RESUMEN

BACKGROUND AND OBJECTIVE: Aneurysms of the posterior cerebral circulation constitute a burdensome condition with high mortality and morbidity. In the modern era, there has been a trend toward favoring an endovascular approach over microsurgery for aneurysm cases. Nevertheless, this transition has yet to be mirrored in low-to-middle-income countries where endovascular therapy may not be widely available. Herein, we aim to illustrate our experience treating these challenging conditions in patients from low-income backgrounds and discuss the relevance of the clinical setting in the treatment decision. METHODS: The authors conducted a retrospective review of the health records of patients who received microsurgical treatment for aneurysms in the posterior circulation, including the basilar artery (BA), posterior cerebral artery (PCA), and posterior inferior cerebellar artery (PICA) in an institution providing treatment to people of low-income backgrounds. Epidemiological data, microsurgical technique, and neurological function were retrieved and analyzed. RESULTS: Surgical clipping was employed for 12 patients (75% female) harboring 15 aneurysms (87% in the posterior circulation and 62% ruptured at presentation). Aneurysms were predominately located in the BA (69%), followed by the PCA (15%) and PICA (15%). Among neurological complications, 25% of patients developed oculomotor nerve palsy. The mortality rate was 17% owing to complications such as cerebral vasospasm, infarction, and severe intracranial hypertension. At the 6-month follow-up, 90% of patients had a good clinical outcome (modified Rankin scale scores of 0-2). CONCLUSION: The present case series illustrates the manifest role of microsurgical techniques for posterior circulation aneurysms, particularly in a scenario where endovascular techniques are not easily accessible. Importantly, this clinical setting pressure could exhort trainees to strive for microsurgical mastery and gain a competitive advantage.

Asunto(s)

RESUMEN

OBJECTIVE: Computed tomography angiography (CTA) is the most widely used imaging modality for intracranial aneurysm (IA) management, yet it remains inferior to digital subtraction angiography (DSA) for IA detection, particularly of small IAs in the cavernous carotid region. The authors evaluated a deep learning pipeline for segmentation of vessels and IAs from CTA using coregistered, segmented DSA images as ground truth. METHODS: Using 50 paired CTA-DSA images, the authors trained (n = 27), validated (n = 3), and tested (n = 20) a deep learning model (3D DeepMedic) for cerebrovasculature segmentation from CTA. A landmark-based coregistration algorithm was used for registration and upsampling of CTA images to paired DSA images. Segmented vessels from the DSA were used as the ground truth. Accuracy of the model for vessel segmentation was evaluated using conventional metrics (dice similarity coefficient [DSC]) and vessel segmentation-specific metrics, like connectivity-area-length (CAL). On the test cases (20 IAs), 3 expert raters attempted to detect and segment IAs. For each rater, the authors recorded the rate of IA detection, and for detected IAs, raters segmented and calculated important IA morphology parameters to quantify the differences in IA segmentation by raters to segmentations by DeepMedic. The agreement between raters, DeepMedic, and ground truth was assessed using Krippendorf's alpha. RESULTS: In testing, the DeepMedic model yielded a CAL of 0.971 ± 0.007 and a DSC of 0.868 ± 0.008. The model prediction delineated all IAs and resulted in average error rates of < 10% for all IA morphometrics. Conversely, average IA detection accuracy by the raters was 0.653 (undetected IAs were present to a significantly greater degree on the ICA, likely due to those in the cavernous region, and were significantly smaller). Error rates for IA morphometrics in rater-segmented cases were significantly higher than in DeepMedic-segmented cases, particularly for neck (p = 0.003) and surface area (p = 0.04). For IA morphology, agreement between the raters was acceptable for most metrics, except for the undulation index (α = 0.36) and the nonsphericity index (α = 0.69). Agreement between DeepMedic and ground truth was consistently higher compared with that between expert raters and ground truth. CONCLUSIONS: This CTA segmentation network (DeepMedic trained on DSA-segmented vessels) provides a high-fidelity solution for CTA vessel segmentation, particularly for vessels and IAs in the carotid cavernous region.

Asunto(s)

RESUMEN

To determine the characteristics and to compare the functional outcomes and safety of different subfrontal approaches versus mini Pterional (MPT) approaches mainly for the treatment of ruptured noncomplex intracranial aneurysms. This meta-analysis included articles comparing outcomes of brain aneurysms (BAs) – most for the anterior circulation–, using Lateral supraorbital & Supraorbital keyhole (LSO) versus MPT approach. There were six articles left into the final article pool and the total number of patients was 683 (322 in LSO and 361 in the MPT group). In terms of the early and late time of surgery, the LSO seems to be superior over the MPT approach but with heterogeneity (OR −0.21, CI 95% −0.59 to 0.18, and p=0.04) or (OR −0.21, CI 95% −0.69 to 0.28, and p=0.05), and (p=0.02 and I2=68.97%) or (p=0.05 and I2=61.74%) respectively. Regarding the subgroup of patients with the supra-early time of surgery, surgical duration, completed occlusion, technical intraoperative complications, postoperative infection, intraoperative rupture, vasospasm, good and poor neurological outcomes and clinical deterioration, there was no superiority of the one method over the other. Mini or keyhole craniotomy even challenging might be a good option for neurosurgeons. Particularly in ruptured noncomplex aneurysms’ surgery LSO seems to be superior over the MPT approach in terms of the early time and in the late time of surgery but with heterogeneity (AU)

Determinar las características, comparar los resultados funcionales y la seguridad de los diferentes abordajes subfrontales vs. los abordajes minipterionales (MPT) en el tratamiento principalmente de aneurismas intracraneales rotos. Este metaanálisis incluye artículos que comparan los resultados quirúrgicos de los aneurismas cerebrales (mayoría de circulación anterior), utilizando un abordaje supraorbitario o supraorbitario lateral (LSO) frente un abordaje MPT. En el análisis quedaron seis artículos con un número total de pacientes de 683 (322 en el grupo LSO y 361 en el MPT). En cuanto al tiempo de cirugía precoz y tardío de la cirugía, el LSO parece ser superior al abordaje MPT pero con heterogeneidad (OR -0.21, IC 95% -0.59 - 0.18, y p = 0,04) o (OR -0,21, IC 95% -0,69 - 0,28, y p = 0,05), y (p = 0,02 e 12 = 68,97%) o (p = 0,05 e 12 = 61,74%), respectivamente. En cuanto al subgrupo de pacientes con tiempo de cirugía supraprecoz, la duración quirúrgica, la oclusión completa, las complicaciones técnicas intraoperatorias, la infección postoperatoria, la rotura intraoperatoria, el vasoespasmo, los resultados neurológicos y el deterioro, no hubo diferencias en superioridad de un método sobre el otro. Los resultados muestran que tanto la craneotomía MPT como el LSO, podrían ser una buena opción. Particularmente en la cirugía de aneurismas rotos no complejos el abordaje LSO parece ser superior al abordaje MPT en términos del momento inicial y tardío de la cirugía, aunque existe una heterogeneidad en los resultados (AU)

Asunto(s)

RESUMEN

To determine the characteristics and to compare the functional outcomes and safety of different subfrontal approaches versus mini Pterional (MPT) approaches mainly for the treatment of ruptured noncomplex intracranial aneurysms. This meta-analysis included articles comparing outcomes of brain aneurysms (BAs) - most for the anterior circulation-, using Lateral supraorbital & Supraorbital keyhole (LSO) versus MPT approach. There were six articles left into the final article pool and the total number of patients was 683 (322 in LSO and 361 in the MPT group). In terms of the early and late time of surgery, the LSO seems to be superior over the MPT approach but with heterogeneity (OR -0.21, CI 95% -0.59 to 0.18, and p=0.04) or (OR -0.21, CI 95% -0.69 to 0.28, and p=0.05), and (p=0.02 and I2=68.97%) or (p=0.05 and I2=61.74%) respectively. Regarding the subgroup of patients with the supra-early time of surgery, surgical duration, completed occlusion, technical intraoperative complications, postoperative infection, intraoperative rupture, vasospasm, good and poor neurological outcomes and clinical deterioration, there was no superiority of the one method over the other. Mini or keyhole craniotomy even challenging might be a good option for neurosurgeons. Particularly in ruptured noncomplex aneurysms' surgery LSO seems to be superior over the MPT approach in terms of the early time and in the late time of surgery but with heterogeneity.

Asunto(s)

RESUMEN

Background: Intrasaccular flow disruptors (IFD) have been introduced in the treatment of intracranial aneurysms (IAs) to overcome the low aneurysm occlusion rate and the high recanalization rate of the coiling technique. Among them, the Contour Neurovascular System (CNS) and the Neqstent (NQS) were designed to reconstruct the aneurysmal neck and both can be used as assisting coiling devices. We aimed to report our preliminary experience with the flow disruptor-assisted coiling (IFD-AC) technique. Methods: We performed a retrospective analysis of prospectively collected data of all patients with IAs treated with the IFD-AC. Results: Between February 2021 and April 2022, we treated 15 IAs with the IFD-AC: 10 ruptured and 5 unruptured. The IFD-AC was successfully performed in 13 cases, with a post-operative RROC 1 in 12 cases (92.3%) and RROC 2 in 1 case (7.7%). There was one ischemic event (6.7%) and no hemorrhagic complications. Twelve patients underwent a mid-term radiologic follow-up: Ten IAs (83.4%) presented an adequate occlusion, while 2 (16.7%) had a recurrence. Conclusions: The IFD-AC, both with the CNS and the NQS, seems a safe technique with promising efficacy profile. The IFD-AC has proved to be safe without antiplatelet therapy in ruptured cases. Further studies are needed to confirm our preliminary results.

RESUMEN

BACKGROUND: Although fairly rare, multiple brain aneurysms are well known to occur in certain conditions such as arteriovenous malformations, coarctation of the aorta, renal artery stenosis, adult type 3 polycystic kidney disease, as well as connective tissue disorders (such as Ehlers-Danlos syndrome, Marfan syndrome, and fibromuscular dysplasia). Increased incidence of complications of surgery in such situations is expected to be more likely than in surgery for a single aneurysm, particularly in the absence of intraoperative guidance with adjuncts. METHODS: We report a case of an anterior communicating artery aneurysm, a right middle cerebral artery aneurysm, and a right pericallosal aneurysm in a 70-year-old man. All 3 aneurysms were clipped through a single-stage approach without the aid of any adjuncts such as micro-Doppler ultrasonography, indocyanine green videoangiography, or intraoperative digital subtraction angiography. We carried out a literature review for past publications on similar reports. RESULTS: The patient made a complete postoperative recovery and sustained no neurologic deficits. Out of 388 publications from the literature search, only 1 case report described clipping of 2 tandem aneurysms in a 60-year-old woman without mentioning any intraoperative adjuncts. CONCLUSIONS: This case illustrates that multiple aneurysms can actually be safely operated with adequate planning in the absence of these adjuncts, especially in resource-poor regions. This is particularly crucial in Africa and most low-and-middle-income countries, where such facilities and equipment are not common.

Asunto(s)

RESUMEN

The aim of this study is to compare occlusion rate, complication rate, and clinical outcome of microsurgical clipping (MC) and advanced endovascular techniques (EVT) in unruptured anterior communicating artery-complex aneurysms (ACoCAs). We reviewed the scientific literature reporting occlusion rate, time of occlusion assessment, and clinical outcome of MC and EVT in patients with unruptured ACoCAs, from January 2009 to December 2019. We included in our analysis 25 studies and 872 patients with unruptured ACoCAs (434 treated with endovascular techniques and 438 with MC). Ninety-three (10.7%), 320 (36.7%), 21 (2.4%), and 438 (50.2%) were treated with flow diverter (FD), stent-assisted coiling (SAC), endosaccular devices (ES), and microsurgical clipping (MC) respectively. FD, SAC, ES, and MC subgroups presented minor complications in 11.8%, 3.8%, 14.3%, and 7.1% of cases (p=.016), and major complications in 3.2%, 4.4%, 0%, and 7.1% (p=.136) of patients. A total occlusion rate post-treatment has been achieved in 4.3%, 87.1%, 47.6%, and 98.2% of cases (p=.000), while at 12 months' follow-up in 50%, 66%, 83.3%, and 80% of patients (p=.001). FD, SAC, ES, and MC subgroups had a good clinical outcome at 12 months in 93.5%, 90.5%, 100%, and 67.8% of cases. MC is associated with higher post-treatment total occlusion rate, but higher complication and lower good clinical outcome rates. EVT are promising in treating unruptured anterior cerebral artery aneurysms with high margin of safety and good clinical outcome, despite the lower total occlusion rate.

Asunto(s)

RESUMEN

Traumatic aneurysms are rare and the total number of cases involving the posterior circulation (TIPC) is even smaller. Traumatic brain injury (TBI) may be responsible not only of rupture in brain aneurysm (BrA) pre-existing to trauma, but it has been identified also as a possible pathogenetic cause of TIPC formation in patients not affected by intracranial vascular lesions. A complete literature review was performed of all reported cases regarding rupture of BrA with SAH resulting from TIPC not previously identified at the first radiological screening. A representative case of a left posterior inferior cerebellar artery (PICA) pseudo-aneurysm caused by left vertebral artery's dissection is reported. We show a unique complete collection of all 34 cases. Despite their rarity, TIPCs are associated with a significant morbidity and mortality rate, as high as 40-60%. Of the 22 patients with good neurological status (64.7%), we did not notice a significant correlation with regard to the location of the aneurysm, type of treatment, or clinical onset. Early recognition of a pseudo-aneurysm and adequate treatment seem to be the most important prognostic factor for these patients. Despite their rarity, TIPCs are associated with a significant morbidity and mortality rate. A TIPC should be suspected in case of delayed deterioration in head-injured patient and should be investigated with angiography. Conservative management is worsened by poor prognosis and the goal of treatment is to exclude the aneurysm from circulation with surgical or endovascular methods as soon as possible.

Asunto(s)

RESUMEN

BACKGROUND: Treatment of complex wide neck brain aneurysms is a challenging era in neurosurgery. Both surgical and endovascular therapies are considered for treatment of them. In endovascular, there are different ways such as trapping, coiling, stent and balloon assisted coiling. In this study, we use flow-diverter devices to create new vascular lumen and then coiling the aneurysm sac for three patients. METHODS: We describe three cases with complex cerebral aneurysm who were treated successfully by flow diverter-coil technique and point to technical nuances. RESULTS: In our patients, wide neck aneurysms, two in distal part of ICA (internal carotid artery) and other in basilar tip. We use flow-diverter-coil technique successfully. On the follow-up, aneurysms are treated completely without any complications. CONCLUSION: We think flow diverter devices adjunct to coiling is a useful way for the treatment of complex wide neck cerebral aneurysms.

RESUMEN

The advent of the endovascular era has apparently decreased the role of microneurosurgery for many of the posterior circulation aneurysms. This study consists of a critical appraisal of a retrospective surgical series regarding posterior circulation aneurysms, targeted to define whether microneurosurgery still has a role for some of these. In 28 years, 157 aneurysms were surgically treated, 98 of which ruptured. The Average patient age was 56.7 ± 14.2 years, while in hemorrhagic cases, the mean Hunt-Hess score was 2.17 ± 0.8. Basilar tip, vertebral artery and proximal posterior inferior cerebellar artery were the most frequently involved sites. The treatment consisted of 128 clippings, 19 trappings, 7 wrappings, and 3 bypasses. A total exclusion was achieved in 88.5% of the aneurysms. An average follow-up of 67.1 ± 61.3 months proved no recurrences. The best results were observed in patients <65 years old who harbored small-to-regular aneurysms of the basilar tip, distal cerebellar arteries, or vertebral artery.Clipping proved to be a definitive and durable treatment for a large part of posterior circulation aneurysms, whereas bypass allows for treating aneurysms not amenable for coiling, stenting, or clipping. The present study confirms that microneurosurgery continues to have a paramount role within neurovascular pathology.

Asunto(s)

RESUMEN

The advent of flow diverter (FD) stents has apparently reduced the role of microneurosurgery for paraclinoid aneurysms despite sparse high-quality evidence about their long-term effects.The present study critically reviews the overall results of a microneurosurgical series of 57 paraclinoid aneurysms.Of these aneurysms, 47.4% were regular in size while 19.3 were giant. Barami type I was predominant. In 21 aneurysms a hemorrhagic onset occurred. Pterional approach with intradural anterior clinoidectomy was preferred by far. Clipping was possible in 91.2% of aneurysms and a high-flow bypass was the choice in five cases. An mRS of 0-2 was achieved in 77.3% of patients, typically <50 years old.Visual field appeared improved or unchanged in 36.3% and 63.6% of the symptomatic patients, respectively. In 76.1% of incidental aneurysms, campimetry was unaffected by surgery.A complete aneurysm exclusion was achieved in 93% of cases using a single procedure. No recurrences were documented on an average follow-up of 54.1 ± 34 months.Microneurosurgery is still a valuable, definitive, and durable option for Barami type Ia, Ib, or II paraclinoid aneurysm, especially in patients <50 years old and visually symptomatic. Conditions other than these are ideal candidates for FD stents.

Asunto(s)

RESUMEN

RESUMEN Introducción: la hemorragia subaracnoidea por sí misma puede dar lugar a un daño cerebral, por esto, en pacientes sin complicaciones los trastornos cognitivos pueden estar presentes. Objetivos: analizar las alteraciones neuropsicológicos en los pacientes operados de aneurismas cerebrales y los factores que se asocian a su desarrollo. Metodología: estudio analítico, observacional, ambispectivo, 2013-2020, que incluyó pacientes operados de aneurismas cerebrales rotos en el Hospital de Clínicas. La evaluación cognitiva se realizó con el mini examen cognitivo de Lobo. Se consideró alterado cuando la puntuación fue menor a 27. Se analizaron 12 variables asociando las mismas con el tema de estudio. Los datos fueron analizados con Epiinfo 7.2. Resultados: La edad mayor a 60 años se asoció al déficit cognitivo de forma significativa, así como también la lateralidad a izquierda, el uso de clipado temporario durante la cirugía, la ruptura del aneurisma en el intraoperatorio, el vasoespasmo y la hidrocefalia. No se asoció significativamente con el desarrollo de un trastorno cognitivo; el sexo, el nivel de escolaridad, la cantidad de sangre cisternal, la localización del aneurisma, el Glasgow de ingreso ni la fase en la cual se realzó la cirugía. Discusión: en general los hallazgos coinciden con la literatura. Llamó la atención que la escala de Fisher en la muestra estudiada no demostró tener una asociación significativa con el trastorno cognitivo, sin embargo, hay datos en la literatura que sostienen que la cantidad de sangre cisternal al ingreso es un fuerte predictor del estado cognitivo del paciente al alta.

ABSTRACT Introduction: subarachnoid hemorrhage itself can lead to brain damage, so in uncomplicated patient's cognitive disorders may be present. Objective: To analyze the cognitive impairments in patients following clipping of ruptured aneurysms and the factors that are associated with their development. Methodology: analytical, observational, ambispective study, 2013-2020, including patients operated for ruptured aneurysms at the Hospital de Clínicas. The cognitive evaluation was performed with the Lobo mini cognitive exam. It was considered altered when the score was less than 27. Twelve variables were analyzed associating them with the study topic. The data was analyzed with Epiinfo 7.2. Results: Age over 60 years was significantly associated with cognitive deficit, as well as left laterality, the use of temporary clipping during surgery, intraoperative aneurysm rupture, vasospasm, and hydrocephalus. It was not significantly associated with the development of a cognitive disorder; sex, level of education, amount of cisternal blood, location of the aneurysm, admission Glasgow, and the timing in which the surgery was performed. Discussion: In general, the findings coincide with the literature. It was noteworthy that the Fisher scale in the studied sample did not show to have a significant association with cognitive disorder, however, there are data in the literature that maintain that the amount of cisternal blood on admission is a strong predictor of the patient's cognitive state at discharge.

RESUMEN

Introducción: La Hemorragia Subaracnoidea es el sangrado en el espacio subaracnoideo. La causa espontánea en la mayoría de las veces se debe a ruptura de un aneurisma cerebral. Objetivo: Describir la casuística, manejo y resultados de los aneurismas cerebrales en el Hospital de Clínicas. Pacientes y método: Estudio observacional, descriptivo, transversal, incluyendo pacientes operados de aneurismas cerebrales, mayores de 17 años, en el Hospital de Clínicas del 2011 al 2019. Las variables descriptas fueron: edad, sexo, motivo de consulta, estudios radiológicos, escala de Glasgow y Hunt y Hess, localización, segmento, cantidad, fase, clipado temporario, vasoespasmo e hidrocefalia. Resultados: Se incluyó 249 pacientes; 45% masculino, 65% femenino, con edad promedio de 47,5 años. El motivo de consulta más frecuente fue cefalea. Al ingreso tuvieron predominantemente Hunt y Hess 2, y, Glasgow 15. El 43,2% eran Fisher 4. El Glasgow de egreso fue mayor o igual a 14 en 82,1%. Se diagnosticó el 51,7% con arteriografía; el 50,9% de los aneurismas en la carótida interna y, fueron múltiples en 10,84%. Se operaron en fase aguda 28,3%, 65% en fase tardía y, el 6,7% de los aneurismas fue de hallazgo casual. En 36,44% de los casos se realizó clipado temporario y, en el 70,4% se perforó la lámina terminalis. La mortalidad fue de 4,2%. Presentaron vasoespasmo radiológico en un 46% y, vasoespasmo clínico en 24,5 %. El 11% fue sometido a craniectomía descompresiva y, 5,5% desarrolló hidrocefalia dependiente de VDVP. Conclusión: El clipado de los aneurismas cerebrales es una técnica con buenos resultados y la única accesible en el sector público.

Introduction: Subarachnoid hemorrhage is bleeding in the subarachnoid space. The spontaneous is caused most of the time by rupture of a cerebral aneurysm. Objective: Describe the casuistry, management and results of cerebral aneurysms at the Hospital de Clínicas. Patients and methods: Observational, descriptive, cross-sectional study including patients operated for cerebral aneurysms, older than 17 years, at the Hospital de Clínicas from 2011 to 2019. The variables described were: age, sex, reason for consultation, radiological studies, Glasgow and Hunt and Hess scale, location, segment, quantity, phase, temporary clipping, vasospasm and hydrocephalus. Results: 249 patients were included; 45% male, 65% female, average age 47.5 years. The most frequent reason for consultation was headache. At admission they had predominantly Hunt and Hess 2, and Glasgow 15. 43.2% were Fisher 4. The Glasgow of discharge was greater than or equal to 14 in 82.1%. 51.7% were diagnosed with arteriography; 50.9% internal carotid aneurysms, multiple 10.84%. 28.3% were operated in acute phase, 65% late phase, 6.7% were a casually found. In 36.44% of cases a temporary clipping was performed and in 70.4% the lamina terminalis was perforated. Mortality was 4.2%, radiological vasospasm 46%, clinical vasospasm 24.5%, 11% underwent decompressive craniectomy and 5.5% developed VDVP-dependent hydrocephalus. Conclusion: The clipping of cerebral aneurysms is a technique with good results and the only one in the public sector.

Asunto(s)

RESUMEN

BACKGROUND: Brain aneurysms (BAs) are the most common intracranial vascular condition, with an overall incidence of 1%-2%. Among the common causes of their initial formation and growth, the role of radiation therapy (RT) has been reported in some studies. The aim of the present study is to report the most relevant features of BA related to a previous cranial RT. METHODS: Data deriving from 1 patient treated for RT-induced BA in our institution were added to reports of another 66 BAs retrieved from the literature. The following parameters were evaluated: age, sex, location, primary lesion, clinical presentation, dosage/amount of radiation delivered, type of treatment for the BA, dimension, morphology, chemotherapy, comorbidities, risk factors, and number of BAs. RESULTS: The most commonly involved vessel was the internal carotid artery (34%). In general, the anterior circulation showed higher vulnerability compared with the posterior circulation and middle cerebral artery (56.7%). The average latency between RT and the first imaging showing the BA was 9.01 ± 6.85 years. Vessels coursing in the posterior cranial fossa showed a significant univariate association with lower X-ray dosages (P = 0.014) compared with the other locations. No statistically significant correlation between the continuous variables age, latency of BA appearance, RT delivered dose, and dimension of the BA was shown. CONCLUSIONS: The apparent higher fragility of the vascular structures of the posterior cranial fossa was statistically outlined, and the X-ray dosage, the primary condition target of the RT, the age of the patients, and no statistically significant correlation were outlined. Biological factors could play a significant role.

Asunto(s)

RESUMEN

BACKGROUND: Recent findings on the benefits of glibenclamide as a neuroprotective drug have started a new era for prospective studies on sulfonylureas. The effect of glibenclamide blocking the Sur1-Trpm4 channel was examined in models of subarachnoid hemorrhage and stroke, with findings of significantly reduced tight-junction abnormalities, resulting in less edema formation and considerably reduced transsynaptic apoptosis of hippocampal neurons and significantly ameliorated impairments in spatial learning. Based on these data, we plan a clinical trial to establish evidence of glibenclamide as an adjunct treatment in aneurysmal subarachnoid hemorrhage. METHODS: An estimated 80 patients meeting the inclusion criteria of radiological confirmatory evidence of an aneurysmal subarachnoid hemorrhage, age 18-70 years, and presentation of less than 96 h from the ictus will be allocated randomly into two groups, one receiving 5 mg daily oral intake of glibenclamide for 21 days and another control group receiving a placebo. The study's primary outcome is the modified Rankin scale (mRS) after 6 months, as favorable (mRS 0-2) or unfavorable (mRS 3-6). The secondary outcomes will be late cognitive status, assessed after 6 months by psychological tests (the Short Form Health Survey Questionnaire and the Montreal Cognitive Assessment), as well as death at 6 months, delayed cerebral ischemia and occurrence of serious adverse events due to study medication. DISCUSSION: There is a growing interest in the scientific community regarding glibenclamide in brain edema and traumatic brain injury, but with very little of this interest targeting spontaneous brain hemorrhage, especially aneurism rupture. Positive outcomes are expected for the treatment patients, especially in language and memory preservation, as has been shown in experimental models. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03569540 . Retrospectively registered on 26 June 2018.

Asunto(s)

RESUMEN

OBJECTIVE: Surgical performance evaluation was first described with the OSATS (Objective Structured Assessment of Technical Skills) and modified for aneurysm microsurgery simulation with the OSAACS (Objective Structured Assessment of Aneurysm Clipping Skills). These methods rely on the subjective opinions of evaluators, however, and there is a lack of objective evaluation for proficiency in the microsurgical treatment of brain aneurysms. The authors present a new instrument, the Skill Assessment in Microsurgery for Brain Aneurysms (SAMBA) scale, which can be used similarly in a simulation model and in the treatment of unruptured middle cerebral artery (MCA) aneurysms to predict surgical performance; the authors also report on its validation. METHODS: The SAMBA scale was created by consensus among 5 vascular neurosurgeons from 2 different neurosurgical departments. SAMBA results were analyzed using descriptive statistics, Cronbach's alpha indexes, and multivariate ANOVA analyses (p < 0.05). RESULTS: Expert, intermediate-level, and novice surgeons scored, respectively, an average of 33.9, 27.1, and 16.4 points in the real surgery and 33.3, 27.3, and 19.4 points in the simulation. The SAMBA interrater reliability index was 0.995 for the real surgery and 0.996 for the simulated surgery; the intrarater reliability was 0.983 (Cronbach's alpha). In both the simulation and the real surgery settings, the average scores achieved by members of each group (expert, intermediate level, and novice) were significantly different (p < 0.001). Scores among novice surgeons were more diverse (coefficient of variation = 12.4). CONCLUSIONS: Predictive validation of the placenta brain aneurysm model has been previously reported, but the SAMBA scale adds an objective scoring system to verify microsurgical ability in this complex operation, stratifying proficiency by points. The SAMBA scale can be used as an interface between learning and practicing, as it can be applied in a safe and controlled environment, such as is provided by a placenta model, with similar results obtained in real surgery, predicting real surgical performance.

RESUMEN

The fundamental role of technological instruments in contemporary Neurosurgery is undisputed, and intraoperative magnetic resonance imaging (MRI) represents one of the best examples. The use of a modern high-field magnet and the possibility to match the MRI with an operative microscope and an integrated neuronavigation system has led to successful results in the surgical treatment of different diseases. At our institute, we have performed surgery routinely with the aid of intraoperative MRI over the last 15 years. The aim of this article is to report our experience in the management of neurovascular lesions with the use of this device. We experienced that intraoperative MRI enhanced the surgical experience, leading to an improved postoperative outcome in the treatment of different lesions, such as arteriovenous malformations, dural arteriovenous fistulas, intracranial cavernous angiomas, and intracranial aneurysms. There are several advantages provided by the use of intraoperative MRI. The use of intraoperative MRI coupled with the planning station and the neuronavigation system allows one to obtain preoperative 3-dimensional reconstructions of the vessels, which aids the definition of the anatomy of each neurovascular lesion. Furthermore, the possibility performing an intraoperative scan allows a comparison with preoperative images and, subsequently, the updating of the surgical strategy. Intraoperative diffusion-weighted imaging can detect possible territorial ischemia that would be amenable to intensive treatment. Although increased costs, increased surgical times, increased anesthesiology times, and the possible increased risk of surgical infection may represent some major limitation, the use of intraoperative MRI-equipped operative theaters with integrated neuronavigation systems can prove extremely helpful in the management of neurovascular conditions.

Asunto(s)

RESUMEN

Black blood magnetic resonance imaging (MRI)is a promising imaging tool in predicting aneurysm rupture. Could it be also valuable in evaluating the treatment effect of endovascular and conservative treated aneurysms? Two patients were treated with stent and coil and one with Aspirine (ASS). Correlation of treatment response and contrast enhancement of the aneurysm wall is examined. In the first case stenting failed to treat the aneurysm and contrast enhancement in the wall did never subside during follow up black blood MRI. In the second case the aneurysm responded well to stenting and decreased in size, which was correlating significantly with attenuation of contrast enhancement in black blood MRI. In the third case the aneurysm responded to ASS treatment by decreasing in size as shown in follow up MR-angiography and the contrast enhancement in its wall decreased after 8 months of therapy. Black blood MRI seems to be a promising tool not only in predicting aneurysms at risk of rupture, but also in observing treatment responses after endovascular procedures or even Aspirine administration. When contrast enhancement decreases, aneurysm treatment seems to be successful as can be shown in decreasing size in the follow up angiography.

RESUMEN

Objective The treatment of ruptured aneurysms of the posterior circulation is a controversy in neurosurgery. The aim of this work is to describe the experience and results of the early surgical treatment of this pathology at Centro Hospitalar do Porto. Method We retrospectively analyzed the medical records of all patients aged over 18 who, in the period between 1999­2013, were admitted to our center with the diagnosis of ruptured saccular posterior circulation aneurysm. The patients were clinically staged at admission using the Hunt & Hess (H&H) scale. The modified Glasgow Outcome Scale (mGOS) was used to assess the outcome at discharge and after 6 months. Results Between 1999­2013, 59 patients underwent surgery for ruptured posterior circulation aneurysms. Eighty percent of the patients were female, and their average age was 58.7 years. Posterior-inferior cerebellar artery aneurysms accounted for 49.2% of surgeries, while basilar aneurysms accounted for 28.8%. Upon admission, 86.4% of patients were classified as H&H1­3, and 13.6% as H&H4­5. The outcomes at discharge and at 6 months were as follows: at discharge, mGOS1 in 5.1%, mGOS2­3 in 18.6%, and mGOS4­5 in 76.3%; at 6 months, mGOS1 in 10.2%, mGOS2­3 in 10.2%, and mGOS4­5 in 79.6%. There was a statistically significant correlation between basilar aneurysms and worse outcomes (p » 0.011). No correlation was found between the values of the H&H scale upon admission and outcome. Conclusions The functional outcome of our group of patients is mainly in line with what is described in other series from the literature. However, there is a trend toward lower mortality but higher morbidity rates.

Objetivo O tratamento dos aneurismas rotos da circulação posterior é uma controvérsia neurocirúrgica. Pretende-se com este trabalho relatar a experiência e os resultados do tratamento cirúrgico precoce desta patologia no Centro Hospitalar do Porto. Métodos Foram analisados retrospectivamente os processos clínicos dos pacientes com idade > 18 anos que, no período entre 1999­2013, foram admitidos no nosso centro com o diagnóstico de aneurisma sacular roto da circulação posterior. Utilizou-se a escala de Hunt & Hess (H&H) para aferir a gravidade clínica dos pacientes, e a Escala de Outcome de Glagow modificada (mGOS) para aferir o outcome dos pacientes à data da alta e aos 6 meses. Resultados Entre 1999­2013, foram operados 59 pacientes com aneurismas rotos da circulação posterior. Oitenta por centro dos pacientes eram do sexo feminino, com uma média de idade média de 58.7 anos. Aneurismas da artéria cerebelosa posteroinferior foram responsáveis por 49,2% das cirurgias, ao passo que os da artéria basilar, por 28,8%. À admissão, 86,4% dos pacientes eram H&H1­3, e 13,6%, H&H4­5. O outcome à data da alta e aos 6 meses foi o seguinte: à data de alta, mGOS1 em 5,1%, mGOS2­3 em 18,6%, e mGOS4­5 em 76,3%; aos 6 meses, mGOS1 em 10,2%, mGOS2­ 3 em 10,2%, e mGOS4­5 em 79,6%. Verificou-se uma correlação estatisticamente significativa entre aneurismas da basilar e um pior outcome (p » 0,011). Não se verificou qualquer correlação entre os valores da escala de H&H à admissão e o outcome. Conclusões O outcome funcional do nosso grupo de pacientes está em linha com o descrito noutras séries da literatura. Contudo, destaca-se uma tendência para uma mortalidade mais baixa, mas uma morbilidade mais alta no nosso grupo de pacientes.

Asunto(s)

RESUMEN

Objective: To establish the frequency and results in patients carriers with multiple aneurysms (MA) treated by microsurgery and/or neurological endovascular therapy (NET) in the Hospital of Specialties on The National Medical Center La Raza. Method: It is an ambispective, descriptive and longitudinal study that includes patients carriers of MA treated in the National Medical Center La Raza from March the 1st of 2009 to April the 30th of 2014. Results: 62 patients carriers of 151 aneurysms were treated. According to the type of treatment, 30 patients (49%) were included in the surgical group (GQ), 25 (40%) in the endovascular group (GE) and 7 (11%) in the combinated group (GC). The number of aneurysms was distributed this way: 69 (46%) in the GQ, 61 (40%) in the GE and 21 (14%) in the GC. At GQ, it was not possible to exclude all their aneurysms on 21% of the patients, while it was feasible in only 27%. In all GE patients (40%) the exclusion of all aneurysms was achieved. The GC, meaning surgical cases that were not completed by NET, formed 11% of the cases. At GQ there was a rate of 6% of complications, meanwhile at GE it was 0.5%.

Asunto(s)