Slipped clip: report of two cases

Aneurysm rest occurs in 1 to 10% of operated patients and of these, 21.8% are due to slipped clips. D´Angelo and coworker (1998) found 1 to 10% of residual aneurysms. They suggest that if the residual aneurysm has less than 2 mm, angiographic control must be performed after 3-5 years of the surgical procedure; if between 2 and 4 mm, the angiographic control must be done in the first 6 months after surgery and then, anually. If it has more than 4mm a direct surgical approach is advised. We present the cases of two female patients submitted to microsurgical treatment of intracranial aneurysm, without any intra-operative abnormal event. The angiographic study further made showed displacement of the clip from its original position and aneurysm again. A review of the literature is also presented.A incidência de clipagem de aneurismas em que permanecem restos da dilatação varia, nas séries estudadas, de 1-10%. Deste percentual, 21,8% é devido à migração do clipe.D´Angelo e seus colaboradores (1998), encontraram 1 a 10% de aneurismas residuais. Sugerem que quando o resíduo for menor que 2 mm seja realizado estudo angiográfico entre 3-5 anos após o procedimento cirúrgico; se entre 2 e 4 mm, este estudo deve ser mais precoce, dentro dos primeiros 6 meses e depois anualmente; e, quando maior que 4 mm, a reabordagem. Apresentamos os casos de duas pacientes submetidas a tratamento cirúrgico de aneurismas intracranianos, com intra-operatório sem intercorrências e que, em exames ulteriores, evidenciaram migração do clipe de sua posição original. É apresentada, ainda, revisão da literatura.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Disciplina de NeurocirurgiaUNIFESP, EPM, Disciplina de NeurocirurgiaSciEL

Hematoma cervical epidural com fratura de clivus: relato de caso

Clivus fractures are rare and severe entities, usually associated with vascular or cranial nerve lesions and frequently diagnosed postmortem. Cervical epidural haematomas can be traumatic or spontaneous, manifested in acute or chronic form, and are treated surgically in the majority of cases, although the conservative treatment also can be indicated to patients with incomplete and non-progressive deficits. The authors report the case of a female patient, 8 years old, victim of trampling in public way by a high velocity motorized vehicle, admitted in Glasgow 7, anisocoric pupils (left pupil midriatic), whose radiological investigation showed a transverse fracture of the clivus, cervical epidural haematoma and diffuse axonal injury. The patient was submitted to intracranial pressure monitorization, sedation and conservative treatment with dexamethasone, with good outcome. The authors also present a literature review.As fraturas de clivus são entidades raras e graves, usualmente associadas a lesões vasculares ou de nervos cranianos, sendo freqüentemente diagnosticadas postmortem. Hematomas epidurais cervicais podem ser traumáticos ou espontâneos, manifestos de forma aguda ou crônica, requerendo tratamento cirúrgico na maior parte das vezes, embora o tratamento conservador possa ser indicado a pacientes com déficits incompletos ou não progressivos. Os autores relatam o caso de uma paciente do sexo feminino, 8 anos, vítima de atropelamento em via pública por veículo automotor em alta velocidade, que foi admitida em glasgow 7, com anisocoria (pupila esquerda midriática). A investigação radiológica evidenciou fratura transversa de clivus, hematoma epidural cervical e lesão axonal difusa. A paciente foi submetida a monitorização da pressão intracraniana, sedação e tratamento conservador com corticoesteróides, com boa evolução. Os autores apresentam também uma revisão da literatura pertinente.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Neurosurgery DepartmentUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUNIFESP, EPM, Neurosurgery DepartmentUNIFESP, EPMSciEL

In Memoriam: A Memoir for Our Fallen "Heroes"

This article is made available for unrestricted research re-use and secondary analysis in any form or be any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.Even though neurosurgeons exercise these enormous and versatile skills, the COVID-19 pandemic has shaken the fabrics of the global neurosurgical family, jeopardizing human lives, and forcing the entire world to be locked down. We stand on the shoulders of the giants and will not forget their examples and their teachings. We will work to the best of our ability to honor their memory. Professor Harvey Cushing said: “When to take great risks; when to withdraw in the face of unexpected difficulties; whether to force an attempted enucleation of a pathologically favorable tumor to its completion with the prospect of an operative fatality, or to abandon the procedure short of completeness with the certainty that after months or years even greater risks may have to be faced at a subsequent session—all these require surgical judgment which is a matter of long experience.” It is up to us, therefore, to keep on the noble path that we have decided to undertake, to accumulate the surgical experience that these icons have shown us, the fruit of sacrifice and obstinacy. Our tribute goes to them; we will always remember their excellent work and their brilliant careers that will continue to enlighten all of us. This memorial is intended to commemorate our colleagues who succumbed during the first 4 months

White matter interruption in the surgical approaches to the temporal horn of the lateral ventricle

Introdução: A exploração cirúrgica do como temporal do ventrículo lateral (CTVL) é realizada para o tratamento de lesões neoplásica, vasculares e, principalmente, para o tratamento cirúrgico da epilepsia do lobo temporal. As abordagens cirúrgicas a esta cavidade são realizadas, a partir da superficie cortical e através de suas paredes, pelos acessos laterais, transsilvianos e inferiores. A escolha do acesso cirúrgico se baseia na exposição adequada e nas alterações neurológicas que possam advir do trauma ao parênquima cerebral. A secção dos diferentes feixes de fibras brancas pode resultar em déficits neurológicos mais duradouros do que a lesão ao córtex cerebral. Os déficits visuais oriundos da interrupção das fibras da radiação óptica são os mais estudados. A identificação das interrupções dos demais conjuntos de fibras e as correlações dos déficits neurológicos originados têm sido subestimadas na literatura Objetivo: Avaliar a interrupção dos feixes de fibras brancas nos diferentes acessos cirúrgicos ao como temporal do ventrículo lateral, utilizando a técnica de dissecção de fibras brancas de Klinger. Métodos: Para o estudo, foram utilizados 40 hemisférios cerebrais cadavéricos adultos (20 encéfalos) preparados no Laboratório de Anatomia da UFMS de acordo com a descrição do método de preparação de Klinger. As aberturas da cavidade ventricular, mimetizando os acessos cirúrgicos lateral (através do giro temporal médio), inferior (através do giro parahipocampal), transsilviano e transuncal foram realizados por meio de incisões de l5 mm a partir das superficies corticais. Resultados: A introdução dos instrumentos de dissecção, de 15 mm de largura por 2 mm de espessura, garantiu a uniformidade das transecções das fibras da superficie cortical à cavidade ventricular. Como resultado obteve­se o acesso que causou menor comprometimento de fibras brancas foi o acesso transucal, esse que atingiu apenas 8,3% das fibras analisadas, sendo as fibras em \"U\" situadas no córtex piriforme. Em seguida, os acessos inferior e transsilviano causaram lesões em 25% das fibras brancas. O acesso que acometeu o maior número de fibras, sendo considerado o mais lesivo para a substância branca foi o acesso lateral, esse que acometeu 75% das fibras analisadas durante a pesquisa. Conclusão: O acesso lateral através do giro temporal médio ocasiona lesões da porção inferior do fascículo longitudinal superior (segmento arqueado e vertical), do fascículo uncinado (segmento dorso lateral da porção temporal), do fascículo occipitofrontal (segmento ventral da porção posterior), da comissura anterior (segmento posterior da extensão lateral), das fibras temporopontinas, do pedúnculo talârnico posterior (alça temporal), do pedúnculo talâmico inferior (fibras posteriores) e do tapete. O acesso transsilviano ocasiona lesões do fascículo uncinado (segmento ventromedial da porção temporal), da comissura anterior (segmento anterior da extensão lateral) e da substância cinzenta da amígdala. O acesso inferior, através do giro parahipocampal, ocasiona lesões do segmento inferior do cíngulo e da formação hipocampal. O acesso transuncallesa apenas a substância cinzenta da amígdala .Introduction: Surgical access to the temporal hom of lateral ventric1e is performed to treat tumoral and vascular lesions, but mainly to the surgi cal treatment of temporal epilepsy. The surgi cal exploration of this cavity is realized from the cortical surface towards the ventricular walls, through the lateral, transsylvian and inferior approaches, based on the adequate exposure of the cavity and on the postoperative deficits that might be originated from the brain parenchymal trauma. Lesions to the fibers bundles often result in more severe and prolonged deficits than corticallesions. The most common recognized deficits are the visual fields defects secondary to injuries to the optic radiation. Identification of the interruption of other fibers bundles involved and their correlated c1inical manifestation have been underestimated on the literature. Objective: To identify the interruption of the fiber bundles originated from the different approaches to the temporal hom utilizing the Klinger\'s fiber dissection technique. Methods: We studied 40 cerebral hemispheres of 20 brains, prepared according to Klingers method, at the UFMS Laboratory of Anatomy. The surgical access of the temporal hom was performed simulating the lateral (middle temporal gyrus), inferior (parahippocampal gyrus), transsylvian and transuncal approaches, through 15 mm cortical incisions, followed by stepwise dissection of the fibers. Results: Introduction ofthe dissector (15 mm width, 2 mm height) warranted an uniform transection of the fibers from the cortical surface to the ventricular cavity. The least destructive access encountered was the transuncal access, interrupting 8,3% of the studied fibers. Following it, the inferior and the transsylvian approaches interrupted 25% of the fibers. The most destructive, interrupting 75% of the studied fibers was the lateral approach. Conclusion: The lateral approach through the middle temporal gyrus caused interruptions on the inferior portion (vertical and arcuate segments) of the superior longitudinal fasciculus; on the dorso lateral segment of the temporal portion from the uncinate fasciculus; on the ventral segment of the posterior portion from the occipitofrontal fasciculus; on the posterior segrnent of the lateral extension from the posterior commissure; on the temporopontine fibers; on the anterior loop of the posterior thalamic pedunc1e, on the posterior fibers of the inferior thalamic pedunc1e and the tapetum fibers. The transsylvian approach caused interruptions on the ventromedial segrnent of the temporal portion from the uncinate fasciculus; on the anterior segrnent of the lateral extension from the anterior commissure and transected the amygdala on its anterosuperior surface. The inferior approach through the parahippocampal gyrus caused interruptions on the inferior segment of the cingulum and on the fimbria, due to the transection of the hipocampal formation. The transuncal approach only transected the amygdal

Sarcoma de Ewing epidural lombar primário: Relato de caso

Relatamos o caso de uma jovem de 15 anos, com quadro de paraparesia de inicio agudo, secundário a processo expansivo epidural na coluna lombar, cujo diagnóstico histopatológico foi consistente com sarcoma de Ewing, sem envolvimento ósseo. Revisando a literatura encontramos apenas outros 17 casos de sarcoma de Ewing extra-esquelético de localização primária no espaço epidural raqueano

Surgical management of symptomatic hemangioma of the geniculate ganglion: fascicular-sparing resection or grafting?

Geniculate ganglion hemangioma (GGH) is rarely presented in the neurosurgical literature. It extends extradurally on the middle fossa floor and displaces the intratemporal part of the facial nerve. Surgical treatment is advisable at early symptoms. Proposed techniques include fascicular-sparing resection or nerve interruption with grafting. No definitive conclusions exist about the superiority of a certain technique in preserving facial nerve integrity and function. Through the description of a surgically managed symptomatic GGH, we herein discuss literature data about the surgical results of fascicular-sparing resection versus grafting. A PRISMA-based literature search was performed on the PubMed database. Only articles in English and published since 1990 were selected and furtherly filtered based on the best relevance. Statistical comparisons were performed with ANOVA. One hundred sixteen GGHs were collected, 56 were treated by fascicular-sparing resection, and 60 were treated by grafting. The facial function was improved, or unchanged, in 53 patients of the fascicular-sparing group and 30 patients of the grafting one. Sixty-five patients achieved a good (House-Brackmann (HB) grade III) postoperative facial outcome, of which 47 and 18 belonged to the fascicular-sparing and grafting group, respectively. Greater efficacy of the fascicular-sparing technique in the achievement of a better facial outcome was found (p = 0.0014; p = 0.0022). A surgical resection at the earliest symptoms is critical to preserve the facial nerve function in GGHs. Fascicular-sparing resection should be pursued in symptomatic cases with residual facial function (I-III HB). Conversely, grafting has a rationale for higher HB grades (V-VI). Broader studies are required to confirm these findings and turn them into new therapeutic perspectives

Cortical and Subcortical Anatomy of the Orbitofrontal Cortex: A White Matter Microfiberdissection Study and Case Series

BACKGROUND The literature on white matter anatomy underlying the human orbitofrontal cortex (OFC) is scarce in spite of its relevance for glioma surgery. OBJECTIVE To describe the anatomy of the OFC and of the underlying white matter fiber anatomy, with a particular focus on the surgical structures relevant for a safe and efficient orbitofrontal glioma resection. Based on anatomical and radiological data, the secondary objective was to describe the growth pattern of OFC gliomas. METHODS The study was performed on 10 brain specimens prepared according to Klingler's protocol and dissected using the fiber microdissection technique modified according to U.T., under the microscope at high magnification. RESULTS A detailed stratigraphy of the OFC was performed, from the cortex up to the frontal horn of the lateral ventricle. The interposed neural structures are described together with relevant neighboring topographic areas and nuclei. Combining anatomical and radiological data, it appears that the anatomical boundaries delimiting and guiding the macroscopical growth of OFC gliomas are as follows: the corpus callosum superiorly, the external capsule laterally, the basal forebrain and lentiform nucleus posteriorly, and the gyrus rectus medially. Thus, OFC gliomas seem to grow ventriculopetally, avoiding the laterally located neocortex. CONCLUSION The findings in our study supplement available anatomical knowledge of the OFC, providing reliable landmarks for a precise topographical diagnosis of OFC lesions and for perioperative orientation. The relationships between deep anatomic structures and glioma formations described in this study are relevant for surgery in this highly interconnected area

In Memoriam: A Memoir for Our Fallen "Heroes"

This article is made available for unrestricted research re-use and secondary analysis in any form or be any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.Even though neurosurgeons exercise these enormous and versatile skills, the COVID-19 pandemic has shaken the fabrics of the global neurosurgical family, jeopardizing human lives, and forcing the entire world to be locked down. We stand on the shoulders of the giants and will not forget their examples and their teachings. We will work to the best of our ability to honor their memory. Professor Harvey Cushing said: “When to take great risks; when to withdraw in the face of unexpected difficulties; whether to force an attempted enucleation of a pathologically favorable tumor to its completion with the prospect of an operative fatality, or to abandon the procedure short of completeness with the certainty that after months or years even greater risks may have to be faced at a subsequent session—all these require surgical judgment which is a matter of long experience.” It is up to us, therefore, to keep on the noble path that we have decided to undertake, to accumulate the surgical experience that these icons have shown us, the fruit of sacrifice and obstinacy. Our tribute goes to them; we will always remember their excellent work and their brilliant careers that will continue to enlighten all of us. This memorial is intended to commemorate our colleagues who succumbed during the first 4 months