-Clivus fractures are rare and severe entities, usually associated with vascular or cranial nerve lesions and frequently diagnosed postmortem. Cervical epidural haematomas can be traumatic or spontaneous, manifested in acute or chronic form, and are treated surgically in the majority of cases, although the conservative treatment also can be indicated to patients with incomplete and non-progressive deficits. The authors report the case of a female patient, 8 years old, victim of trampling in public way by a high velocity motorized vehicle, admitted in Glasgow 7, anisocoric pupils (left pupil midriatic), whose radiological investigation showed a transverse fracture of the clivus, cervical epidural haematoma and diffuse axonal injury. The patient was submitted to intracranial pressure monitorization, sedation and conservative treatment with dexamethasone, with good outcome. The authors also present a literature review.KEY WORDS: epidural haematoma, clivus fracture, pediatric trauma.Hematoma cervical epidural com fratura de clivus: relato de caso Hematoma cervical epidural com fratura de clivus: relato de caso Hematoma cervical epidural com fratura de clivus: relato de caso Hematoma cervical epidural com fratura de clivus: relato de caso Hematoma cervical epidural com fratura de clivus: relato de caso RESUMO -As fraturas de clivus são entidades raras e graves, usualmente associadas a lesões vasculares ou de nervos cranianos, sendo freqüentemente diagnosticadas postmortem. Hematomas epidurais cervicais podem ser traumáticos ou espontâneos, manifestos de forma aguda ou crônica, requerendo tratamento cirúrgico na maior parte das vezes, embora o tratamento conservador possa ser indicado a pacientes com déficits incompletos ou não progressivos. Os autores relatam o caso de uma paciente do sexo feminino, 8 anos, vítima de atropelamento em via pública por veículo automotor em alta velocidade, que foi admitida em glasgow 7, com anisocoria (pupila esquerda midriática). A investigação radiológica evidenciou fratura transversa de clivus, hematoma epidural cervical e lesão axonal difusa. A paciente foi submetida a monitorização da pressão intracraniana, sedação e tratamento conservador com corticoesteróides, com boa evolução. Os autores apresentam também uma revisão da literatura pertinente. PALAVRAS-CHAVE: hematoma epidural, fratura de clivus, trauma pediátrico.
Even though neurosurgeons exercise these enormous and versatile skills, the COVID-19 pandemic has shaken the fabrics of the global neurosurgical family, jeopardizing human lives, and forcing the entire world to be locked down. We stand on the shoulders of the giants and will not forget their examples and their teachings. We will work to the best of our ability to honor their memory. Professor Harvey Cushing said: “When to take great risks; when to withdraw in the face of unexpected difficulties; whether to force an attempted enucleation of a pathologically favorable tumor to its completion with the prospect of an operative fatality, or to abandon the procedure short of completeness with the certainty that after months or years even greater risks may have to be faced at a subsequent session—all these require surgical judgment which is a matter of long experience.” It is up to us, therefore, to keep on the noble path that we have decided to undertake, to accumulate the surgical experience that these icons have shown us, the fruit of sacrifice and obstinacy. Our tribute goes to them; we will always remember their excellent work and their brilliant careers that will continue to enlighten all of us.
Relatamos o caso de uma jovem de 15 anos, com quadro de paraparesia de inicio agudo, secundário a processo expansivo epidural na coluna lombar, cujo diagnóstico histopatológico foi consistente com sarcoma de Ewing, sem envolvimento ósseo. Revisando a literatura encontramos apenas outros 17 casos de sarcoma de Ewing extra-esquelético de localização primária no espaço epidural raqueano.
RESUMO -A incidência de clipagem de aneurismas em que permanecem restos da dilatação varia, nas séries estudadas, de 1-10%. Deste percentual, 21,8% é devido à migração do clipe. D´Angelo e seus colaboradores (1998), encontraram 1 a 10% de aneurismas residuais. Sugerem que quando o resíduo for menor que 2 mm seja realizado estudo angiográfico entre 3-5 anos após o procedimento cirúrgico; se entre 2 e 4 mm, este estudo deve ser mais precoce, dentro dos primeiros 6 meses e depois anualmente; e, quando maior que 4 mm, a reabordagem. Apresentamos os casos de duas pacientes submetidas a tratamento cirúrgico de aneurismas intracranianos, com intra-operatório sem intercorrências e que, em exames ulteriores, evidenciaram migração do clipe de sua posição original. É apresentada, ainda, revisão da literatura.PALAVRAS-CHAVE: aneurisma, complicações, "slipped clip".Slipped clip: report of two cases Slipped clip: report of two cases Slipped clip: report of two cases Slipped clip: report of two cases Slipped clip: report of two cases ABSTRACT -Aneurysm rest occurs in 1 to 10% of operated patients and of these, 21.8% are due to slipped clips. D´Angelo and coworker (1998) found 1 to 10% of residual aneurysms. They suggest that if the residual aneurysm has less than 2 mm, angiographic control must be performed after 3-5 years of the surgical procedure; if between 2 and 4 mm, the angiographic control must be done in the first 6 months after surgery and then, anually. If it has more than 4mm a direct surgical approach is advised. We present the cases of two female patients submitted to microsurgical treatment of intracranial aneurysm, without any intra-operative abnormal event. The angiographic study further made showed displacement of the clip from its original position and aneurysm again. A review of the literature is also presented.
BACKGROUND The literature on white matter anatomy underlying the human orbitofrontal cortex (OFC) is scarce in spite of its relevance for glioma surgery. OBJECTIVE To describe the anatomy of the OFC and of the underlying white matter fiber anatomy, with a particular focus on the surgical structures relevant for a safe and efficient orbitofrontal glioma resection. Based on anatomical and radiological data, the secondary objective was to describe the growth pattern of OFC gliomas. METHODS The study was performed on 10 brain specimens prepared according to Klingler's protocol and dissected using the fiber microdissection technique modified according to U.T., under the microscope at high magnification. RESULTS A detailed stratigraphy of the OFC was performed, from the cortex up to the frontal horn of the lateral ventricle. The interposed neural structures are described together with relevant neighboring topographic areas and nuclei. Combining anatomical and radiological data, it appears that the anatomical boundaries delimiting and guiding the macroscopical growth of OFC gliomas are as follows: the corpus callosum superiorly, the external capsule laterally, the basal forebrain and lentiform nucleus posteriorly, and the gyrus rectus medially. Thus, OFC gliomas seem to grow ventriculopetally, avoiding the laterally located neocortex. CONCLUSION The findings in our study supplement available anatomical knowledge of the OFC, providing reliable landmarks for a precise topographical diagnosis of OFC lesions and for perioperative orientation. The relationships between deep anatomic structures and glioma formations described in this study are relevant for surgery in this highly interconnected area.
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