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Background: Malignant middle cerebral artery (MCA) infarction is associated with high mortality, mainly due to intracranial hypertension. This malignant course develops when two-thirds or more of MCA territory is infarcted. Randomized clinical trials demonstrated that in patients with malignant MCA infarction, decompressive craniectomy (DC) is associated with better prognosis. In these patients, some prognostic predictors are already known, including age and time between stroke and DC. The size of bone flap was not associated with long-term prognosis in the previous studies. Therefore, this paper aims to further expand the analysis of the bone removal toward a more precise quantification and verify the prognosis implication of the bone flap area/whole supratentorial hemicranium relation in patients treated with DC for malignant middle cerebral infarcts. Methods: This study included 45 patients operated between 2015 and 2020. All patients had been diagnosed with a malignant MCA infarction and were submitted to DC to treat the ischemic event. The primary endpoint was dichotomized modified Rankin scale (mRS) 1 year after surgery (mRS≤4 or mRS>4). Results: Patients with bad prognosis (mRS 5–6) were on average: older and with a smaller decompressive craniectomy index (DCI). In multivariate analysis, with adjustments for “age“ and “time” from symptoms onset to DC, the association between DCI and prognosis remained. Conclusion: In our series, the relation between bone flap size and theoretical maximum supratentorial hemicranium area (DCI) in patients with malignant MCA infarction was associated with prognosis. Further studies are necessary to confirm these findings.

Background:A subdural hematoma is defined as clot formation in the subdural space after vessel rupture or brain parenchyma damage. Several demographic and tomographic factors were associated to poor prognosis, although some debate according to their specific roles still remains.Methods:Retrospective cohort study of comatose patients admitted to a single-institution, tertiary hospital center, between the years 2013 and 2019 with traumatic acute subdural hematoma requiring surgical evacuation were studied. Demographic and tomographic data were obtained from medical records. Univariate and multivariate statistical analysis were performed, using a value ofP< 0.05 for significance.Results:Seventy-seven patients were selected using the criteria and a total of 37 (48%) head CT exams were evaluated. The overall mortality was 57.1% and achieved 100% at ≥75-years-old subgroup. Univariate analysis only found young age as a good prognosis factor (P= 0.002). Gender (P= 0.784), abnormal pupillary response (P= 0.643), midline shift (P= 0.874), clot thickness (P= 0.206), compressed basal cisterns (P= 0.643), hematoma side (P= 0.879), and subarachnoid hemorrhage (P= 0.510) showed no association. Multivariate analysis showed no statistically significant association between covariates.Conclusion:Traumatic acute subdural hematoma is a life-threatening condition. Younger age was the only positive prognostic factor identified. More research is necessary to establish age as a rule-out criterion to surgical indication.

Background The syndrome of the trephined was described in 1939 by Grant and Norcross and is defined as a progressive neurological deterioration after craniectomy. Commonly, it is associated with sinking of the skin near the bone-free area. The symptoms and signs improve after cranioplasty. This report intends to describe an uncommon case of a patient who presented to the hospital with the syndrome of the trephined and was temporarily treated with a plastered helmet. Case description 45-year old male was submitted to a decompressive craniectomy due to severe traumatic brain injury. After one month, he was diagnosed with the syndrome of the trephined. Once he was in sepsis, cranioplasty could not be done. An alternative treatment was proposed and the patient improved in both clinical and radiological cenarios. Conclusion The external cranioplasty made with plastered helmet proved to be an effective technique that can be safely applied to patients with the syndrome of the trephined who cannot be promptly treated with surgery.

Dorsal root entry zone (DREZ) lesioning is an effective method to treat refractory neuropathic pain in patients with radicular avulsion. In this procedure, we penetrate the spinal cord with a radiofrequency electrode using the posterior lateral sulcus as a guide. The intraspinal electrode trajectory has to be angled medially about 25°-45° to spare the corticospinal tract, which lies lateral to the DREZ, and also to spare the posterior column, which lies medial to it. Here we present a case of a patient with radicular avulsion lesion of rootlets of the cervical spinal cord successfully treated with DREZ lesioning using intraoperative ultrasound as a guide to perform the spinal cord lesions. The use of intraoperative ultrasound during DREZ lesioning in patients with radicular avulsion improves the neurosurgeon ability to precisely localize the posterior lateral sulcus and also to better define the correct angulation of the trajectory.

Introduction Gangliogliomas are tumors commonly found in the temporal lobe and related to seizures; their appearance in the pineal region is rarely described. This report characterizes the first case of anaplastic ganglioglioma of the pineal region. Case Report The authors describe the case of a 32-year-old woman that developed progressive headache. An MRI investigation revealed a pineal tumor. The patient tested negative for biomarkers and underwent surgery through supracerebellar infratentorial approach and achieved gross total resection of the tumor in a challenging location. Pathological analysis revealed a biphasic neoplasm with the following two distinct phenotypes in separate fields: an immature neuronal component with several atypical mitoses and a mature astrocytic component with bipolar cells, microcysts, and eosinophilic bodies. The Ki67/MIB1 proliferation index was 20–30% in localized hotspots. Based on the pathological findings, the tumor was defined as an anaplastic ganglioglioma World Health Organization (WHO) grade III. Discussion/Conclusion Gangliogliomas are classified as glioneural neoplasms based on the histologic findings described as a mixture of neoplastic astrocytes and neurons. Moreover, these tumors represent 0.4–1.3% of tumors of the central nervous system. Authors describe de novo anaplastic ganglioglioma as 1% of the largest series. Gross total resection and adjuvant treatment may play important role in patients' prognostic. In this case, due to the malignant anaplastic component of her tumor, the patient received treatment with temozolamide and radiotherapy after gross total resection of the lesion.

The anatomical characterization of the orbitofrontal cortex in human is limited in literature instead of many functional and clinical studies involving it. Objective Anatomically define the orbitofrontal region aiming to possible neurosurgical treatments and unify the scientific nomenclature as well. Method We analyze eighty four human hemispheres using a surgical microscope. Then we chose four hemispheres and dissect them according to Klinger’ technique. Results We found five main sulcus: olfatory sulcus, orbital medial sulcus, orbital lateral sulcus, orbital transverse sulcus and orbital intermediate sulcus. These sulcus, excluding the intermediate sulcus, delimit five gyrus: rectus gurys, orbital medial gyrus, orbital anterior gyrus, orbital lateral gyrus and orbital posterior gyrus. The main sulcal configuration can be divided on four more frequently patterns. Conclusion Orbitofrontal cortex is associated with many psychiatric disorders. Better anatomical and functional characterization of the orbitofrontal cortex and its connections will improve our knowledge about these diseases. A caracterização do córtex orbitofrontal em humanos é limitada na literatura, a despeito de estudos funcionais e clínicos envolvendo-o. Objetivo Definir anatomicamente o córtex orbitofrontal visualizando possíveis tratamentos neurocirúrgicos e unificar a nomenclatura científica. Método Analisamos oitenta e quatro hemisférios cerebrais humanos usando um microscópio neurocirúrgico. Escolhemos quatro hemisférios e os dissecamos de acordo com a técnica de Klinger para expor a substância branca subcortical. Resultados Encontramos cinco principais sulcos: sulco olfatório, sulco orbital medial, sulco orbital lateral, sulco orbital transverso e sulco orbital intermediário. Estes sulcos, excluindo o sulco orbital intermediário, delimitaram cinco giros: giro reto, giro orbital medial, giro orbital anterior, giro orbital lateral e giro orbital posterior. A conformação de sulcos e giros orbitais pôde ser dividida em quatro padrões mais frequentes. Conclusão O córtex orbitofrontal é associado com várias desordens psiquiátricas. Uma melhora caracterização anatômica, funcional e de suas conexões melhorará nosso conhecimento destas desordens.

The vasogenic edema in structures of posterior fossa secondary to elevated hydrostatic pressure can cause obstructive hydrocephalus, a condition called “reversible obstructive hydrocephalus from hypertensive encephalopathy.” A case of a 27-year-old woman with arterial hypertension and sign of raised intracranial pressure is reported. Her radiologic studies have showed vasogenic cerebellar edema without structural lesion. This edema leads to obstruction of the cerebral aqueduct. We discuss the clinical and therapeutic aspects of this condition. In this clinical situation, the accurate control of blood pressure is the main goal on medical care, and the need of permanent ventricular shunt is quite infrequent.

Epidermoid cyst is a benign and congenital lesion of ectodermal origin. Traditionally, microsurgical techniques are used to treat these lesions, and their occurrence in the third ventricle is rare. Here, the authors report a case of epidermoid cyst in the third ventricle that presented with signs and symptoms of intracranial hypertension, which was treated safely and effectively using neuroendoscopic surgery.

Resumo Objetivo: Averiguar se as características hidrodinâmicas das válvulas se alteram significativamente quando os dimensionamentos originais são violados e a possível repercussão clínica desse fato. Métodos: Foi utilizada uma bancada de testes automatizada, conforme a norma ISO 7197. Um sistema valvular foi testado inicialmente com os componentes preconizados e embalados originalmente com o produto. A seguir, substituiu-se o cateter peritoneal original por diversos dimensionamentos encontrados no mercado nacional. Nos testes para a avaliação da influência do diâmetro do cateter no escoamento, foi utilizado sempre o mesmo comprimento original do cateter. Aplicou-se o mesmo raciocínio lógico para a análise do comprimento do cateter. Nove perfis hidrodinâmicos foram obtidos para as diferentes montagens valvulares. Resultados: Diminuições imperceptíveis no diâmetro do cateter peritoneal alteraram o perfil hidrodinâmico do sistema valvular testado. Alterações de 0,1 mm no diâmetro de um cateter peritoneal aumentaram o efeito resistivo do sistema valvular suficientemente para que ele funcionasse fora do perfil hidrodinâmico preconizado; o efeito resistivo se acentuou conforme o diâmetro diminuiu, e vice-versa. A diminuição do comprimento do cateter também influenciou significativamente no desempenho hidráulico da válvula, de um regime inicial de alta pressão para um regime de média pressão. Conclusão: Alterações de dimensionamento em cateteres peritoneais trazem complicações para o paciente e desorientam o julgamento clínico do neurocirurgião no período pós-implante, pois o sistema valvular funcionará em regime hidráulico fora do especificado, e o raciocínio lógico do neurocirurgião também se torna comprometido. Esse fato pode ser crítico principalmente em crianças e neonatos. Não foram identificados relatos desse fato na literatura que antecede esta apresentação.

Spinal angiolipomas are rare benign tumors that generally induce slow progressive cord compression. Here, the authors describe a case of sudden-onset palsy of the lower extremities caused by hemorrhagic spinal angiolipoma. An emergent laminectomy was performed to achieve total lesion removal. Follow-up examinations indicated neurological improvement and the absence of recurrence.

Spinal angiolipomas are rare benign tumors that generally induce slow progressive cord compression. Here, the authors describe a case of sudden-onset palsy of the lower extremities caused by hemorrhagic spinal angiolipoma. An emergent laminectomy was performed to achieve total lesion removal. Follow-up examinations indicated neurological improvement and the absence of recurrence.

Purpose To analyze the pathways to brainstem tumors in childhood, as well as safe entry zones. Method We conducted a retrospective study of 207 patients less than 18 years old who underwent brainstem tumor resection by the first author (Cavalheiro, S.) at the Neurosurgical Service and Pediatric Oncology Institute of the São Paulo Federal University from 1991 to 2011. Results Brainstem tumors corresponded to 9.1 % of all pediatric tumors operated in that same period. Eleven previously described “safe entry zones” were used. We describe a new safe zone located in the superior ventral pons, which we named supratrigeminal approach. The operative mortality seen in the first 2 months after surgery was 1.9 % (four patients), and the morbidity rate was 21.2 %. Conclusions Anatomic knowledge of intrinsic and extrinsic brainstem structures, in association with a refined neurosurgical technique assisted by intraoperative monitoring, and surgical planning based on magnetic resonance imaging (MRI) and tractography have allowed for wide resection of brainstem lesions with low mortality and acceptable morbidity rates.

Suprapineal recess diverticulum of the third ventricle exerting a mass effect on the midbrain and cerebellum