Albert L. Rhoton Jr., MD: His Philosophy and Education of Neurosurgeons.

Dr. Rhoton's key philosophies included "Keep working hard.", "Make surgery more accurate, gentle and safe", "We want perfect anatomical dissections, because we want perfect surgical operations", "Competence without compassion is worthless. Compassion without competence is meaningless", "Neurosurgeons share a great professional gift; our lives have yielded an opportunity to help mankind in a unique and exciting way" and "There is no finish line for this effort". His words reveal his passion for microneurosurgery and infinite love for humankind. Although his reknown rested on his reputation as a researcher, Dr. Rhoton was also a devoted educator. The principal aim behind the enormous amount of work he performed was that of educating neurosurgeons worldwide, so that they could be better surgeons. His work included: (1) numerous dissection courses, (2) numerous lectures and publications including about 160 original papers (3) the textbook "RHOTON" and Rhoton Collection (4) the education of 119 research fellows. The projects directed in his lab, produced the international dissemination of neuroanatomical knowledge. The ultimate goal of his microsurgical research was to improve the care of patients with neurosurgical diseases around the world. The technical contributions and humble character of Dr. Rhoton should be remembered as we care for patients.

Head positioning for anterior circulation aneurysms microsurgery.

OBJECTIVE: To study the ideal patient's head positioning for the anterior circulation aneurysms microsurgery. METHOD: We divided the study in two parts. Firstly, 10 fresh cadaveric heads were positioned and dissected in order to ideally expose the anterior circulation aneurysm sites. Afterwards, 110 patients were submitted to anterior circulation aneurysms microsurgery. During the surgery, the patient's head was positioned accordingly to the aneurysm location and the results from the cadaveric study. The effectiveness of the position was noted. RESULTS: We could determine mainly two patterns for head positioning for the anterior circulation aneurysms. CONCLUSION: The best surgical exposure is related to specific head positions. The proper angle of microscopic view may minimize neurovascular injury and brain retraction.

Head positioning for anterior circulation aneurysms microsurgery / Posicionamento da cabeça para microcirurgias de aneurismas da circulação anterior

Objective To study the ideal patient's head positioning for the anterior circulation aneurysms microsurgery. Method We divided the study in two parts. Firstly, 10 fresh cadaveric heads were positioned and dissected in order to ideally expose the anterior circulation aneurysm sites. Afterwards, 110 patients were submitted to anterior circulation aneurysms microsurgery. During the surgery, the patient's head was positioned accordingly to the aneurysm location and the results from the cadaveric study. The effectiveness of the position was noted. Results We could determine mainly two patterns for head positioning for the anterior circulation aneurysms. Conclusion The best surgical exposure is related to specific head positions. The proper angle of microscopic view may minimize neurovascular injury and brain retraction. .

Objetivo Estudar o posicionamento da cabeça para a cirurgia de aneurismas cerebrais da circulação anterior. Método Dividimos o estudo em duas partes. Inicialmente, dez cabeças de cadáveres frescos foram posicionadas e dissecadas de modo a expor, de maneira ideal, os principais sítios de aneurismas na circulação anterior do cérebro. Posteriormente, 110 pacientes foram submetidos a microcirurgia para clipagem de aneurismas cerebrais da circulação anterior. Durante as cirurgias, as cabeças foram posicionadas de acordo com a localização específica de cada aneurisma e o resultado obtido no estudo dos cadáveres. Cada paciente teve sua posição avaliada quanto a sua eficácia. Resultados Obtivemos basicamente dois padrões de posicionamento da cabeça para cirurgias de aneurismas cerebrais da circulação anterior. Conclusão A melhor exposição cirúrgica está relacionada à posição específica da cabeça para cada localização aneurismática. O ângulo de visão microscópica adequado minimiza lesões neurovasculares e a excessiva retração cerebral. .

The far-lateral craniotomy: tips and tricks.

This article intends to describe in a didactical and practical manner the suboccipital far-lateral craniotomy. This is then basically a descriptive text, divided according to the main stages involved in this procedure, and that describes with details how the authors currently perform this craniotomy.

The far-lateral craniotomy: tips and tricks / A craniotomia extremo-lateral: dicas e truques

This article intends to describe in a didactical and practical manner the suboccipital far-lateral craniotomy. This is then basically a descriptive text, divided according to the main stages involved in this procedure, and that describes with details how the authors currently perform this craniotomy.

O presente artigo visa descrever de forma didática e prática a realização da craniotomia suboccipital extremo-lateral. Trata-se, portanto, de um texto fundamentalmente descritivo, dividido conforme as principais etapas da realização dessa craniotomia, e que descreve com detalhes a técnica com que o presente grupo de autores evolutivamente veio a realizá-la.

Nuevo reparo anatómico para la identificación del núcleo dentado en el abordaje suboccipital / New anatomical repair for the identification of the tooth nucleus in the suboccipital approach

Introducción: El abordaje suboccipital constituye una de las vías de acceso más frecuentes a la fosa posterior. Objetivo: La finalidad del presente estudio es definir un reparo anatómico reproducible en la superficie suboccipital del cerebelo que permita ayudar a localizar el núcleo dentado (ND) del mismo. Material y Métodos: Quince cerebelos de adulto fueron estudiados, previa fijación con formol y congelación. Se realizaron cortes axiales y sagitales, con medición de las relaciones entre la fisura horizontal (FH) y el ND. Resultados: La proyección en profundidad de la FH permitió identificar el núcleo dentado en casi todos ellos. Conclusión: La identificación del ND en la cirugía a partir de la FH puede ser considerada un método rápido y confiable. Su utilización pre y perioperatoria podría disminuir las complicaciones derivadas de la lesión de dicho núcleo cerebeloso.

Introduction: The suboccipital approach is one of the most common surgical routes to the posterior fossa.Purpose: The aim of this study was to define a reproductible anatomic landmark in the suboccipital surface of the cerebellum, allowing to localize the dentate nucleus (DN).Material and methods: Fifteen cadaveric specimens (adult brains) were studied, previously fixed with formaldehyde and frozen. Sagittal and axial cuts were performed in the specimens, measuring the relationships between the horizontal fissure (HF) of the cerebellum and the DN.Results: The projection in depth of the HF allowed to identify the DN in almost all of them.Conclusion: The identification during surgery of the DN using the HF maybe a safe and quick method and its usage pre and intraoperatively can lower complications related to lesions of the DN.

Axis instrumentation: surgical results.

OBJECTIVE: Evaluate the surgical results of axis screw instrumentation. METHODS: Retrospective evaluation of the clinical and radiological data of patients submitted to axis fixation using screws. RESULTS: Seventeen patients were surgically treated. The mean age was 41.8 years (range: 12-73). Spinal cord trauma was the most common cause of instability (8 patients - 47%). Bilateral axis fixation was performed in all cases, except one, with laminar screw (total of 33 axis screws). Seven patients (41.1%) underwent bilateral pars screws; laminar screws were used in six cases and pedicular screws were used in two. In two cases, we performed a hybrid construction (laminar + pars and pedicle + pars). There was no neurological worsening or death, nor complications directly related to use axis screws. CONCLUSION: Axis instrumentation was effective and safe, regardless of the technique used for stabilization. Based on our learnt experience, we proposed an algorithm to choose the best technique for axis screw fixation.

Axis instrumentation: surgical results / Instrumentação do áxis: resultados cirúrgicos

OBJECTIVE: Evaluate the surgical results of axis screw instrumentation. METHODS: Retrospective evaluation of the clinical and radiological data of patients submitted to axis fixation using screws. RESULTS: Seventeen patients were surgically treated. The mean age was 41.8 years (range: 12-73). Spinal cord trauma was the most common cause of instability (8 patients - 47%). Bilateral axis fixation was performed in all cases, except one, with laminar screw (total of 33 axis screws). Seven patients (41.1%) underwent bilateral pars screws; laminar screws were used in six cases and pedicular screws were used in two. In two cases, we performed a hybrid construction (laminar + pars and pedicle + pars). There was no neurological worsening or death, nor complications directly related to use axis screws. CONCLUSION: Axis instrumentation was effective and safe, regardless of the technique used for stabilization. Based on our learnt experience, we proposed an algorithm to choose the best technique for axis screw fixation.

OBJETIVO: Avaliar os resultados cirúrgicos da instrumentação com parafusos do áxis. MÉTODOS: Avaliação retrospectiva de dados clínicos e radiológicos de pacientes submetidos à instrumentação com parafusos do áxis. RESULTADOS: Dezessete pacientes foram tratados cirurgicamente. A média de idade foi de 41,8 anos (faixa: 12-73 anos). Trauma na coluna foi a causa mais comum de instabilidade (8 casos - 47%). Fixação bilateral do áxis foi realizada em todos os casos, exceto em um, com parafuso de lâmina (total de 33 parafusos). Em sete pacientes (41,1%), foram usados parafusos de pars; em seis, parafusos de lâmina; e em dois, de pedículos. Em dois casos, foi utilizada uma combinação de técnicas (pars + lâmina e pars + pedículo). Não houve piora neurológica nem complicações diretas em decorrência do uso dos parafusos. CONCLUSÃO: A instrumentação do áxis foi eficaz e segura independentemente da técnica escolhida para estabilização. Com base em nossa experiência, foi proposto um algoritmo para auxílio na escolha da melhor técnica a ser empregada.

Decompressive craniectomy in massive cerebral infarction.

Twenty one patients were submitted to decompressive craniectomy for massive cerebral infarct. Ten patients (47.6%) presented a good outcome at the 6 months evaluation, eight had a poor outcome (38%) and three died (14.2%). There was no outcome statistical difference between surgery before and after 24 hours of ictus, dominant and non-dominant stroke groups. Patients older than 60 years and those who had a Glasgow Coma Scale (GCS)<8 in the pre-surgical exam presented worst outcome at six months (p<0.05). Decompressive craniectomy for space-occupying large hemispheric infarction increases the probability of survival. Age lower than 60 years, GCS >8 at pre-surgical exam and decompressive craniectomy before signs of brain herniation represent the main factors related to a better outcome. Dominant hemispheric infarction does not represent exclusion criteria.

Decompressive craniectomy in massive cerebral infarction / Craniectomia descompressiva no infarto cerebral extenso

Twenty one patients were submitted to decompressive craniectomy for massive cerebral infarct. Ten patients (47.6 percent) presented a good outcome at the 6 months evaluation, eight had a poor outcome (38 percent) and three died (14.2 percent). There was no outcome statistical difference between surgery before and after 24 hours of ictus, dominant and non-dominant stroke groups. Patients older than 60 years and those who had a Glasgow Coma Scale (GCS)<8 in the pre-surgical exam presented worst outcome at six months (p<0.05). Decompressive craniectomy for space-occupying large hemispheric infarction increases the probability of survival. Age lower than 60 years, GCS >8 at pre-surgical exam and decompressive craniectomy before signs of brain herniation represent the main factors related to a better outcome. Dominant hemispheric infarction does not represent exclusion criteria.

Vinte e um pacientes foram submetidos a craniectomia descompressiva para o tratamento de infarto cerebral extenso. Dez pacientes (47,6 por cento) apresentaram boa evolução em avaliação após 6 meses, 8 apresentaram evolução desfavorável (38 por cento) e 3 faleceram (14,2 por cento). Durante o seguimento, não se evidenciou diferença estatística na evolução entre pacientes operados antes e após 24 horas do ictus, nem entre lesões envolvendo o hemisfério dominante versus não dominante. Pacientes com mais de 60 anos e aqueles com Escala de Coma de Glasgow (ECG)<8 na avaliação pré-operatória apresentaram pior evolução após 6 meses (p<0,05). A craniectomia descompressiva para infartos hemisféricos extensos aumentam a probabilidade de sobrevivência. Idade abaixo de 60 anos e ECG >8 no exame pré-operatório e craniectomia descompressiva antes de sinais de herniação cerebral representam os principais fatores relacionados a uma melhor evolução clínica. Infarto hemisférico envolvendo o hemisfério dominante não representa um critério de exclusão.

Regeneração de atrofia de substância branca após a cirurgia de epilesia: evidências estruturais através da morfometria baseada em voxel / Recovery of white matter atrophy after epilepsy surgery: structural evidences through voxel-based morphometry

OBJECTIVES: To study pre and postoperative WMA in MTLE patients. METHODS: We performed Voxel-Based Morphometry (VBM) with volume of interest (VOI) in 69 controls (mean age, 34.3±11.1 years) and 67 operated patients (mean age, 34.1±10.4 years) with unilateral MTLE. 34 became seizure-free (SzFree-Group), 23 improved (Engel IB-IIA [Partial recovery-group]) and 10 did not improve (Engel III-IV [Failure-Group]). All had pre and postoperative MRIs (one year minimum). We flipped MRIs of right MTLE patients in order to avoid right-to-left analysis cancelation. VBM was performed on SPM2/MATLAB7.0 with individual masks for surgical lacunae and 1 percent false-discovery-rate to control for multiple comparisons. We used MARSbar routine to select ROIs and t-test for statistical analyses. RESULTS: Mean postoperative follow-up was 60.2 (±SD 30.7) months. On baseline MRI, SzFree-Group showed White Matter Atrophy (WMA) involving temporal lobes [TL], ipsilateral occipital, parietal and frontal regions, with areas of significant recovery of WMA on postoperative MRI. Partial recovery-Group presented a more restricted pattern of WMA, involving ipsilateral temporal lobe, contralateral superior temporal gyrus and few areas in bilateral cingulated and orbitofrontal areas. In this group we also identified areas with relative increase of WM after surgery. By contrast, Failure-Group showed more widespread bi-hemispheric areas of WMA on baseline MRI without postoperative improvement. CONCLUSIONS: Although we have identified some differences in baseline WMA, we were unable to correlate a more widespread pattern with a worse prognosis, as SzFree-Group, also presented a bilateral distribution of WMA. The recovery of WMA in SzFree-Group and Partial recovery-group is in agreement with previous MRS and PET studies and suggests that a network of neuronal dysfunction in MTLE can be, at least in part, reversible after successful postoperative ...

Microsurgical approach of arteriovenous malformations in the central lobule / Abordagem microciúrgica para malformações arteriovenosas no lóbulo central

Arteriovenous malformations (AVM) are neurovascular disorders that occur mainly in young adults. Their clinical presentation is variable and depends on its location, size and occurrence of bleeding. They can represent incidental findings in neuro radiological exams. The treatment of these lesions when located in eloquent areas, namely around the central sulcus, is controversial, with different therapeutical approaches presented in the literature. We consider that surgical extirpation of many of these lesions is feasible in selected cases , when supported by profound anatomical knowledge and refined microsurgical technique, achieving cure with minimal aditional deficit. In the present article, we elaborate a surgical technique for the approach of AVMs located in the central sulcus, specially in finding the topographic lesion location and craniotomy.

Malformações arteriovenosas (MAV) são uma entidade patológica que ocorre mais frequentemente em adultos jovens. Sua manifestação clínica é variável e depende de sua localização, tamanho e ocorrência ou não de sangramento. Podem também ser diagnoticadas como achados incidentais em investigações neurorradiólogicas . O tratamento destas lesões, quando localizadas em áreas eloqüentes, em particular aquelas lesões localizadas próximas ao sulco central do cérebro, é controverso e diferentes abordagens terapêuticas são relatadas. Consideramos que a ressecção cirúrgica destas lesões é viável em casos selecionados, quando realizada sob profundo conhecimento anatômico e técnica microcirúrgica refinada, pois deste modo, as lesões podem ser curadas sem agregar morbidade ao paciente. No presente artigo, discutimos a técnica cirúrgica para MAVs localizadas nas adjacências do sulco central do cérebro, especialmente a localização topográfica da lesão e craniotomia.

Dissection technique for the study of the cerebral sulci, gyri and ventricles.

Neuroanatomy in addition to neurophysiology, are the basic areas for the proper formation from health students to specialized professionals in neuroscience. A step by step guide for practical studies of neuroanatomy is required for this kind of knowledge to become more acceptable among medical students, neurosurgeons, neurologists, neuropediatricians and psychiatric physicians. Based on the well known courses of sulci, gyri and ventricles offered by Beneficência Portuguesa Hospital in São Paulo, Brazil, two times a year, since 1994, totalizing more than 20 complete courses, and answering the request of many neuroscience students and professionals whose asked for a practical guide to the neuroanatomy study, the authors suggest a protocol for the study of superficial and deep brain structures showing how to approach the more structures as possible with minimum damage to the anatomic piece and with the smaller number of brains.

Dissection technique for the study of the cerebral sulci, gyri and ventricles / Técnica de dissecação para o estudo dos sulcos, giros e ventriculos cerebrais

Neuroanatomy in addition to neurophysiology, are the basic areas for the proper formation from health students to specialized professionals in neuroscience. A step by step guide for practical studies of neuroanatomy is required for this kind of knowledge to become more acceptable among medical students, neurosurgeons, neurologists, neuropediatricians and psychiatric physicians. Based on the well known courses of sulci, gyri and ventricles offered by Beneficência Portuguesa Hospital in São Paulo, Brazil, two times a year, since 1994, totalizing more than 20 complete courses, and answering the request of many neuroscience students and professionals whose asked for a practical guide to the neuroanatomy study, the authors suggest a protocol for the study of superficial and deep brain structures showing how to approach the more structures as possible with minimum damage to the anatomic piece and with the smaller number of brains.

Neuroanatomia e a neurofisiologia são as áreas básicas para a adequada formação desde estudantes na área da saúde a profissionais especializados em neurociências. Um guia prático, passo a passo, para o estudo de neuroanatomia é necessário para tornar esse conhecimento mais acessível entre estudantes de medicina, neurologistas, neurofisiologistas, neurocirurgiões, neuropediatras e psiquiatras. Baseados em cursos reconhecidos nacional e internacionalmente a respeito dos sulcos, giros e ventrículos cerebrais elaborados e realizados pelo Instituto de Ciências Neurológicas (ICNE) no Hospital de Beneficência Portuguesa de São Paulo, Brasil, duas vezes ao ano, totalizando mais de 20 cursos já realizados, os autores apresentam um protocolo de dissecação para o estudo das estruturas superficiais e profundas do encéfalo, mostrando como expor o máximo de estruturas com um mínimo de manipulação e dano à peça anatômica e utilizando o menor número de encéfalos possíveis.

Transfusion-related acute lung injury em pós-operatório de neurocirurgia: relato de caso / Transfusion-related acute lung injury after following neurosurgery: case report

JUSTIFICATIVA E OBJETIVOS: O Transfusion-Related Acute Lung Injury (TRALI), é definido como um edema pulmonar não cardiogênico, relacionado à transfusão de sangue ou derivados, evoluindo com necessidade de ventilação mecânica na grande maioria dos casos. O objetivo deste estudo foi apresentar um caso de TRALI em pós-operatório imediato de neurocirurgia. RELATO DO CASO: Paciente do sexo masculino, 69 anos, sem comprometimento pulmonar prévio, foi submetido à ressecção cirúrgica de glioblastoma multiforme, apresentando complicações intra-operatórias (broncoespasmo e diminuição da saturação de oxigênio), após ter recebido plasma fresco congelado, sendo diagnosticado TRALI. O paciente foi mantido sedado, sob ventilação mecânica e monitorização hemodinâmica invasiva, com melhora progressiva do quadro, recebendo alta da unidade de terapia intensiva (UTI) no 8º dia de pós-operatório. CONCLUSÕES: O TRALI deve ser investigado nos pacientes que recebem hemoderivados e apresentam alterações pulmonares.

BACKGROUND AND OBJECTIVES: The Transfusion-Related Acute Lung Injury (TRALI), is defined as noncardiogenic pulmonary edema temporally related to transfusion therapy, evolving with ventilation necessity mechanics in the great majority of the cases. This objective of this study was to present case of TRALI in the immediate postoperative of neurosurgery. CASE REPORT: We describe the case of a patient who presented broncoespasm and decreased oxygen saturation after to have received fresh-frozen plasma in the neurosurgery, who presented TRALI. The patient was submitted a invasive hemodynamic monitoring, sedation and supplemental oxygen with mechanical ventilation, with gradual improvement, leaving the intensive care unit in the eight day of postoperative. CONCLUSIONS: The TRALI must be investigated in the patients who receive transfusion therapy and present lung injury.