Cavernous hemangiomas of the cavernous sinus belong to a welldistinguished entity of extra-axial cavernous hemangiomas located in the cavernous sinus and have a typical appearance on magnetic resonance imaging (MRI). Severe intraoperative bleeding has been described during the excision of these lesions that is probably associated with their pathological features. An atypical case of a sclerosing lesion with distinct MRI features is described. In these particular cases, especially with giant hemangiomas where en bloc excision would be difficult, safe internal decompression and resection can be achieved.

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-In the treatment of complex paraclinoidal and giant cavernous aneurysms, preservation of the patency of the internal carotid artery (ICA) is not always possible, and therapeutic occlusion of the carotid is still an important option for their management. A complete preoperative evaluation of the carotid reserve circulation, including the use of temporary balloon occlusion test and single photon emission computerized tomography (SPECT) should be included in the current paradigms of paraclinoidal and intracavernous aneurysms management. We present a series of fifteen patients with sixteen giant or complex carotid cavernous or ophthalmic aneurysms that were treated following a protocol for our preoperative decision-making analysis. Extracranial to intracranial saphenous vein bypass was reserved to the cases where carotid occlusion would be associated with high risk of ischemic complications and was performed in three patients. Besides the difficulties in dealing with those complex aneurysms, good clinical outcome was possible in our experience with the designed paradigm.KEY WORDS: intracranial aneurysm, cavernous aneurysm, SPECT, balloon occlusion.Aneurismas paraclinoideos complexos e cavernosos gigantes: importância da avaliação pré-operatória com teste de oclusão temporária com balão e SPECT RESUMO -No tratamento de aneurismas paraclinoideos complexos e cavernosos gigantes, a preservação da patência vascular nem sempre é possível, e a oclusão terapêutica da carótida ainda é uma opção importante no seu manejo. Uma avaliação pré-operatória completa da reserva circulatória carotídea, incluindo o uso do teste de oclusão temporária por balão associado à tomografia computadorizada por emissão de fóton único (SPECT) podem ser de grande utilidade para definir a opção terapêutica a ser adotada. Nós apresentamos uma série de quinze pacientes com dezesseis aneurismas complexos ou gigantes do segmento oftálmico e cavernoso da artéria carótida, que foram tratados de acordo com determinado protocolo de investigação pré-operatória. Anastomose com enxerto de veia safena entre a carótida extra e intracraniana foi reservada para os casos em que a oclusão carotídea estaria associada a um alto risco de complicações isquêmicas e foi realizado em três pacientes. Apesar das dificuldades em lidar com aneurismas complexos como os aqui relatados, é possível obter um bom resultado clínico nestes pacientes com o paradigma desenhado.PALAVRAS-CHAVE: aneurisma intracraniano, aneurisma cavernoso, SPECT, oclusão com balão.Advances in surgical techniques and cranial base approaches have greatly improved surgical outcomes with paraclinoidal aneurysms. However, they still represent a challenge for surgical management. A significant number of paraclinoidal aneurysms present as giant and complex aneurysms. Although most of them are manageable by direct clipping, occasionally proximal and distal temporary occlusion and defla-

SUMMARY -Aneurysms arising at the proximal intracranial carotid artery (between cavernous sinus and posterior communicating artery) and at the anterior communicating complex may present with technical difficulties regarding appropriate access without excessive brain retraction. In a series of 15 patients the authors show the use of the cranio-orbital approach, formerly designed in the access of skull base tumors, for these subgroups of aneurysms. They discuss the advantages of a basal avenue in minimizing brain retraction, better anatomical orientation, obviation of tissue ressection and easier extra-dural bone removal. It was not identified any complication due to the described approach.KEY WORDS: intracranial aneurysms, paraclinoidal aneurysms, skull base surgery, subarachnoid hemorrhage. Acesso crânio-orbital para aneurismas paraclinóideos e da comunicante anteriorRESUMO -Aneurismas situados junto à artéria carótida intracraniana proximal (entre seio cavernoso e artéria comunicante posterior) e ao nível do complexo comunicante anterior podem apresentar dificuldades técnicas relacionadas ao acesso apropriado sem retração cerebral excessiva. Em uma série de 15 pacientes os autores mostram o uso do acesso crânio-orbital, utilizado inicialmente para abordagem a tumores da base do crânio, para esses subgrupos de aneurismas. Discutem suas vantagens em minimizar retração, melhor orientação anatômica, evitar ressecção de tecido neural e facilitar remoção óssea. Não foi identificada qualquer complicação devida ao acesso descrito. PALAVRAS-CHAVE: aneurisma intracraniano, aneurisma paraclinóideo, cirurgia da base do crânio, hemorragia subaracnóidea.

Background:Chordomas are rare slowly growing tumors that originate from remnants of the notochord. They have a malignant local behavior, causing symptoms due to bone infiltration and compression of neurovascular structures. Only a few cases of brain tumors associated with pathological laughter have been reported in the literature.Case Description:We report a case of a 42-year-old male patient with this atypical clinical presentation treated at our institution, and discuss the concerning literature.Conclusion:Although being a very rare presentation of chordomas, pathological laughter is usually expected to improve after brain stem decompression.

Background Medulloblastoma (MB),the most common malignant brain tumor of childhood has survival outcomes exceeding 80% for standard‐risk and 60% for high‐risk patients in high‐income countries (HICs). These results have not been replicated in low‐ and middle‐income countries (LMICs), where 80% of children with cancer live. Methods This is a retrospective review of 114 children aged 3–18 years diagnosed with MB from 1997 to 2016 at National Cancer Institute (INCA). Sociodemographic, clinical, and treatment data were extracted from the medical records and summarized descriptively. Overall survival (OS) and progression‐free survival (PFS) were calculated using the Kaplan–Meier method. Results The male‐to‐female ratio was 1.32 and the median age at diagnosis was 8.2 years. Headache (83%) and nausea/vomiting (78%) were the most common presenting symptoms. Five‐year OS was 59.1% and PFS was 58.4%. The OS for standard‐risk and high‐risk patients was 69% and 53%, respectively. The median time to diagnosis interval was 50.5 days and the median time from surgery to radiation therapy initiation was 50.4 days. Patients who lived >40 km from INCA fared better (OS = 68.2% vs. 51.1%, p = .032). Almost 20% of families lived below the Brazilian minimum wage. Forty‐five patients (35%) had metastatic disease at admission. Gross total resection was achieved in 57% of the patitents. Conclusions Although there are considerable barriers to deliver effective MB treatment in countries like Brazil, the OS seen in the present study demonstrates that good outcomes are not only feasible but can and should be increased with appropriate interventions.

Purpose The objective of this study is to evaluate the meningioma`s hormone receptor expression in patients who presented synchronous or metachronous meningioma and breast cancer and compare its profile to the non-breast cancer associated meningiomas described in the literature. Methods The authors conducted a retrospective descriptive study evaluating all cases of synchronous and metachronous meningiomas and breast cancer from January 1st, 1990 to December 31st, 2020. The study was approved by the Ethics Review Board. Variables related to meningioma (age and year of diagnosis, histological grade and subtype, topography, the presence of progesterone and/or estrogen receptors) and to breast cancer (age and year of diagnosis, the histological grade and subtype, the presence of progesterone and/or estrogen receptors) were collected on the hospital`s electronic health records. Results A total of 12 cases were included in the study, being 2 (17%) synchronous and 10 (83%) metachronous. The mean age at meningioma diagnosis was 60.58 (± 10,99). The most frequent intracranial topography was convexity and sphenoid wing meningiomas (25% each). Ten patients (83%) had grade 1 meningiomas and 2 patients (16.6%) presented with grade 2 meningiomas. Eleven cases of meningiomas expressed progesterone receptors (91.67%) while 3 cases expressed estrogen receptors (25%). One patient did not express hormonal receptor. Conclusion The WHO histological analysis and steroid receptors profile did not seem to be different in the meningiomas included in this sample when compared to the description of no-breast cancer associated meningiomas.

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