Helbert de Oliveira Manduca Palmiero

All Publications

• Late Recurrence After Angiographic Cure of Pediatric Arteriovenous Malformations Treated by Transvenous Embolization. Operative neurosurgery (Hagerstown, Md.) de Albuquerque Cavalcanti Mendes, G., da Costa, M. S., Afonso, H. A., de Oliveira Manduca Palmiero, H., Gadelha Figueiredo, E., Mounayer, C. 2026

  Abstract

  Pediatric brain arteriovenous malformations (AVMs) have higher recurrence rates than adult lesions, yet the long-term durability of transvenous embolization (TVE) in children remains poorly defined. We therefore evaluated long-term clinical and angiographic outcomes after curative TVE for ruptured pediatric AVMs.This multicenter retrospective cohort comprised 12 pediatric patients (older than 18 years) treated with curative TVE from 2012 to 2025. Angiographic cure was defined as complete obliteration on 6-month digital subtraction angiography (DSA). Long-term surveillance included annual MRI/magnetic resonance angiography, with confirmatory DSA if recurrence was suspected.Complete angiographic obliteration was achieved in all patients at 6 months. Over a mean follow-up of 103 ± 39 months, no delayed hemorrhages occurred. Late AVM recurrence was identified in 2 patients (17%) after documented angiographic cure and was detected only on delayed imaging surveillance. One recurrence involved a lesion with previous superficial venous drainage, whereas the other occurred in a lesion with deep venous drainage. Both were successfully retreated endovascularly without added morbidity.TVE provides durable hemorrhage control in selected pediatric AVMs; however, late recurrence may still occur despite early angiographic cure. These findings confirm that TVE is no exception to the well-documented late recurrence rate of pediatric AVMs across all treatment modalities, reinforcing that prolonged imaging surveillance is as essential after TVE as after microsurgery or radiosurgery.

  View details for DOI 10.1227/ons.0000000000002133

  View details for PubMedID 42423633

• Letter: Demarcation Line of Tissue Compaction in Traumatic Brain Herniation: A Conceptual and Clinical Model NEUROSURGERY de Oliveira Manduca Palmiero, H., Gadelha Figueiredo, E. 2026; 99 (1): e1-e2

  View details for DOI 10.1227/neu.0000000000004076

  View details for Web of Science ID 001795235400001

  View details for PubMedID 42294934

• Hemodynamic modulation of transnidal pressure during transvenous arteriovenous malformation embolization: an experimental porcine model JOURNAL OF NEUROINTERVENTIONAL SURGERY Mendes, G. A. C., da Costa, M., Palmiero, H., Mounayer, C., Figueiredo, E. 2026

  Abstract

  Optimization of transvenous embolization of brain arteriovenous malformations (AVMs) depends on effective modulation of the transnidal pressure gradient. Pharmacologic flow arrest with adenosine has been proposed as an adjunct, but its hemodynamic equivalence to purely mechanical strategies remains unclear.End-to-end carotid-jugular fistula AVM models were created in 10 pigs. Hemodynamic measurements were obtained with pressure-sensing fractional flow reserve guidewires placed in the feeding artery and draining vein. Measurements included feeding artery mean pressure (MAfF), draining vein mean pressure (MVP), and transnidal pressure gradient (MAfP-MVP). Interventions were performed sequentially and included arterial balloon occlusion, venous coiling, combined arterial-venous strategies, venous balloon occlusion, systemic hypotension (-20%), and adenosine-induced transient cardiac arrest.The model was successfully established in all 10 animals and provided stable hemodynamic measurements throughout the protocol. Baseline mean venous pressure (MVP) was 47.1±14.3 mmHg, and baseline transnidal pressure gradient was 18.1±8.96 mmHg. Significant reductions in MVP were observed with arterial balloon occlusion, combined arterial-venous mechanical strategies, and adenosine-induced transient cardiac arrest. Arterial inflow control consistently produced greater reductions than venous-only interventions and systemic hypotension. Significant reductions in the transnidal pressure gradient were achieved with arterial balloon occlusion and simultaneous arterial-venous balloon occlusion. Adenosine produced hemodynamic effects comparable with the most effective mechanical strategies.Mechanical flow-control strategies replicate the hemodynamic effects of adenosine-mediated flow arrest without systemic exposure. These findings support the use of localized endovascular approaches for gradient modulation and may inform safer procedural strategies for transvenous AVM embolization.

  View details for DOI 10.1136/jnis-2026-025358

  View details for Web of Science ID 001800399900001

  View details for PubMedID 42309822

• Cervical Spine Clearance in Adult and Pediatric Trauma: A Systematic Review JOURNAL OF EMERGENCY MEDICINE Palmiero, H., Figueiredo, E. 2026; 85: 95-113

  Abstract

  Cervical spine clearance after trauma is essential for preventing secondary neurologic injury while avoiding unnecessary immobilization and imaging. Advances in computed tomography (CT) and standardized clinical decision rules such as National Emergency X-Radiography Utilization Study and the Canadian C-Spine Rule have changed protocols for adult and pediatric patients.This systematic review aims to compile current evidence to identify safe, effective, and evidence-based methods for cervical spine clearance.A PubMed/MEDLINE systematic search was conducted through October 2025 for studies evaluating cervical spine clearance in adult and pediatric trauma patients. Eligible studies analyzed clinical decision tools or imaging modalities (such as physical examination, radiography, CT, magnetic resonance imaging [MRI], ultrasound) and reported on diagnostic accuracy, safety, or workflow outcomes. Data was extracted and narratively synthesized due to methodological heterogeneity.Thirty-three adult and eleven pediatric studies met the inclusion criteria. In adults, multidetector CT with multiplanar reconstructions achieved 98-100% sensitivity and >99% negative predictive value for clinically significant or unstable injury, supporting collar removal after a normal CT even in obtunded or intoxicated patients. MRI detected additional findings in 0.4-3% of cases, rarely changing management. In children, structured clinical protocols combining physical examination and plain radiography safely reduced CT use by up to 70%, with MRI reserved for persistent symptoms or ligamentous concerns.Modern multidetector CT is the gold standard for adult cervical spine clearance, while pediatric management favors radiation-sparing, protocol-based approaches. Evidence supports tiered, algorithmic strategies emphasizing clinical assessment, selective imaging, and early collar removal to optimize safety and efficiency in trauma care.

  View details for DOI 10.1016/j.jemermed.2026.03.006

  View details for Web of Science ID 001743538300001

  View details for PubMedID 41955954

• Management of pediatric brain arteriovenous malformation: a systematic review of retrospective studies NEUROSURGICAL REVIEW de Oliveira Manduca Palmiero, H., Gadelha Figueiredo, E. 2026; 49 (1)

  Abstract

  Pediatric brain arteriovenous malformations (bAVMs) are a major cause of hemorrhagic stroke in children, yet management decisions rely largely on heterogeneous cohorts. Contemporary retrospective studies were systematically reviewed to summarize outcomes across treatment modalities and to characterize interstudy variability.PubMed/MEDLINE was searched over the past decade for retrospective pediatric intracranial bAVM cohorts. Eligible studies reported management with observation/conservative care, endovascular embolization, microsurgical resection, stereotactic radiosurgery (SRS), or multimodality therapy. Screened studies had data extracted using a standardized form. Outcomes included obliteration, hemorrhage (first presentation and post-treatment), functional outcomes, complications, and recurrence after apparent cure. Treatment categories were harmonized into mutually exclusive groups for descriptive synthesis.Of 113 identified records, 20 retrospective cohort studies met the inclusion criteria. Hemorrhage was the most common presentation. Across cohorts reporting Spetzler-Martin (SM) grade, low-grade lesions (SM I-II) comprised 740 patients (44.1%), SM III 645 (38.4%), and SM IV-V 293 (17.5%). Treatment strategies varied substantially; among 1,973 classifiable patients, cohorts reported microsurgery-only, SRS-only, endovascular-only, multimodality, and conservative approaches. Definitions of obliteration and assessment methods were inconsistent (DSA-confirmed vs. MRI-based). Microsurgical series reported obliteration rates of 81%-100% in selected populations (unweighted mean ~ 93% across reporting cohorts), whereas SRS-only cohorts demonstrated obliteration rates of 51%-68.5% in the three largest unselected pediatric series (range 36%-84% across all SRS-inclusive cohorts), with latency-period hemorrhage rates of approximately 1.1%-3.2% per series. Recurrence after apparent cure was reported in 7 cohorts, with rates ranging from < 1% to 29%, occurring years after angiographic obliteration.Contemporary retrospective pediatric bAVM data indicate that modality-specific outcomes are strongly influenced by lesion selection, outcome definitions, and follow-up duration. Recurrence after apparent cure is not uncommon and supports explicit long-term surveillance. Standardized definitions and harmonized reporting are needed to improve interpretability and comparative inference.

  View details for DOI 10.1007/s10143-026-04346-2

  View details for Web of Science ID 001778660500002

  View details for PubMedID 42204010

  View details for PubMedCentralID PMC13216134

• Letter on "The cuneus vein: initial anatomical description and preservation technique for posterior interhemispheric approaches"-what defines an anatomic structure? ACTA NEUROCHIRURGICA de Oliveira Manduca Palmiero, H., Gadelha Figueiredo, E. 2026; 168 (1)

  View details for DOI 10.1007/s00701-026-06911-6

  View details for Web of Science ID 001768022100001

  View details for PubMedID 42142115

  View details for PubMedCentralID PMC13179904

• Response to: "Letter to the Editor Regarding Cervical Spine Clearance in Adult and Pediatric Trauma: A Systematic Review". The Journal of emergency medicine de Oliveira Manduca Palmiero, H., Gadelha Figueiredo, E. 2026

  View details for DOI 10.1016/j.jemermed.2026.05.001

  View details for PubMedID 42392905

• AI Models for Surgical Decision Support in Spontaneous Intracerebral Hemorrhage: A Systematic Review in Relation to Trials and Guidelines NEUROCRITICAL CARE de Oliveira Manduca Palmiero, H., Gilberto Carlotti, C., Gadelha Figueiredo, E. 2026; 44 (3): 1063-1076

  Abstract

  Artificial intelligence (AI) applications for spontaneous intracerebral hemorrhage (ICH) are rapidly expanding, particularly in perioperative imaging analysis and surgical decision support. Because most predictive AI models are developed using independent clinical datasets, they are not expected to explicitly reproduce randomized trial protocols or guideline decision rules. We therefore conducted a descriptive systematic review and evidence-mapping study to crosswalk AI model inputs, predicted targets, and outputs to major surgical trials and clinical guidelines (ENRICH, MIND, MISTIE III, SWITCH, STICH II, CLEAR, and AHA/ASA), identifying areas of overlap where AI operationalizes trial-relevant constructs and areas where AI-derived predictors may be hypothesis-generating for future trial design. Of 37 records identified (31 from database searches and 6 from hand searches), 21 studies met eligibility criteria. Publications increased after 2021, peaking in 2024 (n = 5) and remaining in 2025 (n = 3). Most cohorts were single-center (13/21), mainly from China, the USA, and Germany. Inputs were predominantly non-contrast computed tomography (CT); one study used magnetic resonance imaging (MRI) for trajectory planning. Deep learning was the most common analysis method (14/21), followed by classical machine learning (4/21) and radiomics-based methods (2/21). AI applications focused on perioperative imaging tasks, including eligibility assessment, postoperative quality assurance, trajectory planning, workflow optimization, and treatment-effect modeling. Three studies demonstrated direct alignment with surgical trial thresholds (e.g., MISTIE/CLEAR), ten were indirectly aligned, and eight had no clear linkage. AI models add value to imaging-based perioperative assessment in ICH and frequently target constructs central to trial- and guideline-based decision-making, even when trial criteria are not explicitly encoded. This crosswalk clarifies where AI outputs overlap with trial- and guideline-relevant constructs and where AI-derived decision boundaries diverge, reinforcing measurement targets that can be benchmarked against existing evidence and identifying candidates for hypothesis-generating evaluation in future studies.

  View details for DOI 10.1007/s12028-026-02501-7

  View details for Web of Science ID 001733165200001

  View details for PubMedID 41942817

  View details for PubMedCentralID PMC13249920

• Telemedicine in neurosurgery: A systematic review of global implementation, outcomes, and barriers to access JOURNAL OF TELEMEDICINE AND TELECARE Palmiero, H., Figueiredo, E. 2026: 1357633X261436994

  Abstract

  IntroductionTelemedicine has evolved into an integral component of neurosurgical care, especially in expanding access to specialized services in remote or resource-limited areas. This systematic review summarizes worldwide evidence on the implementation, outcomes, and barriers of tele-neurosurgery in emergency and outpatient settings.MethodsFollowing PRISMA guidelines, a comprehensive PubMed/MEDLINE search (2000-2025) identified English-language studies on telemedicine applications in neurosurgery. Eligible studies included emergency cases (trauma, stroke, intracerebral hemorrhage) and outpatient settings. Data on design, interventions, outcomes, and limitations were extracted and analyzed qualitatively.ResultsThirty-six studies met inclusion criteria, covering programs within high-, middle-, and low-income regions. Emergency networks using teleradiology and teleconsultation achieved significant reductions in time-to-specialist evaluation-from about 160 to 38 min-and prevented up to 44% of potential patient transfers, with low failure rates among locally managed cases. Outpatient programs reported patient satisfaction above 80%, surgical decision agreement comparable to in-person visits, and notable travel and cost savings, especially in pediatric teleclinics. Across various settings, telemedicine improved access, workflow efficiency, and cost-effectiveness, though challenges remained regarding connectivity, imaging interoperability, licensure differences, and digital inequality.ConclusionTele-neurosurgery is a safe, effective, and cost-efficient addition to traditional neurosurgical care. It enhances response times, improves triage, and maintains high patient satisfaction across various health systems. Overcoming infrastructural and regulatory barriers through standardized digital networks and equitable access programs will be essential for consolidating telemedicine as a core element of global neurosurgical practice.

  View details for DOI 10.1177/1357633X261436994

  View details for Web of Science ID 001731442100001

  View details for PubMedID 41925237

• From Simpson grade to Ki-67 index for prognostic stratification of meningioma JOURNAL OF NEUROSURGERY Palmiero, H., Figueiredo, E. 2026; 144 (4): 1003-1004

  View details for DOI 10.3171/2025.8.JNS251996

  View details for Web of Science ID 001747660900028

• Technical Description of the Mini Far-Lateral Approach: A Refined, Stability-Preserving Corridor to the Petroclival Region. Operative neurosurgery (Hagerstown, Md.) Gadelha Figueiredo, E., de Oliveira Manduca Palmiero, H., Dogan, S., Gondim Cabral de Vasconcelos, F. R., Brenner, L. B., Gilberto Carlotti, C. J., Spetzler, R. F., Preul, M. C. 2026

  Abstract

  BACKGROUND AND OBJECTIVES: The far-lateral approach remains essential for accessing ventral and ventrolateral lesions of the craniovertebral junction. However, traditional exposures may involve extensive condylar drilling and muscle dissection, which can compromise craniocervical junction stability. This study aimed to define and quantitatively evaluate a stability-preserving mini far-lateral corridor that provides adequate surgical exposure while minimizing bony and soft-tissue disruption.METHODS: A systematic literature review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines to characterize technical advancements of the far-lateral approach. Additional cadaveric dissections were performed on 6 fresh-frozen adult specimens using a Z-shaped incision, single-plane craniocaudal muscle dissection, limited suboccipital craniectomy, and one-third occipital condyle drilling. Neuronavigation-based morphometric measurements were used to quantify petroclival exposure. A comparative statistical analysis was conducted against the classical (Spektor, 2000) and minimally invasive (Zhang, 2011) series.RESULTS: The mean petroclival exposure area was 376.86 ± 45.54 mm2, larger than the values reported by Spektor et al (338.00 ± 86.00 mm2; t(17) = 7.22; P = 1.49 * 10-6) and Zhang et al (208.50 ± 28.40 mm2; t(16) = 20.31; P = 7.61 * 10-13). The approach offered a direct posterolateral trajectory to the bulbomedullary junction and lower cranial nerves while maintaining occipitocervical integrity.CONCLUSION: The mini far-lateral approach provides comparable petroclival exposure, compared with both the classical and keyhole variants, by combining surgical effectiveness with the preservation of stability. These results support its adoption as the standard method for ventral and ventrolateral craniovertebral lesions, with wider condylectomy or fusion reserved for specific trajectory-driven indications.

  View details for DOI 10.1227/ons.0000000000002011

  View details for PubMedID 41885447

• Minipterional and Sphenoid Ridge Keyhole Approaches: A Comparative Anatomic Study. Operative neurosurgery (Hagerstown, Md.) Gadelha Figueiredo, E., de Oliveira Manduca Palmiero, H., Koester, S. W., Freitas, P., Lawton, M. T. 2026

  Abstract

  BACKGROUND AND OBJECTIVES: The pterional craniotomy provides excellent transsylvian exposure but comes with cosmetic and functional drawbacks. Minimally invasive alternatives, including the sphenoid ridge keyhole (SRK) and minipterional (MiniPT) approaches, strive to reduce morbidity while maintaining adequate surgical access. No previous study has directly compared the anatomic exposure offered by MiniPT and SRK.METHODS: Eight adult cadaveric heads were dissected. Each specimen underwent SRK, and MiniPT craniotomies were performed sequentially. A neuronavigation system recorded 3-dimensional coordinates of 5 key anatomical targets around the circle of Willis. Surgical exposure area was calculated using vector cross-products, and angular exposure was determined using vector dot products. Measurements were compared between techniques using Student t-tests.RESULTS: The MiniPT approach offered a significantly larger surgical exposure area compared to the SRK approach (882.3 ± 93.8 mm2 vs 442.2 ± 110.8 mm2; P < .001). MiniPT also provided significantly wider angular exposure for the tuberculum sellae (P = .03), internal carotid artery (P = .01), and contralateral posterior cerebral artery (P = .015). No difference was found for the contralateral middle cerebral artery (P = .85) and the ipsilateral posterior cerebral artery (P = .06). MiniPT consistently delivered broader operative angles, improving multidirectional access to deep anatomical targets.CONCLUSION: Compared with the SRK approach, the MiniPT craniotomy provides significantly better surgical exposure and a broader angular access to critical structures around the circle of Willis. These results support the MiniPT as a more effective and versatile minimally invasive alternative for transsylvian approaches that require improved visualization and maneuverability.

  View details for DOI 10.1227/ons.0000000000002000

  View details for PubMedID 41885438

• Anatomical and quantitative analysis of safe entry zones to the lower brainstem through the far-lateral approach NEUROSURGICAL REVIEW Cavalcanti, D., Figueiredo, E., De Oliveira Manduca Palmiero, H., Preul, M. C., Spetzler, R. F. 2026; 49 (1)

  Abstract

  Safe entry zones (SEZs) in the medulla oblongata offer consistent anatomical corridors for accessing intrinsic lesions while minimizing damage to nuclei and tracts. Data quantifying the geometric parameters of surgical exposure to the lower brainstem are limited. This study aims to anatomically and quantitatively analyze the exposure area, working angles, and linear extent of access to the medullary SEZs via the far-lateral approach. Ten formalin-fixed human cadaveric heads were dissected using simulated operative positioning. The far-lateral approaches were performed under neuronavigation, with coordinates of seven standardized landmarks on the brainstem surface recorded. Customized software calculated exposure areas, horizontal and vertical working angles, and the vertical linear extent of exposure. The far-lateral route optimized exposure of the ventrolateral medulla and olivary zone. The average exposed area for the far-lateral approach was 856.8 ± 139.7 mm². The horizontal and vertical working angles toward the olivary zone were 40.8 ± 10.2° and 54.8 ± 6.8°, respectively, with a vertical linear extent of exposure of 60.0 ± 6.6 mm. These data quantitatively characterize the operative field and instrument maneuverability provided by each approach. This study offers a quantitative anatomical framework for the far-lateral approach to the ventrolateral medulla, outlining objective parameters of exposure area, working angles, and vertical linear extent to the olivary safe entry zone. By converting microsurgical medullary anatomy into measurable operative geometry, these data support the far-lateral route as an effective and reproducible corridor for accessing intrinsic medullary lesions and could improve preoperative planning, trajectory selection, and surgical safety.

  View details for DOI 10.1007/s10143-026-04171-7

  View details for Web of Science ID 001705131600002

  View details for PubMedID 41772321

  View details for PubMedCentralID PMC12953320

• The evolution of intracranial aneurysm treatment: a narrative review integrating historical perspectives and contemporary evidence BRITISH JOURNAL OF NEUROSURGERY de Oliveira Manduca Palmiero, H., Gadelha Figueiredo, E. 2026: 1-16

  Abstract

  The management of intracranial aneurysms (IAs) has undergone a century-long evolution, shifting from vessel ligation to microsurgical clipping and, more recently, to advanced endovascular therapies. This study aims to combine historical milestones with current evidence to clarify the contemporary balance between microsurgical and endovascular approaches within evidence-based practice.A review was conducted using PubMed/MEDLINE and Google Scholar from database inception through September 2025. Eligible studies included historical analyses, randomized trials, systematic reviews, meta-analyses, and international guidelines comparing microsurgical clipping with endovascular treatments-coiling, flow diversion, and intrasaccular devices.The microsurgical era, pioneered by Yasargil and Drake, established durable anatomical reconstructions. Since the 1990s, endovascular advances-from Guglielmi detachable coils to flow diverters-have driven a global paradigm shift. Recent trials (BRAT, Darsaut et al.) and meta-analyses have demonstrated that clipping yields higher long-term occlusion rates and lower retreatment rates, while endovascular approaches offer reduced perioperative morbidity and shorter hospitalization times. Contemporary evidence also supports the importance of aneurysm location and morphology: microsurgery remains superior for large and giant anterior circulation aneurysms, whereas endovascular therapy is often favored for complex posterior circulation territories. Guideline consensus recommends early treatment of ruptured aneurysms (within 24-72 hours) and individualized management of unruptured lesions based on rupture risk, anatomy, and expert judgment.Modern aneurysm treatment balances surgical durability and endovascular minimalism. Multidisciplinary, evidence-based decision-making ensures optimized, patient-specific management for both ruptured and unruptured aneurysms.

  View details for DOI 10.1080/02688697.2026.2624030

  View details for Web of Science ID 001681535600001

  View details for PubMedID 41640107

• Letter: Predicting Intracranial Pressure Levels: A Deep Learning Approach Using Computed Tomography Brain Scans NEUROSURGERY de Oliveira Manduca Palmiero, H., Gadelha Figueiredo, E. 2026; 98 (1): e9

  View details for DOI 10.1227/neu.0000000000003830

  View details for Web of Science ID 001769378900001

  View details for PubMedID 41143525

• Embolic Agents for Middle Meningeal Artery Embolization in Chronic Subdural Hematoma: a Systematic Review and Comparative Pooled Analysis CLINICAL NEURORADIOLOGY De Oliveira Manduca Palmiero, H., Gadelha Figueiredo, E. 2026; 36 (1): 23-37

  Abstract

  Middle meningeal artery (MMA) embolization has emerged as a promising alternative or supplement to surgery for chronic subdural hematoma (cSDH). However, the effectiveness of different embolic agents remains unclear.We systematically reviewed 41 studies published up to September 2025, including 8 meta-analyses, 1 scoping review, and 32 clinical cohorts or series. Embolic agents evaluated included liquid agents (Onyx, Squid, n‑BCA), particulates (polyvinyl alcohol [PVA], microspheres), and coils. The primary endpoint was treatment failure, defined as symptomatic or radiological recurrence of cSDH requiring repeat intervention (repeat MMA embolization or surgical rescue); secondary outcomes included complications, mortality, and functional outcomes.No embolic agent demonstrated consistent superiority in randomized trials, meta-analyses, or observational cohorts. Pooled recurrence rates were lowest with n‑BCA (0.8%), followed by Squid (3.6%), Onyx (4.4%), PVA particles (7.3%), and coils (9.0%). Although pooled recurrence appeared lowest with n‑BCA and highest with coils, most randomized and observational comparative studies did not detect statistically significant differences between embolic agents. Major complications were infrequent (≈1-3%) and similar across agents. Liquid embolics had significantly higher costs than PVA particles but did not lead to improved functional outcomes.MMA embolization is a safe and effective treatment for cSDH. Outcomes are generally similar across different embolic agents, and selection should be based on anatomical factors, operator expertise, and resource availability rather than expectations of agent-specific effectiveness.

  View details for DOI 10.1007/s00062-025-01605-5

  View details for Web of Science ID 001644294500001

  View details for PubMedID 41428034

  View details for PubMedCentralID 4575892

• Fetal myelomeningocele repair after the MOMS trial: a systematic review of neurosurgical outcomes and evolving techniques CHILDS NERVOUS SYSTEM De Oliveira Manduca Palmiero, H., Figueiredo, E. 2025; 41 (1): 401

  Abstract

  To review current evidence on neurosurgical and obstetric outcomes following prenatal versus postnatal repair of myelomeningocele (MMC) after the landmark Management of Myelomeningocele Study (MOMS) trial, emphasizing evolving surgical techniques and long-term implications.A systematic review was performed according to PRISMA guidelines. PubMed/MEDLINE was searched from 2011 (MOMS publication) to the present for studies on fetal MMC repair. Eligible studies included randomized trials, cohort comparisons, technical series, and evidence-based guidelines. Primary outcomes were cerebrospinal fluid (CSF) shunt placement, reversal of hindbrain herniation, and motor/ambulation function; secondary outcomes included maternal morbidity, urological, and orthopedic endpoints.Forty-three studies met the inclusion criteria. Prenatal repair reduced ventriculoperitoneal shunt requirements by approximately 50% (about 40% vs. 80%) and doubled the rate of independent walking (about 45% vs. 24%) compared with postnatal repair, consistent with MOMS findings. Hindbrain herniation reversal occurred in up to 75% of prenatal cases. However, prenatal surgery increased risks of preterm delivery (around 34 weeks), premature membrane rupture, and uterine dehiscence. Refinements such as mini-hysterotomy and fetoscopy achieved similar fetal benefits with improved maternal safety profiles, depending on surgical expertise and institutional experience.Prenatal MMC repair is one of the most significant advances in fetal neurosurgery, providing durable neurological and functional benefits such as reduced reliance on ventriculoperitoneal shunts and improved motor functions. Continued improvements in surgical techniques, maternal-obstetric safety, and equitable access to experienced fetal centers are essential to establishing prenatal surgical repair as a key advancement in modern pediatric neurosurgery and fetal therapy.

  View details for DOI 10.1007/s00381-025-07081-z

  View details for Web of Science ID 001630698300002

  View details for PubMedID 41342964

  View details for PubMedCentralID 8192992

• Regarding a Simple Technique of Cerebrospinal Fluid Leak Prevention Following Endoscopic Third Ventriculostomy: A Technical Note WORLD NEUROSURGERY Palmiero, H., Figueiredo, E. 2025; 202: 124409

  View details for DOI 10.1016/j.wneu.2025.124409

  View details for Web of Science ID 001576291400003

  View details for PubMedID 40849018

• On patient positioning in the "Supracerebellar highway-fast and safe road to pediatric pineal tumor resection": a letter to the editor CHILDS NERVOUS SYSTEM Palmiero, H. 2025; 41 (1): 318

  View details for DOI 10.1007/s00381-025-06993-0

  View details for Web of Science ID 001597205400001

  View details for PubMedID 41110008

• Anatomical assessment of cerebral sulci and gyri for neuroanatomy education using photogrammetry technique to generate 3D-tridimensional models NEUROSURGICAL REVIEW Palmiero, H., Ribas, E., Carlotti Jr, C., Figueiredo, E. 2025; 48 (1): 172

  Abstract

  The surface of the brain is characterized by sulci and gyri. From these surface features, we can identify the frontal, parietal, temporal, occipital, and insular lobes. Learning neuroanatomy traditionally involves studying anatomical figures from atlases and working with cadaveric specimens in the lab. In higher education, technology, such as computer-generated images and three-dimensional (3D) models, can enhance students' understanding and retention of the material. The photogrammetry technique, which involves capturing images with digital cameras or smartphones, allows for the creation of low-cost 3D anatomical models. Five human cadaver brains were microsurgically dissected to expose the sulci and gyri. Using smartphones and free software, tridimensional brain models were created using the photogrammetry technique, with a detailed step-by-step description. The digital models were stored for use in teaching neuroanatomy. Human brains were dissected by removing the arachnoid membrane under microscopic visualization. Using smartphones and free software, tridimensional brain models were created with appropriate visualization in details of the sulci and gyri. These models were stored on computers and made available to neuroanatomy students via the Internet. By using smartphones and low-cost software applications, the pedagogy of neuroanatomy in higher education can be enhanced, providing students with online access to spatially accurate brain models. This improves their ability to perceive the spatial structure of brain specimens.

  View details for DOI 10.1007/s10143-025-03332-4

  View details for Web of Science ID 001414632400009

  View details for PubMedID 39903353

  View details for PubMedCentralID 9174940

• Anatomic evaluation of the posterior temporal approach via the Heschl's gyrus to the thalamus, internal capsule, and atrium ACTA NEUROCHIRURGICA Manduca Palmiero, H., Ribas, E., Teixeira, M., Figueiredo, E. 2023; 165 (2): 517-523

  Abstract

  Posterior temporal craniotomy allows for the exposure of the superior surface of the planum temporale. Heschl's gyrus is the most prominent structure of the planum temporale and can be an anatomical landmark to approach deep brain structures such as the internal capsule, lateral thalamus, and ventricular atrium.Ten human cadavers' heads underwent a posterior bilateral temporal craniotomy and the microsurgical dissection of Heschl's gyrus was performed and variables were measured with a neuronavigation system and statistically analyzed.The mean distance between the keyhole and Heschl's gyrus was 61.7 ± 7.3 mm, the mean distance between the stephanion to Heschl's gyrus was 40.8 ± 6.0 mm, and the mean distance between the temporal lobe and Heschl's gyrus was 54.9 ± 6.9 mm. The length of Heschl's gyrus was 24 ± 7.5 mm, and the inclination angle in the axial plane was 20.0 ± 3.7° having the vertex as its deepest point as the base on the surface of the temporal plane. From Heschl's gyrus, the distance from the surface to the internal capsule was 29.1 ± 5.6 mm, the distance to the lateral thalamus was 34.8 ± 7.3 mm, and the distance to the ventricular atrium was 39.6 ± 7.2 mm. No statistical difference was found between the right and left sides.Through a posterior temporal craniotomy, the temporal planum is exposed by opening the Sylvian fissure, where Heschl's gyrus can be identified and used as a natural corridor to approach the internal capsule, the ventricular atrium, and the lateral thalamus.

  View details for DOI 10.1007/s00701-022-05475-5

  View details for Web of Science ID 000907907500002

  View details for PubMedID 36598545

• Anatomic, qualitative, and quantitative evaluation of the variants of the infratentorial supracerebellar approach to the posteroinferior thalamus NEUROSURGICAL REVIEW de Oliveira Manduca Palmiero, H., Solla, D., dos Santos, L., Teixeira, M., Figueiredo, E. 2021; 44 (4): 2309-2318

  Abstract

  The posteroinferior region of the thalamus is formed by the pulvinar, and it is surgically accessed through the infratentorial supracerebellar approach, between the midline and the retromastoid region. This study aimed to compare the paramedian, lateral, extreme lateral, and contralateral paramedian corridors with the posteroinferior thalamus through a suboccipital craniotomy and an infratentorial supracerebellar access. Ten cadavers were studied, and the microsurgical dissections were accompanied by the measurement of the variables using a neuronavigation system. Statistical analysis was performed using analysis of variance (ANOVA). The distance between the access midpoint at the cranial surface and pulvinar varied between 53.3 and 53.9 mm, the contralateral access being an exception (59.9 mm). The vertical angle ranged from 20.6° in the contralateral access to 23.5° in the lateral access. There was a gradual increase in the horizontal angle between the paramedian (17.4°), lateral (31.3°), and extreme lateral (43.7°) accesses. But, this angle in the contralateral access was 14.6°, similar to that of the paramedian access. The exposed area of the thalamus was 125.1 mm2 in the paramedian access, 141.8 mm2 in the lateral access, and 165.9 mm2 in the extreme lateral access, which was similar to that of the contralateral access (164.9 mm2). The horizontal view angle increased with lateralization of the access, which facilitated microscopic visualization. With regard to the exposure of the microsurgical anatomy, the extreme lateral and contralateral accesses circumvent the neural and vascular obstacles at the midline, allowing a larger area of anatomical exposure.

  View details for DOI 10.1007/s10143-020-01405-0

  View details for Web of Science ID 000582311200002

  View details for PubMedID 33098480

  View details for PubMedCentralID 5765706

• Microsurgery for Upper Basilar Tip Aneurysm With Intraoperative Rupture: 3-Dimensional Operative Video OPERATIVE NEUROSURGERY Granados, O., Silva da Costa, M., Costa, B., Gonzalez-Echeverria, K., Paganelli, S., Caramanti, R., Palmiero, H., Chaddad-Neto, F. 2019; 16 (2): E43

  Abstract

  In the last years, a shift from the microsurgical treatment to an endovascular therapy in patients with basilar apex aneurysm has been settled, part of this phenomenon is related to the significant tendency of vital perforators to be involved in the aneurysm dissection and clipping, which can implicate unfavorable outcomes. Nevertheless, microsurgical treatment remains the treatment that can provide the superior rates of stable and durable aneurysm occlusion, which is most important to young patients.In this video, we present the case of a 45-yr-old female patient who complained of a sudden and severe headache and presented with progressive lethargy during the following 3 d.At admission, computed tomography did not show abnormal findings. However, cerebrospinal fluid analysis showed erythrocytes and corroborated the clinical suspicion of spontaneous subarachnoid hemorrhage. The patient signed the Institutional Consent Form, which allows the use of his/her images and videos for any type of medical publications in conferences and/or scientific articles.Angiography and magnetic resonance imaging revealed a saccular basilar apex aneurysm. It showed a wide neck as well as a lobulated dome with upward and slightly left projection. The aneurysm did not involve angiographically visible thalamoperforator arteries, which allowed the microsurgical treatment by the fronto-orbitozygomatic approach. However, during the interpeduncular cistern dissection, an intraoperative rupture of the aneurysm occurred. This video exemplifies the steps required to manage an intraoperative rupture of a basilar apex aneurysm.

  View details for DOI 10.1093/ons/opy179

  View details for Web of Science ID 000483181700004

  View details for PubMedID 30060222

• Microsurgical Clipping of Ruptured Distal Posterior Inferior Cerebellar Artery Aneurysm: 3-Dimensional Operative Video OPERATIVE NEUROSURGERY Wainberg, R., Silva da Costa, M., Ugalde Hernandez, Y. A., Caramanti, R., Ferreira Alves Filho, C., Palmiero, H., Saick, R., Chaddad-Neto, F. 2019; 16 (2): E48

  Abstract

  The distal posterior inferior cerebellar artery (PICA) is a rare site of aneurysm formation. Only small case series and case reports regarding surgical treatment are found in the literature.The PICA is divided into 5 segments (anterior medullary, lateral medullary, tonsilomedullary, telovelotonsillary, and cortical), and the distal ones represent the most complex, due to anatomic variations. We present a case of a 69-yr-old female patient who has suffered from a sudden and intense occipital headache, associated with nausea and vomiting. CT scan showed intraventricular hemorrhage, and further investigation with MRI and MR Angiography revealed a small distal PICA aneurysm, at the superior part of the medial aspect of the left cerebellar tonsil. Digital angiography has demonstrated the aneurysm at the tonsilomedullary segment of the PICA. In this 3-dimensional video, the authors show the microsurgical clipping of a saccular distal PICA aneurysm in the close relation to a choroidal branch, performed by median suboccipital craniotomy. Step-by-step of the dissection, relevant surrounding anatomy and aneurysm clipping is demonstrated. The patient signed the Institutional Consent Form, which allows the use of his/her images and videos for any type of medical publications in conferences and/or scientific articles.

  View details for DOI 10.1093/ons/opy153

  View details for Web of Science ID 000483181700010

  View details for PubMedID 29917106

• Intracranial Dural Arteriovenous Fistula: 2-Dimensional Operative Video OPERATIVE NEUROSURGERY Manduca Palmiero, H., Lourenco Costa, B., Caramanti, R., Silva da Costa, M., Aparecido Chaddad-Neto, F. 2018; 15 (3): 353

  View details for DOI 10.1093/ons/opx273

  View details for Web of Science ID 000449381000050

  View details for PubMedID 29309660

• Intradural Anterior Clinoidectomy for Ophthalmic Artery Aneurysm Clipping: 3-Dimensional Operative Video OPERATIVE NEUROSURGERY Caramanti, R., Silva da Costa, M., Ugalde Hernandez, Y. A., Ferreira Alves Filho, C., Wainberg, R., Palmiero, H., Saick, R., Chaddad-Neto, F. 2018; 14 (6): 708

  View details for DOI 10.1093/ons/opx225

  View details for Web of Science ID 000449371500032

  View details for PubMedID 29106678

• Angular and metric analysis of the neural structures in the cerebellopontine angle BRITISH JOURNAL OF NEUROSURGERY Manduca Palmiero, H., Silva da Costa, M., Caramanti, R., Aparecido Chaddad-Neto, F. 2018; 32 (3): 250-254

  Abstract

  The cerebellopontine angle (CPA) is a subarachnoid space in the lateral aspect of the posterior fossa. In this study, we propose a complementary analysis of the CPA from the cerebellopontine fissure.We studied 50 hemi-cerebelli in the laboratory of neuroanatomy and included a description of the CPA anatomy from the cerebellopontine fissure and its relationship with the flocculus and the 5th, 6th, 7th, and 8th cranial nerves (CN) origins.The average distance from the 5th CN to the mid-line (ML) was 19.2 mm, 6th CN to ML was 4.4 mm, 7-8 complex to ML was 15.8 mm, flocculus to ML was 20.5 mm, and flocculus to 5th CN was 11.5 mm, additionally, and the diameter of the flocculus was 9.0 mm. The angle between the vertex in the flocculus and the V CN and the medullary-pontine line was 64.8 degrees.The most common access to the CPA is through the retrosigmoid-suboccipital region and this approach can be done with the help of an endoscope. The anatomy of origins of neural structures tends to be preserved in cases of CPA lesions.Knowledge of the average distances between the neural structures in the cerebellar-pontine fissure and the angular relationships between these structures facilitates the use of surgical approaches such as microsurgery and endoscopy.

  View details for DOI 10.1080/02688697.2018.1426722

  View details for Web of Science ID 000440350400005

  View details for PubMedID 29334768

• Treatment of Intradural Spinal Arteriovenous Fistula: Technical Case Report BRAZILIAN NEUROSURGERY-ARQUIVOS BRASILEIROS DE NEUROCIRURGIA Manduca Palmiero, H., Caramanti, R., Aparecido Chaddad-Neto, F. 2017; 36 (4): 264-268

  View details for DOI 10.1055/s-0037-1612621

  View details for Web of Science ID 000418561300014

• Liver Recipient Survival Rate Before and After Model for End-Stage Liver Disease Implementation and Use of Donor Risk Index Palmier, H., Kajikawa, P., Boin, I. F., Coria, S., Pereira, L. A. ELSEVIER SCIENCE INC. 2010: 4113-4115

  Abstract

  The progressive increase in the demand for liver transplantation has led to changes in donor selection and allocation, such as the Model for End-Stage Liver Disease Score (MELD). Characteristics related to the donor, recipient, and transplantation procedure influence the results. The use of expanded-criteria donors (ECDs) and the donor risk index (DRI) are strategies that have been proposed to increase the donors pool.We sought to study liver recipient survival before and after MELD implementation as well as the use of DRI.This retrospective study of prospectively collected data analyzed 1,786 liver recipients and their donors according to gender, age, cause of brain death, intensive care unit time, split liver, infection, ECD, cardiac arrest, cold ischemia time, waiting list time, and donor origin. MELD (without special scoring) and DRI were calculated from the recorded data. The periods of this study were 2004-2006 (pre-MELD) and 2006-2008 (post-MELD). For survival times, we performed the Kaplan-Meier method with log-rank tests and Cox regression analysis (prediction). The Kolmogorov-Sminorv test was used for sample comparisons.The 1-year survivals were similar in the 2 periods (65.4% vs 67.6%). The predictive factors for death among the whole population were DRI >1.5, cold ischemia time ≥9 hours, MELD ≥25, female recipient, and longer waiting list time.MELD is an important tool for allocation, resulting in a reduced waiting list, increased number of split-liver procedures, and use of ECDs without deterioration of survival times. DRI >1.7 was associated with shorter survival.

  View details for DOI 10.1016/j.transproceed.2010.09.092

  View details for Web of Science ID 000285732200056

  View details for PubMedID 21168639

• Donor Risk Index and Survival Rate after Liver Transplantation - Prospective Study Kajikawa, P., Boin, I. F., Palmiero, H. O. M., Ataide, E. C., Bachega, E. B., Sardinha, L. A. C., Zambelli, H. J. L. JOHN WILEY & SONS INC. 2010: S176-S177

  View details for Web of Science ID 000278428000368

• REVIEWING THE CAUSES FOR OVER THOUSAND DISCHARGED LIVER DONORS. CAN DONATIONS BE INCREASED? Boin, I. F., Palmiero, H. O. M., Kajikawa, P., Zambelli, H. JOHN WILEY & SONS INC. 2009: S79

  View details for Web of Science ID 000267792300027

• Reviewing the Causes for 1432 Discharged Liver Donors: Can Donations Be Increased? Boin, I. F., Palmiero, H. M., Kajikawa, P., Zambelli, H. L. ELSEVIER SCIENCE INC. 2009: 797-798

  Abstract

  Thousands of patients are awaiting liver transplantation, mainly owing to the lack of donors. The aim of this study was to analyze the characteristics of discarded livers from donors seeking to understand how to increase the number of grafts. A retrospective analysis of 1432 discarded donor livers was performed in the period between 1994 and 2007. Data were stored in a standardized database in accordance with expanded donor criteria. The average donor age was 35.2 years with; 67.7% male subjects and 20.9% over age 50 years. The main cause of donor discard was family refusal (46.6%), followed by cardiorespiratory arrest (CRA) in 28.3%, and surgeon discard (16.9%), principally owing to sepsis (24.5%). Vasopressor drugs were used in 97.2%. Alcoholism was detected in 44.56% and drug addiction in 12.4%. There was infections documented in 23.9% of records, mainly of the respiratory type (75%). Intensive care time was over 120 hours in 11.0%. Hepatitis B infection was detected in 22.5%, (n = 338), and hepatitis C in 3.5% (n = 593). Finally, there were losses due to hypotension in 45.7% (516/1130) and also loss due to CRA. As family refusal was the principal cause for discarding a donor, it is necessary to investigate the role of information about organ transplantation to increase acceptance.

  View details for DOI 10.1016/j.transproceed.2009.01.049

  View details for Web of Science ID 000265504300004

  View details for PubMedID 19376355

• Profile of cadaveric liver donors of the OPO-UNICAMP from 2002 to 2006 Boin, I. F., Kajikawa, P., Palmiero, H. M., Zarnbelli, H., Stucchi, R., Leonardi, M., Leonardi, L. ELSEVIER SCIENCE INC. 2008: 657-659

  Abstract

  Four decades after the first successful liver transplantation, the organ donation shortage challenges the scientific community to create various new strategies.We sought to analyze the profile of registered cadaveric liver donors for an Organ Procurement Organization (OPO) during the period of 2002 through 2006.This retrospective analysis of 122 deceased donors in the OPO-Unicamp corresponded to the period of 2002 through 2006.Men were identified as 57.14% of donors and the overall average age was 32.88 years with 16.53% over 50 years of age. Analyzing the causes of brain death, cerebral trauma (CET) was responsible for 46.22% and cerebral vascular accidents, 33.61%. The percentage of use of vasoactive drugs was 88.43%. Observing the donors' backgrounds, we observed that 11.90% had alcoholism, 1.23% drug addiction and 27.78% infection. We verified cardiac arrest in 9.43%. In accordance with the expanded criteria of donation, 89.26% of donors fulfilled some of the criteria: 73.55%, one criterion; 14.05%, two; 1.65%, three; and no donor fulfilled 4 or 5.The donor profile in our unit is a young man with CET and who fulfills at least one expanded donation criterion. Finally, to increase the number of donors, the use of vasoactive drugs (89.26%), cardiopulmonary resuscitation (9.43%), and infection (27.78%) were not considered reasons to discard the liver.

  View details for DOI 10.1016/j.transproceed.2008.02.037

  View details for Web of Science ID 000255527600002

  View details for PubMedID 18454979

• Age donor over fiftys decrease survival rate after liver transplantation. Boin, I. F., Leonardi, M. I., Stucchi, R., Palmiero, H. M., Kajikawa, P., Kaiahara, Y. B. F. JOHN WILEY & SONS INC. 2007: S132

  View details for Web of Science ID 000247084700242