Patient satisfaction with temporal lobectomy/selective amygdalohippocampectomy for temporal lobe epilepsy and its relationship with Engel classification and the side of lobectomy.

PURPOSE: The aim of this study was to investigate not only the effectiveness of epilepsy surgery in improving seizure control but also patient satisfaction with the result of the procedure in a sample of patients operated on at a specialized epilepsy unit. METHODS: Patients with temporal lobe epilepsy who had undergone epilepsy surgery (temporal lobectomy/amygdalohippocampectomy) were interviewed in a standardized telephone survey about their satisfaction with the results of the surgery. The morbidity of the surgery was also analyzed retrospectively. The initial study population consisted of 6 amygdalohippocampectomy and 102 temporal lobectomy patients and was reduced to a final sample consisting of 4 amygdalohippocampectomy and 67 lobectomy patients, as the other patients were not available for interview. Surgical results were based on the Engel classification, and satisfaction with the surgery was assessed by asking patients to rate their result and state whether they would make the same decision (to be operated on) again. RESULTS: A significant number of patients classified as Engel I or II, who considered the surgical outcome good or excellent, said they would have the surgery again (p<0.001). Left temporal lobectomy patients whose results fell in the Engel III/IV bracket were less satisfied (p=0.001) than right temporal lobectomy patients with the same Engel classifications (0.048). Left temporal lobectomy patients who were classified as Engel class III and IV were less likely to have the surgery again if they had the choice (p=0.016). DISCUSSION: Patient satisfaction with the results of epilepsy surgery may depend not only on achieving seizure control but also on the temporal lobe resected. Since worse results were associated with lower satisfaction rates only for left temporal resection patients, it is possible that the cognitive consequences of this procedure compound the worse surgical result, leading to decreased satisfaction.

Fiber-Optic Intracranial Pressure Monitoring System Using Wi-Fi-An In Vivo Study.

BACKGROUND: Continuous invasive monitoring of intracranial pressure (ICP) is essential in neurocritical care for surveillance and management of raised ICP. Fluid-based systems and strain gauge microsensors remain the current standard. In the past few decades, several studies with wireless monitoring were developed aiming to reduce invasiveness and complications. OBJECTIVE: To describe a novel Wi-Fi fiber-optic device for continuous ICP monitoring using smartphone in a swine model. METHODS: Two ICP sensors (wireless prototype and wire-based reference) were implanted in the cerebral parenchyma of a swine model for a total of 120 minutes of continuous monitoring. Every 5 minutes, jugular veins compression was performed to evaluate ICP changes. The experimentation was divided in 3 phases for comparison and analysis. RESULTS: Phase 1 showed agreement in ICP changes for both sensors during jugular compression and releasing, with a positive and strong Spearman correlation (r = 0.829, P < .001). Phase 2 started after inversion of the sensors in the burr holes; there was a positive and moderately weak Spearman correlation (r = 0.262, P < .001). For phase 3, the sensors were returned to the first burr holes; the prototype behaved similarly to the reference sensor, presenting a positive and moderately strong Spearman correlation (r = 0.669, P < .001). CONCLUSION: A Wi-Fi ICP monitoring system was demonstrated in a comprehensive and feasible way. It was possible to observe, using smartphone, an adequate correlation regarding ICP variations. Further adaptations are already being developed.

Surgical management of brainstem cavernous malformations.

Bleeding from brainstem cavernomas may cause severe deficits due to the absence of non-eloquent nervous tissue and the presence of several ascending and descending white matter tracts and nerve nuclei. Surgical removal of these lesions presents a challenge to the most surgeons. The authors present their experience with the surgical treatment of 43 patients with brainstem cavernomas. Important aspects of microsurgical anatomy are reviewed. The surgical management, with special focus on new intraoperative technologies as well as controversies on indications and timing of surgery are presented. According to several published studies the outcome of brainstem cavernomas treated conservatively is poor. In our experience, surgical resection remains the treatment of choice if there was previous hemorrhage and the lesion reaches the surface of brainstem. These procedures should be performed by experienced neurosurgeons in referral centers employing all the currently available technology.

Jules Bernard Luys: from a description of the subthalamic nucleus to hypnotism.

The authors review the role of Jules Bernard Luys in the discovery of the subthalamic nucleus (STN) over 150 years ago. The relationships between the STN and movement disorders, particularly hemiballismus and Parkinson's disease, are well known. The academic life of Jules Bernard Luys can be divided into two periods: a brilliant start as a neuroanatomist, culminating in the discovery of the STN, followed by a second period marked by a shift in his academic activity and an increased interest in topics such as hysteria, hypnotism and, eventually, esotericism.

Morphometric Study of the Internal Globus Pallidus Using the Robert, Barnard, and Brown Staining Method.

BACKGROUND: The globus pallidus internus (Gpi) is a major target in functional neurosurgery. Anatomical studies are crucial for correct planning and good surgical outcomes in this region. The present study described the anatomical coordinates of the Gpi and its relationship with other brain structures and compared the findings with those from previous anatomical studies. METHODS: We obtained 35 coronal and 5 horizontal brain specimens from the Department of Anatomy and stained them using the Robert, Barnard, and Brown technique. After excluding defective samples, 60 nuclei were analyzed by assessing their distances to the anatomical references and the trajectories to these nuclei. RESULTS: The barycenter of the Gpi was identified at the level of the mammillary bodies and 1 cm above the intercommissural plane. Thereafter, the distances to other structures were found. The mean ± standard deviation distance was 15.62 ± 2.66 mm to the wall of the third ventricle and 17.02 ± 2.69 mm to its midline, 4.74 ± 1.12 mm to the optic tract, 2.51 ± 0.8 mm and 13.56 ± 2 mm to the internal and external capsule, and 21.3 ± 2.44 mm to the insular cortex. The cortical point of entry should be located 22.03 ± 4.34 mm to 48.74 ± 4.44 mm from the midline. CONCLUSION: The Gpi has less variability in distance to closer anatomical references, such as the optic tract and internal capsule. Distant locations showed a more inhomogeneous pattern. Anatomical studies such as ours are important for the development of new therapeutic approaches and can be used as a basis for new research involving volumetric and specific group analyses.

Morphometric Analysis of the Nucleus Accumbens Using the Mulligan Staining Method.

BACKGROUND: There is a need to further anatomically describe the nucleus accumbens (NA), as there is a growing neurosurgical interest in this locus but a limited understanding of its structure. In this study, we evaluated quantitative NA parameters and spatial relationships with adjacent structures found in the telencephalon. METHODS: A total of 155 NA specimens from coronal sections and 3 NA specimens from transverse sections were stained using the Mulligan technique as modified by Barnard et al. The distance from the NA to other structures was then measured. RESULTS: The mean radius of the 155 NAs in the coronal sections was 6.23 ± 0.964 mm, averaging 8.99 ± 2.02 mm from midline (coordinate x), 27.09 ± 3.15 mm from the insula, 12.95 ± 3.21 mm from the outer border of the putamen, 10.52 ± 2.66 mm from the upper border of the caudate, and 8.84 ± 2.93 mm from the midline of the lateral ventricle. The mean distance from the NA center of gravity to the middle of the intercommissural line parallel to the midline (coordinate y) was 17.08 ±3.61 mm, and the mean vertical distance from the intercommissural line to the NA was 8.12 ± 1.265 mm. CONCLUSIONS: We obtained the stereotactic coordinates of (x, y, z) = (8, 17, -8) for the NA. From this and other delineations of the described position of the NA, it is possible to contribute to stereotactic surgical atlases, improving neurosurgical interventions in this structure.

Preoperative Endovascular Embolization of Glomus Jugulare Tumors: A Retrospective Case Series of 22 Embolizations in 20 Patients and Literature Review

Objective Glomus jugulare tumors, or tympanojugular paragangliomas, are rare, highly vascularized skull base tumors originated from paraganglion cells of the neural crest. With nonabsorbable embolic agents, embolization combined with surgery has become the norm. The authors assess the profile and outcomes of patients submitted to preoperative embolization in a Brazilian tertiary care hospital. Methods The present study is a single-center, retrospective analysis; between January 2008 and December 2019, 22 embolizations were performed in 20 patients in a preoperative character, and their medical records were analyzed for the present case series. Results Hearing loss was the most common symptom, present in 50% of the patients, while 40% had tinnitus, 30% had dysphagia, 25% had facial paralysis, 20% had hoarseness, and 10% had diplopia. In 7 out of 22 embolization procedures (31%) more than a single embolic agent was used; Gelfoam (Pfizer, New York, NY, USA) was used in 18 procedures (81%), in 12 of which as the single agent, followed by Embosphere (Merit Medical, South Jordan, UT, USA) (31%), Onyx (Medtronic, Minneapolis, MN, USA) (9%), and polyvynil alcohol (PVA) and Bead Block (Boston Scientific, Marlborough, MA, USA) in 4,5% each. The most common vessel involved was the ascending pharyngeal artery, involved in 90% of the patients, followed by the posterior auricular artery in 15%, the internal maxillary artery or the occipital artery in 10% each, and the superficial temporal or the lingual arteries, with 6% each. Only one patient had involvement of the internal carotid artery. No complications from embolization were recorded. Conclusions Preoperative embolization of glomus tumors is safe and reduces surgical time and complications, due to the decrease in size and bleeding.

Patterns of neuroaxis dissemination of gliomas: suggestion of a classification based on magnetic resonance imaging findings.

BACKGROUND: Local invasion is the hallmark of malignant glioma dissemination. Leptomeningeal dissemination, a serious complication of malignant gliomas, has been increasingly observed. To correlate the physiopathologic mechanisms and the magnetic resonance imaging patterns of neuroaxis dissemination, a classification of malignant glioma dissemination is proposed (Instituto de Neurologia de Curitiba Classification). METHODS: This classification includes the following patterns of dissemination: leptomeningeal (type I), nodular (type Ia), diffuse (type Ib); subependymal (type II); satellite (type IIIa, IIIb); and mixed (type IV), combination of 2 or more previous types. Of 138 patients with histologically confirmed gliomas treated between 2000 and 2004, 10 presented neuroaxis dissemination and were evaluated. RESULTS: The distribution of dissemination patterns was as follows: subependymal, 4 of 10; diffuse leptomeningeal, 1 of 10; nodular leptomeningeal, 1 of 10; and satellite, 4 of 10. Mean interval between primary tumor and dissemination was 4 months. The most frequent glioma dissemination risk factor was entering the ventricular system during surgery. CONCLUSIONS: Improvements in our diagnostic imaging capabilities have contributed to a better understanding of the patterns of malignant glioma dissemination. Using this information, we present a useful classification scheme, applicable to patients with neuroaxis dissemination, which will help standardize future discussions aimed at understanding these patterns of tumor spread.

Syncope or epileptic fits? Some examples of diagnostic confounding factors.

Syncope is a condition often misdiagnosed as epileptic seizures. However, the differential diagnosis between both conditions can be quite difficult, even for well-trained physicians. Four cases of epilepsy and/or syncope are reported, to exemplify this situation. Each case is discussed individually, and the confounding factors are analyzed.

Jules Bernard Luys: from a description of the subthalamic nucleus to hypnotism / Jules Bernard Luys: da descrição do núcleo subtalâmico ao hipnotismo

ABSTRACT The authors review the role of Jules Bernard Luys in the discovery of the subthalamic nucleus (STN) over 150 years ago. The relationships between the STN and movement disorders, particularly hemiballismus and Parkinson's disease, are well known. The academic life of Jules Bernard Luys can be divided into two periods: a brilliant start as a neuroanatomist, culminating in the discovery of the STN, followed by a second period marked by a shift in his academic activity and an increased interest in topics such as hysteria, hypnotism and, eventually, esotericism.

RESUMO Os autores revisam o papel de Jules Bernard Luys na descoberta do núcleo subtalâmico (NST) há mais de 150 anos. As relações da NST com distúrbios do movimento, em particular o hemibalismo e a doença de Parkinson, são bem conhecidas. A vida acadêmica de Jules Bernard Luys pode ser dividida em duas fases: a primeira, um brilhante começo de sua carreira como neuroanatomista, culminando na descoberta do NST, seguido por um segundo período marcado por uma mudança em sua atividade acadêmica, e maior interesse em tópicos como histeria, hipnotismo e finalmente esoterismo.

[Comparative analysis of human brain slices with three different staining techniques]. / Análise comparativa de cortes de encéfalos humanos com coloração por três técnicas diferentes.

Studying neuroanatomy at brain slices with gray matter staining techniques has several advantages. More often, the models described by Barnard, Robert and Brown, Mulligan, and Green are used. The aim of this study was to identify which of them achieves the best results on differentiation between the gray and the white matter. Thirty coronal slices of human brains underwent staining by the three techniques, and thus compared and analysed according this three parameters: degree of differentiation between white and gray matter, presence of a single and uninterrupted line dividing the white matter from the brain cortex; and degree of impregnation of the color staining in the white matter; scores from 0 to 3 have been given for the three parameters, with total score from 0 to 9. After statistic analysis, the Barnard, Robert and Brown model showed the best results, followed by Green's and Mulligan's.

[Stereoscopic neuroanatomy: comparative study between anaglyphic and light polarization techniques]. / Estereoscopia aplicada à neuroanatomia: estudo comparativo entre as técnicas de filtro de cores e de polarização.

The need of didactic material is increasing in medical science nowadays. The lack of anatomical specimens, and the toxicity of conservators, have originated an intense search for alternative ways of demonstrating the human anatomy. As a solution for this difficulty, three-dimensional (3-D) images may be used, facilitating the learning process. This study aims at comparing and describing two techniques of reproduction of bi-dimensional images into three dimensions, which is called stereoscopy. The methods evaluated are filter of colors (anaglyphic) and polarized light. Techniques were analyzed for clearness and 3-D effect. Fourteen images were evaluated by 5 people, with scores ranging from 0 to 4. Total mean scores of polarized light was superior compared to the anaglyphic technique. Both methods use the codification of the image, which means separation and exclusivity with each eye seeing its corresponding image. After several photographic essays and gradual adaptation to a better technique, based on optical physics, photography and neuroanatomical knowledge, we concluded that both techniques are suitable means for production of 3-D images. The best technique, however, considering the final quality of image was polarized light, which did not alter the natural color of the specimen, conserving clearness of images with lower cost.

Peritoneal dissemination from central neurocytoma: case report.

OBJECTIVE: Central neurocytoma is a low grade tumor of neuroglial origin and a relatively new histological entity. Only a few cases have been reported and its biological behavior is still uncertain. Some cases have shown an aggressive behavior (local recurrence, malignant dedifferentiation or CSF dissemination) and challenged the initial view of its relative benignity. A case of central neurocytoma with peritoneal dissemination is presented. CASE: A six years-old boy with recurrent neurocytoma of III ventricle and left thalamus showed fast growth of tumor rest and ascites three and a half years after subtotal removal of the lesion. Tumor cells were identified in the ascitic fluid and implanted in the peritoneum. Chemotherapy was initiated immediately after diagnosis of peritoneal dissemination (etoposide, carboplatin, doxorubicin and cyclophosphamide). The patient developed metabolic imbalance and respiratory failure due to rapid formation of ascitic fluid and died 3 days after the diagnosis of peritoneal dissemination was established. CONCLUSION: Central neurocytoma is a low grade tumor with low values of the proliferative index in the majority of cases. In spite of that, some tumors may present a very aggressive behavior and extraneural dissemination. Evaluation of proliferative index may be a guideline parameter for planning adjuvant therapies after surgical treatment in selected cases. Extraneural dissemination may occur in some cases specially in patients with ventriculoperitoneal shunt.

[Cerebral and systemic venous thrombosis associated to prothrombin G20210 mutation: case report]. / Trombose de seio venoso cerebral e trombose sistêmica associadas à mutação do gene 20210 da protrombina: relato de caso.

Cerebral venous thrombosis is a clinical condition of difficult diagnosis, and poor prognosis when treatment is not started early. There is a long list of causes, and hereby we describe a case associated to prothrombin G20210 mutation. A 53-year-old man, white, was admitted with status epilepticus. After seizures control, he developed intracranial hypertension, with headache and vomiting, and bilateral papilledema. His past medical and familial history were unremarkable. He was a nonsmoker, no drug and alcohol user. CT scan and MRI showed right temporal and parietal infarct with hemorrhagic transformation. Spinal tap with opening pressure of 500 mmH2O showed normal CSF examination. MRI angiography disclosed superior sinus, right transverse and sigmoid sinus complete thrombosis. He was started with heparin and oral warfarin. In spite of anticoagulation, two months later he developed deep right inferior limb thrombosis. All the initial tests were normal, and test for prothrombin G20210 mutation was positive. He needed a much higher than conventional daily dose of warfarin to keep him asymptomatic.

The usefulness of neuronavigation in functional hemispherectomy / Aplicabilidade da neuronavegação em hemisferectomia funcional

Catastrophic epileptic encephalopathies in children comprise devastating conditions that features cerebral dysfunction in association with refractory epileptic seizures. The diagnosis is based on the clinical findings, on magnetic resonance imaging (MRI) of the brain and on electroencephalographic findings. For these conditions, surgery remains essential for attaining seizure control. We report two cases of 5-year-old girls. The first one had a diagnosis of Rasmussen’s syndrome. The second one had a large porencephalic cyst secondary to perinatal cerebral ischemia. Despite trials of anticonvulsants, both patients deteriorated, and a functional hemispherectomy guided by neuronavigation was indicated and performed, with low morbidity and excellent seizure control. The neuronavigation proved to be a valuable guidance tool in performing the functional hemispherectomy, making the disconnections more accurate, and thus decreasing the surgical time and blood loss.

Aplicabilidade da neuronavegação em hemisferectomia funcional As encefalopatias epilépticas catastróficas da infância compreendem condições graves que associam disfunção cerebral e crises epilépticas refratárias. Seu diagnóstico é firmado com base nos dados clínicos e nos achados de ressonância magnética e eletrencefalográficos. Para algumas destas condições o tratamento cirúrgico continua sendo essencial para o controle das crises. Relatamos dois casos de pacientes de 5 anos. A primeira teve diagnóstico de síndrome de Rasmussen. A segunda tinha antecedentes de encefalopatia hipóxico-isquêmica perinatal. Ambas apresentaram epilepsia parcial refratária em associação com rápida deterioração neurológica, e foram submetidas à hemisferectomia funcional com auxílio da neuronavegação, com baixa morbidade e excelente controle das crises. A neuronavegação se mostrou como uma valiosa ferramenta na realização da hemisferectomia funcional, possibilitando desconexões mais precisas, menor tempo de cirurgia e menor perda sanguínea.

Tratamento endovascular de aneurismas intracranianos não rotos em idosos / Endovascular treatment of elderly unruptured intracranial aneurysms

Introdução: A necessidade de tratamento de aneurismas intracranianos não rotos em idosos e a técnica a ser utilizada encontrasecontroverso na literatura. O objetivo deste estudo é relatar a experiência e o seguimento do tratamento endovascular deaneurismas intracranianos não rotos em idosos em um centro especializado de Curitiba – PR. Método: Foram avaliados retrospectivamente pacientes com 60 anos ou mais com diagnóstico de aneurisma intracraniano não roto tratados pela técnica endovascular entre 2007 e 2012 no INC. Foram excluídos pacientes com aneurisma fusiforme, micótico ou traumático. Foramcoletados dados demográficos, características do aneurisma, técnica utilizada, resultados finais e complicações. Resultados:27 pacientes e 30 aneurismas. A média de idade foi de 71 anos, sendo 70% do sexo feminino. Metade dos aneurismas tinha entre 5 e 15mm e 50% tinha colo largo (>4mm), enquanto na outra metade o colo era estreito. A técnica mais utilizada foi a de Remodeling. Obteve-se 74% de oclusão completa, 13% oclusão parcial e o procedimento não foi concluído em 13%. Houve 6% de complicações com morbi/mortalidade. Conclusões: O tratamento endovascular de aneurismas intracranianos não rotos em idosos mostrou-se seguro para 87% dos casos com complicações aceitáveis e específicas à faixa etária e próximas à população geral.