Giant brain aneurysms account for approximately 5% of all intracranial aneurysms. Although treatment modalities can vary widely, none is ideal for every patient. Endovascular treatment is usually preferred, especially when the large size of the aneurysm limits visualization of the brain parenchyma and parent vessels that arise from the aneurysm, making surgical clip placement across the neck a difficult task. However, despite the higher chances of morbidity, microsurgery is an effective treatment modality due to lower recurrence rates. Surgically, a wide neck, calcifications, or atheroma are complicating factors to be considered while planning the best treatment. Thus, with an appropriate case selection, a favorable outcome is feasible in most cases. Here, we present the case of a 27-yr-old female who presented with a severe headache for 7 mo and 3 mo of progressive left temporal vision loss, which was confirmed by visual field perimetry using the Humphrey visual field analyzer. Magnetic resonance angiography and digital subtraction cerebral angiography showed an anterior communicating artery complex inferiorly and medially oriented aneurysm measuring 25.4 × 16.5 mm, with a 3 mm neck. It was fed by the right A1, associated with a hypoplastic left A1, incorporating the proximal right and left A2 segments, with an intraluminal thrombus and causing mass effect on the optic chiasm and hypothalamus. This video demonstrates the microsurgical steps required to perform this operation, through a right orbitozygomatic craniotomy. At a 3-mo follow-up, the patient was neurological intact without complaints. The patient signed the Institutional Consent Form, which allows the use of his/her images and videos for any type of medical publications in conferences and/or scientific articles.
Brainstem arteriovenous malformations (AVMs) represent 2% to 7% of all brain AVMs. [1][2][3] Compared with other locations, a greater proportion present with hemorrhage and subsequently have a worse prognosis. 2,4 Surgery has been associated with poor outcomes, 5,6 with parenchymal AVMs associated with higher rates of incomplete resection and morbidity compared with subpial type. 7 Concerns over latency from radiosurgery to obliteration after hemorrhage, potential for incomplete obliteration, and risk of adverse radiation effects are cited by proponents of surgery. [6][7][8][9] Limited access to the anterior brainstem and difficulty controlling deep feeders add to the complexity of surgery. Previous authors have recommended occlusion in situ for parenchymal brainstem AVMs. 9,10 We present a case showing microsurgical management of a parenchymal midbrain AVM. The patient, 46-year-old man, presented with an acute headache and diplopia following hemorrhage 1 year prior. Examination revealed bilateral ptosis, conjugate upgaze palsy, right abduction paresis, and normal light and accommodation reflexes in keeping with a dorsal midbrain lesion. Magnetic resonance and digital subtraction angiography confirmed a compact midbrain AVM (1.6 cm) extending from the pulvinar thalamus to the right quadrigeminal plate, supplied by posterior thalamoperforating, right posteromedial choroidal and branches of the P3 segment and SCA posteriorly, and drainage by the vein of Galen. Tractography showed displacement of the long tracts. A combination of a posteroanterior microsurgical approach and selective anteroposterior embolization of feeders allowed complete resection with no new deficits. The patient consented to the procedure. We demonstrated that brainstem AVMs can safely be resected in experienced hands, with selective preoperative embolization, use of indocyanine videoangiography, and intraoperative neurophysiological monitoring. The patient signed the Institutional Consent Form, which states that he accepts the procedure and allows the use his images and videos for any type of medical publications in conferences and/or scientific articles.
Introduction Neurological and neurosurgical disorders are highly prevalent in Brazil. The initial management is performed by general practitioners, showing the importance of theoretical and practical studies of neurology and neurosurgery during undergraduate medical courses. Objective Describe the choices of medical specialty by members of a neurosurgery student league and investigate the existence and composition of neurology and/or neurosurgery courses and neuro-leagues in medical schools in Brazil. Methods We surveyed, in person or through social networks, all medical students who were members of the Neurosurgery Student League of Escola Paulista de Medicina (EPM) from 2007 to 2015 on the completion of their course and residency chosen. An online form was also submitted to all the medical schools registered with the Federal Council of Medicine (Conselho Federal de Medicina [CFM]) Results and Discussion Fifty-seven medical graduates had participated in the Neurosurgery Student League of EPM. Out of these, 45 have completed their undergraduate courses; 6 have undergone neurosurgery and 5 neurology. We obtained responses from 128 out of the 173 medical schools affiliated with the CFM. A total of 91% of the schools responded that they have a structured neurology course. These courses are divided as into: 32 exclusively theoretical, with 12 addressing neurosurgery and 84 are theoretical-practical, with 51 addressing neurosurgery. Structured neurosurgery courses were only present in 19% of the faculties, half of which are theoretical only. Neurosciences leagues were present in 66% of the universities. Conclusions It was noted that neurology and neurosurgery student leagues in 66% of the medical schools in Brazil is, many times, used to supplement theoretical-practical content that should have been addressed at undergraduate level. Unfortunately, only 9.5% of the medical schools include a theoretical-practical neurosurgery course in their curriculum, a fact that is concerning due to the high prevalence of neurologic diseases in the Brazilian population.
Background: Colloid cyst treatment with purely endoscopic surgery is considered to be safe and effective. Complete capsule removal for gross total resection is usually recommended to prevent recurrence but may not always be safely feasible. Our objective was to assess the results of endoscopic surgery using mainly aspiration and coagulation without complete capsule resection and discuss the rationale for the procedure. Methods: A retrospective review was conducted of 45 consecutive symptomatic patients with third ventricle colloid cysts that were surgically treated with purely endoscopic surgery from 1997 to 2018. Results: Mean age was 35.4 years. Male-to-female ratio was 1:1. Clinical presentation included predominantly headache (80%). Transforaminal was the most used route (71.1%) followed by transeptal (24.5%) and interforniceal (4.4%). Capsule was intentionally not removed in 42 patients (93.3%) and cyst remnants were absent on postoperative MRI in 36 (85%). Mild complications occurred in 8 patients (17.8%). Surgery was statistically associated with cyst volume and ventricular size reduction. There were no serious complications, shunts or deaths. Follow-up did not show any recurrence or remnant growth that needed further treatment. Conclusion: Gross total resection may not be the main objective for every situation. Subtotal resection without capsule removal seems to be safer while preserving good results, especially in a limited resource environment. Remnants left behind should be followed but tend to remain clinically asymptomatic for the most part. Surgical planning allows the surgeon to choose among the different resection routes and techniques available. Decisions are predominantly based on preoperative imaging and intraoperative findings.
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