RESUMO
OBJECTIVE: To evaluate the role of preradiosurgical embolization on obliteration rate, reduction of size, irradiation dose, and neurological outcome, in 90 patients presenting large arteriovenous malformations (AVMs). METHODS: Between October 1993 and October 2006, 90 radiosurgical procedures were performed to treat brain AVMs Spetzler-Martin (SM) grades III, IV, and V at the Department of Radiosurgery and Radiology of the Real e Benemérita Associação Portuguesa de Beneficência de São Paulo, São Paulo, Brazil. Fifty-nine patients had embolization before radiosurgery and complete clinical and radiologic follow-up for at least 3 years. Inclusion criteria were as follow: SM grades III, IV, and V AVMs, no previous treatment, and clinical and radiological (angiogram and MRI) follow-up for at least 3 years. Obliteration rate, reduction of size, irradiation dose, and neurological outcome were compared in these two cohorts of patients. Mann-Whitney test, "Student's t-test," and χ(2) tests were used for statistical analysis, as appropriate. The level of significance was determined at p < 0.05. RESULTS: The mean size of the AVMs that underwent embolization was significantly greater when compared with non-embolized group (p < 0.05). Embolization significantly reduced the AVM diameter. Irradiation dose was significantly smaller in the embolized group (p < 0.05). No significant differences in final clinical outcomes, postprocedural radiological findings, rate of occlusion, and need for additional procedures were observed between the two groups (p < 0.05). CONCLUSION: Preradiosurgical embolization of large AVMs does not result in impaired obliteration rate compared with cases treated with radiosurgery alone. It did not add further morbidity and presented benefits of reducing size of the AVMs. Preradiosurgical embolization may facilitate the coverage of the AVM with the effective irradiation dose. Combined management may be effective for selected large lesions considered unsuitable for radiosurgery and otherwise untreatable.
RESUMO
BACKGROUND: Repetitive Transcranial Magnetic Stimulation (rTMS) has been proposed as a new tool in neurological rehabilitation of victims of traumatic brain injury (TBI). However, its usefulness to treat this condition has never been tested rigorously. The primary goal is to conduct a study protocol to determine whether rTMS used to cognitive rehabilitation of victims of TBI with diffuse axonal injury (DAI) is a safe instrument and if it enhances cognitive function recovery. METHODS: Double-blind randomized controlled trial of patients with diffuse axonal injury. Thirty-six patients will be randomized to either an active coil group or sham group in a 1:1 ratio. rTMS protocol: 10 sessions of high-frequency rTMS (10 Hz) over the left dorsolateral prefrontal cortex (DLPFC). Cortical Excitability measures will be obtained. Neuropsychological evaluations will be performed 1 week before, 1 week and 3 months after rTMS. There are 2 study hypotheses: (1) rTMS over the left DLPFC in patients with DAI will improve cognitive function and (2) whether rTMS is safe in TBI patients. DISCUSSION: This study evaluates the immediate and delayed effects of rTMS over the DLPFC on the cognitive domain of patients with DAI following TBI. rTMS has shown good results in treating major depression and may be promising for patients with TBI. As such, the results of this study can greatly modify the cognitive rehabilitation strategies. TRIAL REGISTRATION: This trial was registered in clinicaltrials.gov ( NCT02167971 ) on 17 June 2014.