RESUMO
BACKGROUND: Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant disease associated with neurological complications, including cerebral abscesses (CA). They tend to be unique, supratentorial and lobar. While the surgical intervention is a rule of thumb when treating and diagnosing the etiology of these lesions, this is not always possible due to dangerous or inaccessible locations. We report the case of a patient solely treated with empiric antibiotics without stereotaxic intervention and satisfactory results. CASE PRESENTATION: We present the case of a 21-year-old patient with a right thalamic abscess due to HHT and pulmonary arteriovenous malformations, previously embolized, treated solely with antibiotics. At first, we contemplated the possibility of a stereotaxic biopsy, but the high-risk location and the fact that our patient received a previous full course of antibiotic treatment (in another center), made us discard this intervention because of the low diagnostic yield. We started an empiric antibiotic regime. We followed up very closely the clinical and radiological evaluation the next weeks, adjusting our antibiotic treatment when necessary. The results were favorable from both the radiological and clinical aspects and 6 months after the diagnosis the images show its almost complete disappearance. CONCLUSION: Carefully tailored antibiotic-only regime and vigilance of its adverse effects and close radiological following is a good treatment approach when surgery is not an option.
Assuntos
Antibacterianos/uso terapêutico , Abscesso Encefálico/diagnóstico , Veias Pulmonares/anormalidades , Telangiectasia Hemorrágica Hereditária/patologia , Encéfalo/diagnóstico por imagem , Abscesso Encefálico/tratamento farmacológico , Abscesso Encefálico/etiologia , Humanos , Imageamento por Ressonância Magnética , Masculino , Telangiectasia Hemorrágica Hereditária/complicações , Tomografia Computadorizada por Raios X , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Adulto JovemRESUMO
True pituitary surgical emergencies are rare. These events can occur throughout the perioperative period and are broadly categorized by the timing of occurrence. Acute indications for emergent pituitary surgery include pituitary apoplexy, vision loss, and severe Cushing presentation. Emergencies may also occur intraoperatively, secondary to bleeding. Postoperative emergencies include epistaxis, pneumocephalus, and intracranial bleeding. Cerebrospinal fluid (CSF) leak occurs in about 37.4% of transsphenoidal sellar surgery, yet postoperative CSF leaks are less frequent at approximately 2.6%. As they occur often during pituitary surgery, CSF leaks alone are generally not considered a true surgical emergency unless associated with symptomatic tension pneumocephalus.
Assuntos
Emergências , Neoplasias Hipofisárias , Vazamento de Líquido Cefalorraquidiano/cirurgia , Endoscopia , Humanos , Hipófise/cirurgia , Neoplasias Hipofisárias/cirurgia , Complicações Pós-Operatórias/epidemiologia , Estudos RetrospectivosRESUMO
BACKGROUND: Transorbital endoscopic approach (TOEA) to the cavernous sinus (CS) is a novel surgical technique. However, the necessity of lateral orbital rim (LOR) osteotomy is questionable. OBJECTIVE: To illustrate the surgical dissection of TOEAs to CS and to investigate the additional benefit of LOR osteotomy. METHODS: Anatomic dissections were carried out in 7 cadaveric heads (14 sides). The TOEAs were performed before and after LOR osteotomy; herein referred as the lateral transorbital approach (LTOA) and the lateral orbital wall approach (LOWA), respectively. The stereotactic measurements of the area of exposure, surgical freedom, and angles of attack around CS were quantified. RESULTS: LOWA increased larger area of exposure than LTOA at entry site (5.3 ± 0.6 cm2 and 2.6 ± 0.6 cm2, respectively; P < .001) but both of these techniques provided similar area of exposure at the surgical target site. With regard to the surgical freedoms, those afforded by LOWA were all significantly superior at all of the surgical targets with the difference ranged from 106.6% to 172.5%. No significant differences were found between the vertical angles produced by either approach. On the other hand, the horizontal angles achieved by LOWA were significantly more favorable. CONCLUSION: The TOEAs, either with or without LOR osteotomy are feasible for CS exposure. Although the incremental effect of maneuverability is attained following the LOR osteotomy, it should be performed selectively. Additional research is needed to further validate the safety and efficacy, as well as for precisely defining the clinical application of these techniques.
Assuntos
Seio Cavernoso/cirurgia , Neuroendoscopia/métodos , Procedimentos Neurocirúrgicos/métodos , Órbita/cirurgia , Osteotomia/métodos , HumanosRESUMO
BACKGROUND: The extended supraorbital approach through a modified eyebrow incision is a minimally invasive variant of the frontotemporal or pterional approach that enriches a neurosurgeon's armamentarium for the treatment of pathologies lateral to the anterior clinoid process, by advancing laterally with frontal facial nerve branches monitoring. To demonstrate the steps of the approach, we studied 2 formalin-fixed and artery/vein silicone-injected adult cadaveric heads, and reviewed 1 of the 3 clinical cases operated on to illustrate the applicability of the approach. CLINICAL PRESENTATION: A 56-year-old woman presented with a history of seizures and a complaint of headache that started 2 months ago. She underwent an examination with brain magnetic resonance imaging that showed a dural-based lesion at the medial third of the lesser wing of sphenoid (which is consistent with meningioma). The patient underwent craniotomy with an extended supraorbital approach through a modified eyebrow incision that allowed Simpson grade II removal to be performed and good aesthetic outcome to be achieved. CONCLUSIONS: The extended supraorbital approach through a modified eyebrow incision is a minimally invasive approach that can add to a neurosurgeon's armamentarium and be used with microscopy, assisted by endoscope, or both to reach the anterior and middle cranial fossae.
Assuntos
Sobrancelhas , Procedimentos Neurocirúrgicos/métodos , Neoplasias da Base do Crânio/cirurgia , Osso Esfenoide/cirurgia , Encéfalo/diagnóstico por imagem , Cadáver , Craniotomia , Feminino , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Convulsões/etiologia , Neoplasias da Base do Crânio/diagnóstico por imagem , Osso Esfenoide/diagnóstico por imagem , Resultado do TratamentoRESUMO
OBJECTIVE: To present a case of a well-differentiated primary intradural-extramedullary neuroendocrine tumor of the filum terminale and to conduct a literature review. CASE: A 68-years old patient was assessed after presenting lower back pain and sciatica with ineffective pain relief. The patient presented an intradural-extramedullary lumbar lesion arising from the filum terminale, which was partially resected. The pathology diagnosis was a well-differentiated primary neuroendocrine tumor (carcinoid tumor). After a multidisciplinary evaluation, fractionated stereotactic radiotherapy was administered. No progression or metastatic spread was observed in successive assessments. DISCUSSION: Neuroendocrine tumors are heterogeneous neoplasms derived predominantly from enterochromaffin cells, in which chemotherapy plays a very limited role. In contrast, radiotherapy has been described in partially resected lesions. CONCLUSION: Well-differentiated primary neuroendocrine tumors with intradural-extramedullary lumbosacral location are an exceptional rarity. Isolated surgical resection, or associated with an adjuvant radiotherapy treatment in subtotal resections, could be considered an effective therapeutic strategy.
Assuntos
Tumor Carcinoide/radioterapia , Cauda Equina , Neoplasias do Sistema Nervoso Periférico/radioterapia , Radiocirurgia , Idoso , Tumor Carcinoide/diagnóstico , Tumor Carcinoide/diagnóstico por imagem , Tumor Carcinoide/patologia , Cauda Equina/diagnóstico por imagem , Terapia Combinada , Feminino , Humanos , Dor Lombar/etiologia , Imageamento por Ressonância Magnética , Neoplasias do Sistema Nervoso Periférico/diagnóstico , Neoplasias do Sistema Nervoso Periférico/diagnóstico por imagem , Neoplasias do Sistema Nervoso Periférico/patologia , Ciática/etiologia , Bexiga Urinaria Neurogênica/etiologiaRESUMO
OBJECT: This study proposes a variation of the transorbital endoscopic approach (TOEA) that uses the lateral orbit as the primary surgical corridor, in a minimally invasive fashion, for the posterior fossa (PF) access. The versatility of this technique was quantitatively analyzed in comparison with the anterior transpetrosal approach (ATPA), which is commonly used for managing lesions in the PF. METHODS: Anatomical dissections were carried out in 5 latex-injected human cadaveric heads (10 sides). During dissection, the PF was first accessed by TOEAs through the anterior petrosectomy, both with and without lateral orbital rim osteotomies (herein referred as the lateral transorbital approach [LTOA] and the lateral orbital wall approach [LOWA], respectively). ATPAs were performed following the orbital approaches. The stereotactic measurements of the area of exposure, surgical freedom, and angles of attack to 5 anatomical targets were obtained for statistical comparison by the neuronavigator. RESULTS: The LTOA provided the smallest area of exposure (1.51 ± 0.5 cm2, p = 0.07), while areas of exposure were similar between LOWA and ATPA (1.99 ± 0.7 cm2 and 2.01 ± 1.0 cm2, respectively; p = 0.99). ATPA had the largest surgical freedom, whereas that of LTOA was the most restricted. Similarly, for all targets, the vertical and horizontal angles of attack achieved with ATPA were significantly broader than those achieved with LTOA. However, in LOWA, the removal of the lateral orbital rim allowed a broader range of movement in the horizontal plane, thus granting a similar horizontal angle for 3 of the 5 targets in comparison with ATPA. CONCLUSIONS: The TOEAs using the lateral orbital corridor for PF access are feasible techniques that may provide a comparable surgical exposure to the ATPA. Furthermore, the removal of the orbital rim showed an additional benefit in an enhancement of the surgical maneuverability in the PF.
Assuntos
Fossa Craniana Posterior/cirurgia , Neuroendoscopia/métodos , Neuroendoscopia/normas , Órbita/cirurgia , Osso Petroso/cirurgia , Cadáver , Fossa Craniana Posterior/patologia , Humanos , Órbita/patologia , Osso Petroso/patologiaRESUMO
BACKGROUND/OBJECTIVE: The inframeatal area represents a challenging region for skull base surgeons. Various surgical corridors have been described to access this area and frequently are used in combination. Recent studies describe the expanded endoscopic endonasal approach (EEA) as an established route for midline regions, particularly medial to the internal carotid arteries (ICA). We sought to evaluate the accessibility, maneuverability, and freedom of movement of the expanded endoscopic endonasal approach to the inframeatal region. METHODS: An EEA combining a middle and an inferior transclival corridor with an infrapetrous and a supracondylar lateral expansion was performed in 5 embalmed human cadaveric heads. The area of exposure and the surgical freedom to access the inframeatal area were calculated. The angle of attack and distances from the lacerum segment of the ICA to several anatomical targets also were measured. Our database was searched to select clinical case examples. RESULTS: The EEA provided an exposure area of 101.26 ± 16.66 mm2 and an area of surgical freedom of 1208.50 ± 507.01 mm2. The angles of attack in both the sagittal and axial planes were wider at the lacerum segment of the ICA and narrower at the dural entrance zone of cranial nerves VII/VIII. Three chondrosarcomas are presented as case illustrations. CONCLUSIONS: The EEA is a feasible route to the inframeatal area. This approach provides a safe working corridor for lesions in this region, as shown by the anatomical and clinical findings presented here. Comparative studies and large case series are warranted to further establish its clinical value.