Clipping of Bilateral Ophthalmic Artery Aneurysms Through a Single Craniotomy.

Bilateral ophthalmic aneurysms are rare and involve two aneurysms in the ophthalmic arteries, one on each, leading to potential symptoms such as vision loss and headaches. The treatment options for aneurysms, ranging from surgery and endovascular embolization to observation, depend on various factors, including aneurysm size and the patient's health. Microsurgery, while presenting complexities due to the intricate anatomy of the anterior clinoid region, offers potential advantages such as enhanced decompression rates and reduced aneurysm recurrence. The presented surgical video illustrates the treatment of bilateral ophthalmic artery aneurysms via a single craniotomy. This method reduces surgical duration and trauma, facilitating quicker patient recovery. However, this method bears potential risks, especially to both optic nerves. As underscored in the video, the utmost anatomical understanding in the anterior clinoid area is pivotal for successful outcomes and reduced complications.

Spinal Adhesive Arachnoiditis: A Literature Review.

Adhesive arachnoiditis (AA) is a rare inflammatory and scar-forming disease with several etiologies that may lead to incapacitating sequelae if not managed early. Nevertheless, as the onset of symptoms varies from days to years, the etiology is not often discovered. The disease is characterized by adhesions disrupting the cerebrospinal fluid flow and causing encapsulation and atrophy of the nerve root. Therefore, a range of clinical features may be present, including urinary, gastroenterology, dermatologic, and neurologic. In terms of diagnosis, magnetic resonance imaging is the gold standard showing pseudocysts with adherent and narrow nerve roots toward the center of the dural sac or peripherally cluster and narrow nerve roots with empty thecal sac. Despite its sensitivity and specificity, the imaging findings are not often associated with clinical manifestations, requiring treatment being based on anamneses and clinical findings. Nowadays, AA can be managed with pharmacological and non-pharmacological treatment, although none provides a completely satisfying result.

A Giant Internal Carotid Bifurcation Aneurysm as a Rare and Dangerous Differential Diagnosis of a Craniopharyngioma.

Craniopharyngiomas are supra/parasellar lesions that often present with general, unspecific symptoms. Similarly, internal carotid artery (ICA) bifurcation giant aneurysms may also produce calcified, heterogeneous, parasellar expansive lesions, posing a relevant differential diagnosis due to their inherently different surgical strategies and risks. We report the case of a 54-year-old female presenting with progressive disorientation and apathetic behavior. CT and MRI reports described a suprasellar heterogenous mass with calcifications associated with an adjacent, laterally located fluid collection suggestive of a craniopharyngioma. During the surgical procedure, perfuse and unexplained arterial bleeding ensued, prompting the surgical team to review a previous contrast-enhanced CT scan. Careful inspection revealed an image suggestive of vascular pathology, with an area of continuous hyperdensity along the right ICA bifurcation. The Sylvian fissure was dissected, and an aneurysmal neck was encountered and successfully clipped. Giant intracranial aneurysms are rare but essential differential diagnoses to be considered during the workup and surgical approach toward parasellar mass lesions. This case illustrates the importance of performing a CT angiogram (CTA) for skull base lesions, even when the size is more suggestive of tumor pathology.

E.L., a modern-day Phineas Gage: Revisiting frontal lobe injury.

Background: How the prefrontal cortex (PFC) recovers its functionality following lesions remains a conundrum. Recent work has uncovered the importance of transient low-frequency oscillatory activity (LFO; < 4 Hz) for the recovery of an injured brain. We aimed to determine whether persistent cortical oscillatory dynamics contribute to brain capability to support 'normal life' following injury. Methods: In this 9-year prospective longitudinal study (08/2012-2021), we collected data from the patient E.L., a modern-day Phineas Gage, who suffered from lesions, impacting 11% of his total brain mass, to his right PFC and supplementary motor area after his skull was transfixed by an iron rod. A systematic evaluation of clinical, electrophysiologic, brain imaging, neuropsychological and behavioural testing were used to clarify the clinical significance of relationship between LFO discharge and executive dysfunctions and compare E.L.´s disorders to that attributed to Gage (1848), a landmark in the history of neurology and neuroscience. Findings: Selective recruitment of the non-injured left hemisphere during execution of unimanual right-hand movements resulted in the emergence of robust LFO, an EEG-detected marker for disconnection of brain areas, in the damaged right hemisphere. In contrast, recruitment of the damaged right hemisphere during contralateral hand movement, resulted in the co-activation of the left hemisphere and decreased right hemisphere LFO to levels of controls enabling performance, suggesting a target for neuromodulation. Similarly, transcranial magnetic stimulation (TMS), used to create a temporary virtual-lesion over E.L.'s healthy hemisphere, disrupted the modulation of contralateral LFO, disturbing behaviour and impairing executive function tasks. In contrast to Gage, reasoning, planning, working memory, social, sexual and family behaviours eluded clinical inspection by decreasing LFO in the delta frequency range during motor and executive functioning. Interpretation: Our study suggests that modulation of LFO dynamics is an important mechanism by which PFC accommodates neurological injuries, supporting the reports of Gage´s recovery, and represents an attractive target for therapeutic interventions. Funding: Fundação de Amparo Pesquisa Rio de Janeiro (FAPERJ), Universidade Federal do Rio de Janeiro (intramural), and Fiocruz/Ministery of Health (INOVA Fiocruz).

Undiagnosed Sturge-Weber Syndrome as a Differential Diagnosis of Seizures and Deep Cerebral Venous System Dilation: A Case Report.

Sturge-Weber syndrome (SWS) is a capillary-venous malformation affecting the brain, the eye, and the adjacent trigeminal dermatomes of the skin. This illness is usually diagnosed during the first years of life. If left undiagnosed (and consequently untreated), the condition could develop into severe refractory seizures, ischemic strokes, visual loss, and early cognitive impairment. We report a case of a 23-year-old female patient with a port-wine facial stain, presenting her first convulsive episode in adulthood, associated with a moderate dilation of the deep venous system in the angiography, which raised the diagnostic of Sturge-Weber syndrome.

The Fluorescent Patient: An Unusual Effect of Fluorescein Angiography.

Although fluorescein is widely used for intraoperative angiography, some of its side effects remain obscure. In this report, we present the case of a 41-year-old patient with chronic ischemia caused by moyamoya syndrome who underwent bypass revascularization with intraoperative fluorescein angiography (FA). Immediately after the surgery, the patient presented homogeneous fluorescence of the entire skin. We discuss this curious phenomenon as well as other side effects that may arise due to FA.

Should kyphoplasty curettes be used in nonosteoporotic patients? A cautionary tale.

The authors present the first report of a fracture of the tip of a kyphoplasty curette inside the vertebral body, which occurred during a procedure in a patient with non-osteoporotic fracture. This highlights the need of further biomechanical research focused on the shear load failure properties of such type of pre-bent curettes.

Neuronavigation as a minimally invasive tool in the treatment of intracranial gunshot injuries.

Gunshot injury is the most common cause of penetrating brain injury. The in-hospital mortality for civilians with penetrating craniocerebral injury is 52-95%. There are many surgical techniques suitable for the treatment of survivors. We report a surgical technique consisting of neuronavigation guidance for wound treatment with smaller incisions and craniotomies, followed by bullet removal if feasible. We report case of a 15 year old male patient who sustained an accidental firearm injury to the occipital region, submitted to surgical treatment that consisted in a minimally invasive approach guided by neuronavigation. Immediate neurological examination showed inferior homonymous quadrantanopsia alone as a clinical finding. Patient was discharged after one week, and no complications arised in follow-up. We conclude that using neuronavigation as a tool was effective in the reported case and that minimally invasive neurosurgical techniques may be a safe and efficient option for the treatment of traumatic brain injuries caused by firearm projectiles.

Development of a New Coupled Cobb-Suction Instrument for Posterior Spinal Approaches: Technical Note.

BACKGROUND: During dissection of paraspinal muscles in posterior surgical approaches, the spine surgeon usually holds a subperiosteal (Cobb) elevator in 1 hand and a monopolar cautery in the other hand. In such a scenario, both the surgical smoke generated by the monopolar and eventual bleeding constitute a significant hindrance to simultaneous bilateral dissection of the paraspinal muscles by 2 surgeons. METHODS: To address the identified shortcomings in the currently available instrumentation, we initially analyzed the most common surgical techniques employed by residents and fellows at our institution for paraspinal muscle dissection during posterior spinal approaches. Additionally, we collected trainees' feedback regarding the efficacy of available strategies for dealing with surgical smoke. RESULTS: A new coupled Cobb elevator-suction instrument was designed, manufactured, and tested by residents, fellows, and experienced spine surgeons, and small additional design modifications were performed. CONCLUSIONS: We present what we believe is the first description of a new coupled Cobb-suction instrument that has been developed to enable simultaneous retraction and suction with 1 hand, while allowing the spine surgeon to use the monopolar cautery with the other hand. In our preliminary institutional experience, this new tool has been proven to be especially useful in long posterior spinal approaches in the thoracolumbar region.