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Antecedentes: El conocimiento profundo de la anatomía microquirúrgica del lóbulo de la ínsula es crucial para operar pacientes con tumores en esta región. El objetivo de la segunda parte de este estudio es correlacionar la anatomía microquirúrgica con casos ilustrativos retirados de nuestra casuística de 35 pacientes en los cuales fueron realizados 44 cirugías de tumores en relación con el lóbulo de la ínsula. Métodos: A lo largo de marzo de 2007 y agosto de 2014, 44 microcirugías fueron realizadas en 35 pacientes portadores de tumores insulares y los hallazgos de las cirugías y mapeo cerebral se correlacionaron con la anatomía microquirúrgica. Resultados: De una serie de 44 pacientes con tumores de la ínsula, la mayoría de los casos eran gliomas de bajo grado de malignidad (29 casos). El inicio de los síntomas en 34 pacientes fue epilepsia, siendo esta refractaria al tratamiento medicamentoso en 12 casos. El grado de resección fue subtotal o total en la mayoría de los casos de la serie. La mejoría en la calidad de vida (epilepsia, etc.) estuvo presente en más de la mitad de los pacientes. El dé cit neurológico permanente estuvo presente en tres pacientes. Conclusión: En los tumores insulares, es tan importante el conocimiento profundo de la anatomía, como el saber utilizar e interpretar en tiempo real las observaciones de la monitorización neuro siológica intraoperatoria.

Antecedentes: El lóbulo de la ínsula, o ínsula, se encuentra oculto en la super cie lateral del cerebro. La ínsula está localizada profundamente en el surco lateral o cisura silviana, recubierta por los opérculos frontal, parietal y temporal. Estudiar la compleja anatomía del lóbulo de la ínsula, una de las regiones de mayor complejidad quirúrgica del cerebro humano, y su correlación anatómica con casos quirúrgicos. Métodos: En la primera parte de este estudio presentamos los resultados de nuestras disecciones microquirúrgicas en fotografías 2 D y 3D; en la segunda parte de nuestro trabajo, la correlación anatómica con una serie de 44 cirugías en pacientes con tumores de la ínsula, principalmente gliomas, operados entre 2007 y 2014. Resultados: Extenso conjunto de bras subcorticales, incluyendo el fascículo uncinado, fronto-occipital inferior y el fascículo arcuato, conectan la ínsula a las regiones vecinas. Varias estructuras anatómicas responsables por dé cits neurológicos severos están íntimamente relacionadas con la cirugía de la ínsula, tales como lesiones de la arteria cerebral Media, cápsula interna, áreas del lenguaje en el hemisferio dominante y arterias lenticuloestriadas. Conclusión: El entrenamiento en laboratorio de neuroanatomía, estudio de material impreso en 3D, el conocimiento sobre neuro siología intra-operatoria y el uso de armamento neuroquirúrgico moderno son factores que in uencian en los resultados quirúrgicos.

Background: Cisternostomy is a surgical technique thought of and developed as an option for severe brain trauma treatment. It demands a particular knowledge and skill to microsurgically approach basal cisterns and effectively manipulate their contents. To perform this procedure safely, the anatomy and pathophysiology must be clearly understood. Methods: Detailed microscopic dissection and anatomical review were done, after a detailed reading of facts and recent publications about cisternostomy. Cisternal pathways and landmark planning are described and augmented using a new method to show de arachnoid borders. Finally, a brief discussion is written as a synopsis. Results: Cisternostomy requires thorough microscopic knowledge and microsurgical skills. This paper intends to provide information to understand better the anatomy related, thus, easing the learning curve. The technique used to show arachnoid borders, complementing cadaveric and surgical images, was useful for this purpose. Conclusion: To perform this procedure safely, it is mandatory to handle microscopic details of cistern anatomy. Reaching a core cistern is necessary to assure effectiveness. This procedure needs, as well, surgical step-by-step landmark planning and performing. Cisternostomy could be a life-saving procedure and a new powerful tool for severe brain trauma treatment. Evidence is being collected to support its indications.

Background: Focal cortical dysplasias (FCD) cause a subgroup of malformations of cortical development that has been closely linked to cause drug intractable epilepsy. Attaining adequate and safe resection of the dysplastic lesion has proved to be a viable option to archive meaningful seizure control. Of the three types of FCD (types I, II, and III), type I has the least detectable architectural and radiological abnormalities. This makes it challenging (preoperatively and intraoperatively) to achieve adequate resection. Intraoperatively, ultrasound navigation has proven an effective tool during the resection of these lesions. We evaluate our institutional experience in surgical management of FCD type I using intraoperative ultrasound (IoUS). Methods: Our work is a retrospective and descriptive study, where we analyzed patients diagnosed with refractory epilepsy who underwent IoUS-guided epileptogenic tissue resection. The surgical cases analyzed were from January 2015 to June 2020 at the Federal Center of Neurosurgery, Tyumen, only patients with histological confirmation of postoperative CDF type I were included in the study. Results: Of the 11 patients with histologically diagnosed FCD type I, 81.8% of the patients postoperatively had a significant reduction in seizure frequency (Engel outcome I-II). Conclusion: IoUS is a critical tool for detecting and delineating FCD type I lesions, which is necessary for effective post-epilepsy surgery results.

Background: Most neurosurgical photographs are limited to two-dimensional (2D), in this sense, most teaching and learning of neuroanatomical structures occur without an appreciation of depth. The objective of this article is to describe a simple technique for obtaining right and left 2D endoscopic images with manual angulation of the optic. Methods: The implementation of a three-dimensional (3D) endoscopic image technique is reported. We first describe the background and core principles related to the methods employed. Photographs are taken demonstrating the principles and also during an endoscopic endonasal approach, illustrating the technique. Later, we divide our process into two sections containing explanations, illustrations, and descriptions. Results: The results of taking a photograph with an endoscope and its assembly to a 3D image has been divided into two parts: Photo acquisition and image processing. Conclusion: We conclude that the proposed method is successful in producing 3D endoscopic images.

Background: Presurgical three-dimensional (3D) reconstructions allow spatial localization of cerebral lesions and their relationship with adjacent anatomical structures for optimal surgical resolution. The purpose of the present article is to present a method of virtual preoperative planning aiming to enhance 3D comprehension of neurosurgical pathologies using free DICOM image viewers. Case Description: We describe the virtual presurgical planning of a 61-year-old female presenting a cerebral tumor. 3D reconstructions were created with the “Horos®” Digital Imaging and Communications in Medicine viewer, utilizing images obtained from contrast-enhanced brain magnetic resonance imaging and computed tomography. The tumor and adjacent relevant structures were identified and delimited. A sequential virtual simulation of the surgical stages for the approach was performed with the identification of local gyral and vascular patterns of the cerebral surface for posterior intraoperative recognition. Through virtual simulation, an optimal approach was gained. Accurate localization and complete removal of the lesion were achieved during the surgical procedure. Virtual presurgical planning with open-source software can be utilized for supratentorial pathologies in both urgent and elective cases. Virtual recognition of vascular and cerebral gyral patterns is helpful reference points for intraoperative localization of lesions lacking cortical expression, allowing less invasive corticotomies. Conclusion: Digital manipulation of cerebral structures can increase anatomical comprehension of neurosurgical lesions to be treated. 3D interpretation of neurosurgical pathologies and adjacent anatomical structures is essential for developing an effective and safe surgical approach. The described technique is a feasible and accessible option for presurgical planning.

Background: During aneurysm microsurgery, the aneurysmal sac is excluded from circulation by placing one or more clips at the base of the aneurysm. In some cases of complex aneurysms or subarachnoid hemorrhage history, transient clipping before definitive clipping is necessary. The closing force of the transient clip is less than the permanent clip; however, it is sufficient to stop circulation to the aneurysmal sac. The aim of the following work is to analyze and describe histological changes caused by transient and permanent clipping of the abdominal aorta in Wistar-type rats, to study the correlation between the closing force of the clip and the time, it remains on the vascular tissue structures. Methods: Six groups were formed, with 10 rats each, whereby temporary clipping of the abdominal aorta was performed with subsequent sampling of the site where the vascular clip was placed. The groups were: control and temporary clipping with: 2, 5, 10, and 15 and permanent clipping with 5 min. Results: Resection samples of the 3 μm thick aorta were obtained through the routine histological technique and special histochemical techniques (Masson’s Trichrome and orcein) from the six groups. Transmural changes were found from Group II–VI. Conclusion: There is a vascular histological effect after both transient and permanent clipping. The sum of time and strength of the clip induce vascular changes visible at 5 min.

Background: Tentorial meningiomas (TM) are complex entities with distinguished clinical, radiological and surgical considerations. They comprise approximately 3 - 6% of all intracranial meningiomas1. TM have been classified in 5 subgroups according to the modified Yasargil’s classification, based on their location 2 and 3. Those located at the free margin of the tentorium are still challenging for neurosurgeons, with high morbidity and mortality. Atypical trigeminal neuralgia (ATN) is a type of trigeminal neuralgia that is identified by the constancy of symptoms. They experience less intense pain, but a constant dull aching or burning pain, and it is frequently misdiagnosed. Although it is well known that typical trigeminal (TN) neuralgia responds very well to medical treatment and are related with posterior fossa tumors, ATN is less likely. In this video we demonstrate the microsurgical resection of group 1 tentorial meningioma in the treatment of atypical trigeminal neuralgia. Case Description: A previously healthy 63-year-old female came to our service complaining of long lasting, intermittent, right facial pain for two years. On neurological examination, the patient had hypoesthesia in the territory of maxillae (V2) branch of the right trigeminal nerve. She had no other complaints on the physical examination. Initial treatment with carbamazepine and pregabalin was performed, however, it could not be further increased because of the maximal doses and side effects. Radiological investigation was carried out with cranial computed tomography (CT) and magnetic resonance image (MRI), which showed a high signal density mass lesion in the free margin of the tentorium, with extension to the right cerebello pontine angle (CPA), compressing the trigeminal nerve, that exhibited homogeneous contrast enhancement, suggestive of tentorial meningioma. Given the size, the location of the mass, and no response to the medical treatment, microsurgical resection was performed. Conclusion: The postoperative period was excellent, without any neurological deficit. The patient consented with publication of her images and videos.

Objectives The primary aim of this study was to assess the results attained for 12 patients with an anterior or lateral foramen magnum meningioma, treated microsurgically. Methods Between June 2005 and December 2016, 12 patients with foramen magnum meningiomas underwent microsurgical resection. Patients' age and gender, tumor localization (anterior or lateral), symptoms, approach, and postoperative results were analyzed. Results Eight of the 12 patients were women. The average age of the patients was 47 years. In 8 patients, the tumor was located anteriorly and in 4 patients laterally. The main symptom was occipitocervical pain (8 patients), followed by tetraparesia (3 patients). For all the anterior foramen magnum meningiomas, an extreme-lateral transcondylar approach was performed. In cases where the tumor was lateral, an extreme-lateral retrocondylar approach was adopted. Total and subtotal resection was achieved in 10 and 2 patients, respectively. In the latter instances, a very small piece of tumor remained around the vertebral artery or inside the jugular foramen. Three patients exhibited postoperative cranial nerve XII palsy and 2 cranial nerve XI palsy. One patient experienced cerebrospinal fluid leakage. Conclusions Microsurgery for both anterior and lateral foramen magnum meningiomas can be performed safely and effectively. What is necessary is: (a) good anatomical knowledge of the region; (b) two-step muscle dissection to expose the suboccipital triangle and vertebral artery; (c) to adopt an extreme-lateral retrocondylar approach for lateral meningiomas, and an extreme-lateral transcondylar approach for anterior tumors; and (d) good microsurgical techniques.

OBJECTIVE The aim of this study is to describe the results of 13 patients with facial hemispasm, treated with microvascular decompression. METHODS Between June 2005 and May 2014, 13 patients with facial hemispasm were operated, underwent microvascular decompression. The age, sex, duration of symptoms before surgery, and surgical finds, were all evaluated. In addition, postoperative results were also analyzed. RESULTS Seven patients were women and 6 were men. The average age of the patients was 53 years. The average time between onset of symptoms and surgery ranged from 3 to 9 years. In all cases the facial hemispasm was typical, one with concomitant trigeminal neuralgia, observed in all neurovascular compression intraoperative. In decreasing order of frequency, the cause of compression was anterior inferior cerebellar artery, posterior inferior cerebellar artery, dolicomega basilar artery and dolicomega vertebral artery. The average time of postoperative follow-up after the surgery was 24 months. Complete relief from spasm occurred in 62%; 30% disappearance after 3 weeks-2 months (8% partial) and in 8% had no improvement. Regarding postoperative complications: 3 patients had facial paresis II-III in House-Brackman scale and 1 patient presented CSF leak. None of the patients in the serie had hearing loss or deafness. CONCLUSION The microvascular decompression for facial hemispasm is a safe an effective procedure, which allows complete resolution of the disease in most cases.

Objective To describe the microsurgical anatomy and approaches to the mesial temporal region (MTR), in relation with cavernomas. Methods Five adult cadaveric heads, fixed in formol and injected with colored silicon were studied. Since January 2007 and June 2014, the author operated 7 patients with cavernomas located in the MTR. Anatomy The MTR was divided in 3 portions: Anterior, middle and posterior. Patients The author operated 7 patients with MTR cavernomas. Four cavernomas were located in the anterior portion, 2 were located in the middle portion, and 1 cavernoma was located in the posterior portion. The transsylvian-transinsular approach was used for the anterior portion of the MTR; the transtemporal approach (anterior temporal lobectomy) was used for the middle portion of the MTR; and the supracerebellar-transtentorial approach was used for the posterior portion of the MTR. Conclusion The idea of divide the MTR in 3 portions help to select the correct approach.

Objetivo: la presentacion de un caso de una paciente con un ependimoma sacro con extensa infiltracion y destruccion osea local.

BACKGROUND The aim of this study is to describe the results of 36 patients with trigeminal neuralgia treated with microvascular decompression. METHODS Between June 2005 and May 2012, 36 patients with trigeminal neuralgia were operated by the first author (AC), underwent microvascular decompression. The age, sex, duration of symptoms before surgery, and surgical finds, were all evaluated. In addition, postoperative results were also analyzed. RESULTS Twenty-five patients were women and 11 were men. The average age of the patients was 48 years. The average time of postoperative follow-up after the surgery was 36 months. Relief from pain until now occurred in 32 patients (88%). Pain recurrence was observed in 4 patients; of those, 2 cases showed a vein compression. CONCLUSION The microvascular decompression for trigeminal neuralgia is a safe an effective option. A vein compression could point out an unfavorable follow-up.

Introduccion: los meningiomas del foramen optico producen un rapido deterioro de la funcion visual aun cuando su tamano es pequeno, por eso su diagnostico y manejo difiere del resto de los meningiomas clinoideos. El proposito de este estudio es presentar la tecnica y los resultados de nuestro manejo quirurgico de meningiomas foraminales (MF).

BACKGROUND Tension pneumocephalus is uncommon after transsphenoidal surgery. There are only few cases reported in the literature in which the air was located at the sellar region exclusively, constituting a sellar pneumocele. In this article, an unusual case of a late onset tension sellar pneumocele is reported. CASE DESCRIPTION A 57-year-old woman consulted because of bitemporal hemianopsia. She had undergone a transnasal surgery for pituitary adenoma and a shunt had been placed because of the presence of cerebrospinal fluid leakage. Furthermore, the patient had undergone a transcranial resection of an intracavernous component of the tumor and radiosurgical treatment had been perfomed too because of its aggressiveness. A magnetic resonance imaging was undertaken and it demonstrated a sellar and suprasellar pneumocele. INTERVENTION A transcilliary approach was performed. The sellar region was enclosed by scarring tissue from her earlier procedures. The scar was opened and the air was evacuated. The sellar floor was subsequently closed with fat and fibrin glue. After the procedure, her visual field returned to normal. One year after her last surgery, she is still asymptomatic. CONCLUSION Sellar and suprasellar tension pneumocele is an extremely rare finding following transsphenoidal surgery. Its clinical manifestation would be visual disturbance due to compression on the optic pathway from below. When diagnosed, tension sellar pneumocele should be evacuated within a short time frame.

Background: The central sulcus may be located through magnetic resonance imaging (MRI) by identifying the ipsilateral inverted Omega shape. In a brain with a lesion in this area, its identification becomes a hard task irrespective of the technique applied. The aim of this study is to show the usefulness of the contralateral Omega sign for the location of tumors in and around the central sulcus. We do not intend to replace modern techniques, but to show an easy, cheap and relatively effective way to recognize the relationship between the central sulcus and the lesion. Methods: From July 2005 through December 2010, 43 patients with lesions in and around the central sulcus were operated using the contralateral Omega sign concept. Additionally, 5 formalin-fixed brains (10 hemispheres) were studied to clarify the anatomy of the central sulcus where the Omega shape is found. Results: The central sulcus has three genua. The middle genu is characterized by an inverted Omega-shaped area in axial sections known as the Omega sign. On anatomical specimens, Omega was 11.2 ± 3.35 mm in height, on average, and 18.7 ± 2.49 mm in width, at the base. The average distance from the medial limit of the Omega to the medial edge of the hemisphere was 24.5 ± 5.35 mm. Identification of the Omega sign allowed for the topographic localization of the contralateral central sulcus in all our surgical cases but one. Conclusion: The contralateral Omega sign can be easily and reliably used to clarify the topographic location of the pathology. Hence, it gives a quick preoperative idea of the relationships between the lesion and the pre- and post-central gyri.