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Among all types of trauma in children, traumatic brain injury has the greatest potential for the development of devastating consequences, with nearly three million affected each year in the world. A controlled, nonrandomized experimental study was carried out in pediatric patients with severe traumatic brain injury, whose objective was to evaluate the use of continuous multimodal neuromonitoring (MMN) of intracranial parameters as a guide in the treatment of children of different age-groups. The patients were divided into two groups according to the treatment received; clinical and imaging monitoring was performed in both. Group I included those whose treatment was guided by MMN of intracranial parameters such as intracranial pressure, cerebral perfusion pressure, and intracranial compliance, and group II included those who had only clinical and imaging monitoring. Eighty patients were studied, 41 in group I and 39 in group II. There were no significant differences between the groups with respect to the sociodemographic variables and the results; as a consequence, both forms of treatment were outlined, for patients with MMN and for those who only have clinical and imaging monitoring. It is concluded that both treatment schemes can be used depending on technological availability, although the scheme with MMN is optimal.
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Background: Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is an inflammatory disorder of the CNS with a variety of clinical manifestations, including cerebral edema. Case Summary: A 7-year-old boy presented with headaches, nausea, and somnolence. He was found to have cerebral edema that progressed to brainstem herniation. Invasive multimodality neuromonitoring was initiated to guide management of intracranial hypertension and cerebral hypoxia while he received empiric therapies for neuroinflammation. Workup revealed serum myelin oligodendrocyte glycoprotein antibodies. He survived with a favorable neurologic outcome. Conclusion: We describe a child who presented with cerebral edema and was ultimately diagnosed with MOGAD. Much of his management was guided using data from invasive multimodality neuromonitoring. Invasive multimodality neuromonitoring may have utility in managing life-threatening cerebral edema due to neuroinflammation.
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Continuous neuromonitoring in the neonatal intensive care unit allows for bedside assessment of brain oxygenation and perfusion as well as cerebral function and seizure identification. Near-infrared spectroscopy (NIRS) reflects the balance between oxygen delivery and consumption, and use of multisite monitoring of regional oxygenation provides organ-specific assessment of perfusion. With understanding of the underlying principles of NIRS as well as the physiologic factors which impact oxygenation and perfusion of the brain, kidneys and bowel, changes in neonatal physiology can be more easily recognized by bedside providers, allowing for appropriate, targeted interventions. Amplitude-integrated electroencephalography (aEEG) allows continuous bedside evaluation of cerebral background activity patterns indicative of the level of cerebral function as well as identification of seizure activity. Normal background patterns are reassuring while abnormal background patterns indicate abnormal brain function. Combining brain monitoring information together with continuous vital sign monitoring (blood pressure, pulse oximetry, heart rate and temperature) at the bedside may be described as multi-modality monitoring and facilitates understanding of physiology. We describe 10 cases in critically ill neonates that demonstrate how comprehensive multimodal monitoring provided greater recognition of the hemodynamic status and its impact on cerebral oxygenation and cerebral function thereby informing treatment decisions. We anticipate that there are numerous other uses of NIRS as well as NIRS in conjunction with aEEG which are yet to be reported.
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Analysis of intracranial pressure waveforms (ICPW) provides information on intracranial compliance. We aimed to assess the correlation between noninvasive ICPW (NICPW) and invasively measured intracranial pressure (ICP) and to assess the NICPW prognostic value in this population. In this cohort, acute brain-injured (ABI) patients were included within 5 days from admission in six Intensive Care Units. Mean ICP (mICP) values and the P2/P1 ratio derived from NICPW were analyzed and correlated with outcome, which was defined as: (a) early death (ED); survivors on spontaneous breathing (SB) or survivors on mechanical ventilation (MV) at 7 days from inclusion. Intracranial hypertension (IHT) was defined by ICP > 20 mmHg. A total of 72 patients were included (mean age 39, 68% TBI). mICP and P2/P1 values were significantly correlated (r = 0.49, p < 0.001). P2/P1 ratio was significantly higher in patients with IHT and had an area under the receiving operator curve (AUROC) to predict IHT of 0.88 (95% CI 0.78-0.98). mICP and P2/P1 ratio was also significantly higher for ED group (n = 10) than the other groups. The AUROC of P2/P1 to predict ED was 0.71 [95% CI 0.53-0.87], and the threshold P2/P1 > 1.2 showed a sensitivity of 60% [95% CI 31-83%] and a specificity of 69% [95% CI 57-79%]. Similar results were observed when decompressive craniectomy patients were excluded. In this study, P2/P1 derived from noninvasive ICPW assessment was well correlated with IHT. This information seems to be as associated with ABI patients outcomes as ICP.Trial registration: NCT03144219, Registered 01 May 2017 Retrospectively registered, https://www.clinicaltrials.gov/ct2/show/NCT03144219 .
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Lesões Encefálicas Traumáticas , Hipertensão Intracraniana , Adulto , Humanos , Encéfalo , Hipertensão Intracraniana/diagnóstico , Pressão Intracraniana , PrognósticoRESUMO
Introducción: El manejo de los gliomas cerebrales durante las últimas cuatro décadas ha sufrido cambios relevantes en su estudio y tratamiento. Dentro de estos cambios se encuentra el desarrollo de técnicas imagenológicas, neurofisiológicas e histopatológicas. El presente trabajo intenta estimar el impacto que la utilización de dichas tecnologías ha tenido sobre el pronóstico de los pacientes. Material y método: Revisión exhaustiva de la literatura en medios digitales e impresos abarcando mayormente publicaciones y comunicaciones desde la década de 1980 hasta el presente. Se expone 1 caso sometido recientemente a cirugía por los autores en el que se utilizaron varias de estas herramientas, presentando el análisis que se llevó a cabo en la planificación quirúrgica. Resultados: La literatura muestra mejorías consistentes pero discretas en el pronóstico asociado al uso de tecnologías complementarias intraoperatorias en gliomas cerebrales, relacionadas a la ayuda que prestarían en la extensión de la resección tumoral y en la preservación funcional. Conclusiones: La utilización intensiva de las tecnologías complementarias descritas parece recomendable si la planificación quirúrgica anticipa beneficios fundados en cuanto a morbi-mortalidad para un paciente en particular. Se debe ser cauto en anticipar y generalizar el impacto pronóstico global que puedan tener, beneficio que es consistente en la literatura pero que en estos momentos parece modesto en términos generales en especial para gliomas de alto grado.
Introduction: The management of cerebral gliomas during the last four decades has undergone relevant changes in terms of its study and treatment. Among these changes is the development of imaging, neurophysiological and histopathological techniques. The present study attempts to estimate the impact that the use of these technologies has had on the prognosis of patients. Material and Method: Comprehensive review of the literature in digital and print media covering mostly publications and communications from the 1980s to the present. 1 case recently submitted to surgery by the authors in which several of these tools were used is exposed, presenting the analysis that was carried out in the surgical planning. Results: The literature shows consistent but discrete improvements in the prognosis associated with the use of intraoperative complementary technologies in cerebral gliomas, related to the help they would provide in the extension of tumor resection and functional preservation. Conclusions: The intensive use of the complementary technologies described seems advisable if surgical planning anticipates well-founded benefits in terms of morbidity and mortality for a particular patient. Caution should be exercised in anticipating and generalizing the global prognostic impact they may have, a benefit that is consistent in the literature but currently seems modest in general terms especially for high grade gliomas.
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PURPOSE: We show a systematic review of known complications during intraoperative neuromonitoring (IONM) using transcranial electric stimulation motor evoked potentials (TES-MEP) on cervical spine surgery, which provides a summary of the main findings. A rare complication during this procedure, cardiac arrest by cardioinhibitory reflex, is also described. METHODS: Findings of 523 scientific papers published from 1995 onwards were reviewed in the following databases: CENTRAL, Cochrane Library, Embase, Google Scholar, Ovid, LILACS, PubMed, and Web of Science. This study evaluated only complications on cervical spine surgery undergoing TES-MEP IONM. RESULTS: The review of the literature yielded 13 studies on the complications of TES-MEP IONM, from which three were excluded. Five studies are case series; the rest are case reports. Overall, 169 complications on 167 patients were reported in a total of 38,915 patients, a global prevalence of 0.43%. The most common complication was tongue-bite in 129 cases, (76.3% of all complication events). Tongue-bite had a prevalence of 0.33% (CI 95%, 0.28-0.39%) in all patients on TES-MEP IONM. A relatively low prevalence of severe complications was found: cardiac-arrhythmia, bradycardia and seizure, the prevalence of this complications represents only one case in all the sample. Alongside, we report the occurrence of cardiac arrest attributable to TES-MEP IONM. CONCLUSIONS: This systematic review shows that TES-MEP is a safe procedure with a very low prevalence of complications. To our best knowledge, asystole is reported for the first time as a complication during TES-MEP IONM.
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Parada Cardíaca , Monitorização Neurofisiológica Intraoperatória , Vértebras Cervicais/cirurgia , Estimulação Elétrica , Potencial Evocado Motor/fisiologia , Parada Cardíaca/epidemiologia , Parada Cardíaca/etiologia , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Monitorização Intraoperatória/métodos , Estudos RetrospectivosRESUMO
Resumen Objetivo: La lesión del nervio laríngeo recurrente es una grave complicación en cirugía tiroidea. El propósito del presente estudio es analizar la utilidad de la neuromonitorización vagal continua intraoperatoria en un hospital terciario. Materiales y Método: Estudio observacional, analítico y retrospectivo que recoge pacientes intervenidos de cirugía tiroidea con neuromonitorización en un período de 14 meses. La pérdida de señal se define como amplitud final nerviosa < 100 ^V, realizándose laringoscopia postquirúrgica ante la sospecha de lesión nerviosa. El análisis estadístico se realizó con el programa SPSS® V25,0, con p < 0,05. Resultados: Se incluyeron 120 pacientes intervenidos, registrándose en el 24,2% pérdida de señal. Factores de riesgo para lesión fueron bocio intratorácico (OR 5,31; IC 95% 1,56-17,99; p = 0,007), cirugía cervical previa (OR 5,76; IC 95% 0,64-51,97; p = 0,119) y patología maligna (OR 1,44; IC 95% 0,16-12,79; p = 0,743). Fue posible el cambio de estrategia quirúrgica en 7 casos. En el seguimiento posterior se cuantificó parálisis recurrencial transitoria en 27 pacientes y permanente en 4. Discusión: La neuromonitorización parece reducir la incidencia de parálisis laríngea porque aumenta la seguridad en la identificación del nervio recurrente y reduce su manipulación durante la cirugía. Conclusiones: La neuromonitorización intraoperatoria es útil para identificar el nervio laríngeo recurrente y advierte del riesgo potencial de lesión, permitiendo cambiar la estrategia quirúrgica para evitar la parálisis bilateral de cuerdas vocales.
Aim: Recurrent laryngeal nerve injury is a serious complication in thyroid surgery. The purpose of the present study is to analyze the use of intraoperative continuous vagal neuromonitoring in a tertiary hospital. Materials and Method: Observational, analytical and retrospective study that includes patients who underwent thyroid surgery with neuromonitoring in a period of 14 months. Loss of signal is defined as final nerve amplitude < 100 ^V, and postsurgical laryngoscopy is performed due to suspicion of nerve injury. Statistical analysis was performed with the SPSS® V25.0 program, with p < 0.05. Results: 120 operated patients were included, registering loss of signal in 24.2%. Risk factors for injury were intrathoracic goiter (OR 5.31; 95% CI 1.56-17.99; p = 0.007), previous cervical surgery (OR 5.76; 95% CI 0.64-51.97; p = 0.119) and malignant pathology (OR 1.44; 95% CI 0.16-12.79; p = 0.743). A change in surgical strategy was possible in 7 cases. In the subsequent follow-up, transient recurrent paralysis was quantified in 27 patients and permanent in 4. Discussion: Neuromonitoring seems to reduce the incidence of laryngeal paralysis because it increases the security in the identification of the recurrent nerve and reduces its manipulation during surgery. Conclusions: Intraoperative neuromonitoring is useful to identify the recurrent laryngeal nerve and warns of the potential risk of injury, allowing to change the surgical strategy to avoid bilateral vocal cord paralysis.
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Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Nervo Laríngeo Recorrente/patologia , Glândula Tireoide/cirurgia , Nervo Vago , Análise Multivariada , Estudos Retrospectivos , Monitorização IntraoperatóriaRESUMO
OBJECTIVE: To compare the ONSD measured by ultrasound and tomography in patients with a diagnosis of intracranial hypertension. METHOD: Prospective, transversal, observational, analytical study. 105 patients were included, divided into two groups: healthy (control group) and patients presenting clinical data of intracranial hypertension (study group). ONSD was measured by ultrasound and tomography. The Kruskal-Wallis test was used to compare the ONSD between the patients, and the Spearman test was used to assess the correlation between USG and CT. A value of p <0.05 was considered statistically significant. RESULTS: Of the 105 patients, 58.1% were men and 41.9% women. The study group included 14 patients with TBI, CVD, intracranial neoplasia, or neuroinfection. The highest median of ONSD by Ultrasound was in the CVD group, followed by TBI, neoplasia and neuroinfection and the lowest was in the control group (7.5, 7.0, 6.8, 6.8 and 5.2 mm respectively); these differences being statistically significant (p < 0.001). In the correlation analysis between Ultrasound and CT, a good statistically significant positive correlation was found (rho = 0.893, p < 0.001). CONCLUSIONS: The ultrasound evaluation of ONSD has proven to be a reliable test for the diagnosis and non-invasive monitoring of intracranial hypertension.
OBJETIVO: Comparar el diámetro de la vaina del nervio óptico (DVNO) medido por ultrasonografía (USG) y tomografía computarizada (TC) en pacientes con diagnóstico de hipertensión intracraneal. MÉTODO: Estudio prospectivo, transversal, observacional y analítico. Se incluyeron 105 pacientes divididos en dos grupos: sanos (grupo control) y pacientes que presentaran datos clínicos de hipertensión intracraneal (grupo de estudio). Se midió el DVNO por USG y TC. Para comparar el DVNO entre los pacientes se utilizó la prueba de Kruskal-Wallis, y para evaluar la correlación entre USG y TC se utilizó la prueba de Spearman. Un valor de p < 0.05 fue considerado estadísticamente significativo. RESULTADOS: De los 105 pacientes, el 58.1% eran hombres y el 41.9% mujeres. El grupo de estudio incluyó 14 pacientes con traumatismo craneoencefálico (TCE), evento vascular cerebral (EVC), neoplasia intracraneal o neuroinfección. La mayor mediana de DVNO por USG la tuvo el grupo de EVC, seguido de los pacientes con TCE, neoplasia y neuroinfección, y la menor la tuvo el grupo control (7.5, 7.0, 6.8, 6.8 y 5.2 mm, respectivamente), siendo estas diferencias estadísticamente significativas (p < 0.001). En el análisis de correlación entre USG y TC se encontró una buena correlación positiva estadísticamente significativa (rho = 0.893, p < 0.001). CONCLUSIONES: La evaluación por USG del DVNO ha demostrado ser una prueba confiable para el diagnóstico y el monitoreo no invasivo de la hipertensión intracraneal.
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Hipertensão Intracraniana , Nervo Óptico , Feminino , Humanos , Hipertensão Intracraniana/diagnóstico por imagem , Hipertensão Intracraniana/etiologia , Masculino , Nervo Óptico/diagnóstico por imagem , Estudos Prospectivos , Tomografia Computadorizada por Raios X , UltrassonografiaRESUMO
The most feared complication in spinal surgeries is damage to the spinal cord due to inadvertent compression or interference in the blood supply with the consequent motor and/or sensory déficit. Intraoperative physiological surveillance reduces the risk of generating direct damage or due to hypoxia, helping in the early detection of complications. Publications in the Pubmed database are reviewed.
La complicación más temida en las cirugías de columna es el daño de la médula espinal por una compresión inadvertida o interferencia en el aporte sanguíneo con el consiguiente déficit motor y/o sensitivo. La vigilancia fisiológica intra operatoria disminuye el riesgo de generar daño directo o por hipoxia, ayudando en la detección temprana de las complicaciones. Se revisan publicaciones en base de datos Pubmed.
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Humanos , Medula Espinal/cirurgia , Procedimentos Neurocirúrgicos/métodos , Potenciais Evocados , Monitorização Neurofisiológica IntraoperatóriaRESUMO
Introducción: El neuromonitoreo no invasivo en pacientes críticos representa una opción de primera línea para el manejo de complicaciones fatales derivadas del aumento de la presión intracraneal. En esta modalidad se incluye la ultrasonografía del diámetro de la vaina del nervio óptico, la cual representa una técnica rápida, fácil de realizar y disponible a la cabecera del paciente. Objetivos: Describir aspectos fundamentales y actualizados sobre el uso de la ultrasonografía en el monitoreo de la presión intracraneal a través de la medición del diámetro de la vaina del nervio óptico en los diferentes escenarios neuroclínicos. Métodos: Se realizó una revisión de la literatura publicada en bases de datos como: PubMed/Medline, SciELO y Google académico entre los meses mayo y julio de 2020. Se revisaron publicaciones en inglés y español. Se seleccionaron 46 bibliografías que cumplieron con los criterios de inclusión. Se describen aspectos fundamentales como la anatomía ecográfica del nervio óptico, descripción de la técnica y su uso en entidades neurocríticas como el traumatismo craneoencefálico, ictus, muerte encefálica, entre otros. Conclusiones: La ecografía de la vaina del nervio óptico representa una alternativa no invasiva ampliamente aceptada para la medición del incremento de la presión intracranial. Con un diámetro de 5,0 hasta 5,9 mm o más se puede asumir el diagnóstico de hipertensión intracraneal con alta sensibilidad y especificidad, aunque debe individualizarse su uso en cada patología neurocrítica. La curva de aprendizaje para la realización del proceder es de breve tiempo y satisface las habilidades necesarias(AU)
Introduction: Noninvasive neuromonitoring in critically ill patients is a first-line option for the management of fatal complications derived from increased intracranial pressure. This modality includes ultrasound of optic nerve sheath diameter, which is a quick technique, easy to perform and available at the bedside. Objectives: To describe significant and state-of-the-art aspects regarding the use of ultrasound for monitoring intracranial pressure through measurement of the optic nerve sheath diameter in different neuroclinical settings. Methods: A review was carried out, between May and July 2020, of the literature published in databases such as PubMed/Medline, SciELO and Google Scholar. Publications in English and Spanish were reviewed. Forty-six bibliographic sources were chosen, as long as they met the inclusion criteria. Fundamental aspects are described, such as the ultrasound anatomy of the optic nerve, the technique procedures and its use in neurocritical entities such as head trauma, stroke and brain death, among others. Conclusions: Ultrasound of the optic nerve sheath is a widely accepted noninvasive choice for measurement of increased intracranial pressure. With a diameter of 5.0 to 5.9 mm or more, the diagnosis of intracranial hypertension can be assumed with high sensitivity and specificity, although its use should be individualized in each neurocritical pathology. The learning curve for carrying out the procedure is short and satisfies the necessary skills(AU)
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Humanos , Masculino , Feminino , Nervo Óptico/diagnóstico por imagem , Pressão Intracraniana/fisiologia , Estado Terminal , Acidente Vascular Cerebral , Lesões Encefálicas Traumáticas , Traumatismos CraniocerebraisRESUMO
Surgical resection is the primary treatment of pilocytic astrocytomas and total removal can be curative. However, these lesions occur in critical areas, such as the thalamus, being surrounded by critical life neurovascular structures, which imposes a surgical challenge.1-5 Exhaustive acquisition and meticulous interpretation of preoperative radiological exams; reliable surgical orientation based on profound microneurosurgical anatomic knowledge and judicious discernment of the neuroanatomic distortions on the surface and deep-seated structures inflicted by the neuropathological entity; embracing and comprehensive application of the vast scope of available intraoperative guidance imaging and neurophysiological monitoring; in alliance with the mastered carefully microsurgical technique supported by endoscopic visualization are the keystones to the pursed duet "cure with quality of life" in the treatment of these lesions. We present the case of a 17-yr-old young lady with a progressive motor deficit in her right hemibody for over 2 yr. Her radiological investigation demonstrated a left thalamic lesion displacing the projection fibers (corticospinal tract) within the internal capsule laterally. The patient consented to the surgical procedure. The surgical strategy, intraoperative findings, and microsurgical and endoscopic technique, as well as the postoperative radiological and clinical evaluation are presented. The patient gave her informed consent for the publication of the case.
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Astrocitoma , Neoplasias Encefálicas , Astrocitoma/diagnóstico por imagem , Astrocitoma/cirurgia , Neoplasias Encefálicas/cirurgia , Feminino , Humanos , Procedimentos Neurocirúrgicos , Qualidade de Vida , Tálamo/diagnóstico por imagem , Tálamo/cirurgiaRESUMO
INTRODUCTION: Cerebral critical closing pressure (CrCP) comprises intracranial pressure (ICP) and arteriolar wall tension (WT). It is the arterial blood pressure (ABP) at which small vessels close and circulation stops. We hypothesized that the increase in WT secondary to a systemic hypertensive challenge would lead to an increase in CrCP and that the "effective" cerebral perfusion pressure (CPPeff; calculated as ABP - CrCP) would give more complete information than the "conventional" cerebral perfusion pressure (CPP; calculated as ABP - ICP). OBJECTIVE: This study aimed to compare CrCP, CPP, and CPPeff changes during a hypertensive challenge in patients with a severe traumatic brain injury. PATIENTS AND METHODS: Data on ABP, ICP, and cerebral blood flow velocity, measured by transcranial Doppler ultrasound, were acquired simultaneously for 30 min both basally and during a hypertensive challenge. An impedance-based CrCP model was used. RESULTS: The following values are expressed as median (interquartile range). There were 11 patients, aged 29 (14) years. CPP increased from 73 (17) to 102 (26) mmHg (P ≤ 0.001). ICP did not change. CrCP changed from 23 (11) to 27 (10) mmHg (P ≤ 0.001). WT increased from 7 (5) to 11 (7) mmHg (P Ë 0.005). CPPeff changed less than CPP. CONCLUSION: The CPP change was greater than the CPPeff change, mainly because CrCP increased simultaneously with the WT increase as a result of the autoregulatory response. CPPeff provides information about the real driving force generating blood movement.
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Lesões Encefálicas Traumáticas , Circulação Cerebrovascular , Adulto , Pressão Sanguínea , Lesões Encefálicas Traumáticas/complicações , Humanos , Pressão Intracraniana , Ultrassonografia Doppler TranscranianaRESUMO
(1) Background: Postoperative nerve root injury with dysesthesia is the most frequent sequela following lumbar endoscopic transforaminal discectomy. At times, it may be accompanied by transient and rarely by permanent motor weakness. The authors hypothesized that direct compression of the exiting nerve root and its dorsal root ganglion (DRG) by manipulating the working cannula or endoscopic instruments may play a role. (2) Objective: To assess whether intraoperative neurophysiological monitoring can help prevent nerve root injury by identifying neurophysiological events during the initial placement of the endoscopic working cannula and the directly visualized video endoscopic procedure. (3) Methods: The authors performed a retrospective chart review of 65 (35 female and 30 male) patients who underwent transforaminal endoscopic decompression for failed non-operative treatment of lumbar disc herniation from 2012 to 2020. The patients' age ranged from 22 to 86 years, with an average of 51.75 years. Patients in the experimental group (32 patients) had intraoperative neurophysiological monitoring recordings using sensory evoked (SSEP), and transcranial motor evoked potentials (TCEP), those in the control group (32 patients) did not. The SSEP and TCMEP data were analyzed and correlated to the postoperative course, including dysesthesia and clinical outcomes using modified Macnab criteria, Oswestry disability index (ODI), visual analog scale (VAS) for leg and back pain. (4) Results: The surgical levels were L4/L5 in 44.6%, L5/S1 in 23.1%, and L3/L4 in 9.2%. Of the 65 patients, 56.9% (37/65) had surgery on the left, 36.9% (24/65) on the right, and the remaining 6.2% (4/65) underwent bilateral decompression. Postoperative dysesthesia occurred in 2 patients in the experimental and six patients in the control group. In the experimental neuromonitoring group, there was electrodiagnostic evidence of compression of the exiting nerve root's DRG in 24 (72.7%) of the 32 patients after initial transforaminal placement of the working cannula. A 5% or more decrease and a 50% or more decrease in amplitude of SSEPs and TCEPs recordings of the exiting nerve root were resolved by repositioning the working cannula or by pausing the root manipulation until recovery to baseline, which typically occurred within an average of 1.15 min. In 15 of the 24 patients with such latency and amplitude changes, a foraminoplasty was performed before advancing the endoscopic working cannula via the transforaminal approach into the neuroforamen to avoid an impeding nerve root injury and postoperative dysesthesia. (5) Conclusion: Neuromonitoring enabled the intraoperative diagnosis of DRG compression during the initial transforaminal placement of the endoscopic working cannula. Future studies with more statistical power will have to investigate whether employing neuromonitoring to avoid intraoperative compression of the exiting nerve root is predictive of lower postoperative dysesthesia rates in patients undergoing videoendoscopic transforaminal discectomy.
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Monitoring of the neurocritical in the perioperatory is in constant evolution. There are essentially two ultrasonographic application of neuromonitoring: the diameter of the sheath of the optic nerve and transcranial Doppler. Ultrasound-guided neuromonitoring can detect stenosis or occlusion of intracranial arteries, monitor the evolution of patients with vasospasm after subarachnoid hemorrhage, detect cerebral embolism, evaluate the cerebral collateral system, determine brain death, calculate indirectly Intracranial pressure and cerebral perfusion and helps in clinical decisions and early therapeutic interventions in neurocritical care. The purpose of this review is to present the applications of ultrasonography to the head of the patient in neuromonitoring.
El monitoreo del paciente neurocrítico en el perioperatorio se encuentra en constante evolución. Existen fundamentalmente dos evaluaciones ultrasonográficas de neuromonitoreo: el diámetro de la vaina del nervio óptico y el Doppler transcraneal. En la actualidad, el neuromonitoreo guiado por ultrasonido permite detectar estenosis u oclusión de arterias intracraneales, monitorizar la evolución de los enfermos que presentan vasoespasmo tras una hemorragia subaracnoidea, detectar embolias cerebrales, evaluar el sistema colateral cerebral, determinar la muerte cerebral, calcular de manera indirecta la presión intracraneana y la perfusión cerebral, entre otras, y de esta manera poder tomar decisiones terapéuticas tempranas en el manejo del paciente neurocrítico. El motivo de esta revisión es dar a conocer las aplicaciones de la ultrasonografía a la cabecera del enfermo en neuromonitoreo.
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Transtornos Cerebrovasculares/diagnóstico por imagem , Monitorização Neurofisiológica Intraoperatória/métodos , Neuroimagem/métodos , Nervo Óptico/diagnóstico por imagem , Assistência Perioperatória/métodos , Ultrassonografia Doppler Transcraniana , Morte Encefálica/diagnóstico por imagem , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Circulação Cerebrovascular/efeitos dos fármacos , Tomada de Decisão Clínica , Humanos , Pressão Intracraniana , Órbita/diagnóstico por imagem , Fluxo Pulsátil , Hemorragia Subaracnóidea/diagnóstico por imagem , Vasoconstritores/farmacologia , Vasoespasmo Intracraniano/diagnóstico por imagemRESUMO
En la Unidad de Cuidado Neurocrítico (UCN), el examen neurológico constituye un parámetro fundamental en la evaluación de la evolución de pacientes admitidos en esta unidad; uno de los principales elementos de esta inspección es la valoración de las pupilas, establecida por la estimulación del reflejo pupilar a la luz, ya sea de forma manual o mediante un pupilómetro para medir el diámetro pupilar y su reactividad, lo que se ha constituido como un primer y en algunos contextos casi que el único signo clínico que manifiestan los pacientes con traumas o lesiones encefálicas al momento que hay un empeoramiento del cuadro patológico, por lo que se ha propuesto como una herramienta eficaz para establecer un pronóstico y seguimiento en estos pacientes.
At the neuro-critical care units, the neurological examination constitutes a fundamental parameter in the evaluation of the evolution of patients admitted into these units. One of the main elements of this inspection is the assessment of the pupils, established by the pupillary light reflection stimulation, either manually or by means of a pupilometer to measure the pupillary diameter and its reactivity. It has been constituted as a first, and in some contexts, almost the only clinical sign manifested by patients with traumas or brain injuries at the time where there is a worsening of the pathological picture, so it has been proposed as an effective tool to establish a prognosis and follow-up in these patients.
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Pupila , Reflexo Pupilar , Lesões Encefálicas , Cuidados Críticos , Exame NeurológicoRESUMO
Continuous brain monitoring tools are increasingly being used in the neonatal intensive care unit (NICU) to assess brain function and cerebral oxygenation in neonates at high risk for brain injury. Near infrared spectroscopy (NIRS) is useful in critically ill neonates as a trend monitor to evaluate the balance between tissue oxygen delivery and consumption, providing cerebral and somatic oximetry values, and allowing earlier identification of abnormalities in hemodynamics and cerebral perfusion. Amplitude-integrated electroencephalography (aEEG) is a method for continuous monitoring of cerebral function at the bedside. Simultaneous use of both monitoring modalities may improve the understanding of alterations in hemodynamics and risk of cerebral injury. Several studies have described correlations between aEEG and NIRS monitoring, especially in infants with hypoxic-ischemic encephalopathy (HIE), but few describe the combined use of both monitoring techniques in a wider range of clinical scenarios. We review the use of NIRS and aEEG in neonates and describe four cases where abnormal NIRS values were immediately followed by changes in brain activity as seen on aEEG allowing the impact of a hemodynamic disturbance on the brain to be correlated with the changes in the aEEG background pattern. These four clinical scenarios demonstrate how simultaneous neuromonitoring with aEEG and NIRS provides important clinical information. We speculate that routine use of these combined monitoring modalities may become the future standard for neonatal neuromonitoring.
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El trabajo repasa la evolución histórica en el entendimiento y en el manejo de la cirugía tiroidea. Describe los orígenes de esta cirugía y su ejecución, mucho antes de que se entendiera el funcionamiento de la glándula. Enumera los personajes más trascendentes de esta historia y cómo otras técnicas aplicadas en la cirugía oncológica general se adaptaron a la cirugía de cabeza y cuello. Se mencionan las innovaciones tecnológicas en cirugía tiroidea.
This work reviews the historical evolution of thyroid surgery, its understanding and management. It mentions the origins of this surgical procedure and its execution well before the understanding of the glandular function. The leading persons in this historical field are enumerated; and a review is made of how other techniques applied in surgical oncology were adapted in head and neck surgery. Technological innovations in thyroid surgery are enumerated.
Assuntos
Humanos , Técnicas e Procedimentos Diagnósticos/tendências , Literatura de Revisão como Assunto , Neoplasias da Glândula Tireoide/história , Neoplasias da Glândula Tireoide/cirurgia , Endocrinologia/história , História da Medicina , Desenvolvimento TecnológicoRESUMO
Intraoperative continuous neural monitoring (C-IONM) during thyroid surgery has been recognized as a useful tool to identify and confirm recurrent laryngeal nerve integrity. The aim of the present study is to analyze electromyographic features and thresholds for normal vocal fold function in our initial experience with C-IONM in thyroid surgery. C-IONM was utilized in 57 patients who underwent thyroid surgery between July 2012 and December 2015. EMG parameters were analyzed looking for potential predictors of postoperative vocal fold dismotility. There were 54 females (94.7%) and 3 males (5.3%) with a mean age of 46.7 ± 11.6 years. C-IONM was successfully registered in 89 of 107 nerves at risk (83.1%). Mean basal amplitude was 727.31 ± 471.25 µV and mean final amplitude was 650.27 ± 526.87 µV (P = 0.095, CI 95% 13.83-167.91). Mean basal latency was 5.23 ± 1.42 mS and mean final latency was 5.18 ± 1.50 mS (P = 0.594, CI 95% 0.39-0.24). Four patients had transient postoperative vocal fold paresis. None of these four patients had loss of signal (LOS), three had transient decrease in amplitude, and one had a normal registry throughout the operation. C-IONM is a useful tool to identify patients in whom intraoperative RLN is at risk during surgery. Final amplitude above 500 µV and no LOS is associated with RLN integrity and normal postoperative vocal fold function.
Assuntos
Nervos Laríngeos/fisiologia , Monitorização Intraoperatória/métodos , Glândula Tireoide/cirurgia , Prega Vocal/fisiologia , Eletromiografia/métodos , Feminino , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Intraoperative neuromonitoring of the recurrent laryngeal nerve in thyroid surgery facilitates the identification of anatomical structures in cervical endocrine surgery reducing the frequency of vocal cord paralysis. OBJECTIVE: To study the normal electrophysiological values of the vague and recurrent laryngeal nerves before and after thyroid surgery. To compare rates of injury of recurrent nerve before and after the introduction of the intraoperative neuromonitoring in thyroid surgery. MATERIAL AND METHODS: An observational, descriptive and prospective study in which a total of 490 patients were included. Between 2003-2010, surgery was performed on 411 patients (703 nerves at risk) with systematic identification of recurrent laryngeal nerves. Between 2010-2011 neuromonitorization was also systematically performed on 79 patients. RESULTS: Before the introduction of intraoperative neuromonitoring of 704 nerves at risk, there were 14 recurrent laryngeal nerve injuries. Since 2010, after the introduction of the intraoperative neuromonitoring in thyroid surgery, there has been no nerve injury in 135 nerves at risk. CONCLUSIONS: We consider the systematic identification of the recurrent laryngeal nerve is the 'gold standard' in thyroid surgery and the intraoperative neuromonitoring of nerves can never replace surgery but can complement it.