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Since the first description of the possible utilization of the internal maxillary artery for bypass surgery, there are some reports of its use in aneurysm cases; however, there is no information about the possible advantages of this type of bypass for cerebral ischemic disease. We present a 77-year-old man with a history of diabetes, hypertension, systemic atherosclerosis, and two acute myocardial infarctions with left hemiparesis. Imaging studies reported total occlusion of the right internal carotid artery and 75% occlusion on the left side, with an old opercular infarction and repeated transient ischemic attacks in the right middle cerebral artery territory despite medical treatment. After a consensus, we decided to perform a bypass from the internal maxillary artery to the M2 segment of the middle cerebral artery using a radial artery graft. After performing the proximal anastomosis, the calculated graft's free flow was 216 ml/min. Subsequently, after completing the bypass, the patency was confirmed with fluorescein videoangiography and intraoperative Doppler. Postoperatively, imaging studies showed improvement in the perfusion values and the hemiparesis from 3/5 to 4+/5. The patient was discharged one week after the operation, with a modified Rankin scale of 1, without added deficits. The use of revascularization techniques in steno-occlusive disease indicates a select group of patients that may benefit from this procedure. In addition, internal maxillary artery bypass has provided a safe option for large areas of ischemia that cannot be supplied with a superficial temporal artery - middle cerebral artery bypass.
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Background: Hemifacial spasm (HFS) is characterized by involuntary, progressive, and intermittent spasms in the upper and lower facial muscles. Due to the high success rate, microvascular decompression (MVD) is the treatment of choice, and intraoperative neuromonitoring (INM) is considered useful for achieving safe surgery. Still, most centers do not have this technology. Methods: We analyzed 294 patients with HFS treated with MVD without INM. We only included patients with a neurovascular etiology while excluding other causes, such as tumors. As part of the postoperative evaluation, we assessed preoperative magnetic resonance imaging and pure-tone audiometry. Results: The main complication was peripheral facial paralysis in 50 patients, followed by hypoacusis in 22 patients and deafness in 17 patients, associated with a failed surgical outcome (P = 0.0002). The anterior inferior cerebellar artery (AICA) was an offending vessel, and the involvement of more than one vessel was significantly associated with the development of facial nerve palsy (P = 0.01). AICA was also associated with hearing impairment (P = 0.04). Over 90% of immediate complications improve in the follow-up (6 months), and one patient did not show a cure for initial HFS. Conclusion: MVD is the method with the highest long-term cure rates for treating HFS; however, we must inquire into the multiple factors of the patient and the surgeon to predict surgical outcomes. INM is not a must during MVD for HFS. We recommend its use depending on the availability and mainly on the surgeon's skills, for surgeons.
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BACKGROUND: Paraclinoid aneurysms represent a challenge for neurosurgeons due to the anatomical complexity of this region. Then, innovative techniques such as the extradural sphenoid ridge approach are suitable for a safe microsurgical clipping. METHOD: A description of the surgical technique was made by the senior author, a vascular neurosurgeon experienced with the use of this approach in the management of paraclinoid aneurysms exemplified through a clinical case. CONCLUSION: Microsurgical clipping through an extradural sphenoid ridge keyhole approach for small and midsize paraclinoid aneurysms is an excellent treatment modality with good clinical and surgical results.
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Aneurisma Intracraniano , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Procedimentos Neurocirúrgicos/métodos , Microcirurgia/métodos , Osso Esfenoide/diagnóstico por imagem , Osso Esfenoide/cirurgiaRESUMO
Background: The middle cerebral artery (MCA) is a common site of cerebral aneurysms and 82.6% occur at the bifurcation. When surgery is selected as a therapeutic option, it intends to clip the neck completely because if some remnant occurs, there exists the possibility of regrowth and bleeding in the short- or long-term. Methods: We analyzed one drawback of the fenestrated clips of Yasargil and Sugita types to occlude the neck totally at a specific point formed by the union of the fenestra with the blades, creating a triangular space where the aneurysm can protrude, giving place to a remnant that can lead to a future recurrence and rebleeding. We show two cases of ruptured MCA aneurysms in which a cross-clipping technique occluded a broad base and dysmorphic aneurysm using straight fenestrated clips. Results: In both cases (one using a Yasargil clip and the other with a Sugita clip), a small remnant was visualized when fluorescein videoangiography (FL-VAG) was used. In both cases, the small remnant was clipped with a 3 mm straight miniclip. Conclusion: We should be aware of this drawback when clipping aneurysms using fenestrated clips to ensure a complete obliteration of the aneurysm's neck.
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BACKGROUND: Glioblastoma is one of the most common brain tumors in adult populations, usually carrying a poor prognosis. While several studies have researched the impact of anti-angiogenic therapies, especially anti-VEFG treatments in glioblastoma, few have attempted to assess its progress using imaging studies. PURPOSE: We attempted to analyze whether relative cerebral blood volume (rCBV) from dynamic susceptibility-weighted contrast-enhanced MRI (DSC-MRI) could predict response in patients with glioblastoma undergoing Bevacizumab (BVZ) treatment. METHODS: We performed a retrospective study evaluating patients with recurrent glioblastoma receiving anti-angiogenic therapy with BVZ between 2012 and 2017 in our institution. Patients were scheduled for routine MRIs at baseline and first-month follow-up visits. Studies were processed for DSC-MRI, cT1, and FLAIR images, from which relative cerebral blood volume measurements were obtained. We assessed patient response using the Response Assessment in Neuro-Oncology (RANO) working group criteria and overall survival. RESULTS: 40 patients were included in the study and were classified as Bevacizumab responders and non-responders. The average rCBV before treatment was 4.5 for both groups, and average rCBV was 2.5 for responders and 5.4 for non-responders. ROC curve set a cutoff point of 3.7 for rCBV predictive of response to BVZ. Cox Multivariate analysis only showed rCBV as a predictive factor of OS. CONCLUSION: A statistically significant difference was found in rCBV between patients who responded and those who did not respond to BVZ treatment. rCBV may be a low-cost and effective marker to assess response to Bevacizumab treatment in GBM.
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Background: Lhermitte-Duclos disease (LDD) or dysplastic gangliocytoma of the posterior fossa is a slow-growing and extremely rare mass lesion that involves the Purkinje neurons and the granular layer of the cerebellum. It is characterized by specific neuroradiological features and secondary hydrocephalus. However, documentation of surgical experience is scarce. Case Description: A 54-year-old man with LDD manifesting as progressive headache is presented with vertigo and cerebellar ataxia. Magnetic resonance imaging demonstrated a right cerebellar mass lesion with the characteristic "tiger-striped appearance." We decided to perform partial resection with reduction of tumor volume improving symptomatology as a result of the mass effect in the posterior fossa. Conclusion: Surgical resection is a good alternative for the management of LDD, especially when neurological compromise exists due to mass effect.
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Background: Citrobacter koseri, a Gram-negative organism, rarely causes an epidural spinal abscess. Case Description: A 50-year-old male presented with mild paraparesis attributed to an magnetic resonance (MR)-documented spinal epidural abscess (SEA) at the T10-level. Following surgical debridement, cultures grew C. koseri, a rare Gram-negative organism. The abscess was subsequently managed with a prolonged course of antibiotics resulting in complete symptom and MR-documented radiological resolution. Conclusion: A 50-year-old male presented with a T10 SEA attributed to a rare Gram-negative organism, C. koseri. The abscess was appropriately managed with surgical decompression/debridement, followed by prolonged antibiotic therapy.
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Background: Anomalies of the middle cerebral artery (MCA) are rare; among the different types of anomalies, the aplastic or twig-like (Ap/T) MCA is extremely rare and has been reported under various names, including aplastic, unfused, or rete type anomaly. The occurrence of a brain aneurysm associated with this anatomic variant is an even rare event, and probably their development and rupture are related to hemodynamic stress of the tinny wall of vessels forming the network. Case Description: We present a 43-year-old male patient with an explosive and persistent right orbitofrontal headache. A computed tomography showed a right frontobasal hematoma with intraventricular disruption. Magnetic resonance angiography showed a right MCA aneurysm and what seems to be a MCA trunk stenosis. Cerebral digital subtraction angiography demonstrated a plexiform arterial network and one aneurysm arising from the network. The patient was successfully treated by surgical clipping to evacuate the hematoma and to prevent further intracranial hemorrhages. Conclusion: The Ap/T-MCA may be associated with hemodynamic stress with a significant effect through the tinny wall of the vessels causing hemorrhage or leading to the formation and rupture of cerebral aneurysms. Based on a correct diagnosis of the anomaly, treatment can be completed successfully through different standard methods.
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Background: The third wave of COVID-19 in Mexico produced a high demand for hospital care, which is why it was created a multidisciplinary group to optimize decision-making: the Interinstitutional Command for the Health Sector (COISS, according to its initials in Spanish). So far, there is no scientific evidence of the COISS processes or their effect on the behavior of epidemiological indicators and the hospital care needs of the population in the context of COVID-19 in the entities involved. Objectives: To analyze the trend on epidemic risk indicators throughout the COISS group's management in the third wave of COVID-19 in Mexico. Material and methods: Mixed study: 1) non-systematic review of information from technical documents issued by COISS, 2) secondary analysis of open-access institutional databases through the description of healthcare needs of cases notified with COVID-19 symptoms, and an ecological analysis by each Mexican state on the behavior of hospital occupancy, RT-PCR positivity, and COVID-19 mortality in two-time points. Results: The COISS activity in identifying states with epidemic risk generated actions aimed at a reduction in hospital occupancy of beds, positivity by RT-PCR, and mortality from COVID-19. Conclusions: The decisions of the COISS group reduced the indicators of epidemic risk. Continuing the work of the COISS group is an urgent need. Conclusions: The decisions of the COISS group reduced the indicators of epidemic risk. Continuing the work of the COISS group is an urgent need.
Introducción: la tercera ola por COVID-19 en México provocó una alta demanda de atención hospitalaria, por lo cual se conformó un grupo multidisciplinario para optimizar la toma de decisiones sanitarias: Comando Interinstitucional del Sector Salud (COISS). Hasta el momento, no hay evidencia científica de los procesos del COISS ni de su efecto sobre el comportamiento de indicadores epidemiológicos y las necesidades de atención hospitalaria de la población bajo el contexto de COVID-19 en entidades federativas involucradas. Objetivos: analizar la tendencia de indicadores de riesgo epidémico durante la gestión del grupo COISS en la tercera ola por COVID-19 en México. Material y métodos: estudio mixto: 1) revisión no sistemática de documentos técnicos del COISS, 2) análisis secundario de bases de datos de libre acceso, mediante la descripción de necesidades de atención hospitalaria de los casos notificados con síntomas de la COVID-19 y un análisis ecológico por entidades federativas sobre el comportamiento de la ocupación hospitalaria, positividad y mortalidad por COVID-19 en dos cortes temporales. Resultados: la actividad del COISS en la identificación de entidades federativas de riesgo epidémico generó acciones encaminadas a una reducción en la ocupación hospitalaria de camas generales, positividad por RT-PCR y mortalidad por COVID-19. Conclusiones: las decisiones del grupo COISS disminuyeron los indicadores de riesgo epidémico. Continuar el trabajo del grupo COISS es una necesidad apremiante.
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COVID-19 , Humanos , COVID-19/epidemiologia , México/epidemiologia , Atenção à SaúdeRESUMO
Neurotensin (NTS)-polyplex is a gene nanocarrier that has potential nanomedicine-based applications for the treatment of Parkinson's disease and cancers of cells expressing NTS receptor type 1. We assessed the acute inflammatory response to NTS-polyplex carrying a reporter gene in BALB/c mice. The intravenous injection of NTS-polyplex caused the specific expression of the reporter gene in gastrointestinal cells. Six hours after an intravenous injection of propidium iodide labeled-NTS-polyplex, fluorescent spots were located in the cells of the organs with a mononuclear phagocyte system, suggesting NTS-polyplex clearance. In contrast to lipopolysaccharide and carbon tetrachloride, NTS-polyplex did not increase the serum levels of tumor necrosis factor alpha, interleukin (IL)-1ß, IL-6, bilirubin, aspartate transaminase, and alanine transaminase. NTS-polyplex increased the levels of serum amyloid A and alkaline phosphatase, but these levels normalized after 24 h. Compared to carrageenan, the local injection of NTS-polyplex did not produce inflammation. Our results support the safety of NTS-polyplex. FROM THE CLINICAL EDITOR: This study focuses on the safety of neurotensin (NTS)-polyplex, a gene nanocarrier that has potential in the treatment of Parkinson's disease and cancers of cells expressing NTS receptor type 1. NTS polyplex demonstrates a better safety profile compared with carrageenan, lipopolysaccharide, and carbon tetrachloride in a murine model.
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Técnicas de Transferência de Genes , Terapia Genética/métodos , Nanopartículas , Doença de Parkinson/terapia , Receptores de Neurotensina , Segurança , Administração Intravenosa , Animais , Camundongos , Doença de Parkinson/genética , Doença de Parkinson/metabolismo , Receptores de Neurotensina/biossínteseRESUMO
Zinc or L-NAME administration has been shown to be protector agents, decreasing oxidative stress and cell death. However, the treatment with zinc and L-NAME by intraperitoneal injection has not been studied. The aim of our work was to study the effect of zinc and L-NAME administration on nitrosative stress and cell death. Male Wistar rats were treated with ZnCl2 (2.5 mg/kg each 24 h, for 4 days) and N-ω-nitro-L-arginine-methyl ester (L-NAME, 10 mg/kg) on the day 5 (1 hour before a common carotid-artery occlusion (CCAO)). The temporoparietal cortex and hippocampus were dissected, and zinc, nitrites, and lipoperoxidation were assayed at different times. Cell death was assayed by histopathology using hematoxylin-eosin staining and caspase-3 active by immunostaining. The subacute administration of zinc before CCAO decreases the levels of zinc, nitrites, lipoperoxidation, and cell death in the late phase of the ischemia. L-NAME administration in the rats treated with zinc showed an increase of zinc levels in the early phase and increase of zinc, nitrites, and lipoperoxidation levels, cell death by necrosis, and the apoptosis in the late phase. These results suggest that the use of these two therapeutic strategies increased the injury caused by the CCAO, unlike the alone administration of zinc.