As artérias lenticuloestriadas podem interferir na extensão da ressecção tumoral e sobrevida nos gliomas da ínsula? / Can lenticulostriated arteries interfere with the extent of tumor resection and survival in insula gliomas?

Introdução: Os gliomas são tumores encefálicos e da medula espinhal que se originam nas células gliais e cuja progressão invade o tecido cerebral adjacentee e dentre eles um dos mais desafiadores são localizados no lobo cerebral da ínsula. Estas artérias irrigam estruturas nobres e sua lesão pode produzir danos sensitivos, motores e de linguagem. Objetivo: Descrever o impacto da extensão da ressecção, sobrevida global e dos resultados funcionais após a cirurgia dos gliomas insulares, quando estes tumores estejam ou não envolvidos pelas artérias lenticuloestriadas. Métodos: Revisão integrativa nas plataformas virtuais em português e inglês, buscando AND ou OR dados através dos seguintes descritores "Gliomas da ínsula, Mapeamento cerebral, Artérias lenticuloestriadas". A busca inicial foi baseada no título e/ou resumo. Decididos os trabalhos incluíveis foi realizada a leitura na íntegra dos textos. Ao total foram estudados 55 artigos. Resultados: O lobo da ínsula fica "escondido" pela sobreposição dos lobos frontal, parietal e temporal. Para alcançá-lo pode-se realizar as abordagens transsilviana ou transcortical. Ocorre que ao chegar na ínsula visualiza-se significativa ramificação constituída pelas artérias lenticuloestriadas, cuja manipulação pode determinar déficit neurológico e, ao se aprofundar no córtex insular, depara-se com outras estruturas tão importantes quanto a própria ínsula. O conhecimento anatômico das artérias lenticuloestriadas e suas relações é de fundamental importância para a ressecção de glioma insular, pois o comprometimento delas e da artéria cerebral média podem determinar a isquemia dos núcleos da base e da cápsula interna. Conclusão: O tratamento dos gliomas insulares permanece como grande desafio. Devido à sua localização e possibilidade de desenvolvimento de déficits neurológicos na manipulação cirúrgica é necessário não somente conhecer sua localização topográfica, mas também a íntima relação vascular com as artérias lenticuloestriadas. O envolvimento delas pelo tumor possui implicações na sobrevida e na preservação da função neurológica. O conhecimento detalhado da anatomia da região é fundamental para diminuir complicações que afetem grandemente a qualidade de vida dos pacientes.

Introduction: Gliomas are brain and spinal cord tumors that originate in glial cells and whose progression invades the adjacent brain tissue and among them one of the most challenging are located in the cerebral lobe of the insula. These arteries supply noble structures and their damage can cause sensory, motor and language damage. Objective: To describe the impact of the extent of resection, overall survival and functional results after surgery for insular gliomas, when these tumors are or are not involved by lenticulostriate arteries. Methods: Integrative review on virtual platforms in Portuguese and English, searching for AND or OR data using the following descriptors "Insula gliomas, Brain mapping, Lenticulostriate arteries". The initial search was based on the title and/or abstract. Once the included works were decided, the texts were read in full. In total, 55 articles were studied. Results: The insula lobe is "hidden" by the overlap of the frontal, parietal and temporal lobes. To achieve this, transsylvian or transcortical approaches can be performed. It turns out that when arriving at the insula, a significant branch made up of lenticulostriate arteries is seen, the manipulation of which can cause neurological deficits and, when going deeper into the insular cortex, one comes across other structures as important as the insula itself. Anatomical knowledge of the lenticulostriate arteries and their relationships is of fundamental importance for the resection of insular glioma, as their involvement and that of the middle cerebral artery can determine ischemia of the basal ganglia and internal capsule. Conclusion: The treatment of insular gliomas remains a major challenge. Due to its location and the possibility of developing neurological deficits during surgical manipulation, it is necessary not only to know its topographic location, but also the intimate vascular relationship with the lenticulostriate arteries. Their involvement by the tumor has implications for survival and preservation of neurological function. Detailed knowledge of the region's anatomy is essential to reduce complications that greatly affect patients' quality of life.

É possível prever a mortalidade molecular em meduloblastomas pela análise dos receptores de membrana CD114? / Is it possible to predict molecular mortality in meduloblastomas by analysis of CD114 membrane receptors?

Introdução: Os meduloblastomas são os tumores sólidos mais comuns da infância e classificados em 4 subgrupos moleculares: WNT, SHH, grupo 3 e grupo 4. Muitos estudos buscam desenvolvimento de novos quimioterápicos para os meduloblastomas através da identificação de genes cuja expressão sejam novos alvos moleculares para drogas, como receptores de membrana associados a replicação celular. Objetivo: Avaliar a associação da expressão de CD114 com a mortalidade de pacientes portadores de meduloblastoma. Métodos: Revisão feita colhendo informações publicadas em plataformas virtuais em português e inglês. Inicialmente foi realizada busca por descritores relacionados ao tema - neurocirurgia, oncologia cirúrgica, terapia de alvo molecular e meduloblastoma - e seus equivalentes em inglês - neurosurgery, surgical oncology, molecular targeted therapy e medulloblastoma - com busca AND ou OR, considerando o título e/ou resumo. Após, foram incluídos somente os que tinham maior relação ao tema, e realizada a leitura da íntegra dos textos. Finalmente foram referidos 2 artigos. Resultados: Há diferença na expressão do receptor de membrana CD114 entre o Grupo 3 e os demais grupos moleculares, além de diferença entre o subtipo molecular SHH γ e os subtipos moleculares Grupo 3 α e Grupo 3 ß. Não houve diferença estatisticamente significativa entre os demais grupos e subtipos. Em relação à mortalidade, esta revisão não demonstrou significância estatística na relação entre expressões baixas e elevadas desse gene e a mortalidade. Conclusão: Não há relação direta entre a expressão do receptor de membrana CD114 e a mortalidade em pacientes portadores de meduloblastoma. Entretanto, são necessários estudos adicionais sobre as vias de sinalização intracelulares associadas a esse receptor e ao seu gene, o CSF3R.

Introduction: Medulloblastomas are the most common solid tumors of childhood and classified into 4 molecular subgroups: WNT, SHH, Group 3 and Group 4. Many studies seek to develop new chemotherapy drugs for medulloblastomas by identifying genes whose expression is new molecular targets for drugs, such as membrane receptors associated with cell replication. Objective: To evaluate the association of CD114 expression with mortality in patients with medulloblastoma. Methods: Review carried out collecting information published on virtual platforms in Portuguese and English. Initially, a search was carried out for descriptors related to the topic - neurosurgery, surgical oncology, molecular targeted therapy and medulloblastoma, with AND or OR search, considering the title and/or summary. Afterwards, only those that were most related to the topic were included, and the texts read in full. Finally, 23 articles were referred. Results: There is a difference in the expression of the CD114 membrane receptor between Group 3 and the other molecular groups, in addition to a difference between the SHH γ molecular subtype and the Group 3 α and Group 3 ß molecular subtypes. There was no statistically significant difference between the other groups and subtypes. Regarding mortality, this review did not demonstrate statistical significance in the relationship between low and high expressions of this gene and mortality. Conclusion: There is no direct relationship between the expression of the CD114 membrane receptor and mortality in patients with medulloblastoma. However, additional studies are needed on the intracellular signaling pathways associated with this receptor and its gene, CSF3R.

Superficial-Temporal-Artery-To-Middle-Cerebral-Artery Bypass in Cerebrovascular Occlusive Disease and Hemodynamic-Related Ischemia: Illustrative Case and Literature Review

Stroke is the third most common cause of death worldwide. About 10% to 15% of strokes related to the territory of the carotid artery are associated with its complete occlusion. There is an important subgroup of patients with cerebrovascular occlusive diseases who might benefit from an external-carotid-to-internal-carotid bypass. In the present study, we report a case of a 53-year-old male patient with stenosis of the M2 branch of themiddle cerebral artery (MCA), with a history of 20 episodes of transient ischemic accidents (TIA)s, in whom an anastomosis of the M4 branch of the superficial temporal artery-MCA was performed. The patient was discharged in three days, and in the two years of follow-up, they were no more TIAs.We also conducted a review of the literature on cerebrovascular occlusive disease and extracranial-intracranial bypass surgery. New methods to evaluate cerebral hemodynamics made it possible to classify a new subgroup of patients with symptomatic cerebrovascular disease and documented cerebrovascular compromise in whom the drug therapy fails, who can benefit from the extracranial-intracranial bypass. Our case report illustrates the advantages of revascularization in these selected patients.

Pterygopalatine Fossa: Microsurgical Anatomy and its Relevance for Skull Base Surgery

Introduction The purpose of this study was to define the anatomical relationships of the pterygopalatine fossa (PPF) and its operative implications in skull base surgical approaches. Methods Ten cadaveric heads were dissected at the Dianne and M Gazi Yasargil Educational Center MicrosurgicaLaboratory, in Little Rock, AK, USA. The PPF was exposed through an extended dissection with mandible and pterygoid plate removal. Results The PPF has the shape of an inverted cone. Its boundaries are the pterygomaxillary fissure; themaxilla, anteriorly; themedial plate of the pterygoid process, and greater wing of the sphenoid process, posteriorly; the palatine bone,medially; and the body of the sphenoid process, superiorly. Its contents are the maxillary division of the trigeminal nerve and its branches; the pterygopalatine ganglion; the pterygopalatine portion of the maxillary artery (MA) and its branches; and the venous network. Differential diagnosis of PPF masses includes perineural tumoral extension along the maxillary nerve, schwannomas, neurofibromas, angiofibromas, hemangiomas, and ectopic salivary gland tissue. Transmaxillary and transpalatal approaches require extensive resection of bony structures and are narrow in the deeper part of the approach, impairing the surgical vision and maneuverability. Endoscopic surgery solves this problem, bringing the light source to the center of the surgical field, allowing proper visualization of the surgical field, extreme close-ups, and different view angles. Conclusion We provide detailed information on the fossa's boundaries, intercommunications with adjacent structures, anatomy of the maxillary artery, and its variations. It is discussed in the context of clinical affections and surgical approaches of this specific region, including pterygomaxillary disjunction and skull base tumors.

Co-Occurrence of Pineal-Region and Pituitary-Stalk Hemangioblastomas in a Patient Presenting with Von Hippel-Lindau Disease ­ A Case Report

Introduction Hemangioblastomas of the pineal region or pituitary stalk are extremely rare. Only two cases of hemangioblastomas involving the pineal region have been reported, and four involving the pituitary stalk. The purpose of the present manuscript is to describe an unusual case of supposed hemangioblastoma found concomitantly in the pineal region and pituitary stalk of a patient diagnosed with Von Hippel-Lindau (VHL) disease. Case Report A 35-year-old female patient with a previous diagnosis of VHL complaining of occipital headaches and balance disturbances for three weeks, who previously had a cerebellar hemangioblastoma resected. The visual characteristics of the tumor suggested a friable vascular lesion with a reddish-brown surface, and an incisional biopsy was performed. The tumor consisted of a dense vascular network surrounded by fibrous stroma abundant in reticulin and composed by both fusiform and dispersed xanthomatous cells; the immunohistochemistry was immunopositive for neuronspecific enolase and immunonegative for epithelial membranous antigen. The patient has been monitored closely for 2 years, and the supratentorial masses have not presented any volume alteration. Conclusion This rare association must be taken into account in patients with VHL disease, or at least be suspected in patients who present a thickening of the pituitary stalk and a pineal-region mass. We believe a biopsy of our asymptomatic patient could have been dangerous due to inherent complications like intraoperative bleeding. We recommend close observation of asymptomatic lesions with MRIs every six months or until the lesions become symptomatic. If the pineal-region tumor does become symptomatic, gross resection via a transcallosal approach would be ideal.

El lóbulo de la ínsula: Parte 2 - Anatomía microquirúrgica y correlación clínico-quirúrgica / The lobe of the insula: Part 2 - Microsurgical anatomy and clinical-surgical correlation

Introducción: El conocimiento profundo de la anatomía microquirúrgica del lóbulo de la ínsula es crucial para operar pacientes con tumores en esta región. Objetivo: El objetivo de la segunda parte de este estudio es correlacionar la anatomía microquirúrgica con casos ilustrativos retirados de nuestra casuística de 35 pacientes en los cuales fueron realizados 44 cirugías de tumores en relación con el lóbulo de la ínsula. Material y Métodos: A lo largo de marzo de 2007 y agosto de 2014, 44 microcirugías fueron realizadas en 35 pacientes portadores de tumores insulares y los hallazgos de las cirugías y mapeo cerebral se correlacionaron con la anatomía microquirúrgica. Resultados: De una serie de 44 pacientes con tumores de la ínsula, la mayoría de los casos eran gliomas de bajo grado de malignidad (29 casos). El inicio de los síntomas en 34 pacientes fue epilepsia, siendo esta refractaria al tratamiento medicamentoso en 12 casos. El grado de resección fue subtotal o total en la mayoría de los casos de la serie. La mejoría en la calidad de vida (epilepsia, etc.) estuvo presente en más de la mitad de los pacientes. El déficit neurológico permanente estuvo presente en tres pacientes. Conclusión: En los tumores insulares, es tan importante el conocimiento profundo de la anatomía, como el saber utilizar e interpretar en tiempo real las observaciones de la monitorización neurofisiológica intraoperatoria.

Introduction: The deep knowledge of the microsurgical anatomy of the insular lobe is crucial to operate patients with tumors in this region. Objectives: Our purpose in this second part is to correlate insular surgical anatomy with illustrative cases from 4 surgeries performed on 35 patients with insular tumors. Materials and Methods: From March 2007 to August 2014, 44 microsurgeries were performed on 35 patients with insular glioma tumors. Of these, 29 cases were low-grade gliomas. Seizures were the first symptom in most cases. Total, or near total tumor resection was achieved in most of the patients. Improvement in quality of life was achieved in more than half of the patients after surgery. Moderate and permanent neurological deficits were present in 3 patients. Results: The majority of cases were low grade malignancy gliomas (29 cases). The onset of symptoms in 34 patients was epilepsy, being refractory to drug treatment in 12 cases. The degree of resection was subtotal or total in most cases of this series. The improvement in the quality of life (epilepsy, etc.) was present in more than half of the patients. Permanent neurological deficit was present in three patients. Conclusion: For insular tumors, microsurgical anatomy knowledge is as important as cortical and subcortical mapping

Microsurgical and Endoscopic Anatomy of the Cavernous Sinus

Objective To describe the endoscopic and microsurgical anatomy of the cavernous sinus (CS) with focus on the surgical landmarks in microsurgical anatomy. Materials and methods Ten formalin-fixed central skull base specimens (20 CSs) with silicone-injected carotid arteries were examined through an extended endoscopic transsphenoidal approach. Fifteen formalin-fixed heads were dissected to simulate the surgical position in CS approaches. Results Endoscopic access enables identification of the anterior and posterior surgical corridors. Structures within the CS and on its lateral wall could be visualized and studied, but none of the triangular areas relevant to the transcranial microsurgical anatomy were fully visible through the endoscopic approach. Conclusion The endoscopic approach to the CS is an important surgical technique for the treatment of pathological conditions that affect this region. Correlating endoscopic findings with the conventional (transcranial)microsurgical anatomy is a useful way of applying the established knowledge into a more recent operative technique. Endoscope can provide access to the CS and to the structures it harbors.

Parte I: Anatomía microquirúrgica tridimensional de la ínsula / Part I: Three-dimensional microsurgical anatomy of the insula

Introducción: El lóbulo de la ínsula, o ínsula, se encuentra oculto en la superficie lateral del cerebro. La ínsula está localizada profundamente en el surco lateral o cisura silviana, recubierta por los opérculos frontal, parietal y temporal. Objetivo: Estudiar la compleja anatomía del lóbulo de la ínsula, una de las regiones de mayor complejidad quirúrgica del cerebro humano, y su correlación anatómica con casos quirúrgicos. Material y Métodos: En la primera parte de este estudio presentamos los resultados de nuestras disecciones microquirúrgicas en fotografías 2 D y 3D; en la segunda parte de nuestro trabajo, la correlación anatómica con una serie de 44 cirugías en pacientes con tumores de la ínsula, principalmente gliomas, operados entre 2007 y 2014. Resultados: Extenso conjunto de fibras subcorticales, incluyendo el fascículo uncinado, fronto-occipital inferior y el fascículo arcuato, conectan la ínsula a las regiones vecinas. Varias estructuras anatómicas responsables por déficits neurológicos severos están íntimamente relacionadas con la cirugía de la ínsula, tales como lesiones de la arteria cerebral media, cápsula interna, áreas del lenguaje en el hemisferio dominante y arterias lenticuloestriadas. Conclusión: El entrenamiento en laboratorio de neuroanatomía, estudio de material impreso en 3D, el conocimiento sobre neurofisiología intra-operatoria y el uso de armamento neuroquirúrgico moderno son factores que influencian en los resultados quirúrgicos

Introduction: The insular lobe, or insula, is the cerebral lobe sitting deep in the sylvian fissure and hidden by the lateral surface of the brain. It is covered by the frontal, parietal and temporal operculum. Objectives: To study the anatomy of the insular lobe, one of the most complex parts of the human brain, and to correlate this anatomy with intraoperative findings. Materials and Methods: In the first part of this article we show the results of our dissections, documented in 2D and 3D, and focus on microsurgical anatomy. In the second part we correlate the anatomical structures with intraoperative findings from 44 insular tumor surgeries, mainly gliomas, of patients operated on from 2007 to 2014. Results: Huge bundles of subcortical fibers, like uncinate, inferior fronto-occipital and arcuate fascicles, connect the insula to the neighboring structures. Several anatomical structures related to neurological disabilities are closely related to insular surgery, like the middle cerebral artery, internal capsule, lenticulostriate arteries and cortical and subcortical language circuits. Conclusions: Microsurgical laboratory training, 3D documentation, knowledge of brain mapping and modern neurosurgical armamentarium are important factors in achieving good results with insular glioma tumors.

Surgical treatment of drug-resistant epilepsy caused by gliomas in eloquent areas: experience report / Tratamento cirúrgico de epilepsias refratárias causadas por gliomas localizados em áreas eloquentes: uma série de casos brasileiros

ABSTRACT Drug-resistant epilepsy associated with central nervous system tumors is generally caused by low grade gliomas. This group of tumors is usually found in brain eloquent areas, such as the insular lobe, rolandic cortex and supplementary motor area and, historically, possess a greater risk of postoperative deficits. Objective: The aim of this investigation was to present our surgical experience on patients with drug-resistant epilepsy caused by gliomas in eloquent areas. We retrospectively investigated variables that impact seizure control, such as tumor location, extent of resection, invasion into the lenticulostriate arteries in the patient, especially those with insular gliomas. Methods: Out of 67 patients with eloquent area brain tumors operated on in our service between 2007 and 2016, 14 patients had symptoms of drug-resistant epilepsy. Volumetric analysis, extent of resection (EOR), type of approach and mapping, among other factors were correlated with the 12-month postoperative seizure outcome. Results: Univariate analysis showed that the factors showing statistical relevance with seizure control were preoperative volume (p = 0.005), EOR (p = 0.028) and postoperative volume (p = 0.030). Conclusion: There was a statistically significant association between the EOR and the Engel score for epilepsy control: an EOR < 70 was associated with Engel II, III, IV and an EOR > 90 was associated with Engel I. Eloquent area gliomas can safely be resected when surgeons use not only microsurgical anatomy concepts but also brain mapping.

RESUMO Epilepsia refratária secundária a tumores cerebrais são geralmente causadas por gliomas de baixo grau. Esse grupo de tumor é frequentemente localizado em áreas eloquentes do cérebro como na insula, córtex rolândico e área motora suplementar; e sua ressecção apresenta alto risco de déficits neurológicos no pós operatório. Objetivo: O objetivo do estudo consiste em apresentar nossa experiência no tratamento cirúrgico de pacientes com epilepsia refratária secundário a gliomas em áreas eloquentes. Métodos: O estudo consiste em investigação retrospectiva de variáveis que interferem no controle de crises, tais como localização do tumor, grau de ressecção, invasão tumoral de artérias lenticulo estriadas, principalmente em gliomas insulares. Dentre 67 pacientes portadores de gliomas em área eloquente operados no período de 2007 a 2016, 14 doentes apresentavam epilepsia refrataria associada. Análise volumétrica do tumor, grau de ressecção, acesso cirúrgico, bem como o uso de mapeamento cortical intraoperatório foram correlacionados com desfecho de controle de crises epilepticas em 12 meses. Resultados: Em análise univariada os fatores relacionados com controle de crises em 12 meses foram volume tumoral pré operatório (p = 0,005), grau de ressecção (p = 0,028) e volume tumoral pós operatório. Conclusão: O grau de ressecção apresentou significância estatística em relação ao controle de crises conforme escala de Engel. Ressecções menores que 70% apresentaram correlação com Engel II, III e IV; enquanto ressecções maiores que 90% apresentaram correção positiva com Engel I. Gliomas em áreas eloquentes podem ser ressecados de forma segura desde que seja realizada por equipe experiente com conhecimento acurado da anatomia microcirúrgica e emprego de mapeamento cortical intraoperatório.

Professor Fernando Costa ­ A Man Ahead of His Time

This article describes the milestones in the life Brazil's greatest neurosurgeons, Professor Fernando Costa. Born and raised in the city of Pelotas, RS, Professor Fernando was an exemplary doctor. As former director and professor at the Catholic University of Pelotas, School of Medicine, his courage as well as his ethical attitude and transparency were the central traits of this masterful teacher. He will be eternally remembered as a great physician, teacher, father, husband, grandfather and friend.

Hemangioblastomas de fosa posterior: reporte de 16 casos y revisión de la literatura / Hemangioblastoma of the posterior fossa: report of 16 cases and review of the literature

Objetivo: El propósito del presente trabajo es presentar los resultados de 16 pacientes con diagnóstico de hemangioblastoma de fosa posterior (HBFP), operados con técnicas microquirúrgicas. Método: Desde Junio de 2005 a Diciembre de 2015, 16 pacientes con diagnóstico de HBFP fueron intervenidos quirúrgicamente. Se evaluó: sexo, edad, tipo de lesión (quística con nódulo, quística sin nódulo, sólida y sólida-quística), sintomatología y resultados postoperatorios. Resultados: De los 16 pacientes intervenidos, 11 fueron varones y 5 mujeres. La edad promedio fue de 44 años. La forma más frecuente fue quística con nódulo (57%), seguida por forma sólida (31%). Un solo caso presentó la forma quística sin nódulo (6%), y uno solo la forma sólido-quística (6%). La sintomatología más frecuente fue cefalea acompañada de síndrome cerebeloso (43%), seguido de síndrome de hipertensión endocraneana (25%). En todos los casos la resección fue completa, siendo necesario en un caso una embolización previa. Como complicaciones postoperatorias, 2 pacientes presentaron ataxia (mejoró al cabo de 3 meses), y 1 paciente presentó una fístula de LCR (se solucionó con un drenaje espinal externo). Se registró un óbito por complicaciones postoperatorias. Conclusión: Lo más frecuente de ver en pacientes con HBFP es la forma quística con nódulo, siendo su sintomatología predominante la cefalea acompañada de síndrome cerebeloso. La resección quirúrgica completa es posible, con una baja tasa de morbimortalidad.

Objective: The aim of this study is to describe the results of 16 patients with posterior fossa hemangioblastoma, treated with microsurgical techniques.Method: Between June 2005 and December 2015, 16 patients with posterior fossa hemangioblastoma were operated on, underwent microsurgical resection. The sex, age, imaging findings, symptoms, and postoperative results were analyzed.Results: Eleven patients were men and 5 were women. The average age of the patients was 44 years. The most common form was cystic with nodule (57%); in 31% of the cases the lesion was purely solid. One case (6%) showed a lesion purely cystic, and one case was solid-cystic (6%). The major presenting symptoms were headache and cerebellar syndrome (43%); in 25% of the cases the patients suffered intracranial hypertension syndrome. The total resection was achieved in all the cases; in one patient an embolization was performed before surgery. Regarding postoperative complications: two patients developed ataxia (improved after three months), 1 patient presented a CSF leak (improve with an external spinal drainage). In addition, one patient died because postoperative complications.Conclusion: The major features in patients with posterior fossa hemangioblastoma are a cystic with nodule form, presenting symptoms of headache and cerebellar syndrome. The total resection is possible, with a low morbi-mortality rate.

Cerebral arteriovenous malformations. Integrated global management and therapeutic / Malformações arteriovenosas cerebrais. Manejo global integrado e terapêutica

Melhora significativa dos resultados do tratamento das Malformações Arteriovenosas (MAV) do sistema nervoso central tem sido observada, associada a avanços das modalidades de diagnóstico e tratamento. Os autores relatam esses avanços no diagnóstico e tratamento global integrado das MAV.

Anatomia microcirúrgica das artérias infratentoriais: um estudo estereoscópico / Microsurgical anatomy of the infratentorial arteries: stereoscopic printing study

CONTEXTO: O espaço infratentorial do crânio é uma região que possui complexa rede de artérias que vascularizam o tecido cerebelar e o tronco encefálico. Sua complexa anatomia tridimensional deve ser profundamente entendida pelo neurocirurgião vascular e pelo radiologista intervencionista. OBJETIVO: Descrever as principais artérias do espaço infratentorial e seu trajeto, bem como sua relação com a topografia das estruturas neurais. MÉTODOS: Foram estudados 30 cérebros humanos, fixados em formalina e 6 cabeças de cadáveres dissecadas, utilizando-se microscópico cirúrgico com 3X a 40X de aumento. Os cérebros e todas as cabeças foram injetados com siloxanos polimerizados ou polisiloxanos (silicone) colorido. As dissecções anatômicas foram documentadas utilizando-se técnica para obtenção de imagens tridimensionais (3D), objetivando a produção de impressões estereoscópicas. RESULTADOS: São descritos o trajeto, segmentos e ramos das artérias basilar, cerebelar superior, cerebelar anteroinferior, cerebelar posteroinferior e vertebral. CONCLUSÃO: A anatomia das artérias infratentoriais é complexa e as imagens estereoscópicas apresentadas são um importante instrumento de documentação, pois permitem uma noção de profundidade da anatomia estudada.

BACKGROUND: The infratentorial space is a region with a complex network of arteries supplying the cerebellum and brainstem. Its complex three-dimensional anatomy must be thoroughly understood by the vascular neurosurgeon and the interventional radiologist. OBJECTIVE: To describe the main arteries of the infratentorial space and its trajectory and its relationship to the topography of the neural structures. METHODS: We studied 30 formalin-fixed human brains and we also dissected 6 cadaver heads, using a surgical microscope with 3X to 40X magnification. The brains and all heads were injected with colored silicone. The anatomical dissections were documented with a three-dimensional method, aiming to produce stereoscopic prints. RESULTS: The neurovascular relationships, segments and branches of the basilar artery, superior cerebellar, anteroinferior cerebellar, cerebellar and posteroinferior vertebral are described. CONCLUSION: The microsurgical anatomy of the infratentorial arteries is complex and the stereoscopic images presented are an important tool for documentation.

Anatomia microcirúrgica da artéria carótida externa: um estudo estereoscópico / Microsurgical anatomy of the external carotid artery: a stereoscopic study

CONTEXTO: O conhecimento das estruturas anatômicas da artéria carótida externa por meio do estudo estereoscópico pode determinar melhores resultados em microcirurgias da artéria carótida externa. OBJETIVO: Descrever as estruturas da artéria carótida externa sob a visão estereoscópica, identificando seus múltiplos aspectos. MÉTODOS: Doze regiões cervicais foram dissecadas, utilizando-se microscópico cirúrgico com 3 a 40x de aumento. As dissecções anatômicas foram documentadas utilizando-se a técnica para obtenção de imagens tridimensionais (3D), objetivando a produção de impressões estereoscópicas. RESULTADOS: O uso da técnica estereoscópica possibilitou a abordagem da circulação arterial extracraniana, sendo realizados estudos cirúrgicos do tipo combinado fossa posterior e fossa infratemporal, tornando as microcirurgias e os procedimentos neurocirúrgicos vasculares mais precisos. CONCLUSÃO: O uso das imagens obtidas pela técnica estereoscópica produziu um resultado mais assertivo em relação ao estudo da anatomia para a microcirurgia e procedimentos neurocirúrgicos, facilitando melhor aprendizado previamente à realização de procedimentos complexos em neurocirurgia.

BACKGROUND: The knowledge on the anatomical structures of the external carotid artery through the stereoscopic study may provide better results in microsurgical treatment of the external carotid artery. OBJECTIVE: To describe the structures of the external carotid artery under stereoscopic vision, identifying its multiple aspects. METHODS: Twelve cervical regions were dissected using a surgical microscope with 3 to 40x magnification. The anatomical dissections were documented using the technique to obtain three-dimensional images (3D), aiming at producing stereoscopic prints. RESULTS: The use of the stereoscopic technique enabled the stereoscopic approach to extracranial arterial circulation, and it was followed by a combined posterior fossa and infratemporal approach, making microvascular surgery and neurosurgical procedures more precise. CONCLUSION: The use of images obtained through the stereoscopic technique produced a more assertive result in relation to the anatomy study for microsurgical or neurosurgical procedures, facilitating a better learning before performing complex procedures in neurosurgery.

Brainstem cavernomas: a surgical challenge / Cavernomas de tronco: desafio cirúrgico

Objective: The authors show their experience with brainstem cavernomas, comparing their data with the ones of a literature review. Methods: From 1998 to 2009, 13 patients harboring brainstem cavernomas underwent surgical resection. All plain films, medical records and images were reviewed in order to sample the most important data regarding epidemiology, clinical picture, radiological findings and surgical outcomes, as well as main complications. Results: The mean age was 42.4 years (ranging from 19 to 70). No predominant gender: male-to-female ratio, 6:7. Pontine cases were more frequent. Magnetic resonance imaging was used as the imaging method to diagnose cavernomas in all cases. The mean follow-up was 71.3 months (range of 1 to 138 months). Clinical presentation was a single cranial nerve deficit, VIII paresis, tinnitus and hearing loss (69.2%). All 13 patients underwent resection of the symptomatic brainstem cavernoma. Complete removal was accomplished in 11 patients. Morbidity and mortality were 15.3 and 7.6%, respectively. Conclusions: Cavernomas can be resected safely with optimal surgical approach (feasible entry zone) and microsurgical techniques, and the goal is to remove all lesions with no cranial nerves impairment.

Objetivo: Os autores mostram sua experiência com cavernomas de tronco cerebral, comparando seus dados com os de uma revisão da literatura. Métodos: De 1998 a 2009, 13 pacientes com cavernoma de tronco cerebral foram submetidos a ressecção cirúrgica. Todos os filmes, prontuários e imagens foram revisados para exposição dos dados mais importantes, como epidemiologia, detalhes clínicos, achados radiológicos e resultados cirúrgicos, bem como as principais complicações. Resultados: A média de idade foi de 42,4 anos (variação de 19 a 70). Não houve predominância de gênero na taxa masculino versus feminino, 6:7. Os casos pontinos foram os mais frequentes. Ressonância nuclear magnética foi o método de imagem para o diagnóstico de cavernomas em todos os casos. A média do acompanhamento foi de 71,3 meses (variação de 1 a 138 meses). A apresentação clínica mais frequente foi a paresia do VIII nervo craniano, tinitus e perda auditiva (69,2%). Todos os 13 pacientes com cavernomas de tronco sintomáticos foram submetidos à ressecção cirúrgica. A remoção total foi realizada em 11 pacientes. A morbidade e a mortalidade foram de 15,3 e 7,6%, respectivamente. Conclusão: Os cavernomas podem ser seguramente ressecados por meio de acessos cirúrgicos ideais (zonas de entrada seguras) e técnicas de microcirurgia, sendo que o objetivo é remover toda a lesão sem o comprometimento dos nervos cranianos.

Cirurgia da base do crânio: uma desafiadora especialidade da medicina moderna / Skull base surgery: a challenging speciality of modern medicine

A cirurgia da base do crânio emerge como uma especialidade da medicina moderna. Seu principal objetivo é tratar lesões, principalmente tumores, situados em complexa topografia anatômica e que, há duas décadas, eram considerados inoperáveis. O objetivo desta revisão é fornecer ao médicos generalistas uma visão dos aspectos conceituais, históricos, patológicos, epidemiológicos, clínicos e terapêuticos em cirurgia da base do crânio.

Skull base surgery has emerged as a specialty in modern medicine. Its main objective is to treat injuries, especially tumors located in anatomically complex sites that two decades ago were considered inoperable. The aim of this review is to provide general practitioners with a view of conceptual, historical, pathological, epidemiological, clinical and therapeutic aspects of skull base surgery.