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 .

Neurosurgical Management of Nonmissile Penetrating Cranial Lesions.

OBJECTIVE: The objective of this study is to present a case series of nonmissile penetrating (NMP) injuries and to establish a workflow for an uncommon mechanism of traumatic head injury through the analysis of each case, classification of the type of lesion, management, and outcome score at follow-up. METHODS: From January 1991 to December 2008, 36,000 patients presenting with traumatic brain injury (TBI) were admitted in the Department of Neurosurgery, Hospital Antônio Targino, Campina Grande-PB, Brazil. From these patients, 11 presenting with lesions caused by NMP objects were selected. RESULTS: Among the 11 patients, 9 were men and 2 were women. Their ages ranged from 7 to 74 years old (mean age ± SD, 29.1 ± 22.99 years). All patients underwent neuroradiologic evaluation. The entry point was classified as natural (orbit) or artificial (skull transfixation), and we also divided the patients presenting with secondary parenchymal or vascular damage from those presenting with only lesions caused by the primary penetration into the cranium and meninges. All patients were neurosurgically treated with removal of the foreign body through craniotomy, except the patient whose object (pen) was removed without craniotomy with local anesthesia. Glasgow Coma Scale (GCS) score on admission was a statistically significant factor on prognosis, and any patient who presented with a GCS score of 15 evolved satisfactorily, and there were no deaths in this group of patients (P = 0.04). CONCLUSIONS: TBIs caused by NMP objects are unusual and caused by aggression, self-inflicted harm (in the case of psychiatric patients), and accident. The foreign body may enter into the skull through a natural hole (orbit, nose, mouth, or ear) or crosses the skull, causing a fracture and creating an artificial hole. Preoperative neuroradiologic assessment is paramount for the correct neurosurgical approach. The main prognostic factor for these patients is the GCS score at admission.

Assessment of Cerebral Blood Flow with Micro-Doppler Vascular Reduces the Risk of Ischemic Stroke During the Clipping of Intracranial Aneurysms.

OBJECTIVE: To analyze the impact of the introduction of Micro-Doppler vascular (MDV) as a method of cerebral blood flow analysis during microsurgical clipping of intracranial aneurysms to check the partial occlusion of the aneurysm and the occurrence of stenosis by comparing these results with those provided by the postoperative digital subtraction angiography (DSA) scan as well as the occurrence of ischemic infarction on the postoperative computed tomography (CT) images. PATIENTS AND METHODS: We reviewed retrospectively the last 50 patients operated on before the introduction of the MDV (group 1) compared with the first 50 patients operated on using this technique (group 2). RESULTS: Nine (18%) of the 50 patients evaluated in the group 1 showed a new hypodensity in the postoperative CT images, whereas only 2 (4%) patients showed infarction in the group 2 (P = 0.02). In addition, in the group 1, 10 (20%) patients presented unexpected findings on DSA images (residual aneurysms, stenosis, and arterial occlusion), whereas in the group 2, those unexpected DSA findings were observed in only 3 (6%) patients (P = 0.023). CONCLUSION: MDV is an excellent method for cerebral blood flow assessment during the microsurgical clipping of intracranial aneurysms, reducing the unexpected angiographic results (residual aneurysms, stenosis, and arterial occlusion), as well as reducing the incidence of ischemic infarction on postoperative CT images, evidence of the positive impact of this method in the microsurgical treatment of intracranial aneurysms.

Intracranial aneurysms presenting with mass effect over the anterior optic pathways: neurosurgical management and outcomes.

OBJECT: Intracranial aneurysms may grow closer to anterior optic pathways, causing mass effect over these anatomical structures, including visual deficit. The authors retrospectively reviewed a series of aneurysms in patients presenting with visual field deficit caused by mass effect, to analyze the aneurysm's characteristics, the neurosurgical management of these aneurysms, as well as their clinical, visual, and radiological outcomes. METHODS: The authors reviewed the medical charts, neuroimaging examination results, and surgical videos of 15 patients presenting with visual symptoms caused by an aneurysm's mass effect over the anterior optic pathways. These patients were treated at the Department of Neurosurgery, Center of Neurology and Neurosurgery Associates, Hospital Beneficência Portuguesa de São Paulo, Brazil. Statistical analysis was performed to identify the variables related to partial or total recovery of the visual symptoms. RESULTS: All patients underwent microsurgical clip placement and emptying of their aneurysms. After a mean follow-up of 38.5 months, the mean postoperative Glasgow Outcome Scale score was 4.33, and the visual outcomes were as follows: 1 patient (6.6%) unchanged, 7 (46.6%) improved, and 7 (46.6%) experienced complete recovery from visual deficits. The variables that influenced the visual outcomes were the size of the aneurysm (p = 0.039), duration of the visual symptoms (p = 0.002), aneurysm wall calcification (p = 0.010), and intraluminal thrombosis (p = 0.007). Postoperative examination using digital subtraction angiography showed complete aneurysm occlusion in 14 (93.3%) of the 15 patients. CONCLUSIONS: Intracranial aneurysms causing mass effect over the anterior optic pathways usually present with complex features. The best treatment option must include not only the aneurysm occlusion but also relief of the mass effect. Microsurgical clip placement with reduction of aneurysmal mass effect achieved improvement in visual ability or recovery from visual impairment, as well as total aneurysm occlusion, in 93.3% of the study group. Therefore, this option is well supported as the first choice of treatment for intracranial aneurysms presenting with mass effect over the anterior visual pathways.

Surgical management of foramen magnum meningiomas.

The objective of the study is to describe our experience in the surgical management of foramen magnum meningiomas with regard to the clinical-radiological findings, the surgical approach and the outcomes after mid-term follow up. Over a 5-year period, 15 patients presenting with meningiomas of the foramen magnum underwent surgical treatment. The medical records were reviewed in order to analyze the clinical-radiological aspects, as well as the surgical approach and the outcomes. Based on the preoperative magnetic resonance imaging exams, the tumors were classified as anterior or anterolateral in the axial slices and clivospinal or spinoclival in the sagittal slices. The lateral approach was used in all cases. However, the extent of bone removal and the management of the vertebral artery were tailored to each patient. Fourteen patients were females, and one was male, ranging in age from 42 to 74 years (mean 55,9 years). The occipital condyle was partially removed in eight patients, and in seven patients, removal was not necessary. Total removal of the tumor was achieved in 12 patients, subtotal in two, and partial resection in one patient. Postoperative complications occurred in two patients. Follow-up ranged from 6 to 56 months (mean 23.6 months).There was no surgical mortality in this series. The extent of the surgical approach to foramen magnum meningiomas must be based on the main point of dural attachment and tailored individually case-by-case. The differentiation between the clivospinal and spinoclival types, as well as anterior and anterolateral types, is crucial for the neurosurgical planning of foramen magnum meningiomas.

Meningiomas petroclivais: planejamento cirúrgico / Petroclival meningiomas: surgical planning

Objetivo: O tratamento cirúrgico dos tumores originários da região petroclival, ou com extensão para essa área, é um desafio para os neurocirurgiões. Aqui descrevemos duas abordagens de base de crânio a menigeomas petriclivais, definidos como tumores originários dos dois terços superiores do clivus, na junção petroclival, e medial ao nervo trigêmeo. Descrição: A abordagem cranio-orbito-zigomática (COZ) é descrita. para lesões localizadas no clivus superior, com e sem extensão ao seio cavernoso, e a abordagem petrosa posterior, usada para alcançar lesões no clivus médio com e sem extensão ao clivus superior ou inferior. Na abordagem COZ, o canal auditivo interno é uma extensão inferior. Conclusões: A remoção radical dos meningeomas (graus 1 e 2 da escala simpson) é bem estabelecida com o melhor tratamento. Abordagens à base do crânio são mais adequadas para a remoção radical de meningeomas petroclivais tumores moles como schawannomas trigemiais, cistos epidermóides ou meningeomas com extensão para a região petroclival, porém sem insersão, podem ser removidos pela abordagem retrosigmóidea.

Cervical spinal cord compression due to an osteochondroma in hereditary multiple exostosis: case report and review of the literature.

BACKGROUND: Hereditary multiple exostosis is a benign disorder characterized by multiple osteochondromas affecting long and flat bones, although occasionally vertebral column involvement can be seen. Cervical spinal cord compression in HME is a rare condition. The objective of this manuscript is to describe a rare case of cervical myelopathy due to an exostosis arising from C7 in a patient with HME and a comprehensive review of the current literature. CASE DESCRIPTION: We describe a case of HME in an 18-year-old girl with myelopathy characterized by quadriparesis due to an osteochondroma arising from the lamina of C7. The patient underwent surgery, and a laminectomy was performed with a complete removal of the exostosis and spinal cord decompression. One month after surgery, patient presented an excellent recovery without neurologic deficits. CONCLUSIONS: Cervical spinal cord compression resulting from osteochondroma is an extremely serious complication of HME. Neurosurgical approach should be recommended in order to achieve a spinal cord decompression, which usually results in excellent functional recovery.

Meningioma da região do forame magno / Foramen Magnum Meningiomas

Meningiomas do forame magno estão entre os tumores maisdifíceis de serem removidos. A abordagem cirúrgica, assimcomo a extensão da remoção óssea, são pontos de controvérsia.Neste trabalho os autores apresentam sua experiência com otratamento cirúrgico destes tumores, a forma de abordá-los,baseada na expansão tumoral e no local de origem são ospontos fundamentais que norteiam o planejamento cirúrgico. Asmanifestações clínicas, assim como a morbidade mais comumrelacionada com estes tumores serão apresentadas.

Bilateral putaminal hemorrhage related to methanol poisoning. A complication of hemodialysis?: case report

Um caso de intoxicaçäo aguda por metanol é relatado, no qual o paciente desenvolveu hemorragia putaminal bilateral após hemodiálise. Muito embora o paciente se encontrasse incialmente comatoso e profundamente acidótico, a recuperaçäo foi favorável, com comprometimento neurológico a longo prazo essencialmente restrito a paraparesia crural discreta, amnésia retrógrada e déficit visual acentuado. Uma revisäo comparativa da literatura é avaliada