-The aim of this study is to introduce the fiber dissection technique and its importance in the comprehension of the three-dimensional intrinsic anatomy of the brain. A total of twenty brain hemispheres were dissected. Using Kingler's technique we demonstrated the intrinsic structures of the brain. The supra lateral aspect of the brain as well as the medial aspect were presented. The most important fiber systems were demonstrated. The use and comprehension of new neuroimaging techniques demand a better understanding of this fascinating anatomy. The knowledge acquired with this technique will improve our understanding of critical pathways of the central nervous system. KEY WORDS: brain, anatomy, white matter dissection.Estrutura interna dos hemisférios cerebrais: introdução à técnica de dissecação de fibras RESUMO -O objetivo é mostrar a técnica de dissecação de fibras e sua importância na compreensão da anatomia tridimensional do cérebro. Um total de 20 hemisférios cerebrais foram dissecados. Usando a técnica de dissecação descrita por Kingler, pudemos demonstrar as estruturas que compõem a anatomia interna do cérebro. A anatomia da face súpero-lateral assim como da face medial foi apresentada. O uso e compreensão de novas técnicas de neuroimagem requerem um melhor conhecimento desta anatomia. O conhecimento adquirido com essa técnica contribuirá para o melhor entendimento de vias essenciais do sistema nervoso central.PALAVRAS-CHAVE: cérebro, anatomia, dissecação, substância branca.Traditionally the brain sulci and gyri anatomy of the brain have been studied by anatomists and clinicians but the intrinsic anatomy of the complex fibers of the white matter has been somewhat ignored. Very few books or publications regarding this topic are available when compared to the extensive literature about the external structure of the brain. Recently in Rhoton's masterpiece, "The Supratentorial Cranial Space: Microsurgical Anatomy and Surgical Approaches" -Supplement of Neurosurgery, some beautiful dissections showing the internal fasciculus can be appreciated 1 . With the most recent advances in neuroimaging one can experiences full details pictures of the internal anatomy of the brain 2-7 .Therefore, there is an increasing demand for knowledge of intrinsic brain anatomy. As radiological and surgical techniques become increasingly precise, our knowledge of the superficial anatomy and also the recognition of the internal white matter tracts of the brain is essential. In the last years many studies using diffusion-weighted and diffusion tensor MR imaging were published. The new MRI devices which use high magnetic fields and techniques promoting superior quality images can be used to show the full white matter anatomy in detail 4 . The term so-called tractography is becoming very popular. This analysis of tracts is essential for understanding and explaining the pathophysiologic patterns of certain disease states, especially intrinsic gliomas. In fact, in the studies of the intrinsic brain tumors such as the gliomas, th...
-The transoral approach provides a safe exposure to lesions in the midline and the ventral side of the craniovertebral junction. The advantages of the transoral approach are 1) the impinging bony pathology and granulation tissue are accessible only via the ventral route; 2) the head is placed in the extended position, thus decreasing the angulation of the brainstem during the surgery; and 3) surgery is done through the avascular median pharyngeal raphe and clivus. We analyzed the clinical effects of odontoidectomy after treating 38 patients with basilar invagination. The anterior transoral operation to treat irreducible ventral compression in patients with basilar invagination was performed in 38 patients. The patients' ages ranged from 34 to 67 years. Fourteen patients had associated Chiari malformation and eight had previously undergone posterior decompressive surgery. The main indication for surgery was significant neurological deterioration. Symptoms and signs included neck pain, myelopathy, lower cranial nerve dysfunction, nystagmus and gait disturbance. Extended exposure was performed in 24 patients. The surgery was beneficial to the majority of patients. There was one death within 10 days of surgery, due to pulmonary embolism. Postoperative complications included two cases of pneumonia, three cases of oronasal fistula with regurgitation and one cerebrospinal fluid leak. In patients with marked ventral compression, the transoral approach provides direct access to the anterior face of the craniovertebral junction and effective means for odontoidectomy.KEY WORDS: basilar invagination, odontoidectomy, transoral approach. Acesso transoral para a junção craniocervicalRESUMO -O acesso transoral é uma via direta e segura às lesões situadas na linha média e na face anterior da junção craniocervical. As vantagens do acesso transoral são as seguintes:1) a compressão óssea e o tecido de granulação localizam-se anteriormente e são accessíveis pela via anterior; 2) a cabeça do paciente é colocada em extensão, diminuindo a angulação do tronco cerebral durante a cirurgia; e 3) a cirurgia é feita através de um plano avascular na linha média faríngea e clivo. Analisamos os resultados obtidos após odontoidectomia por via transoral em 38 pacientes portadores de invaginação basilar. Trinta e oito pacientes com compressão ventral da junção craniocervical foram submetidos a odontoidectomia por via transoral. A idade dos pacientes variou de 34 a 67 anos. Quatorze pacientes apresentavam associação com malformação de Chiari tipo I e 8 já haviam sido submetidos à cirurgia descompressiva por via posterior. A maioria dos pacientes apresentou nucalgia, mielopatia, déficits dos nervos cranianos baixos, nistagmo, e distúrbio da marcha. Em 24 pacientes foi necessário ampliar o acesso transoral através de miotomia do palato mole, ou osteotomia do palato duro ou maxilotomia. A cirurgia proporcionou melhora dos sintomas na maioria dos pacientes. Um paciente faleceu no pós-operatório imediato por causa de embolia pulmonar. Dois paci...
Background:We report our surgical series of 35 patients with giant nonfunctioning pituitary adenomas (GNFPA). We analyzed the rule of Ki-67 antigen expression in predicting recurrence.Methods:Thirty-five patients were operated between 2000 and 2010. Suprassellar extension of the tumors were classified according to Hardy and Mohr based on magnetic resonance (MR) studies. Pituitary endocrine function and MR scans were assessed preoperatively and at 1, 6, and 12 months postoperatively. Immunohistochemical studies were based in regard to the expression of the proliferative Ki-67 index and the hormonal receptor for luteinizing hormone, follicle stimulating hormone, growth hormone, thyroid stimulating hormone, adrenocorticotropic hormone, and prolactin. Tumors specimens were obtained from 35 patients with GNFPA. Endoscopic transsphenoidal surgery was the approach of choice.Results:Thirty-five patients were submitted to 49 surgeries, 44 (89.8%) were transsphenoidal and 5 (10.2%) were transcranial. The most frequent preoperative complaints were visual acuity impairment and visual field defect in 25 (71.2%) and 23 (65.7%) cases, respectively. Improvement of visual acuitiy and visual field deficit after surgery was seen in 20 (80%) and 17 (73.9%) patients, respectively. Endocrinological deficits were encountered in 20 patients (57.1%). After surgery, 18 patients (51.4%) required hormonal replacement. Three patients had visual symptoms related to pituitary apoplexy and recovered after surgery. The Ki-67 labeling index (LI) ranged from <1% to 4.8%. The rate of recurrence in tumors with Ki-67 <3% was 7.7% (2 patients), Ki-67 >3% was present in 5 patients and the recurrence committed 3 patients.Conclusion:In our series, regardless the improvement of visual function and compressing symptoms, 5 patients with expression of Ki-67 LI more than 3% experienced a recurrence.
-A paraganglioma is a rare tumor, composed of chromaffin cells, groups of cells associated to the autonomous system. When the tumor occurs in the adrenal gland, it is called pheochromocitoma. The malignant paraganglioma is a very rare presentation; it is diagnosed by local recurrence after total resection of the primary mass, or findings of distant metastases. We present a case report of a 29-year-old woman with cervico-brachial pain. In 1995 she underwent a carotid body tumor resection. Magnetic resonance imaging (MRI), plain X-rays and computerized tomography scan revealed multiple lesions in C5, T5 and T12. She underwent a surgical procedure to correct the cervical lesion. The histological and immunohistochemical assays revealed a malignant paraganglioma. She received adjuvant radiotherapy, showing clinical improvement after treatment, presenting no symptoms after one year. The therapeutic approach is based on the total resection of the tumor. The treatment of distant metastases can be made with adjuvant measures such as conventional radiotherapy, I¹³¹-MIBG, or chemotherapy, especially in malignant pheochromocitomas.KEY WORDS: paraganglioma, vertebral metastasis, spinal tumor P P P P Paraganglioma maligno com metástase vertebral: relato de caso araganglioma maligno com metástase vertebral: relato de caso araganglioma maligno com metástase vertebral: relato de caso araganglioma maligno com metástase vertebral: relato de caso araganglioma maligno com metástase vertebral: relato de caso RESUMO -O paraganglioma é tumor raro, composto de células cromafins, associado ao sistema nervoso autônomo. Quando localizado na glândula supra-renal, o tumor é chamado feocromocitoma. Descreve-se um caso de paciente do sexo feminino, 29 anos, que se apresentou com cervicobraquialgia e que havia sido operada em 1995 para exérese de tumor glômico da carótida cervical. RM, RX e TC revelaram múltiplas lesões acometendo o corpo vertebral de C5, T5 e T12. Foi submetida à ressecção cirúrgica radical da lesão cervical, com substituição do corpo vertebral por prótese de titânio. A histopatologia e o estudo imunohistoquímico da lesão confirmaram o diagnóstico de paraganglioma maligno. As outras lesões foram tratadas com radioterapia. Um ano após os procedimentos, a paciente apresenta-se assintomática. O tratamento destas lesões consiste na associação da ressecção cirúrgica radical do tumor e medidas complementares como radioterapia convencional, aplicação de I 131 -MIBG, ou quimioterapia, principalmente nos paragangliomas malignos. PALAVRAS-CHAVE: paraganglioma maligno, metástase vertebral, tumor vertebral
We report our experience on the treatment of tuberculum sellae meningiomas (TSMs) regarding the involvement of the optic canal and clinical outcomes. We reviewed 23 patients who were operated on between January 1997 and December 2008. The surgical approach was unilateral subfrontal supraorbital osteotomy in one piece. Attempts were made to improve visual function via extra/intradural unroofing of the optic canal, which released the optic nerve. Visual symptoms were present preoperatively in 21 patients, and two patients were asymptomatic. Visual acuity remained intact in 6 patients, improved in 10, was unchanged in 5 patients, and worsened in 2 patients. The postoperative visual field was normal or improved in 17 patients, unchanged in four patients, and worsened in two patients. The optic canal and clinoid were drilled extradurally in eight patients and intradurally in nine patients. Total resection of TSMs was achieved in 19 patients. Incomplete resection occurred in two patients. Decompression of the optic canal seemed to increase the visual outcome. Key words: tuberculum sellae meningioma, optic canal, visual symptoms. Meningiomas do tuberculo selar: aspectos cirúrgicos resuMoApresentamos nossa experiência em 23 pacientes operados com meningiomas do tubérculo da sela, com enfoque na descompressão do nervo óptico e nos sintomas visuais do pós-operatório. Vinte e três pacientes com meningiomas do tubérculo da sela foram operados entre janeiro de 1997 e dezembro de 2008, através do acesso subfrontal via ostetomia supraorbital. Remoção do teto do canal óptico por via extra ou intradural foi realizada em 17 pacientes. Sintomas visuais no pré-operatório ocorreram em 21 pacientes, 2 eram assintomáticos. Melhora visual ocorreu em 10, permaneceu inalterada em 5 e piorou em 2 pacientes. No pós-operatório o campo visual normalizou-se em 17 pacientes, permaneceu inalterado em 4 e diminuiu em 2. Descompressão dos nervos ópticos foi realizada em 17 pacientes. Ressecção total dos meningiomas do tubérculo da sela foi possível em 19 pacientes. Abertura do canal óptico permitiu a manipulação do nervo óptico sem novos déficites. Palavras-chave: meningioma, tubérculo selar, nervo óptico, sintomas visuais.
Dementia implies the decline of intellectual abilities or cognitive function. It is also characterized by behavioral abnormalities and changes in personality 1 . One unusual cause of dementia, characterized mainly by amnestic syndrome, apathy, speech and language disturbances, hypersomnia, vigilance disorder and vertical gaze palsy, is due to thalamic lesion that led to the term "thalamic dementia" 2-4 . This is related to the known thalamic connections with cortical nucleus concerned with memory process, cognition and behavior, the thalamo-fronto-limbic loops 5,6 . Intracranial dural arteriovenous fistula (AVF) with venous drainage into internal cerebral veins and consequently venous hypertension is uncommon and may be associated with thalamic injury. Dural AVF consists of abnormal shunting of blood between the meningeal branches or rarely cortical branches of the external, internal carotid or vertebral arteries, and the venous system, embedded in the dural leaflets of a venous sinus to form the nidus 7-10 . Capillary beds usually interposed are lacking 7. Intracranial dural AVF represent approximately 10% to 15% of all intracranial vascular malformations 8,9, . Since the posterior fossa dural AVF and subsequent venous hypertension is important to be considered in the different diagnosis of thalamic lesions 14 , we report an unique case of thalamic dementia associated with venous hypertension in the bilateral thalamus due to a dural AVF that was successfully treated by endovascular procedures. cASEA 43-year-old man, air professional, coursing political science master, presented subacute onset of apathy and memory deficit. Initially, the symptoms were stress misdiagnosed. Nevertheless, his symptoms worsened progressively. On admission, the patient was awake but confuse in time. There was neither headache, neither visual impairment nor vomits. The thorough neurological examination revealed critical sense mild compromised and amnesia, predominately of recent events. No significant medical history was related.The optic fundi were normal. There was no signal of intra-
This article presents the evolution in medical history which leads to the surgical treatment for ruptured discs. Only at the last century the precise diagnosis of a ruptured lumbar disc could be made after tremendous efforts of the many medical pioneers in the study of the spine. The experience gained with the lumbar spine was rapidly transferred to the cervical spine. We describe the evolution of the clinical and surgical aspects about ruptured discs in the lumbar and cervical spine. An illustrative timeline of the major events regarding the surgical treatment for ruptured disks is outlined in a straight forward manner. Our understandings of the relation between symptoms and signs and of that between anatomy and pathophysiology have led to more successful surgical treatment for this disease. Nowadays lumbar and cervical discectomies are the most frequent operations carried out by neurosurgeons. Our current care of patients with this kind of spinal disorders is based on the work of our ancient medical heroes.
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