Paulo Henrique Aguiar

Hospital De Clínicas De Porto Alegre, Pôrto de São Francisco dos Casaes, Rio Grande do Sul, Brazil

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Publications (108)132.09 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: This study was undertaken to determine variables that could predict, in the perioperative period of anterior communicating artery (ACom) aneurysms surgeries, the likelihood of postoperative sequelae and complications, after temporary arterial occlusion (TAO).
    Acta neurochirurgica. Supplement 01/2015; 120:231-5. · 1.79 Impact Factor
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    ABSTRACT: Background Anterior petrosectomy has become an increasingly used approach for petroclival lesions. This study measures the volume and the anatomical variants of the anterior portion of the petrous apex outlined by the Kawase triangle using computed tomography (CT). Methods This was a transversal retrospective study. We assessed the anterior petrous apex portion outlined by the Kawase triangle in consecutive patients > 18 years of age from CT scans of temporal bone stored in an archive system. The volumetry was performed on a workstation. Results A total of 154 petrosal apex were analyzed in 77 patients (36 men). The average volume of the region outlined by the Kawase triangle was 1.89 ± 0.52 cm(3). The volume average in men was 2.01 ± 0.58 cm(3), and the average in women was 1.79 ± 0.41 cm(3). Intra- and interobserver agreement were both excellent, and there was little variance. Nineteen petrous apex demonstrated anatomical variations. In 18 cases it was pneumatized, and in one case a vascular or nerve-like structure was identified, a report we did not find in the literature. Conclusion The volumetry of the petrous apex anterior portion outlined by the Kawase triangle can be made by CT with excellent intra- and interobserver agreement and reproducibility. There are anatomical variants in this region that are relevant to surgery.
    Journal of neurological surgery. Part B, Skull base. 06/2014; 75(3):147-51.
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    ABSTRACT: The posterior cerebral artery (PCA) is divided into 4 segments: precommunicating segment (P1), postcommunicating segment (P2), quadrigeminal segment (P3), and calcarine segment (P4). Small aneurysms are more prevalent than large aneurysms in patients with ruptured aneurysms. P2 and P3 aneurysms are usually managed by the subtemporal approach. This is a case report of rupture saccular aneurysm of posterior cerebral artery on P2P segment. The authors show the surgical steps of these rare aneurysms with an illustrative case.
    Case Reports in Medicine 01/2014; 2014:325414.
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    ABSTRACT: Intraoperative neurophysiology monitoring (IOM) is a valuable tool in cerebellopontine angle (CPA) surgeries posing risk to the cranial nerves. Transcranial electrical stimulation (TES) for cranial nerves has been performed in the last 7 years, for obtaining the facial nerve motor evoked potential (MEP), using either C3/C4-Cz or C3-C4 (or inverse) stimulating points, which have been correlated with facial nerve functional outcome. Intraoperative surgical and electrophysiological findings were documented prospectively. Patient files were reviewed for clinical data. We studied 23 patients undergoing CPA tumor resection using C5 or C6-Cz montage for TES, and were able to determine the correlation between facial nerve functional outcome and the amplitude drop of facial MEP above 50 %. Patients were evaluated for immediate facial nerve outcome and 6 months after the surgery. Follow-up was performed by structured telephone interviews with local physicians. The sensibility of the studied parameters was 92.8 % for amplitude drop of facial nerve MEP, with positive predictive value of 81.2 %. The absence of changes during IOM has shown a negative predictive value of 100 %. In this series, the used montage was effective in predicting new facial deficit.
    Acta Neurochirurgica 07/2013; · 1.79 Impact Factor
  • Paulo H Pires de Aguiar, Icaro Barros, Bernardo L Paiva, Renata F Simm
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    ABSTRACT: Background: Cerebral vasospasm after subarachnoid hemorrhage (SAH) is a major cause of morbidity and mortality. We studied the effects of clot removal on multiple outcome variables following the clipping of ruptured anterior communicating aneurysms. Methods: From 2007 to 2011, 30 patients with Fisher grade III aneurysmal SAH underwent clipping of an anterior communicating artery aneurysm before SAH day 3. There were 20 women and 10 men, mean age 53.4, range 28-80 years. Seventeen underwent fenestration of lamina terminalis and cisternal removal of clots (group A), and 13 did not (Group B). We compared clinical grades, presence of hydrocephalus at admission, treatment modality, occurrence of clinical vasospasm, the need for interventional vasospasm therapy, and need for ventriculoperitoneal shunting. Findings: Vasospasm affected 5 of 17 (29%) in group A and 8 of 13 (61.5%) in group B (p < 0.05). Endovascular treatment for vasospasm was required in one patient in group A (5.8% of 17, 20% of 5) and in five from group B (38.4% of 13, 62.5% of 8) (p < 0.05). Mortality was observed in one case in group A (5.8% of 17, 20% of 5) and in two cases in group B (15.3% of 13, 25% of 8) and was related to vasospasm after SAH. Ventriculoperitonal shunt (VPS) was required in one case in group A (5.8%) and in five cases in group B (38.4%). Conclusions: Fenestration of the lamina terminalis and removal of cisternal clots significantly decreased the incidence of post-SAH hydrocephalus and was associated with better outcomes in our series.
    Acta neurochirurgica. Supplement 01/2013; 115:91-3. · 1.79 Impact Factor
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    ABSTRACT: Background: Vasospasm is an important complication observed after subarachnoid hemorrhage (SAH) and is a frequent cause of mortality and morbidity. We present our routine management of vasospasm after SAH and emphasize the importance of transcranial Doppler (TCD) ultrasonography in this management. Method: Historical records and images were sampled from June 2005 to September 2011 for 110 patients with SAH due to ruptured aneurysm in the anterior circulation. All surviving patients were followed after discharge. Vasospasm was defined as mild (Lindegaard index 3-4), moderate (Lindegaard index 4-5), and severe (Lindegaard index greater than 5). We excluded patients treated after 72 h of symptom onset. TCD was performed twice per day. Findings: Ninety-nine patients had surgical clipping of the aneurysm, and 11 had endovascular treatment. Seventy patients treated by clipping and six treated by endovascular procedure had vasospasm. Of the 70 clipped patients with vasospasm, 40 had mild vasospasm, 13 had moderate vasospasm, and 17 had severe vasospasm. All six patients treated by coils had moderate vasospasm. The average duration of vasospasm was 9 days (from 7 to 32 days). Conclusions: TCD was crucial for monitoring patients with SAH, and to identify which patients will have a higher risk of developing vasospasm.
    Acta neurochirurgica. Supplement 01/2013; 115:75-6. · 1.79 Impact Factor
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    ABSTRACT: Una hernia de disco lumbar es una causa importante, así como la más frecuente causa del dolor lumbar y ciática. Muchos casos pueden ser fácilmente diagnosticados por el examen semiológico simple. La resonancia magnética (RM) proporciona un diagnóstico definitivo, incluso en atención ambulatoria. Varios tipos de quistes intraespinales con diferentes patogénesis se han descrito en el pasado como quistes perineurales, quistes sinoviales, los quistes aracnoideos y quistes ganglionares, enfermedades que son difíciles de diferenciar de la hernia de disco lumbar. Los autores observaron recientemente un caso de quiste intraespinal, que en comunicación con el disco intervertebral correspondiente, presentando signos y síntomas e incluso algunos hallazgos radiológicos que no se distinguen de los de la hernia discal lumbar. El diagnóstico fue determinado por RM y confirmado en la cirugía. En este artículo se describen las características de esta entidad clínica, incluyendo el aspecto clínico, radiológico e histológico, para discutir la posible patogénesis y tratamiento.
    Coluna/ Columna 12/2012; 11(4):329-332.
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    ABSTRACT: OBJECTIVE: We used an assembly of electrodes C3 and C4-Cz in order to activate the motor cortical area of the corticobulbar tract to elucidate the motor-evoked potential of the contralateral mentalis muscle. METHOD: We compared this setup to that of an assembly with electrodes C5 or C6-Cz using a train of electrical pulses and a single electrical pulse. This analysis was made in 23 consecutive patients who underwent several varied surgeries and were prospectively operated on at Santa Paula Hospital between January and June 2011. RESULTS: The results showed that the assembly with C5 or C6-Cz produced a multisynaptic motor-evoked potential in the contralateral mentalis muscle in 86.9 % of the patients, whereas 82.6 % of patients stimulated at points C3 or C4-Cz presented the same response. However, both assemblies showed similar behavior with the use of a single electrical pulse for peripheral contralateral nerve stimulation. CONCLUSION: We concluded that the C5 or C6-Cz assembly was similar to C3 or C4-Cz in obtaining a multisynaptic response in the contralateral mentalis muscle, although it required less intensive stimulation than the C3 or C4- Cz assembly.
    Acta Neurochirurgica 10/2012; · 1.79 Impact Factor
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    ABSTRACT: The transsphenoidal approach is the preferred access used in surgical treatment of most sellar region pathologies. The use of endoscopy is advantageous, and it is considered a good alternative to the traditional microsurgical technique. The purpose of this study is to recognize and describe anatomical variations of the sphenoid sinus and the sellar region, mainly describing the anatomy of the posterior wall of the sphenoid sinus and analyzing intercarotid distances in 3 regions. Thirty sphenoid blocks treated with formaldehyde were injected and dissected. Using endoscopy, anatomical variations were studied and the intercarotid distances were measured at the tuberculum sellae, sellar floor and clivus. The types of sphenoid sinus found were: conchal in 1 (4.76 %), pré-sellar in 2 (9.52 %) and sellar in 19 (85.7 %) specimens. The mean distance found from the sphenoid sinus ostium to the sella turcica was 19 mm (±6.5) mm. The mean intercarotid distances found at the tuberculum sellae, sellar floor and clivus were respectively 13.32, 18.00 and 18.90 mm. Endoscopy, with its magnification and lighting provide a panoramic view of deep fields. The anatomical variations described in this study support the need for a careful evaluation of preoperative images in each case.
    Pituitary 07/2012; · 2.22 Impact Factor
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    ABSTRACT: BACKGROUND AND PURPOSE:(1)H-MR spectroscopy is a useful tool in brain tumor evaluation. A critical point in obtaining representative spectra is the correct voxel positioning, which can be more accurate after Gd administration. Some experimental data suggested that Gd could cause Cho signal loss. Our aim was to evaluate the effect of Gd in the Cho peak area and width in patients with GBM.MATERIALS AND METHODS:We performed multivoxel (1)H-MR spectroscopy before and after Gd administration in 18 patients with GBM. Quantification of Cho peak area and width in each voxel was completed, and the Cho mean and maximum values before and after Gd injection were calculated in the tumor and contralateral hemisphere. Choline peak area and width values obtained before and after contrast were compared, considering as separate entities enhancing and nonenhancing tumoral voxels and the contralateral hemisphere.RESULTS:No statistically significant differences were found for the Cho peak area mean values in the tumoral voxels or contralaterally (P > .05). A tendency for an increase in the Cho peak width mean value was found in the tumoral enhancing voxels (P = .055). A statistically significant decrease was found for the mean value of the maximum Cho peak area in enhancing tumoral voxels (P = .020). No significant differences were found in the nonenhancing tumoral voxels or contralaterally (P > .05).CONCLUSIONS:The injection of Gd before performing (1)H-MR spectroscopy might not significantly affect the Cho peak area in patients with GBM. The paramagnetic contrast seems to cause a different effect, depending on Gd enhancement.
    American Journal of Neuroradiology 07/2012; · 3.17 Impact Factor
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    ABSTRACT: CONTEXTO: O conhecimento das estruturas anatômicas da artéria carótida externa por meio do estudo estereoscópico pode determinar melhores resultados em microcirurgias da artéria carótida externa. OBJETIVO: Descrever as estruturas da artéria carótida externa sob a visão estereoscópica, identificando seus múltiplos aspectos. MÉTODOS: Doze regiões cervicais foram dissecadas, utilizando-se microscópico cirúrgico com 3 a 40x de aumento. As dissecções anatômicas foram documentadas utilizando-se a técnica para obtenção de imagens tridimensionais (3D), objetivando a produção de impressões estereoscópicas. RESULTADOS: O uso da técnica estereoscópica possibilitou a abordagem da circulação arterial extracraniana, sendo realizados estudos cirúrgicos do tipo combinado fossa posterior e fossa infratemporal, tornando as microcirurgias e os procedimentos neurocirúrgicos vasculares mais precisos. CONCLUSÃO: O uso das imagens obtidas pela técnica estereoscópica produziu um resultado mais assertivo em relação ao estudo da anatomia para a microcirurgia e procedimentos neurocirúrgicos, facilitando melhor aprendizado previamente à realização de procedimentos complexos em neurocirurgia.
    Jornal Vascular Brasileiro 03/2012; 11(1):03-11.
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    ABSTRACT: The authors show their experience with brainstem cavernomas, comparing their data with the ones of a literature review. From 1998 to 2009, 13 patients harboring brainstem cavernomas underwent surgical resection. All plain films, medical records and images were reviewed in order to sample the most important data regarding epidemiology, clinical picture, radiological findings and surgical outcomes, as well as main complications. The mean age was 42.4 years (ranging from 19 to 70). No predominant gender: male-to-female ratio, 6:7. Pontine cases were more frequent. Magnetic resonance imaging was used as the imaging method to diagnose cavernomas in all cases. The mean follow-up was 71.3 months (range of 1 to 138 months). Clinical presentation was a single cranial nerve deficit, VIII paresis, tinnitus and hearing loss (69.2%). All 13 patients underwent resection of the symptomatic brainstem cavernoma. Complete removal was accomplished in 11 patients. Morbidity and mortality were 15.3 and 7.6%, respectively. Cavernomas can be resected safely with optimal surgical approach (feasible entry zone) and microsurgical techniques, and the goal is to remove all lesions with no cranial nerves impairment.
    Einstein (São Paulo, Brazil). 01/2012; 10(1):67-73.
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    Jornal Brasileiro de Neurocirurgia. 01/2012; 23:11-17.
  • Marcus André Acioly, Marina Liebsch, Paulo Henrique Pires de Aguiar, Marcos Tatagiba
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    ABSTRACT: BACKGROUND: Intraoperative neuromonitoring has been established as one of the methods by which modern neurosurgery can improve surgical results while reducing morbidity. Despite routine use of intraoperative facial nerve (FN) monitoring, FN injury still is a complication of major concern due to severe negative impact on patient's quality of life. METHODS: Through searches of PubMed, we provided a systematic review of the current literature up to February, 2011, emphasizing all respects of FN monitoring for cerebellopontine angle and skull base tumor surgery from description to current success on function prediction of standard and emerging monitoring techniques. RESULTS: Currently, standard monitoring techniques comprise direct electrical stimulation (DES), free-running electromyography (EMG), and facial motor evoked potential (FMEP). We included 62 studies on function prediction by investigating DES (43 studies), free-running EMG (13 studies), and FMEP (6 studies) criteria. DES mostly evaluated postoperative function by using absolute amplitude, stimulation threshold, and proximal-to-distal amplitude ratio, whereas free-running EMG used the train-time criterion. The prognostic significance of FMEP was assessed with the final-to-baseline amplitude ratio, as well as the event-to-baseline amplitude ratio and waveform complexity. CONCLUSIONS: Although there is a general agreement on the satisfactory functional prediction of different electrophysiological criteria, the lack of standardization in electrode montage and stimulation parameters precludes a definite conclusion regarding the best method. Moreover, studies emphasizing comparison between criteria or even multimodal monitoring and its impact on FN anatomical and functional preservation are still lacking in the literature.
    World Neurosurgery 11/2011; · 2.42 Impact Factor
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    Marcus André Acioly, Paulo Henrique Pires de Aguiar, Marcos Tatagiba
    Acta Neurochirurgica 08/2011; 153(11):2271-2; author reply 2273-4. · 1.79 Impact Factor
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    ABSTRACT: Objective: Lenticulostriate artery (LSA) aneurysms are rare. Here we present 2 cases of LSA aneurysm, their clinical presentation, diagnosis, surgical treatment, and postoperative follow-up, with a review of the topic. Case Report: We report 2 female patients with LSA aneurysms among 194 surgically treated aneurysms in the Santa Paula and São Camilo Hospitals, who underwent the same surgical treatment. The first patient was a 48-year-old, Latin-American woman whose aneurysms were detected incidentally in an angiographic study carried out due to a cavernous sinus thrombosis. Both cerebral angiogram and magnetic angioresonance were performed and showed a left lenticulostriate aneurysm and 2 parasylvian aneurysms. The other case was a 62-year-old, Japanese, hypertensive patient who presented with subarachnoid hemorrhage, Fisher scale 2, and Hunt-Hess classification 2. Her angiogram showed a right LSA, left-middle cerebral artery, and anterior communicating artery aneurysms. No other pathology or infectious etiology was noted. Both patients were treated by opening the sylvian fissure, allowing the visualization of the lenticulostriate vessels and aneurysm clipping. Postoperative angiographies were performed in both cases. During the 2-year follow-up the younger patient remained with just distal right arm paresis and Rankin scale score of 1; the older patient developed normal pressure hydrocephalus, needing peritoneal ventricular drainage. Conclusions: LSA aneurysms are uncommon. Subarachnoid hemorrhage and intracranial sinus thrombosis are quite common pathologies; nevertheless, the underlying vascular abnormality is rarely identified. The most common clinical presentation is intraparenchymal hemorrhage. Microsurgical treatment is often the chosen modality of intervention. Elderly people are more likely to develop postoperative complications before and after hospital discharge, which may be associated with microscopic alterations in vessels. They are also at higher risk of more severe vasospasm and the development of hydrocephalus in cases of ruptured aneurysms.
    Neurosurgery Quarterly 04/2011; 21(2):110–113. · 0.09 Impact Factor
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    ABSTRACT: Facial motor evoked potential (FMEP) amplitude ratio reduction at the end of the surgery has been identified as a good predictor for postoperative facial nerve outcome. We sought to investigate variations in FMEP amplitude and waveform morphology during vestibular schwannoma (VS) resection and to correlate these measures with postoperative facial function immediately after surgery and at the last follow-up. Intraoperative orbicularis oculi and oris muscles FMEP data from 35 patients undergoing surgery for VS resection were collected, then analysed by surgical stage: initial, dural opening, tumour dissection (TuDis), tumour resection (TuRes) and final. Immediately after surgery, postoperative facial function correlated significantly with the FMEP amplitude ratio during TuDis, TuRes and final stages in both the orbicularis oculi (p = 0.003, 0.055 and 0.028, respectively) and oris muscles (p = 0.002, 0.104 and 0.014, respectively). At the last follow-up, however, facial function correlated significantly with the FMEP amplitude ratio only during the TuDis (p = 0.005) and final (p = 0.102) stages for the orbicularis oris muscle. At both time points, postoperative facial paresis correlated significantly with FMEP waveform deterioration in orbicularis oculi during the final stage (immediate, p = 0.023; follow-up, p = 0.116) and in orbicularis oris during the TuDis, TuRes and final stages (immediate, p = 0.071, 0.000 and 0.001, respectively; follow-up, p = 0.015, 0.001 and 0.01, respectively). FMEP amplitude ratio and waveform morphology during VS resection seem to represent independent quantitative parameters that can be used to predict postoperative facial function. Event-to-baseline FMEP monitoring is quite useful to dictate when intraoperative changes in surgical strategy are warranted to reduce the chances of facial nerve injury.
    Acta Neurochirurgica 04/2011; 153(6):1169-79. · 1.79 Impact Factor
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    ABSTRACT: Bleeding from brainstem cavernomas may cause severe deficits due to the absence of non-eloquent nervous tissue and the presence of several ascending and descending white matter tracts and nerve nuclei. Surgical removal of these lesions presents a challenge to the most surgeons. The authors present their experience with the surgical treatment of 43 patients with brainstem cavernomas. Important aspects of microsurgical anatomy are reviewed. The surgical management, with special focus on new intraoperative technologies as well as controversies on indications and timing of surgery are presented. According to several published studies the outcome of brainstem cavernomas treated conservatively is poor. In our experience, surgical resection remains the treatment of choice if there was previous hemorrhage and the lesion reaches the surface of brainstem. These procedures should be performed by experienced neurosurgeons in referral centers employing all the currently available technology.
    Neurological Sciences 02/2011; 32(6):1013-28. · 1.50 Impact Factor
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    ABSTRACT: One of the key elements for a successful endoscopic intervention in the ventricular system is the ability to recognize the anatomic structures and use them as a reference. To measure the choroid plexus with endoscopy in the interventricular foramen, together with the structures on the third ventricle floor, and to compare these variables. An observational prospective study was carried out on 37 brains of cadavers for which the cause of death was assessed at the Death Check Unit of the University of São Paulo in April 2008. This study was done on adults of both sexes with a rigid neuroendoscope. Endoscopic images were recorded, submitted for correction of distortion, and then measured. The measurements of the choroid plexus in the interventricular foramen, laterolateral distance of mammillary bodies, distance from the infundibular recess to the mammillary bodies, and area of the triangle in the tuber cinereum were 1.71 ± 0.77 mm, 2.23 ± 0.74 mm, 3.22 ± 0.82 mm, and 3.69 ± 2.09 mm, respectively. The ventricle floor was opaque in 84% of cases. The internal distance of mammillary bodies was absent in 89%. Associations between the translucent floor of the third ventricle and laterolateral distance of mammillary bodies, internal distance of mammillary bodies, and age were identified. Before this research, there was no record of the measurements of the choroid plexus in the interventricular foramen. The remaining variables of the present study show a greater number in normal brains compared with others.
    Neurosurgery 02/2011; 68(2 Suppl Operative):347-54; discussion 353-4. · 3.03 Impact Factor
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    ABSTRACT: Cavernous malformations are cerebrovascular anomalies that may be observed throughout the central nervous system, mainly in the supratentorial location, comprising about 10% of all cerebrovascular lesions. They frequently affect young patients, and may be observed as sporadic form or familial (hereditary) form. They may appear as single or multiple lesions. Most patients who present with the multiple lesions are likely to harbor the hereditary form of the disease. Magnetic resonance imaging is the standard imaging to diagnose the cavernous malformation, as they are angiographically occult. An autosomal-dominant pattern of inheritance with variable penetrance is responsible to the familial form of the disease. There are 4 types of clinical presentation of the cavernous malformation: seizures, headaches, neurologic deficits, and asymptomatic presentation. The treatment consists of microscopic surgical resection assisted by intraoperative neuronavigation, stereotaxy, or ultrasound, with minimal morbidity. Radiosurgery may be considered for patient with multiple hemorrhages from a surgically inaccessible lesion, or in clinically ill patients without health for surgery. We report a series of 29 patients harboring supratentorial cavernous malformations surgically removed, operated from 1999 to 2009, at São Paulo, Brazil, by the same surgical crew, to verify surgery as the primary management strategy.
    Neurosurgery Quarterly 01/2011; 21(1):33–38. · 0.09 Impact Factor

Publication Stats

565 Citations
132.09 Total Impact Points

Institutions

  • 2014
    • Hospital De Clínicas De Porto Alegre
      Pôrto de São Francisco dos Casaes, Rio Grande do Sul, Brazil
  • 1995–2013
    • University of São Paulo
      • • Departamento de Neurologia (FM) (São Paulo)
      • • Faculty of Medicine (FM)
      • • Departamento de Radiologia (FM) (São Paulo)
      • • Hospital das Clínicas (FMUSP)
      San Paulo, São Paulo, Brazil
  • 2012
    • Hospital Israelita Albert Einstein
      San Paulo, São Paulo, Brazil
  • 2009–2012
    • Hospital Santa Paula
      San Paulo, São Paulo, Brazil
    • Beneficência Portuguesa Hospital of São Paulo
      Potengy, Rio Grande do Norte, Brazil
  • 2011
    • University of Tuebingen
      • Department of Neurosurgery
      Tübingen, Baden-Wuerttemberg, Germany
  • 2003–2010
    • Santa Casa Medicine School, São Paulo
      San Paulo, São Paulo, Brazil
    • São Paulo State University
      • Departamento de Neurologia, Psicologia e Psiquiatria
      São José do Rio Preto, Estado de Sao Paulo, Brazil
  • 2008
    • Barrow Neurological Institute
      • Department of Neurosurgery
      Phoenix, AZ, United States
  • 1998–2006
    • Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
      San Paulo, São Paulo, Brazil
  • 2002–2003
    • Universidade Federal de São Paulo
      • Departamento de Neurologia e Neurocirurgia
      San Paulo, São Paulo, Brazil