Pharmaceutical equivalent 5-aminolevulinic acid fluorescence guided resection of central nervous system tumors: feasibility, safeness and cost-benefit considerations.

PURPOSE: 5-aminolevulinic acid (5-ALA) fluorescence-guided resection (FGR) has been an essential tool in the 'standard of care' of malignant gliomas. Over the last two decades, its indications have been extended to other neoplasms, such as metastases and meningiomas. However, its availability and cost-benefit still pose a challenge for widespread use. The present article reports a retrospective series of 707 cases of central nervous system (CNS) tumors submitted to FGR with pharmacological equivalent 5-ALA and discusses financial implications, feasibility and safeness. METHODS: From December 2015 to February 2024, a retrospective single institution series of 707 cases of 5-ALA FGR were analyzed. Age, gender, 5-ALA dosage, intraoperative fluorescence finding, diagnosis and adverse effects were recorded. Financial impact in the surgical treatment cost were also reported. RESULTS: there was an additional cost estimated in $300 dollars for each case, increasing from 2,37 to 3,28% of the total hospitalization cost. There were 19 (2,69%) cases of asymptomatic photosensitive reaction and 2 (0,28%) cases of photosensitive reaction requiring symptomatic treatment. 1 (0,14%) patient had a cutaneous rash sustained for up to 10 days. No other complications related to the method were evident. In 3 (0,42%) cases of patients with intracranial hypertension, there was vomiting after administration. CONCLUSION: FGR with pharmacological equivalent 5-ALA can be considered safe and efficient and incorporates a small increase in hospital expenses. It constitutes a reliable solution in avoiding prohibitive costs worldwide, especially in countries where commercial 5-ALA is unavailable.

Association of 5-aminolevulinic acid fluorescence guided resection with photodynamic therapy in recurrent glioblastoma: a matched cohort study.

PURPOSE: Glioblastoma is a malignant and aggressive brain tumour that, although there have been improvements in the first line treatment, there is still no consensus regarding the best standard of care (SOC) upon its inevitable recurrence. There are novel adjuvant therapies that aim to improve local disease control. Nowadays, the association of intraoperative photodynamic therapy (PDT) immediately after a 5-aminolevulinic acid (5-ALA) fluorescence-guided resection (FGR) in malignant gliomas surgery has emerged as a potential and feasible strategy to increase the extent of safe resection and destroy residual tumour in the surgical cavity borders, respectively. OBJECTIVES: To assess the survival rates and safety of the association of intraoperative PDT with 5-ALA FGR, in comparison with a 5-ALA FGR alone, in patients with recurrent glioblastoma. METHODS: This article describes a matched-pair cohort study with two groups of patients submitted to 5-ALA FGR for recurrent glioblastoma. Group 1 was a prospective series of 11 consecutive cases submitted to 5-ALA FGR plus intraoperative PDT; group 2 was a historical series of 11 consecutive cases submitted to 5-ALA FGR alone. Age, sex, Karnofsky performance scale (KPS), 5-ALA post-resection status, T1-contrast-enhanced extent of resection (EOR), previous and post pathology, IDH (Isocitrate dehydrogenase), Ki67, previous and post treatment, brain magnetic resonance imaging (MRI) controls and surgical complications were documented. RESULTS: The Mantel-Cox test showed a significant difference between the survival rates (p = 0.008) of both groups. 4 postoperative complications occurred (36.6%) in each group. As of the last follow-up (January 2024), 7/11 patients in group 1, and 0/11 patients in group 2 were still alive. 6- and 12-months post-treatment, a survival proportion of 71,59% and 57,27% is expected in group 1, versus 45,45% and 9,09% in group 2, respectively. 6 months post-treatment, a progression free survival (PFS) of 61,36% and 18,18% is expected in group 1 and group 2, respectively. CONCLUSION: The association of PDT immediately after 5-ALA FGR for recurrent malignant glioma seems to be associated with better survival without additional or severe morbidity. Despite the need for larger, randomized series, the proposed treatment is a feasible and safe addition to the reoperation.

Dural Closure Training With Prototyped Model.

INTRODUCTION: The hermetic closure of the dura mater is a critical step in neurosurgical training, often undervalued but crucial to preventing serious complications such as cerebrospinal fluid (CSF) leaks leading to meningitis and death. Inadequate closure, often due to insufficient training, can result in challenging complications, including prolonged hospitalization and reoperation. OBJECTIVE: To address the deficiencies in dural closure training, this study aims to describe a 3D prototype for simulating post-craniotomy dura mater suturing. The objective is to reduce the incidence of CSF leaks and improve the training of neurosurgery residents. DESIGN: The study involves the creation of a 3D prototype based on magnetic resonance imaging and computed tomography scans. The additive manufacturing of structures is performed using ABS filament, and a silicone rubber membrane is used to simulate the meningeal dura mater. Neurosurgery residents undergo training using this model, and the effectiveness is evaluated. SETTING: The study is conducted at the Institute of Neurology of Curitiba (Hospital INC), focusing on neurosurgery residents from the first to fifth year of residency. PARTICIPANTS: Seven residents participate in the study, with varying levels of experience in dural closure procedures. The training involves a simulated surgical environment using the 3D prototype. RESULTS: After training, residents show improvements in confidence and theoretical knowledge related to dural closure. Binary questions indicate a strong desire for more practical training on dural closure, with 85.7% believing in the essential role of 3D molds in their neurosurgery training. CONCLUSION: The study highlights the importance of adequate training for dural closure to prevent serious complications in neurosurgery. The use of 3D simulation models, despite some limitations, proves to be an effective educational strategy. The emerging technology of bioprinting holds promise for further enhancing simulation materials, bringing medical education closer to realistic tissue replication.

Ki67 Index Correlates with Tumoral Volumetry and 5-ALA Residual Fluorescence in Glioblastoma.

BACKGROUND: Malignant gliomas are the most prevalent primary malignant cerebral tumors. Preoperative imaging plays an important role, and the prognosis is closely related to surgical resection and histomolecular aspects. Our goal was to correlate Ki67 indexes with tumoral volumetry in semiautomatic segmentation on preoperative magnetic resonance images and residual fluorescence in a 5-ALA-assisted resection cohort. METHODS: We included 86 IDH-wildtype glioblastoma patients with complete preoperative imaging submitted to 5-ALA assisted resections. Clinical, surgical, and histomolecular findings were also obtained. Preoperative magnetic resonance studies were preprocessed and segmented semiautomatically on Visualization and Analysis for whole tumor (WT) on 3D FLAIR, enhancing tumor (ET), and necrotic core on 3D postgadolinium T1. We performed a linear regression analysis for Ki67 and a multivariate analysis for surgical outcomes. RESULTS: Higher Ki-67 indexes correlated positively with higher WT (P = 0.048) and ET (P = 0.002). Lower Ki67 correlated with 5-ALA free margins (P = 0.045). WT and ET volumes correlated with the extent of resection (EOR; P = 0.002 and 0.002, respectively). Eloquence did not impact EOR (P = 0.14). CONCLUSIONS: There is a correlation between Ki67, the metabolically active tumoral volumes (WT and ET), and 5-ALA residual fluorescence. Methodological inconsistencies are probably responsible for contradictory literature findings, and further prospective studies are needed to validate and reproduce these findings.

Perfusion-weighted imaging in vestibular schwannoma: the influence that cystic status and tumor size have on perfusion profiles / Perfusão por ressonância magnética em schwannoma vestibular: influência do tamanho e estádio cístico no perfil da perfusão

Abstract Objective: The perfusion profile of vestibular schwannomas (VSs) and the factors that influence it have yet to be determined. Materials and Methods: Twenty patients with sporadic VS were analyzed by calculating parameters related to the extravascular extracellular space (EES)—the volume transfer constant between a vessel and the EES (Ktrans); the EES volume per unit of tissue volume (Ve); and the rate transfer constant between EES and blood plasma (Kep)—as well as the relative cerebral blood volume (rCBV), and by correlating those parameters with the size of the tumor and its structure (solid, cystic, or heterogeneous). Results: Although Ktrans, Ve, and Kep were measurable in all tumors, rCBV was measurable only in large tumors. We detected a positive correlation between Ktrans and rCBV (r = 0.62, p = 0.031), a negative correlation between Ve and Kep (r = -0.51, p = 0.021), and a positive correlation between Ktrans and Ve only in solid VSs (r = 0.64, p = 0.048). Comparing the means for small and large VSs, we found that the former showed lower Ktrans (0.13 vs. 0.029, p < 0.001), higher Kep (0.68 vs. 0.46, p = 0.037), and lower Ve (0.45 vs. 0.83, p < 0.001). The mean Ktrans was lower in the cystic portions of cystic VSs than in their solid portions (0.14 vs. 0.32, p < 0.001), as was the mean Ve (0.37 vs. 0.78, p < 0.001). There were positive correlations between the solid and cystic portions for Ktrans (r = 0.71, p = 0.048) and Kep (r = 0.74, p = 0.037). Conclusion: In VS, tumor size appears to be consistently associated with perfusion values. In cystic VS, the cystic portions seem to have lower Ktrans and Ve than do the solid portions.

Resumo Objetivo: O perfil de perfusão do schwannoma vestibular (SV) não tem sido estudado, nem os fatores que o influenciam. Materiais e Métodos: Vinte pacientes com SV esporádico foram analisados usando Ktrans, Ve, Kep e rCBV e correlacionados com tamanho e estádio cístico. Resultados: Ktrans, Ve e Kep foram medidos em todos os casos. rCBV só foi possível em tumores grandes. Ktrans e rCBV estavam correlacionados positivamente (r = 0,62, p = 0, 0 31 ) . Ve e Kep estavam negativamente correlacionados (r = -0,51, p = 0,021). Ktrans estava correlacionado positivamente com Ve em SVs sólidos (r = 0,64, p = 0,048). Em SVs pequenos, Ktrans foi menor (0,13 vs 0,029, p < 0,001), Kep foi maior (0,68 vs 0,46, p = 0,037) e Ve foi menor (0,45 vs 0,83, p < 0,001) que nos SVs grandes. Ktrans e Ve foram menores dentro dos cistos que nas porções solidas dos SVs císticos (0,14 vs 0,32, p < 0,001; 0,37 vs 0,78, p < 0.001, respectivamente). Foi encontrada correlação positiva em Ktrans (r = 0,71, p = 0,048) e Kep (r = 0,74, p = 0,037) entre as áreas sólidas e císticas. Conclusão: Nos SVs, o tamanho está consistentemente associado com os valores da perfusão. Nos SVs císticos, as porções císticas parecem ter valores menores de Ktrans e Ve do que nas porções sólidas.

Preoperative Endovascular Embolization of Glomus Jugulare Tumors: A Retrospective Case Series of 22 Embolizations in 20 Patients and Literature Review

Objective Glomus jugulare tumors, or tympanojugular paragangliomas, are rare, highly vascularized skull base tumors originated from paraganglion cells of the neural crest. With nonabsorbable embolic agents, embolization combined with surgery has become the norm. The authors assess the profile and outcomes of patients submitted to preoperative embolization in a Brazilian tertiary care hospital. Methods The present study is a single-center, retrospective analysis; between January 2008 and December 2019, 22 embolizations were performed in 20 patients in a preoperative character, and their medical records were analyzed for the present case series. Results Hearing loss was the most common symptom, present in 50% of the patients, while 40% had tinnitus, 30% had dysphagia, 25% had facial paralysis, 20% had hoarseness, and 10% had diplopia. In 7 out of 22 embolization procedures (31%) more than a single embolic agent was used; Gelfoam (Pfizer, New York, NY, USA) was used in 18 procedures (81%), in 12 of which as the single agent, followed by Embosphere (Merit Medical, South Jordan, UT, USA) (31%), Onyx (Medtronic, Minneapolis, MN, USA) (9%), and polyvynil alcohol (PVA) and Bead Block (Boston Scientific, Marlborough, MA, USA) in 4,5% each. The most common vessel involved was the ascending pharyngeal artery, involved in 90% of the patients, followed by the posterior auricular artery in 15%, the internal maxillary artery or the occipital artery in 10% each, and the superficial temporal or the lingual arteries, with 6% each. Only one patient had involvement of the internal carotid artery. No complications from embolization were recorded. Conclusions Preoperative embolization of glomus tumors is safe and reduces surgical time and complications, due to the decrease in size and bleeding.

Extending the Indications of 5-Aminolevulinic Acid for Fluorescence-Guided Surgery for Different Central Nervous System Tumors: A Series of 255 Cases in Latin America

Introduction Fluorescence guidance with 5-aminolevulinic acid (5-ALA) is a safe and reliable tool in total gross resection of intracranial tumors, especially malignant gliomas and cases of metastasis. In the present retrospective study, we have analyzed 5-ALA-induced fluorescence findings in different central nervous system (CNS) lesions to expand the indications of its use in differential diagnoses. Objectives To describe the indications and results of 5-ALA fluorescence in a series of 255 cases. Methods In 255 consecutive cases, we recorded age, gender, intraoperative 5-ALA fluorescence tumor response, and 5-ALA postresection status, as well the complications related to the method. Postresection was classified as '5-ALA free' or '5-ALA residual'. The diagnosis of histopathological tumor was established according to the current classification of the World Health Organization (WHO). Results There were 195 (76.4%) 5-ALA positive cases, 124 (63.5%) of whom underwent the '5-ALA free' resection. The findings in the positive cases were: 135 gliomas of all grades; 19 meningiomas; 4 hemangioblastomas; 1 solitary fibrous tumor; 27 metastases; 2 diffuse large B cell lymphomas; 2 cases of radionecrosis; 1 inflammatory disease; 2 cases of gliosis; 1 cysticercosis; and 1 immunoglobulin G4-related disease.

Clinical Applications of Additive Manufacturing Models in Neurosurgery: a Systematic Review

Introduction Three-dimensional (3D) printing technologies provide a practical and anatomical way to reproduce precise tailored-made models of the patients and of the diseases. Those models can allow surgical planning, besides training and surgical simulation in the treatment of neurosurgical diseases. Objective The aim of the present article is to review the scenario of the development of different types of available 3D printing technologies, the processes involved in the creation of biomodels, and the application of those advances in the neurosurgical field. Methods We searched for papers that addressed the clinical application of 3D printing in neurosurgery on the PubMed, Ebsco, Web of Science, Scopus, and Science Direct databases. All papers related to the use of any additivemanufacturing technique were included in the present study. Results Studies involving 3D printing in neurosurgery are concentrated on threemain areas: (1) creation of anatomical tailored-made models for planning and training; (2) development of devices and materials for the treatment of neurosurgical diseases, and (3) biological implants for tissues engineering. Biomodels are extremely useful in several branches of neurosurgery, and their use in spinal, cerebrovascular, endovascular, neuro-oncological, neuropediatric, and functional surgeries can be highlighted. Conclusions Three-dimensional printing technologies are an exclusive way for direct replication of specific pathologies of the patient. It can identify the anatomical variation and provide a way for rapid construction of training models, allowing the medical resident and the experienced neurosurgeon to practice the surgical steps before the operation.

Hypoglossal-Facial Anastomosis for Facial Nerve Reconstruction: Outcomes using the Side-to-End Surgical Technique

Introduction The side-to-end hypoglossal-facial anastomosis (HFA) technique is an excellent alternative technique to the classic end-terminal anastomosis, because itmay decrease the symptoms resulting from hypoglossal-nerve transection. Methods Patients with facial nerve palsy (House-Brackmann [HB] grade VI) requiring facial reconstruction from 2014 to 2017were retrospectively included in the study. Results In total, 12 cases were identified, with a mean follow-up of 3 years. The causes of facial paralysis were due to resection of posterior-fossa tumors and trauma. There was improvement in 91.6% of the patients (11/12) after the HFA. The rate of improvement according to the HB grade was as follows: HB III - 58.3%; HB IV - 16.6%; and HB II - 16.6%. The first signs of improvement were observed in the patients with the shortest time between the paralysis and the anastomosis surgery (3.5months versus 8.5 months; p » 0.011). The patients with HB II and III had a shorter time between the diagnosis and the anastomosis surgery (mean: 5.22 months), while the patients with HB IV and VI had a longer time of paresis (mean: 9.5 months; p » 0.099). We did not observe lingual atrophy or changes in swallowing. Discussion and Conclusion Hypoglossal-facial anastomosis with the terminolateral technique has good results and low morbidity in relation to tongue motility and swallowing problems. The HB grade and recovery appear to be better in patients operated on with a shorter paralysis time.

5-aminolevulinic Acid and Surgical Margin Analysis in Calvarial Metastasis with Pericranium or Dural Extension: Technical Note

Metastasis to the calvarium with direct pericranium or dural infiltration may be treated with radical surgical removal in selected cases. We describe microsurgical resection of calvarial metastases with fluorescence-guided technique using 5-aminolevulinic acid (5-ALA) in two female patients with breast cancer. Fluorescence findings were positive in both cases. Margins in the scalp and dural layer were 5-ALA negative at the end of surgical removal. Intraoperative pathology was performed in all cases to confirm if oncological limits were free of disease. One case was 5-ALA positive in the outer layer of the dura-mater and another in the pericranium. At the end of the removal in both cases, the surgicalmargins were 5-ALA fluorescence-free. Intraoperative pathology confirmed oncological limits of the resection. 5-aminolevulinic acid fluorescence-guided surgery for calvarial metastases with pericranium and/or dural extension seems to be a safe and reliable method to aid the surgical margins for complete removal, possibly delaying or avoiding adjuvant irradiation for progression control.

Gamma knife radiosurgery for trigeminal neuralgia: first case series from Latin America / Radiocirurgia por gamma knife para tratamento da neuralgia do trigêmeo: primeira série de casos na América Latina

ABSTRACT Gamma Knife® radiosurgery (GKRS) for trigeminal neuralgia is an effective treatment with at least a 50% reduction of pain in 75-95% of patients. Objective: To present the first series of patients treated for trigeminal neuralgia using GKRS in Latin America. Methods: Retrospective analysis. Analysis consisted of time to improvement of symptoms, best Barrow Neurological Institute scale (BNI) score after procedure, time without pain, time to recurrence and post-procedural hypoesthesia. Results: Nineteen cases of classical trigeminal neuralgia were analyzed and three cases of symptomatic trigeminal neuralgia were described. Mean time from symptom onset to radiosurgery was 99.6 months, and 78.9% of patients had undergone invasive procedures before treatment. Patients were followed for a mean of 21.7 months. BNI I was achieved in 36.8%, IIIa in 21.1%, IIIb in 21.1%, IV in 5.3% and V in 15.7%. New hypoesthesia developed in 12.1% patients, which was associated with achieving BNI I after the procedure (p < 0.05). Time from diagnosis to GKRS was higher in patients who failed to achieve BNI I (143 vs. 76 months). The distance from the root entry zone in patients who achieved BNI I was greater than patients who did not (1.94 vs. 1.14 mm). Mean distance from the root entry zone in patients with new hypoesthesia was 2.85 mm vs. 1.06 mm (p = 0.06). Conclusion: Clinical response to GKRS is related to the time between diagnosis and procedure, thus its indication should be considered early in the management of these patients.

RESUMO A radiocirurgia por Gamma Knife (GKRS) para neuralgia do trigêmeo é um tratamento comprovado, com redução de pelo menos 50% da dor em 75-95% dos casos. Objetivo: Apresentar a primeira série de pacientes tratados por neuralgia do trigêmeo com GKRS na America Latina. Métodos: Análise retrospectiva. A análise consistiu no tempo até melhora do sintoma, melhor escala do Barrow Neurological Institute (BNI) depois do procedimento, tempo sem dor, tempo até recorrência e hipoestesia pós-procedimento. Resultados: Dezenove casos de neuralgia do trigêmeo clássica foram analisados e três casos de neuralgia do trigêmeo sintomática foram descritos. Tempo médio entre começo dos sintomas e GKRS foi de 99,6 meses e 78,9% dos pacientes já tinham sido submetidos a procedimento invasivo prévio. O tempo de acompanhamento médio foi de 21,7 meses. BNI I foi conseguido em 36,8%, IIIa em 21,1%, IIIb em 21,1%, IV em 5,3% e V em 15,7%. Nova hipoestesia apareceu em 12,1% dos casos, o que foi associado a conseguir BNI I pós-procedimento (p < 0,05). Tempo desde o diagnóstico até GKRS foi maior em pacientes que não conseguiram BNI I (143 vs. 76 meses). Distância da zona de entrada do nervo em pacientes que conseguiram BNI I foi maior (1,94 vs. 1,14mm). Distância do zona de entrada do nervo em pacientes com nova hipoestesia foi de 2,85mm vs. 1,06mm (p = 0,06) Conclusão: A resposta à GKRS está relacionada ao tempo entre diagnóstico e procedimento, pelo que a indicação de GKRS deve ser considerada cedo no tratamento desses pacientes.

Salomón Hakim: the man behind normal pressure hydrocephalus / Salomón Hakim: o homem por trás da hidrocefalia de pressão normal

ABSTRACT The illustrious Colombian Professor Salomón Hakim provided the annals of neurology with one of the most brilliant and original bodies of research on record, developing the concept of normal pressure hydrocephalus, as well as proving that ventricular shunting is an effective treatment. Thus, Professor Hakim proved that some of the dementias, at that time considered senile, could be successfully treated. Here the authors present an historical review of his main contributions, which continue to influence the study of dementia to this day.

RESUMO O ilustre professor colombiano Salomón Hakim deixou como legado nos anais da neurologia uma das mais brilhantes e originais séries de pesquisa da história, desenvolvendo o conceito de hidrocefalia de pressão normal, bem como introduzindo a derivação ventricular como tratamento efetivo. Assim, Hakim provou que algumas das demências até então consideradas senis tinham possibilidade de tratamento bem-sucedido. Aqui os autores apresentarão uma revisão histórica de suas maiores contribuições, que continuam a influenciar o estudo de demências até os nossos dias.

Indications of 5-Aminolevulinic Acid and Intraoperative MRI in Glioma Surgery: First Cases in Latin America in a Single Reference Center

Introduction The improvement on the extent of resection (EOR) of gliomas with the combination of 5-aminolevulinic acid (5-ALA) and intraoperative magnetic resonance imaging (iMRI) has been demonstrated in previous studies. We present our results with the combined use of 5-ALA and (iMRI) in the surgery of glial lesions. Methods A total of 64 cases of patients with intracranial gliomas who underwent image-guided surgery using 5-ALA with and without (iMRI) were reviewed. All patients underwent an early postoperative MRI to evaluate the EOR. Other intra-operative techniques (awake surgery, electrophysiological stimulation and monitoring) were also performed according to the location of the tumor. Results A total of 18 tumors did not show intraoperative 5-ALA fluorescence (according to the World Health Organization [WHO] classification of tumors, 2 WHO-grade I, 14 WHOgrade II, 1 WHO-grade III and 1 WHO-grade IV), and 46 tumors showed intraoperative 5-ALA fluorescence (3 WHO-grade II, 3 WHO-grade III, 40 WHO-grade IV). In 28 of the 46 5-ALA positive cases, a safe 5-ALA free resection was achieved. In the 5-ALA negative cases, the (iMRI) findings guided the EOR, and complete resection was achieved in 11 cases. Complete resection was opted out in gliomas infiltrating eloquent areas. Conclusions The combined use of 5-ALA and IMRI showed improved results in glioma surgery, offering the safest maximal EOR. In the 5-ALA positive cases (mostly highgrade), fluorescence was a more useful tool. In the 5- ALA negative cases (mostly lowgrade), the (iMRI) was decisive to guide the EOR of the tumor.

Introdução Em estudos anteriores, foi demonstrado um aperfeiçoamento na extensão da resecção (EDR) de gliomas com a combinação de ácido 5-aminolevulínico (5-ALA) e a imagem de ressonância magnética intraoperatória (iRM). Nossos resultados são apresentados com o uso combinado de 5-ALA e (iRM) para a cirurgia de lesões gliais. Métodos Foram revisados 64 casos de gliomas intracranianos submetidos a cirurgia guiada por imagem por meio do uso de 5-ALA, com ou sem RMI. Todos os pacientes foram submetidos a ressonância magnética (RM) pré-operatória para a avaliação da EDR do tumor. Outras técnicas intraoperatórias (cirurgia acordado, estimulação eletrofisiológica e monitoração) também foram realizadas segundo a localização do tumor. Resultados Um total de 18 tumores não apresentaram fluorescência com o 5-ALA (segundo a classificação de tumores da Organização Mundial de Saúde [OMS], 2 com grau OMS I, 14 com grau II, 1 com grau III e 1 com grau IV) e 46 tumores foram fluorescentes (3 com grau II, 3 com grau III, 40 com grau IV). Dos 46 casos positivos para 5-ALA, em 28 foi obtida uma ressecção segura e livre. Nos casos negativos para 5-ALA, os achados da (iRM) orientaram a EDR, e alcançou-se ressecção total em 11 casos. A ressecção total foi descartada em gliomas com infiltração em áreas eloquentes. Conclusões O uso combinado de 5-ALA e (iRM) mostrou melhores resultados na cirurgia de gliomas, oferecendo uma EDR de segurança máxima. Nos casos positivos para 5-ALA (a maioria de grau alto), a fluorescência mostrou-se um instrumento mais útil. Nos casos negativos para 5-ALA (a maioria de grau baixo), a RMI foi decisiva para orientar a EDR tumoral.

Gait in normal pressure hydrocephalus: characteristics and effects of the CSF tap test / Marcha na hidrocefalia de pressão normal: características e efeitos do tap-test

ABSTRACT Normal pressure hydrocephalus (NPH), described by Hakim and Adams in 1965, is characterized by gait apraxia, urinary incontinence, and dementia. It is associated with normal cerebrospinal fluid (CSF) pressure and ventricular dilation that cannot be attributed to cerebral atrophy. Objectives: To evaluate gait characteristics in patients with idiopathic NPH and investigate the effect of the CSF tap test (CSF-TT) on gait. Methods: Twenty-five patients diagnosed with probable idiopathic NPH were submitted to the CSF-TT. The procedure aimed to achieve changes in gait parameters. Results: Fifteen gait parameters were assessed before and after the CSF-TT. Five showed a statistically significant improvement (p < 0.05): walking speed (p < 0.001), cadence (p < 0.001), step length (p < 0.001), en bloc turning (p = 0.001), and step height (p = 0.004). Conclusion: This study demonstrated that gait speed was the most responsive parameter to the CSF-TT, followed by cadence, step length, en bloc turning, and step height.

RESUMO A hidrocefalia de pressão normal (HPN), descrita por Hakim-Adams em 1965, caracteriza-se por apraxia de marcha, incontinência urinária e demência e está associada com pressão normal do líquido cefalorraquidiano e dilatação ventricular não atribuída a atrofia cerebral. Objetivos: Avaliar as características da marcha em pacientes com HPN idiopática e o efeito do "tap-test" (TT) na marcha. Métodos: Vinte e cinco pacientes com o diagnóstico HPN idiopática provável, foram avaliados com o TT. O procedimento tem como objetivo causar mudanças nas características da marcha. Resultados: Quinze parâmetros da marcha foram avaliados com o TT. Cinco mostraram melhora estatisticamente significativa (p < 0,05): velocidade da marcha (p < 0,001), cadência (p < 0,001), comprimento do passo (p < 0,001), giro em "bloco" (p = 0,001) e altura do passo (p = 0,004). Conclusão: Este estudo demonstrou que a velocidade da marcha foi o parâmetro que mais respondeu ao efeito do TT, seguido da cadência, comprimento do passo, giro em "bloco" e altura do passo.

A patient with posterior cortical atrophy due to Alzheimer's disease / Paciente com atrofia cortical posterior devida à doença de Alzheimer

We describe a 68-year-old right-handed male with 16 years of education. He worked as a bank manager until his retirement in 1999. Ha had a past history of alcohol abuse for 19 years with no other comorbidities or family history of dementia. Four years before the diagnosis, the patient had consulted with some ophthalmologists for visual difficulties such as reading and driving at night. He had been involved in two car accidents - neither was related to drink driving. He also presented several other minor problems driving, which might have been the first true symptoms of his illness.

Descrevemos um homem destro de 68 anos com 16 anos de escolaridade. Ele trabalhou como gerente de banco até sua aposentadoria em 1999. Ha um histórico de abuso de álcool há 19 anos, sem outras comorbidades ou histórico familiar de demência. Quatro anos antes do diagnóstico, o paciente consultou alguns oftalmologistas em virtude de dificuldades visuais, como ler e dirigir à noite. Ele esteve envolvido em dois acidentes de carro - nenhum deles estava relacionado a dirigir alcoolizado. Ele também apresentou vários outros pequenos problemas de condução, que poderiam ter sido os primeiros sintomas verdadeiros de sua doença.

Elastomers three-dimensional biomodels proven to be a trustworthy representation of the angiotomographic images / Biomodelos tridimensionais de elastômero provaram ser uma representação confiável de imagens angiotomográficas

ABSTRACT Intracranial aneurysm (IA) rupture is responsible for 80% of spontaneous arachnoid hemorrhages and associated with an extremely high mortality rate. Two possible surgical interventions are endovascular embolization and microsurgical clipping. Three-dimensional (3D) prototyping models help in surgical planning minimizing perioperative risks in both methods and reducing operating time. Methods 3D biomodels were printed with flexible material (elastomer) using angiotomographic DICOM acquired images and compared to 3D digital subtraction angiography (DSA) images. Results 3D biomodels represented the aneurysm angioarchitecture exactly, especially the neck and domus features. Conclusion Elastomers 3D biomodels proved to be a trustworthy representation of the angiotomographic images and could be used to help surgical planning in IA treatment.

RESUMO A ruptura dos aneurismas intracranianos é responsável por 80% das hemorragias subaracnóideas espontâneas e está associada a uma taxa de mortalidade extremamente alta. Duas intervenções cirúrgicas viáveis são embolização endovascular e clipagem microcirúrgica. Os modelos de prototipagem tridimensional (3D) auxiliam no planejamento cirúrgico e na diminuição dos riscos intra-operatórios nos dois procedimentos e redução do tempo da cirurgia. Métodos Foram impressos biomodelos em 3D com material flexível (elastômero) utilizando imagens DICOM de angiotomografia e comparados com imagens de angiografia por subtração digital em 3D (DAS). Resultados Biomodelos em 3D representam com exatidão a angioarquitetura do aneurisma, particularmente os detalhes do colo e domus. Conclusão Biomodelos em 3D com elastômeros mostraram ser uma representação confiável das imagens angiotomográficas, podendo ser utilizados no planejamento cirúrgico no tratamento de IA.

Spontaneous intracranial epidural hematoma during rivaroxaban treatment / Hematoma epidural intracraniano espontâneo durante tratamento com rivaroxaban

Summary According to our research, this is the first case described in the literature of spontaneous intracranial epidural hematoma secondary to the use of Xareltor. Spontaneous intracranial epidural hematomas are rarely described in the literature. They are associated with infectious diseases of the skull, coagulation disorders, vascular malformations of the dura mater and metastasis to the skull. Long-term post-marketing monitoring and independent reports will probably detect the full spectrum of hemorrhagic complications of the use of rivaroxaban.

Resumo Segundo nossa pesquisa, descrevemos o primeiro caso na literatura de hematoma epidural intracraniano espontâneo secundário ao uso de Xareltor. Hematomas epidurais intracranianos espontâneos raramente são descritos na literatura, sendo comumente associados a doenças infecciosas cranianas, distúrbios de coagulação, malformações vasculares da dura-máter e metástases cranianas. A elaboração de relatórios de monitoramento em longo prazo de pós-comercialização e relatórios independentes provavelmente irá detectar o espectro completo de complicações hemorrágicas do uso desse medicamento.

Surgical exposure of the internal auditory canal through the retrosigmoid approach with semicircular canals anatomical preservation / Avaliação da exposição do fundo do conduto auditivo interno através do acesso retrosigmóide-transmeatal

Objective Evaluate the feasibility of an adequate exposure with anatomical preservation of labyrinth structures through retrosigmoid transmeatal approach (RSA) in surgeries for resection of acoustic neuromas/vestibular schwannomas (VS). Method Thirty patients underwent surgical resection and were preoperatively evaluated with fine slice high definition CT scans and 3D-MRI volumetric reconstructions. Extension of internal auditory canal (IAC) opening during surgery was measured using 3 mm right-angle calibrated hook and neuronavigation parameters. Postoperatively, the extension of IAC opening and integrity of the labyrinth were confirmed through preoperatively images procedures. Results The preoperative length of IACs varied between 7.8 and 12.0 mm (mean 9.3 mm, SD 0.98, 95%CI 8.9 to 9.6, and median 9.0 mm). Postoperative images demonstrated adequate opening of the IAC and semicircular channels integrity. Conclusion A complete drilling of the posterior wall of IAC through the RSA is feasible and allows direct visualization of the IAC-fundus without damaging the semicircular canals. .

Objetivo Avaliar a possibilidade de exposição adequada preservando anatomia das estruturas labirínticas pelo acesso retrosigmóide-transmeatal (RSA) nas ressecções de schwannomas do vestibular (VS). Método Trinta pacientes foram submetidos à ressecção cirúrgica e avaliados no pré-operatório com tomografias de alta definição e reconstruções de ressonância magnética 3D. A extensão da abertura do conduto auditivo interno (CAI) foi medida e confirmada com parâmetros de neuronavegação. No pós-operatório, a extensão da abertura e a integridade do labirinto foram confirmadas por imagens de tomografia computadorizada. Resultados A extensão do CAI no pré-operatório apresentou variação de 7,8-12 mm (média 9,3 mm, DP 0,98, IC95% de 8,9-9,6 e mediana 9 mm). Imagens pós-operatórias demonstraram abertura adequada do IAC e integridade dos canais semicirculares. Conclusão A abertura completa da parede posterior do CAI pelo RSA é possível e permite a visualização direta do fundo do conduto sem prejudicar os canais semicirculares. .

Facial reanimation by hypoglossal-facial neurorrhaphy

Objective: Facial palsy may still occur after removal of large vestibular schwannomas. The aim of this paper is to describe the outcome of patients submitted to facial reanimation and make a concise revision about modern techniques available to reanimate a paralyzed face. Methods: A retrospective study of was performed about the surgical results of 12 patients submitted to hypoglossal-facial neurorrhaphy. These patients were submitted to radical removal of large vestibular schwannomas (> 3 cm) before and anatomic preservation of the facial nerve was not possible. Results: In 10 cases (83%) patients had a good outcome with House-Brackmann facial grading III. In two other cases the facial grading was IV and VI. All patients were follow-up for at least one year after the reanimation procedure. Conclusion: Hypoglossal-facial neurorrhaphy is a very useful technique to restore facial symmetry and minimize the sequela of a paralyzed face. Long last palsy seemed to be the main reason of poor outcome in two cases...

Paralisia facial pode ocorrer após remoção de schwannomas vestibulares volumosos.Neste artigo é descrito o resultado obtido em pacientes submetidos à reanimação facial, bem comoé realizada uma revisão concisa das técnicas modernas disponíveis para reanimação de uma faceparalisada. Métodos: Estudo retrospectivo do resultado cirúrgico de 12 pacientes submetidos àneurorra&a hipoglosso-facial. Todos esses pacientes foram operados anteriormente de schwannomasvestibulares volumosos (> 3 cm) e não foi possível a preservação anatômica ou funcional do nervofacial. Resultados: Em 10 casos (83%), observou-se boa recuperação da paralisia e gradação &nal IIIna escala de House-Brackmann. Em dois outros casos, um paciente evoluiu com grau IV e outro comgrau VI. Todos os pacientes foram seguidos por pelo menos um ano após o procedimento. Conclusão:A neurorra&a hipoglossal-facial é uma técnica útil para restaurar a simetria facial e minimizar as sequelasde uma face paralisada. Paralisia de longa duração foi a causa de insucesso em dois casos nesta série...