Background Stereotactic biopsy is necessary for diagnosing deep-seated brain tumors that are not amenable to surgical resection. The diagnostic yield of stereotaxy ranges from 76.2 to 100%. Several methods have been suggested to improve the yield. These include planning the trajectory on 3D multiplanar reconstruction (3D MPR) software, planning two different trajectories for different target points, centering the burr hole at the entry point, taking at least six specimens from each target, macroscopic assessment of the biopsy bits, and postbiopsy scan. We implemented similar precautions to ensure the diagnostic yield. Three cases were analyzed retrospectively and descriptively. Case descriptions The contrast-enhanced magnetic resonance imaging (CEMRI) of the first patient showed a high-grade neoplasm of the left corona radiata and corpus callosum. Craniostomy and stereotactic biopsy were done. Computed tomography (CT) showed the tract as dots of bleed into the lesion. The histopathological report (HPR) was of anaplastic astrocytoma. The second case was peculiar in the presentation as bilateral high-grade glioma. The CT imaging after stereotaxy showed air within the lesion, confirming the site. The immunohistochemistry (IHC) was suggestive of grade 3 astrocytoma. The third case was a diagnostic dilemma, with incomplete ring enhancement on CEMRI. Postoperative CT confirmed the site of biopsy as a cut. The IHC proved diagnosis of diffuse large B cell lymphoma. Conclusion Placing the stereotactic ring around the lesion, making a craniostomy of size 3 cm, doing surgery under general anesthesia, biopsy from multiple targets, harvesting more than six specimens, and immediate postoperative CT helped in ensuring the accuracy of biopsy.
Rasmussen et al. described a syndrome characterized by intractable focal seizures in childhood, leading to focal motor seizures, progressive hemiparesis, and cognitive impairment. Rasmussen's encephalitis (RE) is now defined as an autoimmune disorder that determines progressive multifocal encephalopathy associated to unilateral cortical atrophy and progressive deterioration. Histologically, RE is characterized by an inflammatory lesion compromising the gray and white matters, with frequent lymphocytes arising in sanguineous vessels and respective perivascular tissues, glial nodules, hydropic degeneration, and atrophy. Currently, conventional antiepileptic therapy drugs remain unhelpful in treating the seizures, but the process appeared to be halted by hemispherectomy. We herein report three cases of RE treated by surgical resection and discuss the pathogenesis and diagnostic histopathological findings of this uncommon process.
Approximately 30% of the patients with treatment-resistant schizophrenia do not respond to clozapine, and approximately 25% do not tolerate its adverse effects, and there is no widely-accepted therapeutic consensus for these patients. In view of the refractoriness of a considerable percentage of patients to the antipsychotic treatment, other therapeutic modalities have become the object of study in the treatment of this disorder. Modulation with an inhibitory effect on the nucleus accumbens is based on the fact that this structure is necessary for the release of dopamine secondary to hippocampal activation, as well as the fact that the nucleus accumbens regulates the release of dopamine intrinsically and in the associative striatum, which is also involved in psychotic manifestations. Bilateral radiofrequency ablation of the ventromedial portion of the accumbens shell has already been performed in the treatment of refractory drug addiction, showing an adequate safety profile and a low rate of complications. Considering the pathophysiology of schizophrenia, the evidence of the preferential action of atypical antipsychotics on the ventromedial portion of the accumbens shell, the diversity of theories related to the mechanisms of resistance to antipsychotics, the promising results presented by the inhibitory modulation of the accumbens, and the safety profile and low complication rate of radiofrequency ablation of the ventromedial portion of the accumbens shell, it is reasonable to infer that this procedure is an admissible therapeutic proposal in the context of clozapine-resistant schizophrenia.
Objective To quantify the surgeries for epilepsy performed within the Brazilian Unified Health System (Sistema Unico de Saude, SUS, in Portuguese) in Brazil, analyze their evolution from 2008 to 2022 and evaluate the historical trend within the national territory. Materials and Methods The present is a quantitative and descriptive study, with a cross-sectional design, that deals with resective surgeries for epilepsy performed by the SUS, in its regions and federative units from 2008 to 2022. The information was summarized in graphs and tables, with the help of the GraphPad Prism (GraphPad Software, LLC) and R (R Core Team) software. Results From 2008 to 2022, 2,921 procedures of microsurgery for temporal lobectomy and selective amygdalohippocampectomy were recorded in the Department of Informatics of the Unified Health system (Departamento de Informatica do Sistema Unico de Saude, DATASUS, in Portuguese). Out of the total 2,921 microsurgeries performed, 588 were carried out through the Treatment Outside the Home (Tratamento Fora do Domicilio, TFD, in Portuguese) program. Of the 27 federative units, 9 states did not perform this type of surgery. The procedure rate started at 0.145 per 100 thousand inhabitants and reached its peak in 2010 (0.170), representing an increase of 17.2%. From 2011 to 2020, the procedure rate plummeted to its lowest point of 0.027 in 2020, growing again in 2021 and 2022, but with a cumulative decline of 76.9%. Conclusion Compared to developed countries, Brazil follows the trend of declining rates of temporal lobectomy and selective amygdalohippocampectomy. Although the reasons are not yet clear, while in developed countries this decline seems to be linked to the incorporation of new technologies, in Brazil, the low access of the population to reference centers appears to be the predominant factor.
Introduction Central nervous system tumors are not among the most common neoplasms. However, when present, they are associated with significant mortality and morbidity, which underscores the need for accurate diagnosis to determine the most appropriate oncological treatment. The present study aimed to analyze the clinical profile, the performance of the surgical technique, and the concordance rate between histopathological and neuroimaging diagnoses in patients undergoing stereotactic biopsy between 2010 and 2023 at a tertiary hospital in the city of Porto Alegre, Brazil. Materials and Methods We conducted a retrospective cohort study using secondary data and a quantitative approach, analyzing 109 procedures. Results The study revealed a predominance of male patients (57.8%) and a mean age of 55.49 +/- 15.74 years. The most frequent histopathological diagnosis was high-grade glioma (42.2%), and the region most commonly affected was the corpus callosum (23.9%). No clinical correlation was found between hematoma diameter and neurological alteration. The prevalence- bias-adjusted Kappa (PABAK) index indicated moderate agreement for gliomas and a high level of agreement with the Magnetic Resonance Imaging (MRI) scans for metastases (0.87). Conclusion The procedures performed at the institution demonstrated a high diagnostic success rate, with the analyzed sample being similar to what was expected, despite minor differences from the literature. The replacement of invasive techniques with non-invasive methods is not yet a reality due to the necessity of tissue analysis to define oncological strategies and guide chemotherapy and/or radiotherapy. It is important to point out that the routine use of advanced technologies, such as spectroscopy, in the differential diagnosis of brain tumors, remains crucial.
Introduction The training of spine surgeons requires an extensive learning curve, especially in instrumentation techniques. Cadaveric training, while valuable, is expensive and involves ethical and legal challenges. In this context, the use of biomodels emerges as an alternative for anatomical study and training of decompression techniques and spinal instrumentation. Objectives The primary objective is to describe a method for creating a low-cost biomodel of the subaxial cervical spine. The secondary objective is to compile the main posterior instrumentation techniques with a step-by-step guide for training on the developed biomodel. Materials and Methods A biomodel of the subaxial cervical spine was created based on computed tomography (CT) scan using a 3D printer. The chosen material was acrylonitrile butadiene styrene (ABS). The techniques for making the biomodel were detailed. Results The subaxial cervical spine biomodel is a cost-effective and reproducible alternative for training in decompression and instrumentation techniques. Surgeons in training can use the described biomodel to aid in surgical training and planning. Conclusion The use of biomodels such as the one described can transform spine surgeons' training by assisting in surgical training and planning. Further studies are needed to confirm the effectiveness of biomodels, particularly in complex spinal surgeries.
Introduction Neuronavigation systems have become an essential tool for accurate surgical guidance. However, the influence of operator experience on the accuracy of these systems is still debated. Objective This study aims to investigate the accuracy and precision of neuronavigation in an environment mimicking the conditions found in a surgical room and the impact of operator experience. Methods We conducted a series of experiments using a neuronavigation system with operators of varying levels of experience. The accuracy of the system was measured and compared across 3 different operators. Results Inexperienced operators exhibited significantly lower levels of accuracy compared with their more experienced counterparts. The measured accuracy for an experienced operator was 2.9 +/- 1.2mm, with an overall mean of 3.5 +/- 1.7 mm when including results from inexperienced individuals. The best scenario appears to be when the point of interest is in the right temporal region, closer to the stereo vision camera of the tracking system. Conclusion Our results demonstrate different accuracies in the neuronavigation system between operators with varying levels of experience. However, individuals without prior experience or training exhibit an acceptable level of accuracy for its use in surgical applications.
Cerebral venous thrombosis (CVT) is a rare, often underdiagnosed condition marked by the formation of thrombi in the cerebral veins and sinuses, which can lead to various clinical symptoms, such as headaches, seizures, and, in some cases, intracranial hemorrhage. This case study presents a 35-year-old hypertensive woman with sudden headache, loss of consciousness, and seizures, who was subsequently diagnosed with CVT complicated by interhemispheric hemorrhage, a rare and challenging presentation. The initial imaging showed frontal interhemispheric hemorrhage and hypodensities, with no arterial abnormalities. Cerebral angiography confirmed CVT due to the absence of opacification in the sagittal sinuses. Treatment involved complete anticoagulation despite hemorrhage, following current guidelines to prevent further thrombotic events. The patient also received anticonvulsants and nimodipine to control seizures and prevent vasospasm, along with close neurological monitoring and blood pressure control. Pneumatic compression was applied to avoid venous thromboembolism due to immobility. This case highlights the diagnostic complexities of CVT, especially when hemorrhage is involved, emphasizing the importance of early, individualized treatment to improve patient outcomes.
Introduction Cushing and Eisenhardt first classified globoid sphenoid wing meningiomas (SWM) into medial, middle and lateral groups. The authors examined 29 consecutive patients with globoid shape SWMs that were surgically treated by the senior author (NG). Based on our results, we would like to modify Cushing's classification system of globoid SWM. Methods All patients who had undergone surgery at two hospitals between 2000 and 2017 were identified. All data from different tumor locations along the sphenoid ridge were compared to determine whether these tumors had different behaviors in presenting symptoms, surgical observation and post-op surgical outcomes. Results All 29 consecutive patients with globoid shape of SWM underwent microsurgical resection during this period. The rates of cavernous sinus (CS) invasion (medial 46.1%, lateral 0%, pterional 0%; p 0.01) and vascular encasement (medial 76.9%, lateral 36.3%, pterional 0%; p 0.008) were all highest in medial SWMs. Gross total removal (GTR) was found less in medial SWMs (medial 23%, lateral 63.6%, pterional 100%; p 0.008). Complication rate was higher in medial SWMs (medial 53.8%, lateral 18.1%, pterional 20%, p 0.04). Visual impairment was higher in medial SWMs (medial 92.3%, lateral 36.3%, pterional 40%; p 0.01). Conclusion The authors report different entities of meningiomas located along the sphenoid wing, including the presenting symptoms, imaging studies, microsurgical observation, extension of surgical resection, surgical outcome and surgical complication. Our results support the idea to modify Cushing's classification system.
Meralgia paresthetica (MP) is a pain-and-paresthesia syndrome of the anterolateral thigh caused by compression of the lateral femoral cutaneous nerve (LFCN). The diagnosis is primarily clinical, while ultrasound, magnetic resonance imaging, and electrodiagnostic studies may assist in atypical cases. We reviewed the most relevant publications on MP from 1979 to 2025, searching PubMed, SciELO, Cochrane, Scopus, ResearchGate, and Google with the descriptors: “meralgia paresthetica” and “lateral femoral cutaneous nerve of the thigh.” A total of 131 articles were considered; 37 references published within the last five years were highlighted. Multiple risk factors contribute to MP. First-line management is conservative; surgery is considered for refractory cases. Diagnosis can be challenging, often delayed by variable presentation and low awareness. Evidence guiding the most effective non-surgical and surgical interventions remains limited. Further studies are needed to improve clinical diagnosis and clarify optimal treatment strategies.
Intracranial arachnoid cysts are cerebrospinal fluid–filled lesions present in 1.2–1.4% of the population. They are often asymptomatic but may cause headache, seizures, deficits, or hydrocephalus. Surgery is indicated in symptomatic cases, yet the optimal technique—endoscopic fenestration or microsurgery—remains debated. To compare efficacy and safety of endoscopic fenestration versus microsurgery for symptomatic intracranial arachnoid cysts through systematic review and meta-analysis. PubMed, Embase, Scopus, Web of Science, and Cochrane Library were searched up to March 2024, following PRISMA 2020. Comparative studies reporting cyst volume reduction (>50%) or postoperative complications (hematoma, cranial nerve palsy, mortality) were included. Data were analyzed with Review Manager 5.4 and R. Pooled relative risks (RR) with 95% confidence intervals (CI) were calculated using Hartung-Knapp adjustments and Paule-Mandel variance. Publication bias was assessed with funnel plots and Egger's test. Sixteen studies (1,157 patients; 596 endoscopic, 561 microsurgery) were included. Eight studies (n = 441) showed no significant difference in cyst reduction (RR = 0.92; 95% CI: 0.77–1.10; p = 0.325; I2 = 63.4%). Twelve studies (n = 716) suggested fewer hematomas with endoscopy, though not significant (RR = 0.61; 95% CI: 0.32–1.17; p = 0.139; I2 = 0%). Cranial nerve palsy was rare (<3%), and no mortality was reported. Endoscopic fenestration and microsurgery provide similar efficacy and safety. Choice should be guided by cyst anatomy and surgeon expertise. Further randomized trials are warranted.
A 48-year-old male patient was admitted to an emergency care unit with a history of gunshot wound and traumatic brain injury. He underwent neurosurgical debridement, with removal of fractured bone fragments in the left frontal region, drainage of the underlying brain contusion, and dural plastic surgery. He showed clinical improvement, underwent autologous cranioplasty approximately 4 weeks after the hospital admission, and was discharged for neurological outpatient follow-up. After 6 months, he returned to the hospital with signs of dehiscence of the surgical wound in the left frontal region, with the presence of larvae at the site, compatible with the diagnosis of cranial myiasis. He underwent two debridements of the surgical site to remove visible larvae on the bone flap, which also showed signs of infectious involvement, confirming the diagnosis of osteomyelitis. A wide left frontal craniectomy was also performed, with removal of the infected cranial bone. The culture of surgical material showed the presence of the bacterium Klebsiella aerogenes. Ivermectin and broad-spectrum antibiotic therapy were prescribed. The patient showed good progress and was discharged from the hospital. Myiasis is caused by the fly Dermatobia hominis, whose eggs are laid in open wounds, where their larvae feed on tissues and body fluids. It is usually a self-limiting condition with low morbidity, except in the presence of cranial osteomyelitis, a rare complication that can lead to amaurosis, sepsis, and death. Therefore, rigorous removal of the larvae, extensive surgical debridement, craniectomy, and prolonged antibiotic therapy are the main therapeutic strategies.
Introduction Professionals employ a variety of scoliosis classifications to aid in patient care and outcome prediction. The Lenke classification is being utilized for surgical planning. Discussing the surgical results of treating adolescent idiopathic scoliosis (AIS) and assessing their viability, effectiveness, and safety were the objectives of this study. Methods This prospective study was conducted on 30 patients with idiopathic scoliosis and cobb angle >40 degrees. All patients were subjected to imaging (plain X-ray radiography, computed tomography (CT) scan, magnetic resonance imaging (MRI) and 3D printed model spine). Results There was a positive correlation between height gain and degree of correction (r = 0.396, p = 0.030). There was a positive correlation between the number of fused levels and (postoperative height gain and postoperative shoulder balance) (P value < 0.05). There was a positive correlation between thoracoplasty and (postoperative height, postoperative cobb, 1year postoperative forced vital capacity (FVC) and postoperative pelvic incidence) (P value <0.05). Conclusions Surgical correction of AIS significantly improved spinal alignment, height, and deformity correction, with height gain influenced by factors such as the number of fused levels and preoperative cobb angle. While complications were minimal, thoracoplasty was linked to greater height gain but lower postoperative FVC, indicating potential effects on pulmonary function.
Introduction Coil protrusion is a rare but potentially serious complication of intracranial aneurysm embolization. Although several solutions exist, many raise procedural costs or require dual antiplatelet therapy. This case highlights a safe, cost-effective method for repositioning a protruding coil using only a microcatheter and microguidewire. Clinical Presentation An elderly patient with a left MCA bifurcation aneurysm experienced coil protrusion during embolization. A microguidewire, shaped and advanced via the inferior MCA trunk as a fulcrum, successfully repositioned the coil without extra devices or antiplatelet therapy. Post-procedure imaging confirmed stable repositioning without ischemic or hemorrhagic events. The patient developed moderate vasospasm, treated medically, and showed significant functional recovery after three months. Conclusion This specific technique provides a simple, effective, and economical alternative for managing coil protrusion, minimizing risks and costs while potentially improving outcomes in both standard and complex aneurysm cases.
The presence of posttraumatic hydrocephaly signs and symptoms in conjunction with those of the primary injury sometimes makes diagnosis challenging. There is a paucity of literature about the correlation between optic nerve sheath diameter (ONSD) and the outcome of cerebral spinal fluid diversion procedures in adults with posttraumatic hydrocephaly. The present case report illustrates the efficacy of ONSD monitoring in evaluating intracranial hypertension after blast head injury complicated by occlusive hydrocephaly and in assessing the efficacy of cerebrospinal fluid diversion procedures.
Pituitary tumors are present in approximately 15% of the population and are often discovered incidentally during imaging for headache evaluation. Headaches are prevalent in patients with pituitary adenomas, occurring in 37-70% of cases. However, determining whether the tumor itself causes the pain is frequently challenging. A 27-year-old woman presented with progressive daily holocranial headaches, photophobia, phonophobia, nausea, and secondary amenorrhea. Laboratory tests and pituitary imaging confirmed a macroprolactinoma. Initial treatment with cabergoline and bromocriptine was unsuccessful due to intolerable side effects. Transsphenoidal surgery produced marked clinical improvement and a partial reduction in serum prolactin. However, tumor regrowth occurred with recurrence of daily headaches, and a second surgery was delayed due to the COVID-19 pandemic. Multiple medical treatments, which included topiramate, divalproex sodium, amitriptyline, propranolol, and riboflavin with magnesium resulted in no improvement. After the second neurosurgery, she presented normoprolactinemia with no residual tumor and once again a complete resolution of the headache episodes. Risk factors for headache related to adenoma include high prolactin or IGF-1 levels, cavernous sinus invasion (but not adenoma size), and a history of primary headache disorder. International diagnosis criteria emphasize headache resolution following endocrine normalization or tumor removal. This case highlights the intricate relationship between prolactinomas and headaches, underscoring the need for individualized treatment strategies.
Objective To perform the clinical and therapeutic follow-up of patients with meningioma and to evaluate the risk and protective factors for the outcomes obtained during the treatment. Materials and Methods We conducted a retrospective cohort study using clinical, radiological, and histopathological data contained in the records of patients with meningiomas; we also performed retrospective monitoring for 5 years, evaluating the initial symptoms and clinical evolution, demographic data, risk factors, location, laterality and dimensions, treatment, complete radiological resection, death, additional deficits, and changes in the performance score. Results We followed up a sample of 86 patients with a mean age of 47 years and a predominance of female subjects. The most frequent histological types were the meningothelial, followed by the fibrous, the transitional subtype, and the mixed and psamomatous subtypes. Grade-II and -III injuries represented 8.13% and 3.12% of the total respectively. The initial clinical conditions presented nonspecific signs in 79% of the individuals and focal neurological signs in 12%, the most common being appendicular deficit, unilateral amaurosis, and cranial nerve syndrome. Regarding treatment distribution, all patients studied underwent surgical resection (Simpson 1: 15%; Simpson 2: 12%; Simpson 3: 35%; and Simpson 4: 36%), with a good correlation of the total radiological resection for the first 3 degrees. Conclusion Thus, the need for early diagnosis and therapy is emphasized to achieve a better outcome, and we recommend the performance of prospective studies that evaluate other variables to clarify the risk factors for mortality and recurrence.
Objective To compare the geometric registration in the Eximius Med (Artis Tecnologia) and MNPS (Mevis Informatica Medica LTDA.) stereotactic software. Materials and Methods The study design included acquisition of skull images by computed tomography, marking of point coordinates (X, Y, and Z) in the MNPS and Eximius Med software performed by two independent evaluators, and statistical evaluations of precision and accuracy. Data were expressed as means, variances, and standard deviation. For comparisons between variables, the Euclidean distance, Student's t-test, Levene's test, the calculation of Cohen's D, and the intraclass correlation coefficient (ICC) were used. Values of p < 0.05 were considered statistically significant. Results The mean Euclidean distance was 0.07 +/- 0.056 (95%CI: -0.037-0.18) mm. It is possible to state that there is a submillimetric difference in the coordinates with low effect size between the measurements made in Eximius and MNPS. The intraobserver evaluation showed that there is a positive correlation (ICC = 1) in the markings of each evaluator, while in the interobserver evaluation, there was no significant difference in any of the coordinates (p > 0.5) between the two software, when comparing evaluators 1 and 2. Conclusion Eximius Med, therefore, is a consistent, comparable, precise, and highly accurate alternative for use in cranial stereotaxy.
Objective To establish anatomical and functional criteria, based on stereotactic imaging and electrophysiological recordings, which enable the precise implantation of electrodes in the dentate nucleus and its projections for the treatment of movement disorders. Materials and Methods Ten patients with movement disorders or cerebellar abnormalities underwent bilateral deep brain stimulation (DBS) of the dentate nucleus (DN). The initial targets were defined using coordinates based on the fastigial point (FP); then, the target was refined through direct visualization of the DN using susceptibility weighted imaging (SWI) and T2-weighted magnetic resonance imaging (MRI) sequences and further adjusted based on reconstruction of the dentato-rubro-thalamic tract (DRTT). Results The ventral portion of the DN and the estimated vicinity of the DRTT were established as the target region, with the distal electrode contact positioned in the white matter and the proximal contacts within the DN. The coordinates were refined using direct imaging of the DN on SWI and T2 sequences, fused with stereotomography and contrast-enhanced volumetric T1 MRI. The electrode trajectory was adjusted to remain within the DN, as parallel and close as possible to the DRTT fibers. Surgical planning also defined the entry points and intracranial trajectories of the instruments, ensuring a safe path from the suboccipital bone to the targets, while avoiding venous sinuses and vessels visualized on contrast-enhanced images. Conclusion Precise localization of the DN based on DRTT tractography proved feasible using currently available stereotactic and imaging processing resources. The technique described enables coregistration of computed tomography (CT), MRI, and tractography images, representing a simple, safe, and effective methodology for performing DBS of the DN.
Objective Aneurysmal subarachnoid hemorrhage (aSAH) poses a significant challenge in neurological emergencies, demanding effective therapeutic interventions to improve patient outcomes. Intrathecal fibrinolysis has emerged as a potential intervention to promote the resolution of blood clots within the subarachnoid space. within the subarachnoid space. Methods Extensive literature searches identified relevant RCTs exploring intrathecal fibrinolysis for aSAH management. Data extraction included study characteristics, the quality assessment of the study, and primary outcomes: delayed ischemic neurological deficit (delayed ischemic neurological deficit (DIND)) occurrence and poor neurological recovery (defined by GOS 1-3 or mRS 3-6). Along with the complications and drug preferences. Results 9 RCTs were included in this meta-analysis. The majority of the RCTs demonstrate the promising effect of intrathecal fibrinolysis. Intracisternal fibrinolysis was found to significantly diminish the incidence of delayed ischemic neurological deficit (DIND) (RR, 0.54; 95% CI, 0.32-0.91) and poor neurological recovery (defined by GOS 1-3 or mRS 3-6) events (RR, 0.65; 95% CI, 0.47-0.90). The significant impact in delayed ischemic neurological deficit (DIND) events also showed in the subgroup analysis along with urokinase administration (RR, 0.31; 95% CI, 0.16-0.62). While intraventricular fibrinolysis did not achieve statistical significance for the primary outcomes, overall findings suggested a beneficial effect considering the choice of drugs administered. Conclusion This comprehensive meta-analysis highlights the potential benefits of intrathecal fibrinolysis in reducing delayed ischemic neurological deficit (DIND) occurrence and improving neurological recovery in aSAH patients. The promising results with intracisternal fibrinolysis and urokinase administration warrant further consideration in treatment protocols. Our findings contribute valuable insights, guiding evidence-based clinical decision-making and promoting advancements in aSAH management.
