Awake Craniotomy for Removal of Left Insular Cavernous Malformation.

The insula plays a crucial role in speech planning due to its connections with cortical and subcortical areas. Surgical management of cavernous malformation (CM) of the insula consists of total resection of the lesion and the surrounding gliosis to avoid or reduce seizures. When located in the dominant hemisphere, an awake craniotomy with intraoperative mapping reduces the risk of functional damage. The insula is covered by the operculum and has a relationship with the middle cerebral artery and its branches that run along its lateral surface. Therefore high expertise is required to manage the exposure of the insula and its complex anatomy. This video demonstrates the surgical management of a large left insular CM. A 29-year-old female with multiple CM and 7 years of partial seizures and recent onset of short memory loss. Neuroimaging showed a large left insular and planum polare CM with important mass effect and hemorrhage signs. The patient consented to surgery, and an awake pretemporal craniotomy was carried out with continuous motor evoked potential monitoring. No language function was localized in the superior temporal gyrus; therefore corticectomy of the middle portion was performed to expand the operative corridor. The vessel manipulation during wide opening of the sylvian fissure increased the risk of postoperative vasospasm and blood drain into the surgical field. The CM was exposed and completely removed without functional damage. The patient recovered from surgery without complications, and no seizures occurred at 2 months' follow-up. Postoperative imaging showed complete removal of the CM.

Surgical anatomy of the superior hypophyseal artery and its relevance for endoscopic endonasal surgery.

OBJECTIVE: The endoscopic endonasal approach has become a routine corridor to the suprasellar region. The superior hypophyseal arteries (SHAs) are intimately related to lesions in the suprasellar space, such as craniopharyngiomas and meningiomas. Here the authors investigate the surgical anatomy and variations of the SHA from the endoscopic endonasal perspective. METHODS: Thirty anatomical specimens with vascular injection were used for endoscopic endonasal dissection. The number of SHAs and their origin, course, branching, anastomoses, and areas of supply were collected and analyzed. RESULTS: A total of 110 SHAs arising from 60 internal carotid arteries (ICAs), or 1.83 SHAs per ICA (range 0-3), were found. The most proximal SHA always ran in the preinfundibular space and provided the major blood supply to the infundibulum, optic chiasm, and proximal optic nerve; it was defined as the primary SHA (pSHA). The more distal SHA(s), present in 78.3% of sides, ran in the retroinfundibular space and supplied the stalk and may also supply the tuber cinereum and optic tracts. In the two sides (3.3%) in which no SHA was present, the territory was covered by a pair of infundibular arteries originating from the posterior communicating artery. Two-thirds of the pSHAs originated proximal to the distal dural ring; half of these arose from the carotid cave portion of the ICA, whereas the other half originated proximal to the cave. Four branching patterns of the pSHA were recognized, with the most common pattern (41.7%) consisting of three or more branches with a tree-like pattern. Descending branches were absent in 25% of cases. Preinfundibular anastomoses between pSHAs were found in all specimens. Anastomoses between the pSHA and the secondary SHA (sSHA) or the infundibular arteries were found in 75% cases. CONCLUSIONS: The first SHA almost always supplies the infundibulum, optic chiasm, and proximal optic nerve and represents the pSHA. Compromising this artery can cause a visual deficit. Unilateral injury to the pSHA is less likely to cause an endocrine deficit given the artery's abundant anastomoses. A detailed understanding of the surgical anatomy of the SHA and its many variations may help surgeons when approaching challenging lesions in the suprasellar region.

Rinorraquia secundaria a meningocele transclival. A propósito de un caso y revisión de la literatura / Cerebrospinal fluid rhinorrhea from a transclival meningocele: a case report and literature review

El lugar más común de fístulas de líquido cefalorraquídeo (LCR) es el suelo de la fosa craneal anterior, menos comúnmente el seno esfenoidal. Solo el 3-4% de fístulas de LCR son espontáneas. Nosotros presentamos el cuarto caso clínico de rinorraquia secundaria a meningocele transclival, lugar muy poco común de asiento de estas lesiones, y discutimos la vía de abordaje. Varón de 39años, sin antecedentes de traumatismo previo, historia reciente de salida de líquido transparente a través de las ventanas nasales y cuadro de meningitis. La tomografía computarizada y la resonancia magnética mostraron el defecto óseo clival y meningocele transclival. El defecto fue reparado mediante abordaje endonasal endoscópico transesfenoidal transclival con resultado favorable. A pesar de la rareza del meningocele transclival, se recomienda considerarlo en el diagnóstico diferencial de las fístulas nasales espontáneas. El abordaje endonasal endoscópico es una técnica directa que ofrece resultados satisfactorios en la resolución de rinorrea de LCR

The most common site of CSF leakage is the floor of the anterior cranial fossa, and less commonly in the sphenoid sinus. Only 3-4% of CSF fistulas are spontaneous. The fourth case is presented of a CSF rhinorrhea due to a transclival meningocele, an extremely rare location for these lesions, and the surgical approach. The patient is a 39-year-old male with no history of trauma, and a recent history of watery rhinorrhe and meningitis. CT scan and MRI showed clival bone defect and trans-sphenoidal transclival meningocele. The defect was repaired by transclival trans-sphenoidal endoscopic endonasal approach with good results. Despite the rarity of transclival meningocele, it is recommended to consider it in the differential diagnosis of spontaneous nasal fistulas. The endoscopic endonasal approach is a direct technique that provides satisfactory results in the resolution of CSF rhinorrhea

Migración intratorácica de catéter de derivación ventriculoperitoneal: a propósito de un caso / Intrathoracic migration of a ventriculoperitoneal shunt catheter: a case report

Introducción: Las complicaciones intratorácicas secundarias a la colocación de una derivación ventriculoperitoneal son infrecuentes, aunque se asocian a graves consecuencias si no son tratadas de forma adecuada. Caso clínico: Describimos un caso de migración intratorácica de un catéter peritoneal tras derivación ventriculoperitoneal y se revisan las escasas referencias en la literatura, con discusión de los posibles mecanismos de penetración en la cavidad torácica. En ninguno de los artículos publicados se describe la presencia de un paciente con estereotomía previa como en nuestro caso. Conclusión: Es recomendable que tras el diagnóstico de la migración descrita, se proceda a un tratamiento precoz de reposicionamiento del catéter que evite complicaciones posteriores de mayor relevancia. Asimismo, durante la colocación de una derivación ventriculoperitoneal destacamos la importancia de la palpación permanente del catéter durante la tunelización subcutánea para evitar la migración intratorácica del mismo

Background: The intrathoracic complications from ventriculoperitoneal shunt placement are very rare. However, they are potentially serious if not treated. Clinical case: We report the case of thoracic migration of a peritoneal catheter after ventriculoperitoneal shunt and we also review the literature references with discussion of the different mechanisms of shunt-tip migration described. No case of previous sternotomy as in our patient has been found published. Conclusion: All reports recommend early catheter repositioning into the peritoneal cavity after diagnosing the migration described, to prevent worse complications. Moreover, it is important to keep in mind that intrathoracic migration can happen and it is necessary to palpate the catheter continuously during passage through subcutaneous tunnelling to prevent it

[Cerebrospinal fluid rhinorrhea from a transclival meningocele: A case report and literature review]. / Rinorraquia secundaria a meningocele transclival. A propósito de un caso y revisión de la literatura.

The most common site of CSF leakage is the floor of the anterior cranial fossa, and less commonly in the sphenoid sinus. Only 3-4% of CSF fistulas are spontaneous. The fourth case is presented of a CSF rhinorrhea due to a transclival meningocele, an extremely rare location for these lesions, and the surgical approach. The patient is a 39-year-old male with no history of trauma, and a recent history of watery rhinorrhe and meningitis. CT scan and MRI showed clival bone defect and trans-sphenoidal transclival meningocele. The defect was repaired by transclival trans-sphenoidal endoscopic endonasal approach with good results. Despite the rarity of transclival meningocele, it is recommended to consider it in the differential diagnosis of spontaneous nasal fistulas. The endoscopic endonasal approach is a direct technique that provides satisfactory results in the resolution of CSF rhinorrhea.

[Intrathoracic migration of a ventriculoperitoneal shunt catheter: a case report]. / Migración intratorácica de catéter de derivación ventriculoperitoneal: a propósito de un caso.

BACKGROUND: The intrathoracic complications from ventriculoperitoneal shunt placement are very rare. However, they are potentially serious if not treated. CLINICAL CASE: We report the case of thoracic migration of a peritoneal catheter after ventriculoperitoneal shunt and we also review the literature references with discussion of the different mechanisms of shunt-tip migration described. No case of previous sternotomy as in our patient has been found published. CONCLUSION: All reports recommend early catheter repositioning into the peritoneal cavity after diagnosing the migration described, to prevent worse complications. Moreover, it is important to keep in mind that intrathoracic migration can happen and it is necessary to palpate the catheter continuously during passage through subcutaneous tunnelling to prevent it.

Tumor glioneuronal formador de rosetas del cuarto ventrículo. Presentación de un caso y revisión de la literatura / No disponible

INTRODUCCIÓN: El tumor glioneuronal formador de rosetas (TGFR) del cuarto ventrículo es un tumor infrecuente que ha sido recientemente caracterizado. Fue incluido como una nueva neoplasia glioneural en el ańo 2007 por la Organización Mundial de la Salud (OMS) en la clasificación de tumores del sistema nervioso central. Dentro de este grupo hemos encontrado 34 casos documentados. En este artículo presentamos un nuevo caso de TGFR del cuarto ventrículo con hemorragia intratumoral postraumática y revisamos la literatura existente de esta nueva entidad. CASO CLÍNICO: Paciente de 30 ańos que tras sufrir traumatismo craneoencefálico leve presentó cefalea, diplopía y ataxia. Los estudios de tomografía computarizada y resonancia magnética cerebral revelaron una tumoración a nivel del cuarto ventrículo con sangrado intralesional y áreas de calcificación. La paciente fue intervenida realizándose extirpación tumoral macroscópicamente completa. El estudio anatomopatológico mostró un tumor glioneuronal formador de rosetas del cuarto ventrículo. CONCLUSIONES: Los TGFR del cuarto ventrículo son raros y afectan a adultos jóvenes. La evidencia demuestra que el pronóstico suele ser favorable, pero existe la posibilidad de progresión y recidiva. La hemorragia intratumoral es una forma de presentación muy poco habitual que implica riesgo para la vida del paciente. La resección quirúrgica debe ser cuidadosa debido a la localización de estas lesiones y su extensión hacia zonas críticas. Todos los pacientes, independientemente del grado de resección logrado, precisan un seguimiento a largo plazo por el riesgo de recidiva tardía

INTRODUCTION: Rosette-forming glioneuronal tumor (RGNT) of the fourth ventricle is a rare tumor that has been recently characterized. RGNT was included as a new glioneuronal tumor in 2007 by the World Health Organization (WHO) in classification of tumors of the central nervous system. Within this group we found 34 documented cases. We present a new case of RGNT of the fourth ventricle with intratumoral posttraumatic bleeding and review the existing literature of this new entity. CASE REPORT: A 30-year-old patient was admitted after suffering mild traumatic brain injury (TBI) had headache, diplopia and ataxia. Studies of computed tomography and magnetic resonance imaging revealed a tumor at the fourth ventricle with intralesional bleeding and areas of calcification. She was operated performing macroscopically complete tumor resection. Pathologic examination showed a rosette-forming glioneuronal tumor of the fourth ventricle. CONCLUSIONS: The RGNT of the fourth ventricle are rare and affect young adults. The evidence shows that the prognosis is usually favorable but there is the possibility of progression and recurrence. Intratumoral hemorrhage is a very unusual presentation that involves risk to the patient's life. Surgical resection should be careful due to the location of these lesions and their extension into critical areas, all patients regardless of extent of resection achieved require a long-term monitoring of the risk of late relapse

[Rosette-forming glioneuronal tumor of the fourth ventricle. Case report and literature review]. / Tumor glioneuronal formador de rosetas del cuarto ventrículo. Presentación de un caso y revisión de la literatura.

INTRODUCTION: Rosette-forming glioneuronal tumor (RGNT) of the fourth ventricle is a rare tumor that has been recently characterized. RGNT was included as a new glioneuronal tumor in 2007 by the World Health Organization (WHO) in classification of tumors of the central nervous system. Within this group we found 34 documented cases. We present a new case of RGNT of the fourth ventricle with intratumoral posttraumatic bleeding and review the existing literature of this new entity. CASE REPORT: A 30-year-old patient was admitted after suffering mild traumatic brain injury (TBI) had headache, diplopia and ataxia. Studies of computed tomography and magnetic resonance imaging revealed a tumor at the fourth ventricle with intralesional bleeding and areas of calcification. She was operated performing macroscopically complete tumor resection. Pathologic examination showed a rosette-forming glioneuronal tumor of the fourth ventricle. CONCLUSIONS: The RGNT of the fourth ventricle are rare and affect young adults. The evidence shows that the prognosis is usually favorable but there is the possibility of progression and recurrence. Intratumoral hemorrhage is a very unusual presentation that involves risk to the patient's life. Surgical resection should be careful due to the location of these lesions and their extension into critical areas, all patients regardless of extent of resection achieved require a long-term monitoring of the risk of late relapse.