Revisiting Parkinson: After six decades, his triangle remains useful.

Background: The welcome advent and subsequent development of interventional neuroradiology led to an important paradigm shift in the management of many cerebrovascular diseases. This paradigm shift is especially true for carotid cavernous fistula and, for some time now, endovascular techniques are the mainstay approach for these lesions. The neurosurgical intervention should be adopted when the endovascular treatment is not practicable. Case Description: We present the surgical solution adopted to treat a patient with an indirect carotid cavernous fistula (CCF), with quickly progressive symptoms, in which it was not possible to treat using the currently standardized endovascular technique. A pretemporal craniotomy with peeling of the dura mater at the middle fossa and exposure of Parkinson's triangle on the lateral wall of the cavernous sinus was performed. Fibrin glue was injected by puncture of the lateral wall of the cavernous sinus for direct thrombosis of this sinus and the superior ophthalmic vein. Conclusion: In the now far 60s, Parkinson already treated patients with CCF effectively and elegantly through the lateral wall of the cavernous sinus. Revisiting techniques from the past, associating them with the supplies widely available today, can sometimes be the solution to some especially challenging cases that we face in our profession.

The diagnostic accuracy of MRI in determining the relations between paraclinoid aneurysms and the cavernous sinus.

PURPOSE: The location of paraclinoid aneurysms is determinant for evaluation of its intradural compartment and risk of SAH after rupture. Advanced MRI techniques have provided clear visualization of the distal dural ring (DDR) to determine whether an aneurysm is intracavernous, transitional or intradural for decision-making. We analyzed the diagnostic accuracy of MRI in predicting whether a paraclinoid aneurysm is intracavernous, transitional or intradural. METHODS: We conducted a prospective cohort between January 2014 and December 2018. Patients with paraclinoid aneurysms underwent 3D fast spin-echo MRI sequence before surgical treatment. The DDR was the landmark for MRI characterization of the aneurysms as follow: (i) Intradural; (ii) Transitional; and (iii) Intracavernous. The MRI sensitivity, specificity, positive and negative likelihood ratios were determined compared to the intraoperative findings. We also evaluated the intertechnique agreement using the Cohen's kappa coefficient (κ) for dichotomous classifications (cavernous vs non-cavernous). RESULTS: Twenty patients were included in the cohort. The accuracy of MRI showed a sensitivity of 86.7% (95%CI:59.5-98.3) and specificity of 90.0% (95%CI:55.5-99.8). Analyzing only patients without history of SAH, accuracy test improved with a sensitivity of 92.3% (95%CI:63.9-99.8) and specificity reached 100% (95%CI: 63-100). Values of Cohen's kappa (κ), intertechnique agreement was considered substantial for dichotomous classifications (κ = 0.754; p < 0.001). For patients without previous SAH, intertechnique agreement was even more coincident for the dichotomous classification (κ = 0.901; p < 0.001). CONCLUSION: 3D fast spin-echo MRI sequence is a reliable and useful technique for determining the location of paraclinoid aneurysms in relation to the cavernous sinus, particularly for patients with no history of SAH.

Vertex epidural hematoma: A rare cause of post-traumatic headache and a diagnostic challenge.

BACKGROUND: Vertex epidural hematomas (VEH) account for only 8% of all epidural hematomas. However, these traumatic injuries may be underestimated or overlooked altogether when only computed tomography (CT) scans are used for diagnosis. The vertex may be a potential anatomic "blind spot" on this radiological method. In such cases, magnetic resonance (MRI) offers a great diagnostic aid. CASE DESCRIPTION: This manuscript reports a patient of a head trauma who developed progressive and intractable headache. MRI made the diagnosis of progressive VEH and highlighted the detachment of the superior sagittal sinus by the hematoma. Surgical treatment, because of the refractory clinical findings, was performed with good postoperative recovery. CONCLUSION: Multiple trauma patients with progressive and refractory headache should have their head CT thoroughly reviewed and, if necessary, be investigated with MRI.

Microsurgical anatomy and internal architecture of the brainstem in 3D images: surgical considerations.

OBJECT Brainstem surgery remains a challenge for the neurosurgeon despite recent improvements in neuroimaging, microsurgical techniques, and electrophysiological monitoring. A detailed knowledge of the microsurgical anatomy of the brainstem surface and its internal architecture is mandatory to plan appropriate approaches to the brainstem, to choose the safest point of entry, and to avoid potential surgical complications. METHODS An extensive review of the literature was performed regarding the brainstem surgical approaches, and their correlations with the pertinent anatomy were studied and illustrated through dissection of human brainstems properly fixed with 10% formalin. The specimens were dissected using the fiber dissection technique, under ×6 to ×40 magnification. 3D stereoscopic photographs were obtained (anaglyphic 3D) for better illustration of this study. RESULTS The main surgical landmarks and their relationship with the cerebellum and vascular structures were identified on the surface of the brainstem. The arrangements of the white matter (ascending and descending pathways as well as the cerebellar peduncles) were demonstrated on each part of the brainstem (midbrain, pons, and medulla oblongata), with emphasis on their relationships with the surface. The gray matter, constituted mainly by nuclei of the cranial nerves, was also studied and illustrated. CONCLUSIONS The objective of this article is to review the microsurgical anatomy and the surgical approaches pertinent to the brainstem, providing a framework of its external and internal architecture to guide the neurosurgeon during its related surgical procedures.

Os sulcos e giros na face súpero-lateral do lobo occipital / The occipital lobe convexity sulci and gyri

Introdução: A anatomia da face súpero-lateral do lobo occipital é tão complexa e variável que a sua descrição precisa não é encontrada nos livros clássicos de anatomia. Os sulcos e giros occipitais da convexidade cerebral encontram-se descritos com nomenclaturas diferentes de acordo com os diversos autores. O objetivo deste estudo foi investigar e descrever a anatomia da face súpero-lateral lobo occipital e esclarecer a sua nomenclatura. Métodos: As configurações anatômicas dos sulcos e giros na face súpero-lateral do lobo occipital de 20 hemisférios cerebrais foram examinados a fim de identificar os padrões mais característicos e consistentes. Resultados: Os sulcos occipitais mais característicos e consistentes identificados neste estudo foram o sulco intraoccipital, o sulco occipital transverso e o sulco occipital lateral. A morfologia da junção do sulco occipital transverso com o sulco intraoccipital foi identificada como sendo o aspecto mais importante para definir o padrão de giros cerebrais da face súperolateral do lobo occipital. Conclusões: O conhecimento das principais características dos sulcos e giros occipitais permite o reconhecimento de uma configuração básica do lobo occipital e a identificação de suas principais variações anatômicas.

Background: The anatomy of the occipital lobe convexity is so intricate and variable that its precise description is not found in the classic anatomy textbooks, and the occipital sulci and gyri are described with different nomenclatures according to different authors. The aim of this study was to investigate and describe the anatomy of the occipital lobe convexity and clarify its nomenclature. Methods: The configurations of sulci and gyri on the lateral surface of the occipital lobe of 20 cerebral hemispheres were examined in order to identify the most characteristic and consistent patterns. Results: The most characteristic and consistent occipital sulci identified in this study were the intraoccipital, transverse occipital, and lateral occipital sulci. The morphology of the transverse occipital sulcus and the intraoccipital sulcus connection was identified as the most important aspect to define the gyral pattern of the occipital lobe convexity. Conclusions: Knowledge of the main features of the occipital sulci and gyri permits the recognition of a basic configuration of the occipital lobe and the identification of its sulcal and gyral variations.

Microsurgical anatomy of the optic radiation and related fibers in 3-dimensional images.

BACKGROUND: The fiber dissection technique provides unique 3-dimensional anatomic knowledge of the white matter. OBJECTIVE: To examine the optic radiation anatomy and its important relationship with the temporal stem and to discuss its findings in relation to the approaches to temporal lobe lesions. METHODS: We studied 40 cerebral hemispheres of 20 brains that had been fixed in formalin solution for 40 days. After removal of the arachnoid membrane, the hemispheres were frozen, and the Klingler technique was used for dissection under magnification. Stereoscopic 3-dimensional images of the dissection were obtained for illustration. RESULTS: The optic radiations are located deep within the superior and middle temporal gyri, always above the inferior temporal sulcus. The mean distance between the cortical surface and the lateral edge of the optic radiation was 21 mm. Its fibers are divided into 3 bundles after their origin. The mean distance between the anterior tip of the temporal horn and the Meyer loop was 4.5 mm, between the temporal pole and the anterior border of the Meyer loop was 28.4 mm, and between the limen insulae and the Meyer loop was 10.7 mm. The mean distance between the lateral geniculate body and the lateral margin of the central bundle of the optic radiation was 17.4 mm. CONCLUSION: The white matter fiber dissection reveals the tridimensional intrinsic architecture of the brain, and its knowledge regarding the temporal lobe is particularly important for the neurosurgeon, mostly because of the complexity of the optic radiation and related fibers.

Topical antibiotics and neurosurgery: Have we forgotten to study it?

BACKGROUND: For neurosurgery, the last decades have been a time of incredible improvement in areas such as imaging, microscopy, endoscopy, stereotactic guidance, navigation, radiosurgery and endovascular techniques. However, the efficacy of topical antibiotic prophylaxis in neurological operations remains to be established by neurosurgeons. METHODS: The authors did an historical review of the literature regarding the utilization of topical antibiotic prophylaxis in neurological operations. The Pub Med database of the U.S. National Library of Medicine / National Institutes of Health was utilized as the primary source of the literature. The authors performed the search by using the following Mesh terms: "neurosurgery" or "neurosurgical procedures" and "administration, topical" and "antibiotic prophylaxis"; "neurosurgery" or "neurosurgical procedures" and "administration, topical" and "antibacterial agents." RESULTS: In the last 70 years, we have poorly studied the use of topical antibiotics in neurosurgery. All the papers reported were Class III evidence. CONCLUSION: To the best of our knowledge, there is no publication that provided Class I or II evidence about topical antibiotic prophylaxis in neurosurgery.

Cistos sinoviais espinhais causando déficit neurológico: relato dois casos distintos / Spinal synovial cists causing neurological deficit: report of two distinct cases

Cistos sinoviais da coluna são normalmente assintomáticos e raramente determinam compressão radicular ou medular. Os autores relatam dois casos de cistos sinoviais da coluna vertebral. Um paciente possuía um cisto cervical causando mielopatia, e um segundo paciente apresentava um cisto lombar, com gradual quadro de radiculopatia. Em ambos os casos, os pacientes tiveram melhora dos sintomas e boa evolução clínica após remoção cirúrgica dos cistos. Os cistos sinoviais devem ser incluídos no diagnóstico diferencial de lesões extradurais raquidianas. A literatura é revista e a etiologia, apresentação clínica, diagnóstico e tratamento são discutidos.

Meningiomas induzidos por radiação: a importância seguimento contínuo após irradiação craniana / Radiation-induced meningiomas: the importance of continued follow up after cranial irradiation

O surgimento de tumores é uma complicação tardia após irradiação craniana, e destes a maior parte corresponde a meningiomas intracranianos. O período de latência entre a exposição à radiação e o diagnóstico de um meningioma induzido por radiação varia com o período inicial de exposição à radiação e a dose total recebida. Os autores relatam dois casos de meningiomas resultantes de altas doses de radiação recebidas para tratamento de um PNET. Ambos os pacientes foram submetidos à ressecção cirúrgica do tumor, e a análise imunohistoquímica revelou se tratar de meningioma típico.Estes casos ilustram a importância do seguimento contínuo após irradiação craniana na população pediátrica.

Processos infecciosos e torcicolo, há algo com que se preocupar? / Infectious process and torticollis, is there something to worry about?

A subluxação rotatória atlantoaxial em associação com processos infecciosos da cabeça e do pescoço (Síndrome de Grisel)é uma doença rara e pobremente relatada e não reportada. A patogênese da síndrome é incerta e diversas teorias foram propostas para explicá-la. Este trabalho relata uma criança de 7anos de idade com s Síndrome de Grisel e a literatura sobre o tema é brevemente revisada.

Ependimoma simulando cavernoma do terceiro ventrículo: relato de caso / Ependymoma mimicking cavernous malformation of the third ventricle: case report

Introdução: Erro diagnóstico de lesões do terceiro ventrículonão são raras. Descrição do caso: Os autores relatamum paciente que se apresentou com uma lesão no terceiroventrículo cuja aparência inicial em exames de neuroimagemlevou ao diagnóstico de malformação cavernosa. Um acessotranscaloso transcoroídeo foi realizado e ressecção completada lesão foi obtida. Análise histopatológica e imunohistoquímicarevelaram um raro diagnóstico de ependimoma doterceiro ventrículo. Conclusão: Ependimomas não devem seromitidos dos diagnósticos diferenciais de lesões do terceiroventrículo, apesar de tal localização não ser usual para estaslesões e serem raramente descritas.

A ética e a comunidade médica de uma cidade desprovida de instituição de ensino médico / Medical ethics and the medical profession in a brazilian city without a medical school

O ensino de ética médica nas faculdades de Medicina brasileiras é caracterizado, predominantemente, por uma visão legalista e deodontológica, insuficiente para a adequação do profissional à sociedade moderna. Esta pesquisa procurou caracterizar os médicos que atuam numa cidade do interior de São Paulo, que não dispõe de uma escola médica, quanto ao seu grau de conhecimento sobre Ética Médica. Este conhecimento possibilitará que os responsáveis pelo ensino da graduação e por programas de educação continuada promovam as necessárias reformulações em suas atividades, assegurando o aprimoramento e a otimização ética dos estudantes e dos médicos em atuação.

Doença cerebrovascular oclusiva crônica (doença de Moyamoya) / Moyamoya disease. Case report

A doença cerebrovascular oclusiva crônica (doença de Moyamoya) é patologia de etiologia desconhecida, em princípio considerada afecção restrita às pessoas de origem japonesa. Trata-se de uma doença incomum, mas importante causa de acidente vascular cerebral. Apresentamos o caso de um paciente com 38 anos de idade, de descendência japonesa, que apresentou a forma isquêmica da doença, embora a forma mais encontrada em adultos seja a hemorrágica. Chamamos a atenção para a inclusão dessa patologia no diagnóstico diferencial das neuropatologias vasculares.