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BACKGROUND: Several diseases that involve the optic canal or its contained structures may cause visual impairment. Several techniques have been developed to decompress the optic nerve. OBJECTIVE: To describe minimally invasive extradural anterior clinoidectomy (MiniEx) for optic nerve decompression, detail its surgical anatomy, present clinical cases, and established a proof of concept. METHODS: Anatomic dissections were performed in cadaver heads to show the surgical anatomy and to show stepwise the MiniEx approach. In addition, these surgical concepts were applied to decompress the optic nerve in 6 clinical cases. RESULTS: The MiniEx approach allowed the extradural anterior clinoidectomy and a nearly 270° optic nerve decompression using the no-drill technique. In the MiniEx approach, the skin incision, dissection of the temporal muscle, and craniotomy were smaller and provided the same extent of exposure of the optic nerve, anterior clinoid process, and superior orbital fissure as that usually provided by standard techniques. All patients who underwent operation with this technique had improved visual status. CONCLUSIONS: The MiniEx approach is an excellent alternative to traditional approaches for extradural anterior clinoidectomy and optic nerve decompression. It may be used as a part of more complex surgery or as a single surgical procedure.

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BACKGROUND: The mesial temporal region (MTR) is located deep in the temporal lobe and it is surrounded by important vascular and nervous structures that should be preserved during surgery. OBJECTIVE: To describe microsurgical anatomy and approaches to the MTR in relation to cavernomas and arteriovenous malformations (AVMs). METHODS: Five formalin-fixed and red silicone-embedded heads of adult cadavers were used for this study. Between January 2003 and June 2014, 7 patients with cavernomas and 6 patients with AVMs in the MTR underwent surgery. RESULTS: The MTR of the cadavers was divided into 3 areas: anterior, middle, and posterior. Of the 7 patients with MTR cavernomas, 4 were located anteriorly, 2 were located medially, and 1 was located posteriorly. Of the 6 patients with MTR AVMs, 3 were located in the anterior sector, 2 in the middle sector, and 1 in the posterior sector. For the anterior portion of the MTR, a transsylvian-transinsular approach was used; for the middle portion of the MTR, a transtemporal approach was used (anterior temporal lobectomy); and for the posterior portion of the MTR, a supracerebellar-transtentorial approach was used. CONCLUSION: Dividing the MTR into 3 regions allows us to adapt the approach to lesion location. Thus, the anterior sector can be approached via the sylvian fissure, the middle sector can be approached transtemporally, and the posterior sector can be approached via the supracerebellar approach.

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OBJECTIVE: We used microscopy to conduct qualitative and quantitative analysis of 4 surgical approaches commonly used in the surgery of the ambient cistern: infratentorial supracerebellar (SC), occipital interhemispheric, subtemporal (ST), and transchoroidal (TC). In addition, we performed a parahippocampal gyrus resection in the ST context. METHODS: Each approach was performed in 3 cadaveric heads (6 sides). After the microscopic anatomic dissection, the parahippocampal gyrus was resected through an ST approach. The qualitative analysis was based on anatomic observation and the quantitative analysis was based on the linear exposure of vascular structures and the area of exposure of the ambient cistern region. RESULTS: The ST approach provided good exposure of the inferior portion of the cistern and of the proximal segments of the posterior cerebral artery. After the resection of the parahippocampal gyrus, the area of exposure improved in all components, especially the superior area. A TC approach provided the best exposure of the superior area compared with the other approaches. The posterolateral approaches (SC/occipital interhemispheric) to the ambient cistern region provided similar exposure of anatomic structures. There was a significant difference (P < 0.05) in linear exposure of the posterior cerebral artery when comparing the ST/TC and ST/SC approaches. CONCLUSIONS: This study has demonstrated that surgical approaches expose dissimilarly the different regions of the ambient cistern and an approach should be selected based on the specific need of anatomic exposure.

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PURPOSE: Knowledge of anatomy of the IV ventricle is basic to surgical approach of any kind of lesion in its compartment as well as for those located in its neighborhood. The purpose of this study is to demonstrate the surgical approach options for the IV ventricle, based on the step by step dissection of anatomical specimens. METHODS: Fifty formalin-fixed specimens provided were the material for this study. The dissections were performed in the microsurgical laboratory in Gainesville, Florida, USA. RESULTS: The IV ventricle in a midline sagittal cut shows a tent-shaped cavity with its roofs pointing posteriorly and the floor formed by the pons and the medulla. The superior roof is formed by the superior cerebellar peduncles laterally and the superior medullary velum on the midline. The inferior roof is formed by the tela choroidea, the velum medullary inferior, and the nodule. The floor of the IV ventricle has a rhomboid shape. The rostral two thirds are related to the pons, and the caudal one third is posterior to the medulla. The median sulcus divides the floor in symmetrical halves. The sulcus limitans runs laterally to the median sulcus, and the area between the two sulci is called the median eminence. The median eminence contains rounded prominence related to the cranial nucleus of facial, hypoglossal, and vagal nerves. The lateral recesses are extensions of the IV ventricle that opens into the cerebellopontine cistern. The cerebellomedullary fissure is a space between the cerebellum and the medulla and can be used as a surgical corridor to the IV ventricle. CONCLUSIONS: We obtained in this study a didactic dissection of the different anatomical structures, whose recognition is important for addressing the IV ventricle lesions.

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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.

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Objetivo: el propósito del presente trabajo es presentar los resultados de 13 pacientes con diagnóstico de espasmo hemifacial (EHF), en los cuales se realizó una descompresión microvascular (DMV). Material y Método: Desde Junio de 2005 a Mayo de 2014, 13 pacientes con diagnóstico de EHF fueron intervenidos quirúrgicamente, realizando una DMV. Se evaluó: edad, sexo, tiempo de evolución de la sintomatología, hallazgos intraoperatorios y resultados postoperatorios. Resultados: De los 13 pacientes intervenidos, 7 fueron mujeres y 6 varones. La media de edad fue de 53 años. El tiempo medio entre el inicio de la sintomatología y la intervención quirúrgica osciló entre 3 y 9 años. En todos los casos el EHF era típico, uno de ellos con neuralgia trigeminal concomitante, observándose en todos compresión neurovascular intraoperatoria. Por orden decreciente de frecuencia la causa de la compresión fue arteria cerebelosa anteroinferior, arteria cerebelosa posteroinferior, arteria dolicomega basilar y arteria dolicomega vertebral. El seguimiento postoperatorio fue en promedio de 24 meses. El 62% presentó desaparición postquirúrgica inmediata de la sintomatología preoperatoria, el 30% desaparición tras un período de 3 semanas a 2 meses (8% con mejoría parcial), y en el 8% no hubo mejoría. En cuanto a las complicaciones postoperatorias: 3 pacientes presentaron paresia facial II-III en la escala de House-Brackman (se recuperaron en un período de 6 meses), y 1 paciente presentó fístula de líquido cefalorraquídeo. Ninguno de los pacientes de la serie presentaron hipoacusia transitorio o permanente. Conclusión: La DMV como tratamiento del EHF es un procedimiento efectivo y seguro, que permite la resolución completa de la patología en la mayoría de los casos.

Objective: the aim of this study is to describe the results of 13 patients with facial hemispasm, treated with microvascular decompression.Method: 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: 7 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.

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The transcondylar variation of the far-lateral, retrosigmoid approach is intended for pathologies in the anterolateral portion of the foramen magnum. That area is more clearly visualized when a fraction of the ipsilateral occipital condyle is removed. In this study, the biomechanical effect of this approach on occiput-C2 rotation was investigated. Our hypothesis was that the biomechanical characteristics are significantly altered following the transcondylar approach. Five human cadaveric upper cervical spine specimens (occiput-C7) were used in the study. Torsional moments were applied from zero to a maximum of 1.5 N m to the left and to the right using a mechanical testing machine. The resulting rotational motions of the O-C1, C1-2, and O-C2 segments were measured in the intact specimen and after a simulated right-sided transcondylar approach with resection of 2/3 of the condyle, confirmed by CT scanning and visual inspection. After the posterior two-thirds of the occipital condyle were removed, the neutral zone (NZ) increased 1.3° to the left and 2° to the right at C0-C1, and 7.4° to the left and 6.2° to the right at C1-2. The cumulative increase in NZ between O and C2 was 8.7° to the left and 8.2° to the right. The transcondylar approach also resulted in significant increases in range of motion (ROM) in axial rotation to both sides in all segments. ROM increased 2.8° to the left and 2.4° to the right between C0 and C1, 7.3° to the left and 5.4° to the right between C1 and C2, and 10.1° to the left and 7.8° to the right between CO and C2. Upon inspection, the area of the occipital condyle where the alar ligament attaches had been completely removed in three of the five specimens. Removing the posteromedial two-thirds of one occipital condyle alters the normal axial rotational movements of the craniovertebral junction on both sides. The insertion of the alar ligament can be inadvertently removed during condylar resection, and this could contribute to atlanto-axial instability. There is a biomechanical substrate to cranio-cervical instability following a transcondylar approach; these patients may need to be followed over several years to ensure it does not progress and necessitate occipito-cervical fusion.

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OBJECTIVE: To establish preoperatively the localization of the cortical projection of the inferior choroidal point (ICP) and use it as a reliable landmark when approaching the temporal horn through a middle temporal gyrus access. To review relevant anatomical features regarding selective amigdalohippocampectomy (AH) for treatment of mesial temporal lobe epilepsy (MTLE). METHOD: The cortical projection of the inferior choroidal point was used in more than 300 surgeries by one authors as a reliable landmark to reach the temporal horn. In the laboratory, forty cerebral hemispheres were examined. CONCLUSION: The cortical projection of the ICP is a reliable landmark for reaching the temporal horn.

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Objective To establish preoperatively the localization of the cortical projection of the inferior choroidal point (ICP) and use it as a reliable landmark when approaching the temporal horn through a middle temporal gyrus access. To review relevant anatomical features regarding selective amigdalohippocampectomy (AH) for treatment of mesial temporal lobe epilepsy (MTLE). Method The cortical projection of the inferior choroidal point was used in more than 300 surgeries by one authors as a reliable landmark to reach the temporal horn. In the laboratory, forty cerebral hemispheres were examined. Conclusion The cortical projection of the ICP is a reliable landmark for reaching the temporal horn. .

Objetivo Estabelecer a projeção cortical do ponto coiroideo inferior e usá-la como referência para realizar a corticectomia e a abordagem do corno temporal do ventrículo lateral em cirurgias para o tratamento da epilepsia temporal mesial. Método A projeção cortical do ponto coroideo inferior foi utilizada por um dos autores seniors em mais de 300 casos de epilepsia temporal mesial para atingir o corno temporal do ventrículo lateral. Conclusão A projeção cortical do ponto coroideo inferior foi útil e confiável na abordagem do corno temporal do ventrículo lateral e ela está geralmente localizada na margem inferior do giro temporal médio, em média, a 4,52 cm posterior ao polo temporal. .

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Introducción: la anastomosis hipogloso-facial es la técnica de elección para la reparación de la parálisis facial cuando no se dispone de un cabo proximal sano del nervio facial. La técnica de anastomosis mediante fresado mastoideo y sección parcial del hipogloso minimiza la atrofia lingual sin sacrificar resultados a nivel facial. El objetivo del presente trabajo es presentar la técnica habitualmente empleada por los autores para realizar el fresado de la porción ósea del nervio facial. Descripción: la porción mastoidea del nervio facial transcurre por la pared anterior de la AM, a un promedio de 18+/-3mm de profundidad respecto de la pared lateral. Se debe reconocer la cresta supramastoidea, desde la cual se marca una línea vertical paralela al eje mayor de la AM, 1cm por detrás de la pared posterior del CAE. El fresado se comienza desde la línea medio mastoidea hasta la pared posterior del CAE. Una vez encontrado el nervio facial en el tercio medio del canal mastoideo, el mismo es seguido hacia proximal y distal. Discusión: el abordaje descripto permite acceder al nervio facial infratemporal en su porción mastoidea, y efectuar un fresado óseo sin poner en riesgo al nervio o a estructuras vasculares cercanas. Se trata de un procedimiento técnicamente más sencillo que los abordajes amplios habitualmente utilizados al hueso temporal; no obstante su uso debe ser restringido mayormente a la anastomosis hipogloso-facial. Conclusión: esta es una técnica relativamente sencilla, que puede ser reproducida por cirujanos sin mayor experiencia en el tema, luego de su paso por el laboratorio de anatomía.

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Introducción: la anastomosis hipogloso-facial es la técnica de elección para la reparación de la parálisis facial cuando no se dispone de un cabo proximal sano del nervio facial. La técnica de anastomosis mediante fresado mastoideo y sección parcial del hipogloso minimiza la atrofia lingual sin sacrificar resultados a nivel facial. El objetivo del presente trabajo es presentar la técnica habitualmente empleada por los autores para realizar el fresado de la porción ósea del nervio facial. Descripción: la porción mastoidea del nervio facial transcurre por la pared anterior de la AM, a un promedio de 18+/-3mm de profundidad respecto de la pared lateral. Se debe reconocer la cresta supramastoidea, desde la cual se marca una línea vertical paralela al eje mayor de la AM, 1cm por detrás de la pared posterior del CAE. El fresado se comienza desde la línea medio mastoidea hasta la pared posterior del CAE. Una vez encontrado el nervio facial en el tercio medio del canal mastoideo, el mismo es seguido hacia proximal y distal. Discusión: el abordaje descripto permite acceder al nervio facial infratemporal en su porción mastoidea, y efectuar un fresado óseo sin poner en riesgo al nervio o a estructuras vasculares cercanas. Se trata de un procedimiento técnicamente más sencillo que los abordajes amplios habitualmente utilizados al hueso temporal; no obstante su uso debe ser restringido mayormente a la anastomosis hipogloso-facial. Conclusión: esta es una técnica relativamente sencilla, que puede ser reproducida por cirujanos sin mayor experiencia en el tema, luego de su paso por el laboratorio de anatomía.(AU)

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BACKGROUND: Hypoglossal-facial anastomosis is the gold standard treatment for facial reanimation in those cases where the facial nerve has been damaged near the brainstem. The technique that requires temporal bone drilling and partial section of the hypoglossal nerve is usually preferred. This technique diminishes tongue morbidity while preserves good facial reanimation. The goal of the present work is to describe a simple technique to expose the mastoid portion of the facial nerve. METHODS: The mastoid portion of the facial nerve runs on the anterior wall of the mastoid process; mean 18+/-3 mm deeply to the lateral wall. The supramastoid crest has to be identified; a parallel line is marked from the crest to the mastoid tip, and bone drilling is performed anterior to the line. Once the facial nerve is identified, proximal and distal dissection is performed. RESULTS: This limited approach allows to a safe exposure of the mastoid segment of the facial nerve. This procedure is technically less demanding but should be restricted to hypoglossal-facial anastomosis. CONCLUSION: Surgeons not fully experienced in temporal bone drilling can do this simple approach after performing some laboratory practice.

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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.

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The orbits are paired structures, located on the anterior part of the face. Morphologically, each orbit is a four sided pyramid with a posterior apex and anterior base. In the orbit, all openings are arranged around the base, apex or between the orbital walls. An anatomical characteristic of the orbit is that structures are arranged in groups of seven: there are seven bones, seven intraorbital muscles and seven nerves in the orbit. Tumors confined within the periorbita in the anterior two thirds of the orbit can often be approached extracranially, but those located in the apical area, and especially those on the medial side of the optic nerve, often require a transcranial approach. Thus, knowledge of orbital osteology is paramount in adequately choosing and performing an orbital approach. Understanding the critical topographical elements in this area helps to classify an orbital lesion and provides for a solid basis in choosing the most adequate intraorbital route for its treatment.

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We aim to describe the technical details of the transzygomatic approach to intracranial surgery. The incision begins at the level of the inferior border of the zygomatic arch, anterior to the tragus, and extends towards the contralateral pupillary line. A subgaleal and interfascial dissection is performed. Then, the zygomatic arch is vertically sectioned twice and mobilized downwards, together with the masseter muscle. Next, a fronto-temporo-sphenoidal craniotomy is performed and complete exposure of the anterior temporal dura achieved. Thus, the surgical possibilities are: (i) intradural access to the middle fossa; (ii) intradural pretemporal access to the basal cisterns; (iii) intradural transtemporal access to the insular region; and (iv) extradural access to the middle fossa. The transzygomatic approach offers excellent exposure to the floor of the middle fossa and the lateral wall of the cavernous sinus (both intradurally and extradurally). Also, combined with a pretemporal approach, it affords a good view of the interpeduncular cistern; and using a transtemporal approach, it provides good access to the insular region.

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We aimed to determine the position, number and variability of the sphenoid sinus ostia. A total of 32 dry skulls were examined under x6 magnification. The septum and nasal turbinates were removed to expose the anterior wall of the sphenoid sinus. A caliper was used for measurements. We found 2 ostia per skull, except for one (3%), in which the left ostium was absent. The inferior edges of both ostia were found at the same height in only four skulls (12.5%), and the superior edges of both ostia were found at the same height in only one skull (3%). Thus, in 27 skulls (84%) the lower and upper margins of both ostia were at different levels. The distance from the internal edge of the right ostium to the midline was 2.04mm on average (range: 0.3-5.3mm). The distance from the internal edge of the left ostium to the midline was 2.18mm on average (range: 0.2 to 5.1mm). In most skulls, the sphenoid ostia are located at different heights on each side; also a great variability in the distance from the internal border of the ostia to the midline was found. We found this anatomical knowledge useful when performing a transsphenoidal approach to the sella turcica.

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The external structure of each cavernous sinus (CS) is made of four dural walls. The aim of this study was to describe the anatomy of the dural walls of the CS. We studied 42 adult cadaveric heads, fixed with formalin and injected with coloured silicon. The main findings were: (i) the lateral wall of the CS has two layers - the external, which is thick and pearly grey, and the internal, which is semi-transparent and containing the cranial nerves (CNs); (ii) the medial wall of the CS has two areas - sellar and sphenoidal, both made up of one dural layer only; and (iii) the superior wall of the CS is formed by three triangles - oculomotor, clinoid and carotid - CN III may be found in a cisternal space of the oculomotor triangle; and (iv) the posterior wall of the CS is made up of two dural layers - meningeal dura and periostic dura - and this wall is close to the vertical segment of CN VI.

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Paraclinoid aneurysms constitute formidable surgical challenge. The complex surgical anatomy and several factors such as size and projection of the lesion, choice of the surgical approach, relationships between the aneurysm and perforator vessels, site of proximal control, and potential improvement or worsening of visual symptoms account for these difficulties. In such complex cases, surgical nuances frequently determine the final outcome. In this paper, the authors present a comprehensive review of the tricky regional anatomy and describe the operative nuances one of the senior authors (E. dO.) has used to operate on these complex lesions.

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Basilar artery bifurcation aneurysms (BAAs) constitute a major surgical challenge, due to the depth of the target anatomy and narrowness of field, the close relationship with thalamoperforating arteries, and difficulty in obtaining proximal control. Moreover, to treat these aneurysms may be especially technically demanding when situated in a low-lying basilar apex configuration. The most used approaches to treat BAA are the subtemporal approach and the pterional approach. The advantages and disadvantages of these techniques are very well known. Variations of these approaches were created attempting to overcome the limitations imposed by the limited deep operative area. They have not been able to improve the working space in the depths of the interpeduncular and prepontine cisterns. The transcavernous approach was devised as a means of enlarging the area of exposure around the interpeduncular and prepontine cisterns. It involves the removal of the anterior clinoid process, cutting distal and proximal dural rings, opening the cavernous sinus, and drilling varied extension of dorsum sellae and clivus. The senior author (EdO) has used a pretemporal approach to deal with BAAs. The authors have added a transcavernous approach in a pretemporal perspective to treat low-lying, complex, or giant basilar artery aneurysms. In this paper, the authors detail its anatomical principles and technical nuances and present the clinical experience with using this technique.

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BACKGROUND: The lateral approach to the craniocervical junction is directed along the atlantal and occipital condyles to the dens. The advantages of the lateral approach compared with the anterior transoral and transnasal approaches are that it provides a sterile field, and anterior decompression and postdecompression fixation can be performed in one procedure. OBJECTIVE: To examine the usefulness of endoscopy as an auxiliary tool during lateral transatlantal odontoidectomy. METHODS: Six cadaver heads, in which the vessels were injected with colored silicone, were dissected using a surgical microscope and 0- and 30-degree endoscopes. A flap incision was chosen to accomplish exposure of the area of the decompression, the occipital squama and adjacent laminae for fixation, and the vertebral artery from C2 to its dural entrance for its stabilization. RESULTS: Study findings revealed that endoscopy adds several advantages to microscopy in the lateral transatlantal approach to the craniovertebral junction in cases of craniovertebral malformation by providing magnification and illumination not limited by corners, thus helping to avert substandard decompression and complications such as dural tears and cerebrospinal fluid leaks; flexibility in surgical positioning of patients; and improved ergonomics that enable the surgeon to complete the procedure in a more efficient, comfortable, and safe manner. CONCLUSION: Endoscopy is a useful adjunct to microscopy in completing lateral approaches to the craniovertebral junction.

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