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-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.

Objective: In this study, we investigate our institutional experience of patients who underwent endoscopic endonasal transsphenoidal approach for treatment of large and giant pituitary adenomas emphasizing the surgical results and approach-related complications. Method: The authors reviewed 28 consecutive patients who underwent surgery between March, 2010 and March, 2014. Results: The mean preoperative tumor diameter was 4.6 cm. Gross-total resection was achieved in 14.3%, near-total in 10.7%, subtotal in 39.3%, and partial in 35.7%. Nine patients experienced improvement in visual acuity, while one patient worsened. The most common complications were transient diabetes insipidus (53%), new pituitary deficit (35.7%), endonasal adhesions (21.4%), and cerebrospinal fluid leak (17.8%). Surgical mortality was 7.1%. Conclusions: Endoscopic endonasal transsphenoidal surgery is a valuable treatment option for large or giant pituitary adenomas, which results in high rates of surgical decompression of cerebrovascular structures.Keywords: endoscopic endonasal approach; giant pituitary adenomas; large pituitary adenomas; complication rates. RESUMOObjetivo: Neste manuscrito investigamos a experiência institucional com o acesso endonasal endoscópico transesfenoidal no tratamento de adenomas hipofisários grandes e gigantes com ênfase às complicações relacionadas ao acesso cirúrgico. Método: Foram incluídos neste estudo 28 pacientes consecutivos submetidos à cirurgia entre Março de 2010 e Março de 2014. Resultados: O diâmetro médio pré-operatório dos tumores era 4,6 cm. Uma ressecção total foi obtida em 14,3%; quase total, em 10,7%; subtotal, em 39,3% e parcial, em 35,7%. Nove pacientes evoluíram com melhora na acuidade visual, enquanto um paciente apresentou piora da função visual. As complicações mais comuns foram diabetes insipidus transitório (53%), novo défice hipofisário (35,7%), sinéquias endonasais (21,4%) e fistula liquórica (17,8%). A mortalidade cirúrgica foi 7,1%. Conclusões: A cirurgia por via endonasal endoscópica transesfenoidal é uma opção terapêutica extremamente útil para adenomas hipofisários grandes e gigantes, a resultar numa significativa descompressão das estruturas cerebrovasculares.Palavras-chave: acesso endoscópico endonasal; adenoma hipofisário gigante; adenoma hipofisário grande; índices de complicação.

-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

Globally, the discipline of neurosurgery has evolved remarkably fast. Despite being one of the latest medical specialties, which appeared only around hundred years ago, it has witnessed innovations in the aspects of diagnostics methods, macro and micro surgical techniques, and treatment modalities. Unfortunately, this development is not evenly distributed between developed and developing countries. The same is the case with neurosurgical education and training, which developed from only traditional apprentice programs in the past to more structured, competencebased programs with various teaching methods being utilized, in recent times. A similar gap can be observed between developed and developing counties when it comes to neurosurgical education. Fortunately, most of the scholars working in this field do understand the coherent relationship between neurosurgical education and neurosurgical practice. In context to this understanding, a symposium was organized during the World Federation of Neurological Surgeons (WFNS) Special World Congress Beijing 2019. This symposium was the brain child of Prof. Yoko Kato-one of the eminent leaders in neurosurgery and an inspiration for female neurosurgeons. Invited speakers from different continents presented the stages of development of neurosurgical education in their respective countries. This paper summarizes the outcome of these presentations, with particular emphasis on and the challenges faced by developing countries in terms of neurosurgical education and strategies to cope with these challenges.

Cerebrospinal fluid (CSF) rhinorrhea implies a communication between the subarachnoid space and the upper respiratory tract. Trauma and postoperative defects are the more common causes of CSF rhinorrhea. The authors review their results with endoscopic repair of skull base defects associated with CSF rhinorrhea involving the paranasal sinuses. A total of 10 patients, 7 males and 3 females, were treated under endoscopic vision from 1997 to 2001. The causes of CSF rhinorrhea were traumatic (7), postoperative (2) and spontaneous (1). Four patients had the diagnosis and the site confirmed after intrathecal fluorescein-saline injection. The obliteration of the CSF leak was achieved with fat free, mucoperichondrial, or mucoperiostal free grafts taken from the middle or inferior turbinate and kept in place by fibrin glue. Primary closure was obtained in 10 patients and one patient developed a recurrence 14 months later. The repair of the CSF rhinorrhea by endonasal endoscopic surgery is safe, very effective and is a valid alternative to the cranial approach.