BackgroundMalignant ischemic stroke is characterized by the involvement of 2/3 of the area of the middle cerebral artery, associated with cerebral edema, intracranial hypertension (ICH) and cerebral herniation, generating high morbidity and mortality. Over the years, several therapies have been studied in an attempt to reverse or reduce the damage caused by this vascular disorder, including decompressive craniectomy (DC), a surgical technique reserved for cases that evolve with refractory ICH.MethodsThis study seeks to perform a comparative analysis on the effectiveness of decompressive craniectomy using four randomized clinical trials and the results found in the retrospective study conducted in a neurosurgical reference center between 2010 and 2018.ResultsThe total sample consisted of 263 patients, among which 118 were randomized and 145 were part of the retrospective study. The outcome was analyzed based on the modified Rankin Scale (mRS) for 6 and 12 months. The mean time to perform the DC was 28.4 h in the randomized trials, with the late approach (> 24 h) associated with unfavorable outcomes (mRS between 4 and 6).ConclusionCompared to the aforementioned studies, the study by Bem Junior et al. shows that a surgical approach in < 12 h had a better outcome, with 70% of the patients treated early classified as mRS 2 and 3 at the end of 12 months (1). Decompressive craniectomy is currently the most effective measure to control refractory ICH in cases of malignant ischemic stroke, and the most appropriate approach before surgery is essential for a better prognosis for patients.
IntroductionFalcotentorial meningiomas (FTM) are a rare entity of tumors, corresponding to 2-8% of pineal tumors and 1% of all intracranial meningiomas and are more prevalente in womens. These tumors originate from posterior portion of the velum interpositum or falcotentorial union and can present different relationships with vital neuroanatomical structures. The surgical treatment is not well established in literature, due to the necessity of validating criteria for the surgical approach and the discussion of the risks to obtain radical resections.Case descriptionIt is a case report of a 41-year-old man with FTM, who was admitted with progressive paresis in the left lower limb for the last one year as the only neurological symptom. A computed tomography (CT) was realized, revealing a solid mass in the pineal region, causing hydrocephalus. After that, brain magnetic resonance imaging (MRI) showed a solid mass inside the third ventricule in contact with the falcotentorial dural junction. The patient was submited of a subtotal tumor resection by an approach throught occipito-transtentorial acess.CommentsThe clinic of the FTMs varies with headaches (the most common symptom), ataxia, personality changes and bradpsychia with homonymous hemianopsia. There exists four types of FMTs tumors according to Boussioni classification, which is based on the location of the tumor and, in this case, the tumor is type I, which originated from posterior cerebral falx and displaced the venous system inferiorly. This classification it’s important to guide the decision of the surgical approach. The surgical objective is to relieve or solve neurological/clinical symptoms and acquire a tissue sample for histological diagnosis. Some surgical approaches can be done for these tumors, but the transtentorial/transfalcine occipital approach is most frequently used for pineal meningiomas, especially in types I and IV FTMs.ConclusionThe choice of the surgical approach is essential for the effective treatment of a FTM tumor, and can be analysed with the help of imaging tests. This case of a subtotal resection showed success on the reduce of neurological defict of the patient. Keywords: Falcotentorial meningiomas, Surgical approach, Neurosurgery.
Meningiomas arising from the falcotentorial junction are rare, and the selection of the optimal surgical approach is essential. We report a 41-year-old man presented with progressive left paresis in the lower limbs. An MRI showed a solid mass inside the third ventricle in contact with the falcotentorial dural junction. The tumor was removed by the transtentorial/transfalcine occipital approach, performed with the patient in the three-quarter prone position. The tumor was devascularized from the tentorium, then debulked and finally dissected. The affected falx and tentorium were resected, but all of patent dural venous sinuses were preserved. The tumor was a subtotal resect. Choosing the surgical approach is essential for the safe and effective removal of an FTM and preoperative imaging analysis should identify the tumor’s anatomical relations and guide toward the least disruptive route that preserves the neurovascular structures. This article aims to report a successfully treated FTM.
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