Bilateral congenital infantile hemangioma of upper eyelids.

A newborn female baby presented to us with horizontally oval swelling involving posterior lamella of both upper eyelids and is limited by lid margin. The swelling was bright red, nontender, firm in consistency, nonreducible, blanches on pressure, and fixed to underlying structures with no rise in temperature. The size of the swelling was 2.8 cm × 1.1 cm × 1 cm in the right upper eyelid and 2.8 cm × 1.3 cm × 1 cm in the left upper eyelid. There was total occlusion of the visual axis [Fig. 1]. Magnetic resonance imaging of both orbit shows diffusely bulky and heterogeneous altered signal intensity lesions involving the posterior lamella of upper eyelid on both sides [Fig. 2]. The patient was prescribed oral propranolol 2 mg/kg in two divided doses under the supervision of a pediatrician and responded well to the treatment within a week of the initiation of the treatment [Fig. 3] and reduce further in size within 12 weeks of the treatment with the clearing of the visual axis [Fig. 4]. Discussion Infantile hemangioma, a benign tumor of vascular endothelial cells, is the most common type of childhood tumor.[1] Infantile hemangiomas are more common in premature or low‑birth‑weight infants.[2] It usually presents at birth or is evident by 6–8 months of age. The lesion typically manifests within the first few weeks of life, grows rapidly in the 1st year during the proliferative phase then invariably and slowly regresses over the following 4–5 years during the involutional phase.[3] For the management, the long‑term use of topical 0.5% timolol maleate solution is safe and effective in treating superficial infantile hemangiomas.[4] As compared to corticosteroids, oral propranolol also represents an effective therapy for periorbital infantile hemangioma.[5]

Neuroendoscope in aneurysm surgeries: past, present and future / Neuroendoscopia em cirurgia de aneurismas: passado, presente e futuro

Even with the use of most sophisticated microscope sometimes the relationship between the aneurysm and the adjacent structures are not clearly defined. The straight line of view by microscope results in inadequate visualization of structures thatlie immediately behind other structures like the neck, branches or perforators of the aneurysm. Hence exposure of these structures may require risky retraction either of the parent artery or the aneurysm itself, which can be overcome by clear anatomical information obtained by the use of endoscope instead of attempting extensive manipulation under the microscope. The endoscope permits close up, wide angled views of regional anatomic features and verification of the optimal clip position. Visual conformation of regional anatomy achieved using the rigid endoscope provides valuable information for subsequent microsurgical procedures and enhances the safety and reliability. Endoscopic-assisted microsurgery is an exceptional aid and using the PIP (picture-in picture) technology, simultaneous observation of microscope and endoscopic images can be viewed through the ocular system of microscope. The advantages of neuroendoscope include the ability to look around corners and behind obstructions. With less brain retraction, smaller operative exposures and better visualization, neuroendoscopy may reduce operative morbidity. However he surgeon should be familiar with this technique and be prepared for the inconveniences and risks during the procedure.

A neuroendoscopia reflete a tendência da neurocirurgia moderna em buscar acessos mínimos., ou seja, acessar e visualizar lesões através de corredores o menor possível e com máxima efetividade ao objetivo, com mínima alteração do tecido norma;. Embora o primeiro procedimento endoscópico intracraniano tenha sido realizado no início do século 20, esta técnica tornou-se popular entre os neurocirurgiões, somente nos anos recentes, após o refinamento dos endoscópios e de seus instrumentos. Mesmo com o uso de microscópios, as vezes as relações entre os aneurismas e as estruturas vizinhas não é claramente definida. A visão reta oferecida pelo microscópio resulta em visualização inadequada de estruturas que se colocam imediatamente atrás, como o colo, ramos ou perfurantes do aneurisma. Assim, a exposição destas estruturas pode requerer retrações de risco para a artéria aferente ou o próprio aneurisma, o que pode ser superado por uma clara informação anatômica obtida com o endoscópio, ao invés de uma eventual manipulação externa com o microscópio. O endoscópio permite “close-up”, amplas e anguladas observações das características anatômicas e verificação do posicionamento ótimo do clipe. A conformação visual da anatomia regional obtida com o uso do endoscópio rígido oferece aliosa informação para subseqüentes e a confiabilidade. Microscopia assistida por endoscopia é um auxílio excepcional, e o uso de tecnologia PIP (quadro a quadro), permite a observação simultânea das imagens no microscópio e no endoscópio, através da ocular do microscópio. As vantagens da neuroendoscopia incluem a habilidade de olhar em volta de ângulos e atrás de obstáculos. Com menos retração cerebral, menores abordagens e melhor visualização, a neuroendoscopia pretende reduzir a morbidade operatória. Para tal, o neurocirurgião deve estar familiarizado com a técnica e preparado para os inconvenientes e riscos do procedimento.