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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.

Objective To describe the technical details of a 3-piece orbitozygomatic approach. Introduction In a 3-piece orbitozygomatic approach, soft tissue exposure is mostly comparable to the classic frontopterional approach. Osseous resection is a 3-piece operation that consists of first performing anterior and posterior cuts along the zygomatic arch, reflecting it down, attached to the masseter. This is followed by a classic frontotemporosphenoidal craniotomy, and finally, an osteotomy of the orbital rim, roof, and lateral wall of the orbit. Results When compared with its 1- and 2-piece counterparts, 3-piece orbitozygomatic craniotomy, as described here, is a relatively simple operation and is thus advisable when considering an anterior or middle fossa approach. Brain exposure is wide, whereas cerebral retraction is minimal. We recommend avoiding orbit sectioning as deep as the superior orbital fissure. Conclusion The modifications described herein show the technical features of the 3-piece orbitozygomatic approach, which provides excellent brain exposure with less retraction and a good cosmetic result.

Objective: To define the characteristics of the arachnoidal sleeve and cistern that accompany the oculomotor nerve through the cavernous sinus roof. Methods: Forty cavernous sinuses were examined using 3 to 40x magnification. Information was obtained about the size of the oculomotor cistern and its relationship to the roof of the cavernous sinus and anterior clinoid process. Results: An arachnoidal sleeve and cistern, referred to as the oculomotor cistern, accompanied the oculomotor nerve into the roof of all the cavernous sinuses examined. The oculomotor cistern extends from the oculomotor porus, where the nerve enters the roof of the cavernous sinus, to the area below the tip or the adjacent part of the lower margin of the anterior clinoid process. From the porus, the nerve passes forward and downward to the depth of the cistern where it becomes incorporated into the fibrous lateral wall of the cavernous sinus. The width of the cistern was maximal at the oculomotor porus averaged 5.5 mm (range, 3.0–9.2 mm), and tapered slightly towards the midpoint and deep end of the cistern. The cistern's average length was 6.5 mm (range, 3.0–11.0 mm). The oculomotor nerve usually coursed closer to the anterior than the posterior wall of the cistern at the level of the oculomotor porus. Conclusion: The oculomotor cistern, an arachnoidal and dural cuff, accompanies the oculomotor nerve through the cavernous sinus roof to the area just below or anterior to the lower edge of the tip of the anterior clinoid process. The segment of the nerve inside the oculomotor cistern is interposed between its free portion in the interpeduncular cistern and the part of its course where it is incorporated into the fibrous lateral wall of the cavernous sinus. The cistern can be opened to aid in the exposure and mobilization of the nerve in dealing with pathology in the area.

Objective This study was conducted to clarify the boundaries, relationships, and components of the medial wall of the cavernous sinus (CS). Methods Forty CSs, examined under x3 to x40 magnification, were dissected from lateral to medial in a stepwise fashion to expose the medial wall. Four CSs were dissected starting from the midline to lateral. Results The medial wall of the CS has two parts: sellar and sphenoidal. The sellar part is a thin sheet that separates the pituitary fossa from the venous spaces in the CS. This part, although thin, provided a barrier without perforations or defects in all cadaveric specimens studied. The sphenoidal part is formed by the dura lining the carotid sulcus on the body of the sphenoid bone. In all of the cadaveric specimens, the medial wall seemed to be formed by a single layer of dura that could not be separated easily into two layers as could the lateral wall. The intracavernous carotid was determined to be in direct contact with the pituitary gland, being separated from it by only the thin sellar part of the medial wall in 52.5% of cases. In 39 of 40 CSs, the venous plexus and spaces in the CS extended into the narrow space between the intracavernous carotid and the dura lining the carotid sulcus, which forms the sphenoidal part of the medial wall. The lateral surface of the pituitary gland was divided axially into superior, middle and inferior thirds. The intracavernous carotid coursed lateral to some part of all the superior, middle, and inferior thirds in 27.5% of the CSs, along the inferior and middle thirds in 32.5%, along only the inferior third in 35%, and below the level of the gland and sellar floor in 5%. In 18 of the 40 CSs, the pituitary gland displaced the sellar part of the medial wall laterally and rested against the intracavernous carotid, and in 6 there was a tongue-like lateral protrusion of the gland that extended around a portion of the wall of the intracavernous carotid. No defects were observed in the sellar part of the medial wall, even in the presence of these protrusions. Conclusion The CS has an identifiable medial wall that separates the CS from the sella and capsule of the pituitary gland. The medial wall has two segments, sellar and sphenoidal, and is formed by just one layer of dura that cannot be separated into two layers as can the lateral wall of the CS. In this study, the relationships between the medial wall and adjacent structures demonstrated a marked variability.