Microsurgical Treatment of Ruptured Spetzler-Martin Grade 3 Right Hippocampal Arteriovenous Malformation: 3-Dimensional Operative Video.

We present a 14-yr-old male with a history of traumatic brain injury in March 2016, secondary to clonic tonic generalized seizures. CT scan showed hemorrhage at mesial temporal region in the body of right hippocampus, intraventricular hemorrhage at the level of lateral ventricles (right and left side) and fourth ventricle. After this the patient presented with pulsating right temporal headache of high intensity (VAS 10/10) that improved with common analgesics, dizziness, and clonic tonic generalized seizures despite taking Phenobarbital 100 mg/24 h. Neuropsychological assessment reveal major deficits regarding executive functions: working memory, verbal fluency, and planning abilities. Brain MRI and angiography showed AVM at the right level of hippocampus body. An intranidal aneurysm was also observed. Venous drainage was through the basal vein of Rosenthal. We planned for surgery and resection of the hippocampal AVM through the trans-T2 approach. Postoperatively, the patient was without medical complications. We present a 3-dimensional video of the microsurgical treatment for right hippocampal AVM performed through a trans-T2 approach. The patient signed the Institutional Consent Form, which allows the use of his/her images and videos for any type of medical publications in conferences and/or scientific articles.

Reproducibility of a new classification of the anterior clinoid process of the sphenoid bone.

BACKGROUND: Pneumatization of the anterior clinoid process (ACP) affects paraclinoid region surgery, this anatomical variation occurs in 6.6-27.7% of individuals, making its preoperative recognition essential given the need for correction based on the anatomy of the pneumatized process. This study was conducted to evaluate the reproducibility of an optic strut-based ACP pneumatization classification by presenting radiological examinations to a group of surgeons. METHODS: Thirty cranial computer tomography (CT) scans performed from 2013 to 2014 were selected for analysis by neurosurgery residents and neurosurgeons. The evaluators received Google Forms with questionnaires on each scan, DICOM files to be manipulated in the Horos software for multiplanar reconstruction, and a collection of slides demonstrating the steps for classifying each type of ACP pneumatization. Interobserver agreement was calculated by the Fleiss kappa test. RESULTS: Thirty CT scans were analyzed by 37 evaluators, of whom 20 were neurosurgery residents and 17 were neurosurgeons. The overall reproducibility of the ACP pneumatization classification showed a Fleiss kappa index of 0.49 (95% confidence interval: 0.49-0.50). The interobserver agreement indices for the residents and neurosurgeons were 0.52 (0.51-0.53) and 0.49 (0.48-0.50), respectively, and the difference was statistically significant (P < 0.00001). CONCLUSION: The optic strut-based classification of ACP pneumatization showed acceptable concordance. Minor differences were observed in the agreement between the residents and neurosurgeons. These differences could be explained by the residents' presumably higher familiarity with multiplanar reconstruction software.

Microsurgical Clip Placement for a Giant Anterior Communicating Artery Aneurysm With Intraluminal Thrombus: 2-Dimensional Operative Video.

Giant brain aneurysms account for approximately 5% of all intracranial aneurysms. Although treatment modalities can vary widely, none is ideal for every patient. Endovascular treatment is usually preferred, especially when the large size of the aneurysm limits visualization of the brain parenchyma and parent vessels that arise from the aneurysm, making surgical clip placement across the neck a difficult task. However, despite the higher chances of morbidity, microsurgery is an effective treatment modality due to lower recurrence rates. Surgically, a wide neck, calcifications, or atheroma are complicating factors to be considered while planning the best treatment. Thus, with an appropriate case selection, a favorable outcome is feasible in most cases. Here, we present the case of a 27-yr-old female who presented with a severe headache for 7 mo and 3 mo of progressive left temporal vision loss, which was confirmed by visual field perimetry using the Humphrey visual field analyzer. Magnetic resonance angiography and digital subtraction cerebral angiography showed an anterior communicating artery complex inferiorly and medially oriented aneurysm measuring 25.4 × 16.5 mm, with a 3 mm neck. It was fed by the right A1, associated with a hypoplastic left A1, incorporating the proximal right and left A2 segments, with an intraluminal thrombus and causing mass effect on the optic chiasm and hypothalamus. This video demonstrates the microsurgical steps required to perform this operation, through a right orbitozygomatic craniotomy. At a 3-mo follow-up, the patient was neurological intact without complaints. The patient signed the Institutional Consent Form, which allows the use of his/her images and videos for any type of medical publications in conferences and/or scientific articles.

Transtentorial Approach for Parahippocampal Gyrus Arteriovenous Malformation Resection: 3-Dimensional Operative Video.

Medial temporal basal arteriovenous malformations (AVMs) have complex anatomy. They usually drain to the basal vein of Rosenthal, and arterial feeders can arise from the anterior choroidal artery and its branches, or from the posterior cerebral artery. If the AVM is more posterior in the parahippocampal gyrus, there is a predominance of arterial feeders arising from P2P or P3 segments of the posterior cerebral artery. As posterior AVMs are difficult to reach using anterior approaches, the supracerebellar transtentorial approach provides a direct pathway to the malformation, allowing better visualization and exposure of the vascular anatomy. In this video, we present a 29-yr-old woman with a left parahippocampal AVM with P2P arterial feeders and Rosenthal basal vein drainage. The patient had three months of moderate headache and two abrupt seizures before admission. Emergency computed tomography showed intraventricular hemorrhage. Magnetic resonance imaging and cerebral angiography revealed an AVM located in the parahippocampal gyrus, posterior to pulvinar thalamus. The patient underwent microsurgical treatment in semi-sitting position using a supracerebellar and infratentorial approach with transtentorial resection. The AVM was completely removed, and the patient recovered without neurological deficits. The authors present a 3-dimensional video of the microsurgical steps required to perform a transtentorial approach for AVM resection in the parahippocampal gyrus. The patient signed the Institutional Consent Form, which allows the use of his/her images and videos for any type of medical publications in conferences and/or scientific articles.

Microsurgery for Upper Basilar Tip Aneurysm With Intraoperative Rupture: 3-Dimensional Operative Video.

In the last years, a shift from the microsurgical treatment to an endovascular therapy in patients with basilar apex aneurysm has been settled, part of this phenomenon is related to the significant tendency of vital perforators to be involved in the aneurysm dissection and clipping, which can implicate unfavorable outcomes. Nevertheless, microsurgical treatment remains the treatment that can provide the superior rates of stable and durable aneurysm occlusion, which is most important to young patients.In this video, we present the case of a 45-yr-old female patient who complained of a sudden and severe headache and presented with progressive lethargy during the following 3 d.At admission, computed tomography did not show abnormal findings. However, cerebrospinal fluid analysis showed erythrocytes and corroborated the clinical suspicion of spontaneous subarachnoid hemorrhage. The patient signed the Institutional Consent Form, which allows the use of his/her images and videos for any type of medical publications in conferences and/or scientific articles.Angiography and magnetic resonance imaging revealed a saccular basilar apex aneurysm. It showed a wide neck as well as a lobulated dome with upward and slightly left projection. The aneurysm did not involve angiographically visible thalamoperforator arteries, which allowed the microsurgical treatment by the fronto-orbitozygomatic approach. However, during the interpeduncular cistern dissection, an intraoperative rupture of the aneurysm occurred. This video exemplifies the steps required to manage an intraoperative rupture of a basilar apex aneurysm.

Trombose do seio dural em idade pediátrica / Dural sinus thrombosis in pediatric age

A trombose do seio dural é uma situação clínica rara, que resulta normalmente da complicação de processos infecciosos dos seios perinasais. Os sintomas e sinais são extremamente variados e inespecíficos sendo o diagnóstico feito através da ressonância magnética nuclear. Esse trabalho relata a ocorrência de trombose do seio dural em um paciente com idade pediátrica. Paciente com 10 anos de idade, sexo masculino, foi enviado ao serviço de urgência devido à diplopia e endotropia no olho esquerdo. No exame oftalmológico foi detectado papiledema bilateral, diplopia binocular e endotropia do olho esquerdo. Apresentava acuidade visual de 10/10 bilateralmente. Diante da suspeita de lesão ocupando espaço do sistema nervoso central, foi realizada ressonância magnética nuclear que confirmou o diagnóstico de TSD. Para avaliar a pressão intracraniana foi efetuada uma punção lombar com manometria, e esta demonstrou uma pressão intracraniana de 20mmHg (normal: <15mmHg). Perante isto a criança ficou internada para tratamento médico (enoxaparina de baixo peso molecular 1,5 mg/kg/dia subcutâneo (60 mg/dia), prednisolona 35 mg/dia oral e acetazolamida 250 mg/dia oral) durante 10 dias. Após 1 mês de follow-up verificou-se agravamento oftalmológico. A realização de nova punção lombar apresentou uma pressão intracraniana de 40 mmHg que não cedia ao tratamento médico. Após discussão multidisciplinar do caso optou-se pela realização de derivação lombo-peritoneal. A necessidade de uma grande dose de suspeição clínica, tanto para o diagnóstico inicial quanto para a monitorização das complicações, tornam a abordagem da trombose do seio dural um processo singular.

Dural sinus thrombosis is a rare condition, usually results from a late complication of an infection of the paranasal sinuses. The signs and symptoms are extremely varied and nonspecific, being the diagnosis made through magnetic resonance imaging. Ten-year-old male patient that was sent to our emergency department with left endotropia and diplopia. Ophthalmic examination was performed and showed papilledema with margin blurred right and left eye, binocular diplopia and left eye endotropia. Visual acuity was 10/10 bilaterally. Given the suspected space occupying lesion of the central nervous system, the MRI was performed and confirmed the diagnosis of DST. For evaluating the intracranial pressure (IP), a lombar puncture (LP) with manometry was carried out and revealed IP of 20 mmHg (normal values: <15mmHg). Towards this, the child’s was admitted for medical treatment (low molecular weight enoxaparin subcutaneous 1,5 mg/kg/day (60 mg/day), prednisolone 35 mg/per day and acetazolamide 250 mg/per day) over 10 days. After 1 month of follow-up there was deterioration of the ophthalmologic condition. A new LP was made and showed IP of 40 mmHg resilient to medical treatment. After multidisciplinary discussion of the case, it was decided for conducting lumboperitoneal shunt. The need for a great deal of suspicion for both the initial diagnosis and for monitoring complications make DST approach a special process.

Tersons syndrome: neurosurgical considerations on the subject of a rare case with ophthalmological sequelae / Síndrome de Terson: considerações neurocirúrgicas a propósito de um raro caso com sequelas oftalmológicas

According to prospective studies, vitreous hemorrhage may be diagnosed in 8%-27% of the patients with aneurysmal subarachnoid hemorrhage (SAH) (Terson?s syndrome) and has been associated with a bad neurological outcome. In spite of its incidence and prognostic value, vitreous hemorrhage is underdiagnosed. We describe the case of a 48 year-old woman who was diagnosed with a SAH due to the rupture of an aneurysm of the right middle cerebral artery bifurcation that was surgically treated with minimal neurological morbidity. However, due to vitreous hemorrhage in the right eye, the patient developed visual loss that did not recovered after proper surgical treatment. In the context of the present case we take a timely review of the literature, discussing the incidence, pathophysiology, treatment and prognosis of Terson?s syndrome. The reported case stresses that the natural history of Terson?s syndrome is not always synonymous with good outcome. Significant visual sequelae due to vitreous hemorrhage are very rare after proper conservative or surgical treatment. The severe visual loss of this patient emphasizes the need for a systematic, early and serial ophthalmological evaluation of all patients with aneurysmal SAH...

De acordo com estudos prospectivos, a hemorragia do vítreo pode ser diagnosticada em 8%-27% dos doentes com hemorragia subaracnóidea aneurismática (síndrome de Terson) e foi associada a mau prognóstico neurológico. Apesar da sua incidência e valor prognóstico, a hemorragia do vítreo é subdiagnosticada. Os autores descrevem o caso de uma doente de 48 anos, diagnosticada com hemorragia subaracnóidea por rotura de um aneurisma da bifurcação da artéria cerebral média direita, que foi tratado cirurgicamente com mínima morbilidade neurológica. Contudo, por causa da hemorragia do vítreo do olho direito, a doente desenvolveu perda de visão, que não recuperou após tratamento adequado. No contexto do presente caso, revimos a literatura e discutimos a incidência, a fisiopatologia, o diagnóstico e o prognóstico da síndrome de Terson. O caso descrito enfatiza que a história natural da síndrome de Terson não é necessariamente sinônimo de boa evolução. Sequelas visuais significativas após hemorragia do vítreo são muito raras após tratamento conservador ou cirúrgico. A importante perda de visão dessa doente enfatiza a necessidade de avaliação oftalmológica sistemática, precoce e seriada de todos os doentes com hemorragia subaracnóidea aneurismática...