Large Pontine Cavernoma Operated by Anterior Petrosal Approach-Two-Dimensional Operative Video.

Brainstem cavernoma is a challenging neurosurgical pathology and microsurgery remains the only treatment option. Although the decision-making between interventional and conservative approach to this disease may be complex, malformations presenting multiple bleedings are usually good candidates for surgery. 1 On the other hand, microsurgical resection of cavernomas can offer an effective resolution with acceptable morbidity. In this video, we present a case of pontine cavernoma with multiple hemorrhages in a young patient. The anatomical characteristic of the lesion defines the best suitable craniotomy for surgery. In this case, an anterior petrosal approach 2 3 4 was used to access the peritrigeminal area and safely perform the resection. Anatomical considerations are described on this skull base approach along with the rationale and benefits of this exposure. Electrophysiological neuromonitoring is essential for this kind of procedure and preoperative tractography also enabled the best understanding of the disease. Finally, we also discuss alternative managements and potential complications. 5 With the patient's consent, we also show the excellent clinical evolution after few weeks of recovery and the restoration of the corticospinal tract, previously displaced by the cavernoma, to its original position.

Clinoidal Meningioma with Cavernous Sinus Invasion.

We present a-49-year old female presenting headache and progressive right eye visual loss in the last 6 months. Magnetic resonance imaging showed a large clinoidal meningioma on the right side, invading the superior, lateral and medial aspects of the cavernous sinus, the optic canal, and the clinoidal segment of the internal carotid artery (ICA). A cranio-orbital approach was performed. The anterior clinoid process was removed extradurally to achieve devascularization of the anterior clinoidal meningioma, followed by the peeling of the middle fossa to decompress V2 and open the superior orbital fissure. We open the dura in a standard fronto-temporal flap to access the lower portion of the skull base allowing retractorless dissection. We complete the removal of the anterior clinoid process and optic strut through an intradural approach. It allows safer dissection of the clinoidal segment of the ICA and avoids its injury by adherent and hard consistency tumor. Intraoperative neurophysiological monitoring, sharp dissection, and avoiding the use of bipolar coagulation when dissecting the cavernous sinus are essential to minimize the risk of cranial nerve injury. We also like to point that cranial nerve deficit caused by surgical manipulation without primary lesion of the nerve can be recovered postoperatively. The link to the video can be found at: https://youtu.be/ozUCsnUGxyM .

Spheno-Orbital Meningioma with Cavernous Sinus Extension.

We present a case of a 37-year-old female, with progressive left eye proptosis and an extensive ipsilateral en plaque spheno-orbital meningioma, with diffuse involvement of the lateral wall of the cavernous sinus and the orbit. A cranio-orbital zygomatic approach was performed to reach all extension of the lesion. We made an extradural clinoidectomy and an extensive bone removal of the orbit, exposition of the superior and lateral walls of the cavernous sinus, unroofing of the optic canal, superior orbital fissure, foramen rotundum, and foramen ovale. We performed the peeling of the lateral wall of cavernous sinus with total removal and preservation of the cranial nerves anatomy and function. In this video, we illustrate the importance of the first time aggressive removal of such tumors. We also demonstrate the concept that secondary invasion of the cavernous sinus are suitable for removal with cranial nerve preservation. The link to the video can be found at https://youtu.be/GJmkqVa6jSs .

Anterior Petrosal Approach to Petrous Apex Meningioma: Climbing the Rock-Two-Dimensional Operative Video.

A 47-year-old woman was referred to the neurological surgery department after a self-limiting episode of dizziness and headache. Magnetic resonance imaging showed an extra-axial mass in the right petrous apex, suggesting a meningioma. We chose the anterior petrosal approach (APA) because meningioma is a benign tumor with brainstem compression, and our goal was total removal for potential cure of the disease. The APA is appropriate for lesions located in the superior petroclival region with a narrow dural tail, above cranial nerves VII and VIII. The posterior petrosal approach is for large petroclival meningiomas that cross the midline, involving the basilar artery and perforating branches, extending below cranial nerves VII and VIII and above the jugular foramen. The retrosigmoid approach is for lesions located in the petrous apex and petroclival regions. Limitations include working between the posterior fossa cranial nerves and removing extensions of the tumor to Meckel cave and middle fossa. The endoscopic endonasal approach is for petroclival lesions. Limitations are the longer distance, nasal disturbances, middle fossa dural tail removal, and cerebrospinal fluid fistula.1-8 We performed the APA through a suprapetrous craniotomy, which exposes the petrous temporal portion, to drill the posteromedial triangle of the middle fossa to create a surgical corridor to the posterior fossa after splitting the tentorium.1-8 Removal of the tumor through the APA leads to a direct route to the petrous apex, with short distance and predominant extradural dissection. We achieved gross total removal. The patient presented with transient cranial nerve IV and V disturbances, but recovered entirely in 6 weeks, returning to her professional activities with preserved quality of life (Video 1).

Delayed Cerebral Metastasis of Breast Cancer: Case Report and Molecular Review

Breast cancer (BC) is a prevalent disease, and its incidence of brain metastasis (BM) varies from5 to 30% according to the literature.We present the case of a delayed isolated cerebral metastasis in a female patient following a period of 16 years after the diagnosis and first treatment. During this time, there was no other recurrence. We also review the literature concerning central nervous systemspread and themolecular subtypes of such late tumors.

Nobel Direct - Um novo conceito de implantes para ativação imediata - Relato de caso clínico / Nobel Direct – A new implant design for immediate loading - Clinical case report

Implantes unitários permitem altos índices de sucesso e, quando submetidos à ativação imediata, podem preservar o osso alveolar e permitir ótimas condições de tecido mole. Implantes de corpo único eliminam a necessidadede intermediários e podem evitar a manipulação de tecidosmoles. Este trabalho discute as indicações, vantagens e a técnica cirúrgica para instalação e ativação imediata de implantes Nobel Direct em áreas estéticas.

Resultados da operação reconstrutora da valva mitral em pacientes com idade inferior a 15 anos / Outcomes of mitral valve repair surgery in under 15-year-old patients

OBJETIVO: Avaliar a evolução dos pacientes portadores de regurgitação valvar mitral menores de 15 anos submetidos à operação reconstrutora da valva mitral. MÉTODO: Cento e dezessete pacientes com idade inferior a 15 anos, submetidos à plastia valvar mitral, no período de maio de 1980 a novembro de 2001. A idade variou de 1 a 15 anos, com média de 10 anos. Setenta e quatro pacientes (63,2 por cento) eram do sexo feminino. A etiologia mais freqüente foi a doença reumática (81,2 por cento). Oitenta e sete pacientes (63,2 por cento) apresentavam regurgitação mitral e 30 (25,6 por cento) estenose associada. Outras doenças estiveram presentes em 28 pacientes (23,9 por cento), sendo a doença da valva aórtica a mais comum (13,7 por cento). Diversas técnicas foram aplicadas na reconstrução valvar, como o encurtamento e/ou alongamento de cordas tendíneas, comissurotomia e papilarotomia. O anel valvar mitral foi remodelado em todos os pacientes. RESULTADOS: A evolução tardia mostrou 96,6 por cento dos pacientes vivos e 88.9 por cento com sua própria valva. Quinze pacientes (12,8 por cento) foram reoperados. O anel mitral foi remodelado na totalidade dos pacientes, sendo utilizado o anel de Gregori-Braile em 69 (58,9 por cento) e o de Carpentier em 35 (29,9 por cento). As técnicas mais freqüentes foram o encurtamento de cordas em 66 pacientes (56,4 por cento), e a comissurotomia e/ou papilotomia em 30 pacientes (25,6 por cento). Houve um óbito hospitalar (0,9 por cento) e três (2,6 por cento) óbitos tardios. CONCLUSÃO: A operação reconstrutora na regurgitação valvar mitral foi factível, apresentando resultados que orientam para sua aplicabilidade neste grupo de pacientes menores de 15 anos.