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BACKGROUND: Cerebral aneurysms, especially large and giant aneurysms, pose challenges in neurointerventional surgery. Treatment choices involve clinical presentation, aneurysm details, and global resource variations. Neurointerventional methods, while innovative, may be cost restrictive in certain regions. In public healthcare, cost is crucial, notably in countries like Brazil. This study examines the device specific cost estimation of flow diverters (FD) and traditional stent assisted coiling (SAC) for large and giant cerebral aneurysms, providing insights into optimizing neurosurgical interventions within the Brazilian public health system's unique challenges. METHODS: A comprehensive retrospective analysis was conducted at our medical center of cases of large and giant aneurysms treated between 2013 and 2023. Determination of the estimated number of coils for aneurysms previously treated with FDs at our center was made, with the cost of each case, and the difference between both treatments was calculated. RESULTS: We investigated the profiles of 77 patients: 40 had large aneurysms (51.9%) and 37 had giant aneurysms (48.1%). Large aneurysms had a mean cost difference of US$274 (standard deviation (SD) $2071), underscoring the device specific cost estimation of FDs over SAC in their treatment. For giant aneurysms, the mean cost difference increased to $6396 (SD $2694), indicating FDs as the more economically sound choice. CONCLUSION: Our study indicated that, for the treatment of giant aneurysms and some large aneurysms, the FD intervention was more economical than SAC.

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BACKGROUND: Cerebral Venous Sinus Thrombosis (CVST) is a rare but potentially life-threatening condition, often associated with specific risk factors. The primary treatment for CVST is anticoagulation, but some cases progress to Refractory CVST (rCVST), requiring endovascular treatment. A combination of stent retriever and catheter aspiration is emerging as a promising technique to enhance treatment effectiveness. We conducted a systematic review and meta-analysis to assess the safety and efficacy of this approach, aiming to improve recanalization success and neurological outcomes while reducing complications in rCVST patients. METHODS: A search following PRISMA guidelines was conducted across Pubmed, Embase, Web of Science, and Cochrane databases to identify studies on the use of stent retrievers and catheter aspiration for rCVST. Pooled analysis with 95 % confidence intervals was used to assess the effects. Heterogeneity was evaluated using I2 statistics and a random-effects model was used. Complete recanalization. good clinical outcomes (mRS ≤ 2), hemorrhagic, neurological, ischemic, and total complications, poor clinical outcomes (mRS > 2), and mortality were assessed. RESULTS: A meta-analysis of five retrospective studies involving 55 patients examined outcomes in CVST. The median mean age was 40 years. Complete recanalization rate: 36 % (95 % CI: 9 % to 62 %, I2 = 90 %). Good clinical outcomes: 72 % (95 % CI: 50 % to 94 %, I2 = 76 %). Hemorrhagic complications: 2 % (95 % CI: 0 % to 8 %, I2 = 15 %). Ischemic complications: 0 % (95 % CI: 0 % to 6 %, I2 = 0 %). Neurological complications: 7 % (95 % CI: 0 % to 14 %, I2 = 0 %). Poor clinical outcomes: 26 % (95 % CI: 6 % to 46 %, I2 = 70 %). Total complications: 6 % (95 % CI: 0 % to 15 %, I2 = 10 %). Mortality rate: 5 % (95 % CI: 0 % to 13 %, I2 = 19 %). CONCLUSION: This systematic review and meta-analysis scrutinized the efficacy of combining Stent Retriever and Catheter Aspiration for rCVST. Findings highlighted varied outcomes, including recanalization rates, complications, and mortality. The dichotomy between good and poor outcomes underscores the necessity for personalized therapeutic decisions. While offering a comprehensive overview, the study emphasizes literature heterogeneity, suggesting a need for more rigorous and standardized research to optimize therapeutic strategies in clinical practice.

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Brain tumors are considered one of the deadliest types of cancer, being challenging to treat, especially due to the blood-brain barrier, which has been linked to treatment resistance. The genomic classification of brain tumors has been helping in the diagnostic precision, however tumor heterogeneity in addition to the difficulties to obtain tissue biopsies, represent a challenge. The biopsies are usually obtained either via neurosurgical removal or stereotactic tissue biopsy, which can be risky procedures for the patient. To overcome these challenges, liquid biopsy has become an interesting option by constituting a safer procedure than conventional biopsy, which may offer valuable cellular and molecular information representative of the whole organism. Besides, it is relatively easy to obtain such as in the case of blood (venipuncture) and urine sample collection. In the present comprehensive review, we discuss the newest information regarding liquid biopsy in the brain tumors' field, methods employed, the different sources of bio-fluids and their potential circulating targets.

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Different cancers have multiple genetic mutations, which vary depending on the affected tumour tissue. Small biopsies may not always represent all the genetic landscape of the tumour. To improve the chances of identifying mutations at different disease stages (early, during the disease course, and refractory stage), liquid biopsies offer an advantage to traditional tissue biopsy. In addition, it is possible to detect mutations related to metastatic events depending on the cancer types analysed as will be discussed in this case report, which describes a patient with brain metastasis and lung cancer that harboured K-RAS mutations both in the brain tumour and in the ctDNA present in the bloodstream.

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Introduction: Liquid biopsy is a non-invasive method used to detect cancer and monitor treatment responses by analyzing blood or other bodily fluids for cancer biomarkers. Meningiomas are the most common primary central nervous system tumors, and biomarkers play a crucial role in their diagnosis, prognosis, and treatment monitoring. The World Health Organization (WHO) classifies meningiomas based on tumor grades and molecular alterations in genes such as in NF2, AKT1, TRAF7, SMO, PIK3CA, KLF4, SMARCE1, BAP1, H3K27me3, TERT promoter, and CDKN2A/B. Liquid biopsy, specifically cell-free DNA (cfDNA) analysis, has shown potential for monitoring meningiomas as it can detect ctDNA release in the blood, unaffected by the blood-brain barrier. MicroRNAs (miRNAs) have also been found to be deregulated in various cancers, including meningiomas, presenting potential as diagnostic biomarkers. Additionally, studying cytokines in the tumor microenvironment may aid in establishing prognostic or diagnostic panels for meningiomas. Methods: In the present study we analyzed the DNA coming from both the plasma and tumor samples, in addition to analyze miRNA-21 and cytokines in the plasma of 28 meningioma patients. Discussion and Conclusion: Our findings indicate that the detection of ctDNA in the plasma of meningioma patients is feasible. However, it's important to note that certain challenges persist when comparing plasma DNA analysis to that of tumor tissues. In our study, we observed a paired identification of mutations in only one patient, highlighting the complexities involved. Furthermore, we successfully identified miR-21 and cytokines in the plasma samples. Notably, our analysis of Interleukin 6 (IL-6) unveiled higher expression in the clear cell subtype compared to the other types. Despite the ongoing research, the clinical implementation of liquid biopsy in meningiomas remains somewhat limited. Nevertheless, our promising results underscore the need for further investigation.

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OBJECTIVE: stroke etiology is ischemia in 85%, and in circa 25% of these, the source is the extracranial carotid. Recurrence is frequent and usually more severe. Carotid revascularization prevents new ischemic strokes. The sooner the treatment is undertaken, complete recovery chances are greater with less recurrences. But, historically, intervention in the acute setting was catastrophic. Objective: Identify determinants of success when carotid revascularization after a recent cerebral ischemic event is performed. MATERIALS AND METHODS: A cohort of 50 subjects underwent carotid revascularization after ischemic symptoms, within a period of 71 months. The currently diagnostic tools were used, and the symptoms stratified by the Rankin scale. The extension of the cerebral lesion and the source location the source of the event was analyzed. RESULTS: indications were based on the Rankin Scale (R0: 35.4%; R1: 45.8%; R2:18.8% and R3: zero), on the location of the source and the absence of ischemic areas greater than 15mm. An early surgical approach was adopted in all patients. Extreme care was applied to control arterial pressure. At discharge, no additional deficits were observed. CONCLUSIONS: carotid revascularization after ischemic events can be achieved without additional morbidity and no recurrences, using the most appropriate therapy in the shortest time, in patients with Rankin Scale up to 2, absence of intracranial hemorrhage and single or multiple ischemic intracerebral areas, with 15mm or less in their greater dimension.

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Acquired resistance during cancer treatment is unfortunately a frequent event. There are several reasons for this, including the ability of the ATP-binding cassette transporters (ABC transporters), which are integral membrane proteins, to export chemotherapeutic molecules from the interior of the tumor cells. One important member of this family is the protein known as Permeability Glycoprotein (P-Glycoprotein, P-gp or ABCB1). Its clinical relevance relies mainly on the fact that the inhibition of P-gp and other ABC transporters could result in the reversal of the multidrug resistance (MDR) phenotype in some patients. Recently, other roles apart from being a key player in MDR, have emerged for P-gp. Therefore, this review discusses the relationship between P-gp and MDR, in addition to the possible role of this protein as a biomarker in cancer.

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ABSTRACT Objective: stroke etiology is ischemia in 85%, and in circa 25% of these, the source is the extracranial carotid. Recurrence is frequent and usually more severe. Carotid revascularization prevents new ischemic strokes. The sooner the treatment is undertaken, complete recovery chances are greater with less recurrences. But, historically, intervention in the acute setting was catastrophic. Objective: Identify determinants of success when carotid revascularization after a recent cerebral ischemic event is performed. Materials and Methods: A cohort of 50 subjects underwent carotid revascularization after ischemic symptoms, within a period of 71 months. The currently diagnostic tools were used, and the symptoms stratified by the Rankin scale. The extension of the cerebral lesion and the source location the source of the event was analyzed. Results: indications were based on the Rankin Scale (R0: 35.4%; R1: 45.8%; R2:18.8% and R3: zero), on the location of the source and the absence of ischemic areas greater than 15mm. An early surgical approach was adopted in all patients. Extreme care was applied to control arterial pressure. At discharge, no additional deficits were observed. Conclusions: carotid revascularization after ischemic events can be achieved without additional morbidity and no recurrences, using the most appropriate therapy in the shortest time, in patients with Rankin Scale up to 2, absence of intracranial hemorrhage and single or multiple ischemic intracerebral areas, with 15mm or less in their greater dimension.

RESUMO Introdução: isquemia é a etiologia do acidente vascular cerebral em 85% dos casos e em cerca de 25% destes, a fonte é a carótida extracraniana. Recorrência é frequente e usualmente mais grave que a inicial. A revascularização carotídea previne novos acidentes. Quanto mais cedo for realizado o tratamento, maiores as chances de recuperação e menor o risco de recorrência. Mas, historicamente, os resultados das intervenções precoces eram catastróficos. Objetivos: identificar determinantes de sucesso da revascularização carotídea após um evento isquêmico cerebral recente. Materiais e Métodos: uma coorte de 50 pacientes foi submetida à revascularização carotídea após sintomas isquêmicos, em um período de 71 meses. Foram empregados os métodos de investigação atuais e os sintomas estratificados pela Escala de Rankin. A extensão das lesões cerebrais e a fonte do evento foram estudados e analisados. Resultados: as indicações foram baseadas na escala de Rankin (R0: 35.4%; R1: 45.8%; R2: 18.8% e R3: zero), na localização da fonte e na ausência de áreas isquêmicas com menos de 15mm. Uma abordagem cirúrgica precoce foi empregada em todos os pacientes. Cuidados extremos com a pressão arterial foram aplicados. Na alta hospitalar, nenhum déficit adicional foi observado. Conclusões: a revascularização carotídea após eventos isquêmicos pode ser realizada sem morbidade adicional ou recorrências, empregando a terapêutica mais apropriada no período de tempo mais curto, em pacientes classificados como Rankin até 2, na ausência de hemorragia intracraniana e com áreas isquêmicas intracerebrais únicas ou múltiplas, com menos de 15mm em sua maior dimensão.

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Neurofibromatosis type 1 (NF1) is a genetic syndrome which typically presents with neurological manifestations. Some of the patients may also present with vasculopathies, among which arterial aneurysms and stenosis are the most common. Deep vein thrombosis (DVT) has rarely been described, and, to the best of our knowledge, the present is the first report of DVT due to venous compression by a neurofibroma in the setting of NF1. This is the case of a 23-year-old male with NF1 who experienced DVT due to compression of the left posterior tibial veins by a large tumor arising from the tibial nerve. The DVT was acutely treated with enoxaparin and then with rivaroxaban. Two months after the diagnosis, Doppler ultrasonography showed partial recanalization and persistence of the DVT. The patient was then referred to neurosurgery for surgical resection of the tumor. There were no complications during the procedure, and the patient did not present postoperative neurological deficits. The final histopathological diagnosis was of a benign neurofibroma. After one year of follow-up with vascular surgery, the patient presented no more episodes of DVT. In case there is a tumor compressing the deep vessels of the leg and promoting DVT, surgical resection with microsurgical techniques may be curative.

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The dissemination of specialty hospitals throughout the urban centers has revolutionized the full spectrum of care for cardiology, oncology and orthopedics during the last decades. To centralize care, from translational and basic research to clinicians and surgeons, in the same dedicated institution leads to a decrease in complications rates, mortality and possible reductions in the length of hospital stays. Moreover, there has been a significant impact on hospital costs and on the quality of care. The Insituto Estadual do Cérebro Paulo Niemeyer (IECPN, in the Portuguese acronym) was opened in June 2013 in Rio de Janeiro, Brazil. It is the very first high-volume neurosurgical institution in the country. The core foundation of this institution is that the anesthesiologists, intensive care practitioners, nurses, pathologists, radiologists and rehabilitation staffs are trained and live the full management of neurosurgical lesions at the same facility on a daily basis. The present paper seeks to analyze the circumstances in which the institution was planned and opened as well as its complexity, infrastructure and initial results following its first 24 months of operation.

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Pallidal stimulation has been the usual surgical treatment for dystonia in the last decades. The continuous investigation of the physiopathology and the motor pathways involved leads to the search for complementary targets to improve results. The authors present the case of a 37-year-old woman who had suffered from idiopathic hemidystonia with hyperkinetic and hypokinetic movements for 11 years, and who was treated with deep brain stimulation. A brief literature review is also provided. The globus pallidus internus and the ventral intermediate/ventral oral posterior complex of the thalamus were stimulated separately and simultaneously for 3 months and compared using the Burke-Fahn-Marsden Dystonia Rating Scale and the Global Dystonia Severity Rating Scale, with a 3.5-year follow-up. The synergism of multiple-target stimulation resulted in a complete improvement of the mixed dystonic symptoms.

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OBJECTIVE: To call attention to an unusual complication of decompressive haemicraniectomy in the treatment of malignant haemispheric infarction. METHOD: We describe a case in which partial decompression occurred despite large craniectomy. Complete decompression followed resection of the temporal muscle. Pertinent literature is briefly reviewed. CASE DESCRIPTION: A 55-year old woman developed massive right middle cerebral artery infarction evolving to cerebral haerniation in 40 hours. Decompressive haemicraniectomy without cortical excision was unable to revert coma and decerebrate posturing because of a massive temporal muscle haemorrhage with persistent contralateral deviation of midline structures. Muscle resection was followed by adequate external haerniation of the affected haemisphere and fast recovery. Cranioplasty was succesfully performed 22 days later, following gradual regression of cerebral oedema. CONCLUSION: There is an increasing perception of the need to operate patients with massive middle cerebral or internal carotid artery territory infarctions before the development of coma and cerebral haerniation. The most common factor leading to inadequate surgical decompression is small size craniectomy. The case reported calls attention to temporal muscle bleeding as an additional complication of craniectomy.

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OBJECTIVE: To call attention to an unusual complication of decompressive haemicraniectomy in the treatment of malignant haemispheric infarction. METHOD: We describe a case in which partial decompression occurred despite large craniectomy. Complete decompression followed resection of the temporal muscle. Pertinent literature is briefly reviewed. CASE DESCRIPTION: A 55-year old woman developed massive right middle cerebral artery infarction evolving to cerebral haerniation in 40 hours. Decompressive haemicraniectomy without cortical excision was unable to revert coma and decerebrate posturing because of a massive temporal muscle haemorrhage with persistent contralateral deviation of midline structures. Muscle resection was followed by adequate external haerniation of the affected haemisphere and fast recovery. Cranioplasty was succesfully performed 22 days later, following gradual regression of cerebral oedema. CONCLUSION: There is an increasing perception of the need to operate patients with massive middle cerebral or internal carotid artery territory infarctions before the development of coma and cerebral haerniation. The most common factor leading to inadequate surgical decompression is small size craniectomy. The case reported calls attention to temporal muscle bleeding as an additional complication of craniectomy

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Relatamos a associaçäo impar entre esclerose múltipla (EM), tumor medular e tumor intracraniano em uma paciente de 63 anos de idade e com EM há dez anos com evoluçäo em surtos de remissäo e exacerbaçäo. Havia melhora dos sintomas com o uso de corticosteráides. Em 1997 apresentou paraparesia crural e do membro superior direito, de instalaçäo progressiva e que näo respondeu à corticoterapia. A ressonância magnética da coluna cervical evidenciou tumor intramedular, que se revelou um ependimoma, e a do crânio, a presença de meningioma parietal à esquerda. Ressaltamos a associaçäo incomum entre tumores do sistema nervoso central e EM e enfatizamos a necessidade de investigaçäo clínica e por imagem diante de uma manifestaçäo ou evoluçäo clínica incomum no curso da doença

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Apresentamos o caso de uma menina de 15 anos que foi enviada inicialmente ao Serviço de Neurocirurgia com diagnóstico de macroadenoma hipofisário näo funcionante, por apresentar lesäo expansiva em regiäo selar à RNM e näo ter qualquer sintoma ou sinal de hipersecreçäo hormonal. Feito o diagnóstico de hipotireoidismo e iniciada reposiçäo de L-tiroxina (na dose diária de até 150 mcg) com normalizaçäo da funçäo tireoidiana, nova RNM mostrou regressäo da imagem hipofisária. Este caso demonstra que em qualquer lesäo suspeita da regiäo hipotálamo-hipofisária deve ser realizada avaliaçäo hormonal completa antes do envio à cirurgia.

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Descrevemos o caso de um menino com três anos de idade e puberdade precoce central por tumor hipotalâmico (hamartoma). O diagnóstico de processo expansivo do sistema nervoso central foi estabelecido pela tomografia computadorizada e ressonância magnética de crânio. As alteraçöes hormonais mais importantes na investigaçäo foram a elevaçäo do nível sérico de testosterona e a resposta das gonadotrofinas ao hormônio liberador das gonadotrofinas (GnRH). O tratamento com o agonista do GnRH, após a cirurgia, tornou-se útil para bloquear a progressäo da precocidade central.

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Num período de 10 anos, 53 pacientes com espasmo hemifacial foram submetidos a 54 procedimentos de descompressäo microvascular da raiz do facial, na fossa posterior. A técnica empregada foi a mesma desenvolvida por Jannetta e o resultado cirúrgico inicial foi considerado excelente em 91% dos casos. O follow-up variou de 60 dias a 7 anos, com 40 pacientes acompanhados por mais de 2 anos e 16, por mais de 5 anos. Apenas um apciente apresentou recidiva dos espasmos. Näo houve óbito e as complicaçöes näo foram importantes, sendo, em sua maioria, transitórias e relacionadas à VII e VII raízes. Em 4 pacientes näo encontramos compressäo da raiz. Concluimos que, quaisquer sejam as causas do espasmo hemifacial ou mecanismos de açäo da cirurgia, os resultados da descompressäo microvascular säo excelentes, a curto e longo prazo, e superiores aos obtidos pelas demais formas de tratamento clínico ou cirúrgico

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Refere que o traumatismo cranioencefalixo e uma das principais causas de morte e invalidez nas grandes cidades. Mostra os principais tipos de lesoes sugerindo metodos de avaliaçao e a conduta indicada em cada caso

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Säo analisados os diferentes aspectos etiopatogênicos, clínicos, laboratoriais, radiológicos e terapêuticos da acromegalia à luz de 26 casos observados durante cinco anos pelos autores

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