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Publicações | 2015

Endoscopic Endonasal Approach to Ventral Posterior Fossa Meningiomas: From Case Selection to Surgical Management.

Beer-Furlan A, Vellutini EA, Balsalobre L, Stamm AC.Neurosurg Clin N Am. 2015 Jul;26(3):413-26. 



Clival, petroclival, and foramen magnum meningiomas are challenging lesions to manage independently of the selected surgical approach. The expanded endoscopic endonasal approach (EEA) provided a safe alternative on the armamentarium of skull base approaches. There is a paucity of literature regarding endoscopic management of meningiomas because of certain limiting factors, including rarity of the pathologic condition, technical challenges, expertise of the surgical team, and available resources. The surgical technique, possible complications, and postoperative care are described in detail. This article highlights the important aspects in choosing this surgical approach and managing ventral posterior fossa meningiomas through the EEA. 

Biomechanical effects of the transcondylar approach on the craniovertebral junction.

Cardoso AC, Fontes RB, Tan LA, Rhoton AL Jr, Roh SW, Fessler RG. Clin Anat.2015 Jul;28(5):683-9.


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 attachés 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.



Genetic susceptibility is a well-recognized factor in the onset of multiple sclerosis (MS). The objective of this study was to determine the frequency of oligoclonal bands (OCB) restricted to the cerebrospinal fluid, in an ethnically mixed group of MS patients in the city of São Paulo, Brazil. Techniques used to detect OCB consisted of isoelectric focusing followed by immunoblotting. OCB were found in 49 (54.4%) out of 90 patients with clinically definite MS; out of the 23 brown/black patients, 17 (73.9%) were OCB+; out of the 66 white patients, 32 (48.5%) were OCB+; and the only patient yellow was OCB+ (p = 0.05). Analysis of the IgG index was also consistent with the findings, but with lower statistical significance. The data presented in our study show that the ethnic differences in MS extend to the immune response.

Immunohistochemical expression of cyclin D1 is higher in supratentorial ependymomas and predicts relapses in gross total resection cases.

de Andrade FG, Marie SK, Uno M, Matushita H, Taricco MA, Teixeira MJ, Rosemberg S, Oba-Shinjo SM. Neuropathology. 2015 Aug;35(4):312-23. 



Ependymomas are tumors of the CNS. Although cyclin D1 overexpression has been related to several cancers, its prognostic value in ependymomas has not yet been fully established. We evaluated cyclin D1 expression by an immunohistochemistry analysis of 149 samples of ependymomas, including some relapses, corresponding to 121 patients. Eighty-one patients were adults, 60 were intracranial cases and 92 tumors were grade II. Gross total resection (GTR) was achieved in 62% of cases,and relapse was confirmed in 41.4% of cases. Cyclin D1 protein expression was analyzed by immunohistochemistry and scored with a labeling index (LI) calculated as the percentage of positively stained cells by intensity. We also analyzed expression of CCND1 and NOTCH1 in 33 samples of ependymoma by quantitative real-time PCR. A correlation between cyclin D1 LI score and anaplastic cases (P < 0.001), supratentorial location (P < 0.001) and age (P = 0.001) were observed. A stratified analysis demonstrated that cyclin D1 protein expression. was strong in tumors with a supratentorial location, independent of the histological grade or age. Relapse was more frequent in cases with a higher cyclin D1 LI score (P = 0.046), and correlation with progression-free survival was observed in cases with GTR (P = 0.002). Only spinal canal tumor location and GTR were suggestive markers of PFS in multivarite analyses. Higher expression. levels were observed in anaplastic cases for CCND1 (P = 0.002), in supratentorial cases for CCND1 (P = 0.008) and NOTCH1 (P = 0.011). There were correlations between the cyclin D1 mRNA and protein expression levels (P < 0.0001) and between CCND1 and NOTCH1 expression levels (P = 0.003). Higher cyclin D1 LI was predominant in supratentorial location and predict relapse in GTR cases. Cyclin D1 could be used as an immunohistochemical marker to guide follow-up and treatment in these cases.



Multiple sclerosis (MS) is a chronic, neurological, immune-mediated disease that can worsen in the postpartum period. There is no consensus on the use of immunoglobulin for prevention of disease relapses after delivery. We have shown that the controversial beneficial effect of immunoglobulin given immediately after birth could not be observed in patients with MS.

Endoscopic combined "transseptal/transnasal" approach for pituitary adenoma: reconstruction of skull base using pedicled nasoseptal flap in 91 consecutive cases.

Fujimoto Y, Balsalobre L, Santos FP, Vellutini E, Stamm AC. Arq Neuropsiquiatr. 2015 Jul;73(7):611-5.  



The purpose of this study was to describe the endoscopic combined "transseptal/transnasal" approach with a pedicled nasoseptal flap for pituitary adenoma and skull base reconstruction, especially with respect to cerebrospinal fluid (CSF) fistula.



Ninety-one consecutive patients with pituitary adenomas were retrospectively reviewed. All patients underwent the endoscopic combined "transseptal/transnasal" approach by the single team including the otorhinolaryngologists and neurosurgeons. Postoperative complications related to the flap were analyzed.



Intra- and postoperative CSF fistulae were observed in 36 (40%) and 4 (4.4%) patients, respectively. Among the 4 patients, lumbar drainage and bed rest healed the CSF fistula in 3 patients and reoperation for revision was necessary in one patient. Other flap-related complications included nasal bleeding in 3 patients (3.3%).



The endoscopic combined "transseptal/transnasal" approach is most suitable for a two-surgeon technique and a pedicled nasoseptal flap is a reliable technique for preventing postoperative CSF fistula in pituitary surgery.



Esta edição traz as Diretrizes Brasileiras sobre o Manejo da Ressuscitação Cardiopulmonar (RCP). Embora a ressuscitação tenha uma longa história que remonta aos tempos bíblicos e se prolonga através dos séculos1, o seu 'nascimento' moderno é amplamente considerado como tendo ocorrido em 1960, quando Koewenhoven, Jude e Knickerbocker publicaram seu memorável artigo sobre o uso da compressão torácica: eles salientaram que "tudo o que se precisa são duas mãos" e de fato escreveram sobre 14 sobreviventes em um universo de 20 tentativas em que utilizaram esta técnica. Conquanto manobras semelhantes tenham sido descritas inúmeras vezes em períodos anteriores, naquele momento, elas assumiriam uma nova importância, porque Safar já havia feito experimentos com a ventilação boca a boca e a desfibrilação externa já era uma realidade. Tudo o que restava era juntar esses três componentes-chave, o que aconteceu em setembro de 1960, em um simpósio organizado pelo Corpo Docente de Medicina e Cirurgia do Estado de Maryland, onde se consagrou que "esses componentes não podiam mais ser considerados como elementos isolados, e sim como parte de uma abordagem completa para a ressuscitação. Naquele momento, no entanto, a ressuscitação era considerada um procedimento estritamente médico; até mesmo enfermeiros e dentistas eram impedidos de executar a prática. De modo que seu impacto era limitado, apesar do grande interesse internacional. Gradualmente, os pontos de vista foram mudando e, por volta de 1974, as grandes vantagens de envolver o público em geral tornaram-se mais evidentes quando a American Heart Association publicou suas primeiras diretrizes destinadas tanto aos profissionais da saúde quanto a leigos. A publicação das novas diretrizes de RCP em uma importante revista médica tomou, como ponto de partida, dois princípios. O primeiro princípio consistia no fato de que um método ideal poderia ser definido para todas as situações de parada cardíaca inesperada; e o segundo, de que a disseminação desse procedimento poderia e deveria ser posta em prática no âmbito da sociedade em geral. Embora esses pontos de vista parecessem plausíveis, não eram compartilhados universalmente naquela época. Mais alguns anos se passariam antes que as diretrizes de ressuscitação viessem a tornar-se verdadeiramente internacionais. Mais uma vez, foi a American Heart Association que assumiu a liderança nesse sentido. Mais de 25% dos participantes de sua conferência em Dallas, no ano de 1992, vinham de fora dos Estados Unidos. Nesse encontro, decidiu-se criar uma comissão internacional de especialistas dos cinco continentes para orientar a prática de ressuscitação, um grupo que mais tarde seria conhecido como a Aliança Internacional dos Comitês de Ressuscitação (International Liaison Committee on Resuscitation - ILCOR)6. Ao longo dos anos, este órgão consultivo evoluiu em termos de sua importância e influência devido à reconhecida competência dos seus membros. No que diz respeito à sua aplicabilidade em situações diversas, os diferentes requisitos voltados para crianças e, posteriormente, aos lactentes e recém-nascidos, tornaram-se rapidamente aceitos. Mais tarde, também, foram surgindo diferenças nacionais baseadas em parte nos costumes locais, mas também nas variações epidemiológicas. Por este motivo, o termo "diretriz" foi descartado pelo comitê internacional dando lugar ao "consenso", fazendo com que grupos regionais fossem adaptando as práticas às suas necessidades específicas. A aceitação da necessidade de promulgar diretrizes no âmbito da sociedade não sofreu qualquer tipo de oposição após meados dos anos 1970, mas até relativamente há pouco tempo, observavam-se grandes diferenças no nível de aplicação dessas diretrizes. A capacitação em grande escala depende da existência de organizações locais capazes de disseminar a formação voltada para essas técnicas. Poucos países tiveram grupos fortes capazes de aceitar este desafio, uma situação que mudou, em parte, porque foram criados inúmeros conselhos e comitês de ressuscitação, e organizações como a Cruz Vermelha Internacional que vêm desempenhando um papel crescente nessa iniciativa. Um aspecto da prática de ressuscitação, no entanto, enfrentou obstáculos. Em diversos países, principalmente na Europa, considerava-se ilegal o uso de desfibriladores por parte de pessoas não qualificadas na área médica. Embora essas barreiras tenham sido transpostas, ainda se observa uma espécie de relutância em algumas áreas gerada por considerações equivocadas sobre questões de segurança, principalmente para os membros do público em geral (leigos), que não possuem certificação em cursos de treinamentos reconhecidos. Este pensamento é inadequado quando se trata de desfibriladores modernos automáticos, para os quais aspectos de segurança não são uma grande preocupação. As diretrizes brasileiras de 2012 se baseiam no Consenso Científico da ILCOR de 20107, tendo sido muito bem-vindas. O novo consenso não introduziu ideias radicais. De fato, enfatizou-se a primazia das compressões como sendo a chave para o sucesso da ressuscitação em casos de parada cardíaca, com recomendações adicionais destinadas a reduzir atrasos particularmente na administração de choques em vítimas com fibrilação ventricular ou taquicardia ventricular sem pulso. Outros capítulos da diretriz apresentam orientações sobre temas como síndromes coronarianas agudas, qualificação e primeiros socorros. Esta diretriz necessita ser bem-conhecida e divulgada na comunidade, devendo-se coletar dados em todas as regiões do país, sobre a frequência na qual pessoas leigas que presenciam os eventos são capazes de iniciar os primeiros socorros ou as manobras de ressuscitação cardiopulmonar antes da chegada de profissionais da saúde. Não estamos no final do processo evolutivo, o qual começou em 1960. A cadeia de sobrevivência exige a rápida notificação de paradas cardíacas, assistência das pessoas próximas à vítima, desfibrilação precoce, mesmo antes da chegada dos serviços de emergência e de cuidados especializados. Em nenhum país, pode-se afirmar que todos esses requisitos são atendidos de forma satisfatória. Assim como a implementação mais efetiva dos conceitos existentes sobre as melhores práticas, as diretrizes propriamente ditas não permanecerão inalteradas, mas continuarão evoluindo no mesmo passo da evolução da ciência da ressuscitação. O papel da terapia farmacológica vem sendo analisado de perto, porém a ciência básica também apresenta possibilidades interessantes para a área clínica. Pode-se também questionar se o suporte básico de vida administrado pelos membros da comunidade (para quem a simplicidade é um fator-chave) deve ser quase idêntico ao suporte dado pelos profissionais da saúde, que podem fazer maior uso de habilidades adaptadas a diferentes circunstâncias.

Application of indocyanine green video angiography in surgical treatment of intracranial aneurysms.

Pahl FH, Oliveira MF, Brock RS, Lucio JE.Arq Neuropsiquiatr. 2015 Jul;73(7):607-10.



Indocyanine green (ICG) video angiography has been used for several medical indications in the last decades. It allows a real time evaluation of vascular structures during the surgery. This study describes the surgical results of a senior vascular neurosurgeon. We retrospectively searched our database for all aneurysm cases treated with the aid of intraoperative ICG from 2009 to 2014. A total of 61 aneurysms in 56 patients were surgically clipped using intraoperative ICG. Clip reposition after ICG happened in 2 patients (3.2%). Generally, highly variable clip adjustment rates of 2%-38% following ICG have been reported since the introduction of this imaging technique. The application of ICG in vascular neurosurgery is still an emerging challenge. It is an adjunctive strategy which facilitates aneurismal evaluation and treatment in experienced hands. Nevertheless, a qualified vascular neurosurgeon is still the most importante component of a high quality work.



A novel syndrome characterized by a distinctive sleep disorder accompanied by variable symptoms of brainstem involvement and a highly restricted haplotype was recently described in association with antibodies to a neuronal cell adhesion protein named IgLON5. Because of the symptoms and chronic disease progression, most of these patients are primarily seen by specialists in sleep and neurodegenerative disorders. Since the initial description of this encephalopathy in 2014, only 1 additional patient has been reported.1 In order to improve clinical recognition we report a new patient who presented with the characteristic sleep dysfunction and subsequently developed chorea.

Low back pain as the first presentation of Hürthle cell carcinoma of thyroid.

Botelho RV; Oliveira MF, Gameleira Filho ST; Ferreira JA; Takahashii LR, Rotta JM.Arq Bras Neurocir 2015; 34(01): 053-055 



Hürthle cell carcinoma is a rare variant of differentiated thyroid cancer and occasionally generates distant metastases. There are few reports of Hürthle cell carcinoma metastases to the vertebral column and none with sacral involvement. Here, we report a 48-year-old woman with a 2-year history of moderate low back pain, alleviated with analgesic medication. Her previous medical files were unremarkable. She performed medical evaluation, and a magnetic resonance of lumbar spine revealed a solitary hypointense T2 lesion on the left lamina of S1. The patient was submitted to percutaneous biopsy that displayed carcinomatous pattern compatible with Hürthle cell carcinoma of thyroid. After that, she was submitted to thyroid ultrasound that showed a nodule. Even in the presence of metastases, patients with Hürthle cell carcinoma usually have a relatively good prognosis. We discuss aspects of the diagnosis, management, and surgical treatment of metastatic Hürthle cell carcinoma in reference to the literature.

Paraplegia following massage therapy intervention in a patient with undiagnosed multiple myeloma.

Botelho RV, Oliveira MF, Reis RC, Ferreira JÁ, Gameleira Filho ST, Rotta JM.J Bras Neurocirurg 2015;24(4):313- 315 




Due to increased number of available alternative therapies to the treatment of back pain and sometimes a difficult access to specialized medical evaluations, there is a widespread use of alternative therapies for the treatment of back pain.



We describe a case with a catastrophic consequence of massage therapy in a patient with initial symptoms of back pain resulting in definitive paraplegia and discuss the needs for medical diagnosis for any treatment.



We discuss the potencial harms to the patient when initiating a questionable treatment method, which are late diagnosis, direct physical harm, interference with tradiotional treatments, financial harm and time loss. Alternative treatments are valuable tools to control refractory symptoms, especially pain. But we reinforce the need of adequate medical screening before performing therapies which may bring unwilling outcomes.

Evidences in the treatment of idiopathic normal pressure hydrocephalus.

Oliveira MF, Reis RC, Trindade EM, Pinto FC.Rev Assoc Med Bras (1992). 2015 May-Jun;61(3):258-62. 




idiopathic normal pressure hydrocephalus (INPH) is characterized by gait apraxia, cognitive dysfunction and urinary incontinence. There are two main treatment options: ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV). However, there are doubts about which modality is superior and what type of valve should be applied. We are summarizing the current evidence in INPH treatment.



an electronic search of the literature was conducted on the Medline, Embase, Scielo and Lilacs databases from 1966 to the present to obtain data published about INPH treatment.



the treatment is based on three pillars: conservative, ETV and VPS. The conservative option has fallen into disuse after various studies showing good results after surgical intervention. ETV is an acceptable mode of treatment, but the superiority of VPS has made the latter the gold standard.



well-designed studies with a high level of appropriate evidence are still scarce, but the current gold standard for treatment of INPH is conducted using VPS.

Nuances in malignant glioma surgery.. Neurociencias en Colombia.

Rotta JM, Oliveira MF.Neurociencias en Colombia. 2015; 21;305-310. 


Central nervous system tumors are a major cause of morbidity and mortality. Outside of  brain metastasis, low and high grade gliomas are the most common intrinsic brain tumors.The optimal  treatment  of  malignant  gliomas  has  developed  through  the  last  years.  Early  management  with radical surgery and adjuvant chemotherapy and radiotherapy are the standard protocol. Prognostic factors involved are age at presentation, histology, molecular biology characteristics, Karnofsky Score (KS), surgical results and adjuvant therapy. Once age, histology, tumor behavior and KS are independent  factors  associated  to  patient  and  adjuvant  therapy  is  usually  standard  for  all  patients,  surgery is the one in which medical management can perform greatest change in evolution of disease. Therefore, surgical results with maximal resection of neoplastic tissue and minimal risk of functional neurological deficit, is the aim in malignant glioma surgery. Surgical act involves a complex structure which demands planning, knowledge of cerebral anatomy and physiology, and technical execution. A special anatomic and physiological knowledge must involve the white matter, once malignant gliomas spread through such structures.

Fundamentals of brain tumor surgery in eloquent areas.

Rotta JM, Oliveira MF. Arq Bras Neurocir 2015; 34(02): 122-127 



Central nervous system tumors are a major cause of morbidity and mortality. The main pathology involved is brain metastases, followed by intrinsic gliomas. In nearly all cases, surgery is the initial and most important measure to change natural course of disease. In brain metastases and meningiomas, gross total resection is also precluded, and usually more achievable, because of biological behavior of tumor and extrinsic presentation. Generally these tumors push or compress eloquent areas, but spare them. In intrinsic tumors, complete resection is often difficult, once tumor is invasive and may even be within eloquent cortex. When tumors occur in eloquent areas such as sensorial, motor and language cortex, there is the need for taking several measures to avoid worsening of symptoms after surgery. Especially in lesions involving language cortex, an awake craniotomy may be performed to assess intraoperatively language functions.

Survival analysis in patients with metastatic spinal disease: the influence of surgery, histology, clinical and neurologic status.

Oliveira MF, Rotta JM, Botelho RV.Arq Neuropsiquiatr. 2015 Apr;73(4):330-5.



Spine is the most common site for skeletal metastasis in patients with malignancy. Vertebral involvement quantification, neurological status, general health status and primary tumor histology are factors to set surgical planning and therapeutic targets. We evaluated the impact of general clinical and neurological status, histologic type and surgery in survival.



The study sample consisted of consecutive patients admitted from July 2010 to January 2013 for treatment.



Sixty eight patients were evaluated. 23 were female and 45 were male. Main primary neoplasic sites were: breast, prostate, lung/pleura and linfoproliferative. Thirty three out of 68 received surgical treatment, 2 received percutaneous biopsy and 33 had nonsurgical treatment.



Log Rank curves revealed no statistical significant difference according to histological type, surgical approach and Frankel Score. Karnofsky Score was statistically different.



Histological type and clinical status were statistically associated with life expectancy in vertebral metastatic disease.

Risk of complications in spine surgery: a prospective study.

Reis RC, de Oliveira MF, Rotta JM, Botelho RV.Open Orthop J. 2015 Jan 31;9:20-5.

Hypertonic saline: a brief overview of hemodynamic response and anti-inflammatory properties in head injury. 

Neural Regen Res de Oliveira MF, Pinto FC.. 2015 Dec;10(12):1938-9.


Hypertonic saline (HS) has been applied in several medical areas such as pneumology (asthma, cystic fibrosis and bronchiolytis), endocrinology (hyponatremia) and especially in emergency medicine, in traumatic and inflammatory/infectious disorders. It may be composed of 3% or 7.5% sodium chlorate. By far, 3% solution is the most widely studied and used solution (Pinto et al., 2006, 2015; Dekker et al., 2014; Gantner et al., 2014; Shein et al., 2014). Transcranial doppler (TD) is a widely applied diagnostic tool to access brain hemodynamics. It can measure several parameters related to arterial and venous circulation in anterior and posterior circulation. It is a fast and practical evaluation tool that is used to clarify clinical effects of HS (Pinto et al., 2006, 2015).

Prospective randomized study comparing clinical, functional, and aesthetic results of minipterional and classic pterional craniotomies.

Welling LC, Figueiredo EG, Wen HT, Gomes MQ, Bor-Seng-Shu E, Casarolli C,Guirado VM, Teixeira MJ.J Neurosurg. 2015 May;122(5):1012-9. 



The object of this study was to compare the clinical, functional, and aesthetic results of 2 surgical techniques, pterional (PT) and minipterional (MPT) craniotomies, for microsurgical clipping of anterior circulation aneurysms.



Fifty-eight patients with ruptured and unruptured anterior circulation aneurysms were enrolled into a prospective randomized study. The first group included 28 patients who underwent the MPT technique, and the second group comprised 30 patients who underwent the classic PT craniotomy. To evaluate the aesthetic effects, patients were asked to grade on a rule from 0 to 100 the best and the worst aesthetic result. Photographs were also taken, assessed by 2 independent observers, and classified as showing excellent, good, regular, or poor aesthetic results. Furthermore, quantitative radiological assessment (percentage reduction in thickness and volumetric analysis) of the temporal muscle, subcutaneous tissue, and skin was performed. Functional outcomes were compared using the modified Rankin Scale (mRS). Frontal facial palsy, postoperative hemorrhage, cerebrospinal fistula, hydrocephalus, and mortality were also analyzed.



Demographic and preoperative characteristics were similar in both groups. Satisfaction in terms of aesthetic result was observed in 19 patients (79%) in the MPT group and 13 (52%) in the PT group (p = 0.07). The mean score on the aesthetic rule was 27 in the MPT group and 45.8 in the PT group (p = 0.03). Two independent observers analyzed the patient photos, and the kappa coefficient for the aesthetic results was 0.73. According to these observers, excellent and good results were seen in 21 patients (87%) in the MPT and 12 (48%) in the PT groups. The degree of temporal muscle, subcutaneous tissue, and skin atrophy was 14.9% in the MPT group and 24.3% in the PT group (p = 0.01). Measurements of the temporal muscle revealed 12.7% atrophy in the MPT group and 22% atrophy in the PT group (p = 0.005). The volumetric reducti on was 14.6% in the MPT and 24.5% in the PT groups (p = 0.012). Mortality and mRS score were similar in both groups at the 6-month evaluation (p = 0.99).



Minipterional craniotomy provides clinical results similar to those of the PT technique. Moreover, it provides better cosmetic results. It can be used safely and effectively to surgically treat aneurysms of the anterior circulation instead of the PT approach.

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