-Vein of Galen aneurysm is a rare pathology, representing less than 1% of intracranial vascular malformations. We report on a 65 years-old man who experienced a generalized tonic-clonic seizure. Brain imaging showed a large calcified expanding mass in the pineal region, confirming the diagnosis of a vein of Galen aneurysm. Because of the spontaneous thrombosis of the malformation, there was no need for microsurgical or endovascular treatment and he is been regularly followed since that.KEY WORDS: vein of Galen aneurysm, vein of Galen malformation, cerebral vein, congenital vascular malformation. Aneurisma da veia de Galeno em adulto: relato de casoRESUMO -Aneurisma da veia de Galeno é patologia rara, representando menos de 1% das malformações vasculares intracranianas. Apresentamos o caso de um homem de 65 anos que teve episódio de crise convulsiva tônico-clônica generalizada. Exames de imagem evidenciaram grande processo expansivo calcificado na região pineal, confirmando o diagnóstico de aneurisma trombosado de veia de Galeno. Devido à trombose espontânea da malformação, foi excluída a possibilidade de tratamento endovascular bem como microcirúrgico, mantendo-se o acompanhamento clínico. PALAVRAS-CHAVE: aneurisma da veia de Galeno, mal-formação da veia de Galeno, veias cerebrais, malformação vascular congênita.Vein of Galen aneurysm (VGA) is a rare vascular malformation representing less than 1% of vascular intracranial abnormalities. It is a congenital process frequently detected between the 6 th and 11 th months of gestational age 1 , during early childhood or neonatal period 2 . This finding in adult age is very rare, presenting or not symptoms throughout childhood 3 . Clinical manifestations can present at any age in the form of heart failure, delayed neuropsychomotor development, hydrocephalus and seizures 4 .We describe a case of VGA reporting clinical symptoms, radiological findings and management relating to current published literature. CASEA 65 year-old man was brought to the emergency room at the University Hospital of the Pontifical Catholic University of Paraná, Brazil because of generalized tonic-clonic seizures. On admission, he was treated with anticonvulsant therapy for status epilepticus. Past medical history was significant for treated high blood pressure and heart failure diagnosed late in life. Also significant for an episode of ischemic cerebrovascular disease two years before, resulting in left hemiparesis. During childhood and adult life there was no neuropsycomotor development delay, no signs of cardiopathy, no neurological signs or symptoms as well as no history of epilepsy.CT scan showed a calcified expanding process in the pineal region (Fig 1). MRI showed a heterogenic roundshaped mass localized in the supra-vermian cistern with dimensions of 35x32x30 mm showing high signal in T2-weight imaging (Fig 2). The MRI images were suggestive of a thrombosed VGA. Cerebral angiography showed a thrombosed VGA also (Fig 3).Considering the fact that the aneurysm was already thrombosed ...

Eventhough supratentorial glioblastoma multiforme (GBM) is the most frequent primary brain tumor in adults, its localization in the cerebellum is extremely rare 1 . It is very important for the neurosurgeon to make the differential diagnosis between the cerebellar GBM, and other diseases like metastasis, anaplasic astrocytomas, and cerebellar infarct because their treatment modalities, prognosis, and outcome are different 2 . Clinical manifestations of these diseases are very similar, so making an appropriate diagnosis is fundamental for the management of each of them 3 .We describe a case of cerebellar GBM managed at our institution reporting its clinical presentation, radiological and histological findings, and treatment instituted. CaSeA 65 year-old male patient was admitted with a clinical history of headache, mental confusion, left hemiparesis, gait and trunk ataxia, and dismetry. The symptoms had been worsening on the last five months. Past medical history was significant for previous cerebral ischemic event without persistent deficits, and an emergency laparotomy for a bleeding gastric ulcer was done one year before and aortic ectasy.An investigation with brain CT and MRI scan, showed an heterogenic contrast enhancing expanding process in the vermis and left cerebellar hemisphere. The MRI showed an intra-axial, infiltrative, heterogenic mass localized in the vermis with extension to left cerebellar hemisphere, left superior cerebellar peduncle and brainstem. The lesion was isointense in T1-weighted images, hyperintense in T2-weighted images, showing enhancement after paramagnetic contrast administration. Its dimensions were 4.8 cm × 3.6 cm × 2.6 cm. The lesion compressed the IV th ventricle, and caused hydrocephalus (Fig 1A).Abdominal ultrasound, thoracic imaging and investigation for metastasis were negative.The patient was submitted to microsurgical resection of the lesion through a cisternal craniectomy and transvermian approach. The surgery was uneventful but a subtotal resection was performed because the tumor infiltrated the superior cerebellar peduncle and brainstem (Fig 1B). Postoperatively, the hydrocephalus diminished, but an occipital pseudo-meningocele originated another surgery for its closure. Control MRI six moths after the first surgery shows residual tumor without signs of disease progression (Fig 1C).Histological examination showed a poor-differentiated glial neoplasm with intense pleomorphism, nuclear hyperchromasy, and necrosis (Fig 2). The histological diagnosis was GBM.The case was eligible for cranial radiotherapy starting for-

-Treatment of intracranial tumoral lesions is related to its correct histological diagnostic. We present a retrospective analysis of 32 patients submitted to 36 cerebral biopsies using neuronavigation and 44 patients using frame-based stereotaxy. Mean age was 46.6 and 49.3 years old respectively. Sex distribution in both groups was 50% for each. Most of lesions were lobar in both groups. Diagnostic yielding was 91.7% and 83.4%, respectively (p=0.26). We found in the postoperative CT scans intracranial hemorrhages in 13.8% cases of the first group and 9.8% cases in the second. Most of them were mild post-operative hemorrages in the biopsy site. There was one death related to the procedure in each group. Astrocytomas and metastatic adenocarcinomas were the most frequent diagnosis. Diagnostic yielding and the number of postoperative hemorrhage and death were similar on both groups and the same found in the literature.KEY WORDS: brain tumor, neuronavigation, stereotaxy.biópsia cerebral: comparação entre estereotaxia com arco e neuronavegação em um centro de oncologia resumo -O manejo das lesões intracranianas tumorais está relacionado ao seu diagnóstico histológico adequado. Foi realizado estudo retrospectivo com 32 pacientes submetidos a 36 biópsias cerebrais por neuronavegação e 44 pacientes por estereotaxia com arco. A idade média foi 46,6 e 49,3 anos respectivamente. Nos dois grupos a distribuição por sexo foi 50% para cada. A maioria das lesões biopsiadas eram lobares nos dois grupos. A positividade diagnóstica foi 91,7% para neuronavegação e 83,4% para a estereotaxia com arco, respectivamente (p=0,26). Identificou-se hemorragia intracraniana na TC pós-operatória em 13,8% dos casos no primeiro grupo e em 9,8% no segundo, a maioria de pequena monta sem provocar piora neurológica. Ocorreu uma morte relacionada ao procedimento em cada grupo. Os diagnósticos mais freqüentes foram astrocitomas e adenocarcinomas metastáticos. A positividade diagnóstica, taxas de hemorragia pós-operatória e de mortalidade foram equiparáveis estatisticamente entre os dois métodos e se assemelham com as descritas na literatura. PALAVRAS-CHAVE: tumor cerebral, neuronavegação, estereotaxia.

Large multicenter studies on unruptured aneurysms have shown a relatively low rupture rate for smaller aneurysms compared with larger ones 1,2 . Nevertheless, controversy on the subject still persists, based on the fact that a high percentage of patients admitted to reference centers with subarachnoidal hemorrhage (SAH) present with aneurysms smaller

Hemifacial spasm (HS) is a movement disorder characterized by paroxysmal and irregular contractions of the muscles innervated by the facial nerve. Chiari malformation type I (CM I) is a congenital disease characterized by caudal migration of the cerebellar tonsils, and surgical decompression of foramen magnum structures has been used for treatment. The association of HS with CM I is rare, and its pathophysiology and therapeutics are speculative. There are only a few cases reported in the literature concerning this association. The decompression of the posterior fossa for the treatment of CM I has been reported to relieve the symptoms of HS, suggesting a relation between these diseases. However, the possible complications of posterior fossa surgery cannot be underrated. We report the case of a 66-year-old patient, in ambulatory follow-up due to right HS, no longer responding to botulinum toxin treatment. Magnetic resonance imaging (MRI) of the skull revealed compression of the facial nerve and CM I. The patient underwent surgery for HS by neurovascular microdecompression of the facial nerve via right lateral suboccipital craniectomy, but presented significant clinical worsening in the postoperative period even though the cerebellum edema related to surgical manipulation was mild. Due to the clinical worsening, the patient underwent a median suboccipital craniectomy with decompression of the foramen magnum structures. After this second surgery, the patient had progressive improvement and was discharged from the hospital for ambulatory care.

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RESUMO -I n t rodução: Uma nova via relacionada com a dor visceral foi recentemente descrita. Esta via localiza-se na linha média da coluna dorsal na medula espinhal, sendo o alvo da técnica cirúrgica aqui descrita. Objetivo: Apresentar os resultados de três pacientes submetidos ao tratamento da dor visceral oncológica por mielotomia punctiform e . Método: Três pacientes, com dor abdominal oncológica re f r a t á r i a ao tratamento clínico, foram submetidos à mielotomia punctiforme por meio de de pequena laminectomia torácica. Resultados: Dois pacientes obtiveram controle completo da dor, sendo que um deles não mais necessitou de opióides. O terceiro paciente, que era intolerante aos opióides, obteve melhora de 80% da d o r. Nenhum dos pacientes apresentou déficit neurológico no pós-operatório. Conclusão: Ratificamos a existência de uma via, localizada na linha média da coluna dorsal, relacionada com a dor visceral em humanos, cuja ablação está relacionada à melhora da dor abdominal visceral de origem oncológica. PALAVRAS-CHAVE: mielotomia, dor oncológica, dor visceral.Punctate midline myelotomy for the treatment of oncologic visceral pain: analysis of three cases ABSTRACT -I n t roduction: A new midline posterior column pathway related to visceral pain has been re c e n t l y d i s c o v e re d . Objective: To present its interruption by a punctate midline myelotomy providing significant visceral oncologic pain re l i e f . Method: T h ree patients with abdominal cancer re f r a c t o ry pain from opiate analgesics were treated by a punctate midline myelotomy through thoracic laminectomy. Results: C o m p l e t e pain control was achieved in two patients, one had no more narcotics and the other one had significant lowering of opiate intake doses. The third patient was intolerant to narcotics having 80% relieving pain. T h e rewere no postoperative neurological deficits. Conclusion: The present re p o rt re a ff i rms the existence of a dorsal column midline pathway related to visceral pain in humans, and its interruption ameliorates abdominal pain due to cancer. KEY WORDS: myelotomy, oncologic pain, visceral pain.O tratamento da dor abdominal de origem oncológica é um dos grandes desafios na prática clínica, sendo o uso racional de analgésicos opióides o tratamento pre f e r i d o 1 , 2 . Todavia, em pacientes que não toleram ou que não têm uma melhora adequada apenas com o tratamento clínico, é necessária a utilização de medidas não farmacológicas para o cont role da dor. Classicamente aceita-se que as aferências da dor somática ascendem pelo trato espinotalâmico â n t e ro-lateral enquanto que as sensações epicríticas p e rc o rrem o cordão dorsal da medula espinhal 2 . Contudo, recentemente, foi descoberta uma nova via relacionada com a dor visceral localizada na coluna dorsal da medula, independente e muito mais importante para esta modalidade sensorial do que as fibras do trato espinotalâmico [3][4][5][6] .A primeira tentativa de ablação desta via em humanos para o tratamento da dor oncológica visceral fo...