Drug resistant epilepsy of the insular lobe: A review and update article.

Background: Epilepsy is a chronic disease that affects millions of people around the world generating great expenses and psychosocial problems burdening the public health in different ways. A considerable number of patients are refractory to the drug treatment requiring a more detailed and specialized investigation to establish the most appropriate therapeutic option. Insular epilepsy is a rare form of focal epilepsy commonly drug resistant and has much of its investigation and treatment involved with the surgical management at some point. The insula or the insular lobe is a portion of the cerebral cortex located in the depth of the lateral sulcus of the brain; its triangular in shape and connects with the other adjacent lobes. The insular lobe is a very interesting and complex portion of the brain related with different functions. Insula in Latin means Island and was initially described in the 18th century but its relation with epilepsy was first reported in the 1940-1950s. Insular lobe epilepsy is generally difficult to identify and confirm due to its depth and interconnections. Initial non-invasive studies generally demonstrate frustrating or incoherent information about the origin of the ictal event. Technological evolution made this pathology to be progressively better recognized and understood enabling professionals to perform the correct diagnosis and choose the ideal treatment for the affected population. Methods: A literature review was performed using MEDLINE/PubMed, Scopus, and Web of Science databases. The terms epilepsy/epileptic seizure of the insula and surgical treatment was used in various combinations. We included studies that were published in English, French, or Portuguese; performed in humans with insular epilepsy who underwent some surgical treatment (microsurgery, laser ablation, or radiofrequency thermocoagulation). Results: Initial search results in 1267 articles. After removing the duplicates 710 remaining articles were analyzed for titles and abstracts applying the inclusion and exclusion criteria. 70 studies met all inclusion criteria and were selected. Conclusion: At present, the main interests and efforts are in the attempt to achieve and standardize the adequate management of the patient with refractory epilepsy of the insular lobe and for that purpose several forms of investigation and treatment were developed. In this paper, we will discuss the characteristics and information regarding the pathology and gather data to identify and choose the best therapeutic option for each case.

Proteomics pinpoints alterations in grade I meningiomas of male versus female patients.

Meningiomas are among the most common primary tumors of the central nervous system (CNS) and originate from the arachnoid or meningothelial cells of the meninges. Surgery is the first option of treatment, but depending on the location and invasion patterns, complete removal of the tumor is not always feasible. Reports indicate many differences in meningiomas from male versus female patients; for example, incidence is higher in females, whereas males usually develop the malignant and more aggressive type. With this as motivation, we used shotgun proteomics to compare the proteomic profile of grade I meningioma biopsies of male and female patients. Our results listed several differentially abundant proteins between the two groups; some examples are S100-A4 and proteins involved in RNA splicing events. For males, we identified enriched pathways for cell-matrix organization and for females, pathways related to RNA transporting and processing. We believe our findings contribute to the understanding of the molecular differences between grade I meningiomas of female and male patients.

Microsurgical Resection of Cerebellopontine Angle Meningioma.

Meningiomas of the cerebellopontine angle (CPA) are the second most frequent lesions related to this region (around 10-15%), 1 being the vestibular schwannomas the first (around 85%). This lesions arise from the dura of the petrosal surface of the temporal bone, lateral to the trigeminal nerve ( Fig. 1 ). Variable attachment sites and directions of growth make different clinical presentations and operative challenges. This pathologies can be classified accordingly to they're extension related to the internal acoustic meatus in: postmeatal, premeatal, and large meningiomas with pre- and postmeatal extension ( Fig. 2 ). We present an operative video performed by the senior author (L.A.B.B.). A 64-year-old woman with 3 months of complaint of left facial pain on the V2 territory of the trigeminal nerve and diplopia secondary to VI nerve paresis. Magnetic resonance imaging (MRI) scans demonstrated a large homogeneous enhancing lesion at the left CPA, extending pre- and postmeatal and from the tentorium cerebeli to the jugular foramen region, highly suggestive of CPA meningioma. Surgery was offered to the patient as a first option. In our point of view, neurophysiological monitoring with somatosensory and motor evoked potentials is mandatory while dealing with such large tumors around the CPA. The surgery was performed after a standard retrosigmoid craniotomy, with careful dissection and debulking while devascularizing the tumor from its petrosal attachment. Near-total resection was achieved and the patient had a remarkable postoperative outcome with improvement of the diplopia and facial pain with preservation of VII and VIII nerves function. The pathology demonstrated a grade 1 meningioma. The link to the video can be found at: https://youtu.be/UVVyEhq8Fu0 .

Combined Presigmoid and Retrosigmoid Approach to Petroclival Meningiomas.

Introduction The management of petroclival meningiomas is among the most intimidating in neurosurgery, due to its difficult accessibility and close relationship with vital structures; therefore, an appropriate exposure is mandatory. We present a surgical video demonstrating a presigmoid transtentorial approach, associated with the opening of the retrosigmoid dura to a petroclival meningioma, performed by the senior surgeon (L.A.B.B.), along with its indications and pitfalls. Approach Decision The patient's clinical history is summed to the tumor's radiological features as its extension, vascularization, and venous drainage, when selecting the appropriate approach. The presigmoid transtentorial approach offers a wide exposure of the petroclival area along with the tumor's attachment. Its association with the retrosigmoid route allows the surgeon to freely work through multiple paths, and parallel to the skull base, reducing the traction in the temporal lobe. Clinical Case This is a 39-year-old female presenting with trigeminal neuralgia. Imaging depicted a petroclival meningioma, extending from the posterior aspect of the cavernous sinus to the cerebellopontine angle, extending inferiorly to the jugular bulb. A Simpson II resection was achieved through a combined presigmoid and retrosigmoid approach, and the patient was discharged with no complications or new deficits. Conclusion Petroclival meningiomas are a formidable and surgically treatable disease. The appropriate approach is design to each patient and should not be the limiting factor for total tumor removal, which is truly given by the absence of a dissection plane between the tumor and the brainstem, nerves and vascular structures of the skull base. The link to the video can be found at: https://youtu.be/MFjqZvElBSo .