The illustrious Colombian Professor Salomón Hakim provided the annals of neurology with one of the most brilliant and original bodies of research on record, developing the concept of normal pressure hydrocephalus, as well as proving that ventricular shunting is an effective treatment. Thus, Professor Hakim proved that some of the dementias, at that time considered senile, could be successfully treated. Here the authors present an historical review of his main contributions, which continue to influence the study of dementia to this day.

A Malformação Arteriovenosa da Veia de Galeno (MAVG) representa cerca de 1% das malformações vasculares intracranianas. É caracterizada por uma dilatação acentuada da Veia de Galeno, contendo múltiplas fístulas arteriovenosas que drenam para uma veia prosencefálica mediana chamada de veia de Markowski, precursora da veia de Galeno. A MAVG tem etiologia ainda desconhecida e sem relação com histórico familiar. Durante o período perinatal, a primeira manifestação clínica geralmente é o quadro de insuficiência cardíaca. O diagnóstico pode ser obtido desde a gestação através da ultrassonografia gestacional e, posteriormente, através de ultrassom transfontanelar, ressonância magnética e angiografia, sendo este o exame padrão. O método mais seguro e mais aceito atualmente para o tratamento é a embolização endovascular. Apresentamos o caso de um recém-nascido com ultrassonografia gestacional sugerindo MAVG, com quadro clássico de insuficiência cardíaca 8 dias após seu nascimento, com hipótese confirmada após investigação com neuroimagem. Após estabilização clínica durante o internamento, o paciente foi submetido à embolização em 3 etapas com boa evolução clínica. A deterioração do prognóstico, quando não tratada, ressalta a importância de se diagnosticar precocemente essa condição que, apesar de rara, deve entrar como diagnóstico diferencial frente a um recém-nascido com insuficiência cardíaca.

Introduction Fluorescence guidance with 5-aminolevulinic acid (5-ALA) is a safe and reliable tool in total gross resection of intracranial tumors, especially malignant gliomas and cases of metastasis. In the present retrospective study, we have analyzed 5-ALA-induced fluorescence findings in different central nervous system (CNS) lesions to expand the indications of its use in differential diagnoses. Objectives To describe the indications and results of 5-ALA fluorescence in a series of 255 cases. Methods In 255 consecutive cases, we recorded age, gender, intraoperative 5-ALA fluorescence tumor response, and 5-ALA postresection status, as well the complications related to the method. Postresection was classified as ‘5-ALA free’ or ‘5-ALA residual’. The diagnosis of histopathological tumor was established according to the current classification of the World Health Organization (WHO). Results There were 195 (76.4%) 5-ALA positive cases, 124 (63.5%) of whom underwent the ‘5-ALA free’ resection. The findings in the positive cases were: 135 gliomas of all grades; 19 meningiomas; 4 hemangioblastomas; 1 solitary fibrous tumor; 27 metastases; 2 diffuse large B cell lymphomas; 2 cases of radionecrosis; 1 inflammatory disease; 2 cases of gliosis; 1 cysticercosis; and 1 immunoglobulin G4-related disease. Conclusion Fluorescence with 5-ALA can be observed in lesions other than malignant gliomas or metastases, including meningiomas, hemangioblastomas, pilocytic astrocytomas, and lymphomas. Although there is need for further evidence for the use of 5-ALA beyond high-grade gliomas, it may be a safe and reliable tool to improve resection in positive tumors or to guide the histopathologic analysis in biopsies.

Metastasis to the calvarium with direct pericranium or dural infiltration may be treated with radical surgical removal in selected cases. We describe microsurgical resection of calvarial metastases with fluorescence-guided technique using 5-aminolevulinic acid (5-ALA) in two female patients with breast cancer. Fluorescence findings were positive in both cases. Margins in the scalp and dural layer were 5-ALA negative at the end of surgical removal. Intraoperative pathology was performed in all cases to confirm if oncological limits were free of disease. One case was 5-ALA positive in the outer layer of the dura-mater and another in the pericranium. At the end of the removal in both cases, the surgical margins were 5-ALA fluorescence-free. Intraoperative pathology confirmed oncological limits of the resection. 5-aminolevulinic acid fluorescence-guided surgery for calvarial metastases with pericranium and/or dural extension seems to be a safe and reliable method to aid the surgical margins for complete removal, possibly delaying or avoiding adjuvant irradiation for progression control.

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Background. Cranial navigation in brainstem surgery can be especially challenging due to registration method limitation and complex anatomic orientation. Surface anatomical landmarks are not available and fiducial registration usually needs image acquisition at the day of surgery. Intraoperative registration is often used during spinal navigation with safe and reliable accuracy. We present our technique of navigation for brainstem lesions surgeries using intraoperative anatomical landmarks for registration. Methods. From March 2008 to November 2018, 38 patients underwent suboccipital midline approaches for removal of brainstem and/or fourth ventricle lesions with frameless navigation. We performed CT scan and MRI sequence with gadolinium enhancement for each patient a day before the operation. The CT/MRI image fusion and surgical planning was performed in Brainlab® workstation. Navigation registration was performed after skin incision and external skull base anatomical landmarks exposure. Results. The anatomical landmarks used for registration was based on bone structures visible on CT images. The accuracy flaw was insignificant for brainstem navigation, especially for the roof and lateral limits of the fourth ventricle. The image-guided system was very useful for tumor localization and removal in all cases. Conclusions. Intraoperative anatomical landmarks registration is a fast and safe method for brainstem navigation. The brainstem is a fixed encephalic structure and the shifting is insignificant. Anatomical landmarks (inion, foramen magnum, nucal lines, C1 posterior arc) and a careful surgical planning are necessary in order to avoid accuracy lost.

A dissecção traumática da artéria vertebral tem uma incidência de 1,1 a 1,5 para cada 10.000 habitantes. Apesar de ser considerada uma doença rara, esse tipo de lesão pode estar associado a traumas de baixo impacto ou mecanismos de trauma pouco valorizados. Muitos pacientes apresentam-se com poucos sintomas ou mesmo assintomáticos, o que dificulta sobremaneira o diagnóstico e, portanto, o devido tratamento dessa condição. Apesar de oligossintomática, a dissecção da artéria vertebral pode cursar com áreas de isquemia na região da fossa posterior do cérebro, lesão que se não for reconhecida pode levar à morte. Apresentamos o caso de um paciente jovem, que após uma queda durante a prática de surfe foi atendido no serviço de emergência, internado com quadro de lesões isquêmicas recentes em áreas da circulação posterior e durante investigação evidenciou-se dissecção da artéria vertebral esquerda.

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