was carried out starting by coagulation of middle meningeal artery. Some tumor was already identified and removed, and then the anterior petrosectomy was performed until we exposed the posterior fossa dura. The middle fossa dural incision was connected with the other one at the posterior fossa dura, by coagulation of the superior petrosal sinus. The tentorium was completely cut toward the incisura. After lesion debulking, the tumor was progressively removed by peeling the arachnoid from the lesion to maintain arachnoid planes and preserve the nerves and their blood supply. Postoperative imaging demonstrated complete tumor resection. The patient's symptoms improved, and there were no neurologic deficits on follow-up. Extensive laboratory training is fundamental to be familiarized with the normal anatomic nuances and prepared to face the anatomy distorted by lesion. Informed consent was obtained from the patient for the procedure and publication of this operative video.

Application of Intraoperative Ultrasound Navigation in Neurosurgery.

Effective intraoperative image navigation techniques are necessary in modern neurosurgery. In the last decade, intraoperative ultrasonography (iUS), a relatively inexpensive procedure, has gained widespread acceptance. Aim: To document and describe the neurosurgery cases, in which iUS has been employed as the primary navigational tool. This includes a discussion of the advantages that iUS may possess relative to other forms of neuronavigation. Conclusion: The application of iUS as an intraoperative navigation tool during neurosurgery holds great potential as it has been shown, relative to other neuronavigation techniques, to be quick, repeatable, and able to provide real-time results.

Drug resistant epilepsy of the insular lobe: A review and update article.

Background: Epilepsy is a chronic disease that affects millions of people around the world generating great expenses and psychosocial problems burdening the public health in different ways. A considerable number of patients are refractory to the drug treatment requiring a more detailed and specialized investigation to establish the most appropriate therapeutic option. Insular epilepsy is a rare form of focal epilepsy commonly drug resistant and has much of its investigation and treatment involved with the surgical management at some point. The insula or the insular lobe is a portion of the cerebral cortex located in the depth of the lateral sulcus of the brain; its triangular in shape and connects with the other adjacent lobes. The insular lobe is a very interesting and complex portion of the brain related with different functions. Insula in Latin means Island and was initially described in the 18th century but its relation with epilepsy was first reported in the 1940-1950s. Insular lobe epilepsy is generally difficult to identify and confirm due to its depth and interconnections. Initial non-invasive studies generally demonstrate frustrating or incoherent information about the origin of the ictal event. Technological evolution made this pathology to be progressively better recognized and understood enabling professionals to perform the correct diagnosis and choose the ideal treatment for the affected population. Methods: A literature review was performed using MEDLINE/PubMed, Scopus, and Web of Science databases. The terms epilepsy/epileptic seizure of the insula and surgical treatment was used in various combinations. We included studies that were published in English, French, or Portuguese; performed in humans with insular epilepsy who underwent some surgical treatment (microsurgery, laser ablation, or radiofrequency thermocoagulation). Results: Initial search results in 1267 articles. After removing the duplicates 710 remaining articles were analyzed for titles and abstracts applying the inclusion and exclusion criteria. 70 studies met all inclusion criteria and were selected. Conclusion: At present, the main interests and efforts are in the attempt to achieve and standardize the adequate management of the patient with refractory epilepsy of the insular lobe and for that purpose several forms of investigation and treatment were developed. In this paper, we will discuss the characteristics and information regarding the pathology and gather data to identify and choose the best therapeutic option for each case.

Endoscopic Transnasal Approaches to Petrous Apex.

Endoscopic extended transnasal approaches to the apex of the temporal bone pyramid are rapidly developing and are widely used in our time around the world. Despite this, the problem of choosing an approach remains relevant and open not only between the "open" and "endoscopic transnasal" access groups but also within the latter. In the article, we systematized all endoscopic approaches to the pyramid of the temporal bone and divided them into three large groups: medial, inferior, and superior-in accordance with the anatomical relationship with the internal carotid artery-and also presented their various, modern (later described), modifications that allow you to work more targeted, depending on the nature of the neoplasm and the goals of surgical intervention, which in turn allows you to complete the operation with minimal losses, and improve the quality of life of the patient in the early and late postoperative period. We described the indications and limitations for these accesses and the problems that arise in the way of their implementation, which in turn can theoretically allow us to obtain an algorithm for choosing access, as well as identify growth points.