Evaluation of konjac noodle as a microsurgery training model: learning curve analysis.

BACKGROUND: classical models of microsurgical anastomosis training are expensive and have ethical implications. Some alternatives join low cost and easiness to store. However, the translation of knowledge acquired by training in these methods into the traditional ones is not clear. This project aims to assess the feasibility of konjac noodles as a reliable microsurgery-training model. METHODS: 10 neurosurgery residents performed an end-to-end anastomosis in a 2-3mm placenta artery. The anastomoses were evaluated quantitatively, recording time; and qualitatively, applying a validated score (Anastomosis Lapse Index - ALI) by three experienced neurosurgeons and verifying the presence of gross leakage through the infusion of fluorescein. Subsequently, they performed 10 non-consecutive sessions of anastomosis training in the konjac noodle. Eventually, a final anastomosis in the placenta model was performed and the same parameters were scored. RESULTS: we observed a 17min reduction in the mean time to perform the anastomosis in the placenta model after the training in the konjac (p<0.05). There was a non-significant 20% reduction in gross leakage, but the training sessions were not able to consistently improve the ALI score. CONCLUSIONS: we demonstrate a reduction in anastomosis performing time in placental arteries after training sessions in the konjac noodle model, which can be regarded as a feasible low-cost method, particularly useful in centers with surgical microscopes only in the operation room.

Evaluation of konjac noodle as a microsurgery training model: learning curve analysis / Avaliação do uso de macarrão japonês para treinamento microcirúrgico: análise objetiva da melhora na performance

ABSTRACT Background: classical models of microsurgical anastomosis training are expensive and have ethical implications. Some alternatives join low cost and easiness to store. However, the translation of knowledge acquired by training in these methods into the traditional ones is not clear. This project aims to assess the feasibility of konjac noodles as a reliable microsurgery-training model. Methods: 10 neurosurgery residents performed an end-to-end anastomosis in a 2-3mm placenta artery. The anastomoses were evaluated quantitatively, recording time; and qualitatively, applying a validated score (Anastomosis Lapse Index - ALI) by three experienced neurosurgeons and verifying the presence of gross leakage through the infusion of fluorescein. Subsequently, they performed 10 non-consecutive sessions of anastomosis training in the konjac noodle. Eventually, a final anastomosis in the placenta model was performed and the same parameters were scored. Results: we observed a 17min reduction in the mean time to perform the anastomosis in the placenta model after the training in the konjac (p<0.05). There was a non-significant 20% reduction in gross leakage, but the training sessions were not able to consistently improve the ALI score. Conclusions: we demonstrate a reduction in anastomosis performing time in placental arteries after training sessions in the konjac noodle model, which can be regarded as a feasible low-cost method, particularly useful in centers with surgical microscopes only in the operation room.

ABSTRACT Introdução: modelos tradicionais de treinamento de anastomose microcirúrgica costumam ter custos elevados e implicações éticas de aquisição e manutenção, buscando-se alternativas que reúnam baixo custo e facilidade de armazenamento. Existem diferentes propostas, porém há poucas evidências de que conhecimentos adquiridos com o treinamento nessas plataformas se traduza em melhora na performance, quando estes são comparados a modelos consagrados. Este projeto objetiva avaliar a viabilidade do macarrão de konjac como modelo confiável de treinamento microcirúrgico. Métodos: 10 residentes de neurocirurgia realizaram uma anastomose término-terminal em artéria placentária humana de 2-3mm. As anastomoses foram avaliadas quantitativamente, registrando-se o tempo de confecção e qualitativamente, aplicando-se um escore validado (Anastomosis Lapse Index - ALI) por neurocirurgiões experientes e verificando-se a presença de vazamento grosseiro através da visualização no modo fluorescente injetando-se fluoresceína. Subsequentemente, realizaram 10 sessões de treinamento não consecutivos de anastomose términoterminal no modelo de konjac. Por fim, uma anastomose final foi realizada no modelo placentário e os mesmo parâmetros reavaliados. Resultados: observamos uma redução de 17 min no tempo médio de confecção da anastomose no modelo de placenta após os treinos no modelo do macarrão (p<0.05). Houve uma redução não significativa de 20% no vazamento grosseiro. As sessões de treino no macarrão não foram capazes de melhorar consistentemente o score ALI. Conclusão: o treinamento em modelo de macarrão konjac é capaz de reduzir o tempo para realização das anastomoses no modelo em placenta humana, mostrando-se alternativa viável de baixo custo e manutenção, útil em serviços que disponham de microscópio apenas no ambiente cirúrgico.

Cerebral Venous Sinus Stenting for the Treatment of Idiopathic Intracranial Hypertension in a Child / Angioplastia de Seio Venoso Cerebral para Tratamento de Hipertensão Intracraniana Idiopática em Criança

Idiopathic intracranial hypertension (IIH) is a disease characterized by an increase in the opening pressure of the cerebrospinal fluid (CSF) associated with symptoms of elevated intracranial pressure (ICP). The condition is more prevalent in women and typically managed clinically. Surgical treatment is reserved for select refractory cases. The well-established surgical procedures for the management of IIH are CSF shunting and fenestration of the optic nerve sheath. These procedures, however, are associated with high rates of complication and recurrence. More recently, venous sinus angioplasty with stents has been employed in cases with documented narrowing of the sigmoid-transverse sinuses. This technique is associated with a significant reduction in the venous pressure gradient at the stenosis site, alleviating the symptoms of intracranial hypertension. We report a case of a previously healthy 12-year-old patient who presented with 10-day history of headaches, blurring of vision, nausea and vomiting, which evolved with worsening of the visual acuity and papilledema. Imaging scans disclosed stenosis of the right transverse and sigmoid sinuses. The patient underwent stenting of the stenotic venous segments and showed good evolution, with significant clinical improvement within 24 hours of the procedure.

A hipertensão intracraniana idiopática (HII) é uma doença caracterizada pelo aumento da pressão de abertura do líquido cefalorraquidiano associado a sintomas de aumento da pressão intracraniana. É mais frequente em mulheres, sendo habitualmente tratada com medidas clínicas. O tratamento cirúrgico é reservado a uma minoria de casos que se mostram refratários. Os procedimentos cirúrgicos consagrados para este fim são a derivação liquórica e a fenestração de bainha do nervo óptico. Entretanto, eles estão associados a altos índices de complicações e recorrência. Mais recentemente, a angioplastia de seio venoso com uso do stent vem sendo utilizada em casos em que há redução documentada no calibre dos seios transverso-sigmoide com repercussão comprovada no gradiente pressórico. Essa técnica está associada a uma redução significativa no gradiente de pressão venosa no local da estenose. Consequentemente, resulta em alívio dos sintomas da hipertensão intracraniana. Neste trabalho, descrevemos o caso de um paciente de 12 anos de idade, sem doenças prévias, que apresentava quadro de cefaleia, turvação visual, náuseas e vômitos de início havia dez dias, tendo evoluído com piora da acuidade visual e papiledema. Realizou exame de imagem que identificou estenose dos seios transversos e sigmoide à direita. O paciente foi submetido a angioplastia dos segmentos venosos estenosados, apresentando boa evolução, com melhora clínica significativa já nas primeiras 24 horas após o procedimento.

Intracranial Aneurysm in Pediatric Population: A Single-Center Experience.

PURPOSE: Pediatric intracranial aneurysms (PIA) are rarer and more complex when compared to adult aneurysms. In general, the clinical presentation of PIA is due to a mass effect, but the presenting symptoms can be also related to ischemia, subarachnoid hemorrhage (SAH), or in a combination of different symptoms. This paper aimed to report a single-center experience with clinical and angiographic aspects of brain aneurysm in children. METHODS: We retrospectively reviewed our prospectively maintained database for patients with intracranial aneurysms in our institution from July 2015 to February 2021. Among these, all patients under 18 years of age submitted to a diagnostic or therapeutic procedure for an intracranial aneurysm were included. RESULTS: Twelve patients were submitted to diagnostic or therapeutic procedures in our department. Three of them had multiple aneurysms, and in total, 17 intracranial aneurysms were assessed in this study. The most frequent location was in the middle cerebral artery (7 cases/41%). Five out of twelve children (42%) presented SAH due to ruptured aneurysm. Three patients (25%) had symptoms due to the mass effect from large aneurysms, with compression of cranial nerves or brainstem. Aneurysms diameters ranged from 1.5 mm to 34 mm (mean 14.2 mm), with six aneurysms being giant and eight being nonsaccular/fusiform. Twelve aneurysms were submitted to endovascular treatment, with one treatment-related clinical complication and later death. CONCLUSION: PIAs are rare diseases that can arise from a variety of different underlying pathological mechanisms. The management of these conditions requires a detailed understanding of the pathology and a multidisciplinary approach. Despite the availability of new technologies, parent vessel occlusion remains a valid option for aneurysms in the pediatric population.

Woven EndoBridge device shape modification can be mitigated with an appropriate oversizing strategy: a VasoCT based study.

BACKGROUND: The Woven EndoBridge (WEB) shape modification (WShM) during follow-up may be a potential cause of poor angiographic outcomes. WShM predisposing factors have not yet been determined. Our systematic use of rotational cone beam computed tomography (VasoCT) imaging during follow-up allowed us to perform the first quantitative analysis of the shape of WEBs over time. Our goal was to identify possible strategies to reduce the occurrence of this phenomenon. METHODS: All patients treated in our hospital with a WEB device between October 2015 and January 2019 were included. Using VasoCT acquisitions, systematically performed after implantation and during follow-up, we analyzed WEB morphology. WShM was defined as the percentage reduction in the distance between the two WEB markers. RESULTS: Sixty-three aneurysms treated with a WEB device were finally included in this analysis. At the last follow-up (mean 15.5 months), mean WShM was 48%±24. The mean WShM was significantly higher in the aneurysm recurrence group than in the adequate occlusion group (51±6.5% vs 36±3.4%, difference 15% points (95% CI 0.7 to 30); p<0.05). Conversely, the extent of WShM did not directly correlate with occlusion rates. Indeed, 32% of completely occluded aneurysms presented severe WShM (≥50%). Importantly, the absence of WShM guaranteed complete occlusion in our study (n=12). We demonstrated that oversizing the width of the WEB significantly correlated with WShM reduction during follow-up (r=-0.38, p=0.002). CONCLUSION: WShM can be partly overcome by use of an appropriate width oversizing strategy that could lead to improved angiographic results.

WEB device for treatment of posterior communicating artery aneurysms.

BACKGROUND: Woven EndoBridge (WEB) device treatment of wide-neck bifurcation aneurysms has proved to be safe and effective, but the use of these devices in sidewall aneurysms has been reported only in a small number of case series. OBJECTIVE: To report our results in a cohort of consecutive patients in whom a WEB device was used as first-line treatment for posterior communicating artery (PComA) aneurysms. METHODS: We conducted a retrospective analysis of a prospectively maintained database of PComA aneurysms treated with a WEB device in our institution from June 1, 2012 to November 15, 2020. Clinical and radiological findings were evaluated at immediate and last follow-up. RESULTS: A total of 219 aneurysms were treated with a WEB device, including 15 PComA aneurysms in 15 patients, 10 of which were ruptured. Aneurysms were wide necked, with a mean aspect ratio of 1.6 (range 0.7-3.0) and a mean neck size of 4.2 mm (range 2.6-7.4 mm). No intraoperative rupture occurred and only one thromboembolic event was noted. Among the group with at least a 3-month digital subtraction angiography (DSA) follow-up, complete and adequate occlusion were obtained in 54% and 72%, respectively (average follow-up 13 months). Re-treatment was needed for two initially ruptured aneurysms. No procedure-related morbidity or mortality was reported. CONCLUSION: This series suggests the high safety profile of WEB devices even when used in off-label indications. Treatment with these devices seems to be a valuable strategy for ruptured wide-neck PComA aneurysms, avoiding the need for antiplatelet medication. However, occlusion rates should be investigated in further larger studies.

Extending the stroke treatment window beyond DAWN in patients with very slow progressor type collaterals: How far can we go?

Five trials published in 2015 showed the benefit of endovascular thrombectomy (ET) in patients with stroke and large vessel occlusion, extending the treatment window has become an obsession of all physicians. In 2018, the DAWN and DEFUSE-3 trials showed that, with careful selection of patients, the procedure could be carried out up to 24 hours after symptom onset with good outcomes. In addition, there have been cases where the DAWN criteria were met, and treatment occurred >24 hours after symptom onset. We present the case of a 68-year-old female whose groin puncture occurred 52 hours after the time last known well (TLKW), after neurological worsening of the initial situation, with a large mismatch ratio observed on magnetic resonance imaging, achieving TICI (the Thrombolysis in Cerebral Infarction scale) grade 3 recanalization. Five days after the procedure, the patient was discharged with NIHSS (National Institutes of Health Stroke Scale) score of 3. Some types of collateral circulation (slow progressors and "turtle" progressors, our term for very slow progressors) can extend the treatment window beyond 24 hours of the TLKW but can lead to a hyperperfusion-like syndrome immediately after the ET. Further studies are needed to evaluate the reproducibility of this hypothetical syndrome.

Observational study of patients with occipital condyle fracture at a brazilian referral trauma center.

OBJECTIVE: to evaluate the clinical-epidemiological characteristics, treatment, and evolution of patients with occipital condyle fracture (OCF) at one of the largest referral trauma centers in Latin America. METHODS: this was a retrospective observational study of OCF identified from trauma cases admitted between December 2011 and December 2019 by the neurosurgery team at a Type 3 trauma center. RESULTS: a total of twenty-eight occipital condyle fractures were identified in twenty-six patients. The incidence was less than 0.2% per year and more common in male patients (4:1 ratio) involved in traffic accidents. The mean age was 42.08 years. Anderson and Montesano type II and Tuli type 1 were the most frequent (67.9% and 89.3%, respectively) and no case presented C0-C1-C2 instability. All patients were treated with a cervical collar for 3 to 6 months. About 65% of the patients exhibited good progression (Glasgow Outcome Scale equal to 4), and the severity of traumatic brain injury was the main determinant for negative outcomes. CONCLUSION: the findings of this study are in accordance with available literature data. The use of external stabilization with a cervical collar is reinforced for the treatment of stable lesions, even when these are bilateral. Assessment of the patients' follow-up results in the studied sample may contribute with useful information for the treatment of occipital condyle fractures.

Slip Clip after successful microsurgery of a blister aneurysm: Should bypass always be the first option?

Blood Blister-like aneurysms are intracranial non-saccular aneurysms with higher rupture risk due to its fragile wall. Diagnosis is performed in the acute phase of a subarachnoid hemorrhage. There are several treatment options based on reconstructive or deconstructive techniques. This paper aims to discuss the limitations of microsurgery clipping for a ruptured blister aneurysm. We report on a case of a female patient presented with a Fisher III subarachnoid hemorrhage. Cerebral angiography revealed an internal carotid artery blister aneurysm. Initially microsurgery clipping was successfully performed. However, after a few days the patient presented new subarachnoid hemorrhage. The new cerebral angiography showed growth of the previously clipped aneurysm, with displacement of the clip from the position adjacent to the artery. High-flow bypass was performed obtaining definitive treatment. This is a definitive approach for blister aneurysms. If microsurgery clipping is chosen, a strict follow-up is required due to the dynamic nature of this lesion and the chance of re-bleeding even after successfully clipping.

Periodontoid pseudotumoral lesions.

BACKGROUND: Periodontoid pseudotumoral lesions (PPL) are an uncommon cause of cervical pain and myelopathy. In addition, they may be associated with atlantoaxial instability (AAI). CASE DESCRIPTION: Two patients over 60 years of age presented with neck pain alone. Their MR scans showed expansive lesions involving the odontoid process. One patient with AAI required an occipitocervical arthrodesis, while the other patient without instability was managed with an external orthosis (Philadelphia collar). Both of them experienced full resolution of pain and remained neurologically intact an average 36 months later (range 24-48). CONCLUSION: Here, we discussed the clinical, MR, and non-surgical (without AAI) versus surgical management (with AAI) for different types of PPL.

Acute Disseminated Encephalomyelitis Related to a Cytomegalovirus Infection in an Immunocompetent Patient.

Cytomegalovirus (CMV) infection can cause acute disseminated encephalomyelitis (ADEM). However, it is rare in immunocompetent people. We describe a 17-year-old patient who was brought with flu-like symptoms. After one week, she experienced rapidly progressive weakness in all four extremities, followed by coma. The neurologic examination showed no response to verbal and pain stimuli. A Babinski sign was noted in both lower extremities, along with clonus and hyperreflexia in all four limbs. Brain magnetic resonance imaging (MRI) demonstrated extensive areas of hyperintense signal on fluid-attenuated inversion recovery (FLAIR) sequences in the white matter which was asymmetrically distributed in both hemispheres, as well as in the brainstem and cerebellar peduncles, compatible with acute demyelinating lesions. Cerebrospinal fluid (CSF) showed mild lymphocytic pleocytosis and normal glucose levels. Polymerase chain reaction to herpes simplex virus was negative. Serum immunoglobulin G (IgG) and immunoglobulin M (IgM) were positive for cytomegalovirus. The patient was treated with methylprednisolone pulse therapy for five days. Subsequently, the patient showed neurologic improvement with the recovery of consciousness and muscle strength. In terms of prognosis, in patients with ADEM, the sooner the diagnosis, the better the outcome. The cornerstone of treatment is immunosuppression with steroids. Some patients require intravenous immunoglobulin G (IVIG) or plasmapheresis, and in refractory cases, cyclophosphamide is used.

Spontaneous Bone Flap Resorption Following Cranioplasty Using Autologous Bone.

ABSTRACT: Cranioplasty is a common neurosurgical procedure. The main reasons for performing cranioplasty are, in addition to aesthetic correction and protection of the brain, the reestablishment of the adequate flow of cerebrospinal fluid and the prevention of complications inherent to the perpetuation of bone failure. In our institution the patient's autologous bone remains the best method for performing cranioplasty, despite the existence of other heterologous grafts and bone substitutes. Despite representing for us, the best material for cranioplasty, the use of autologous grafting is subject to complications. In this paper, the authors present the case of a patient who underwent cranioplasty with autologous bone that progressed with spontaneous resorption of the bone flap. The authors herein briefly discuss the case and review the literature on the subject, with an emphasis on the factors that can lead to such an outcome.

Observational study of patients with occipital condyle fracture at a brazilian referral trauma center / Estudo observacional de pacientes com fratura de côndilo ocipital em centro de referência em trauma no brasil

ABSTRACT Objective: to evaluate the clinical-epidemiological characteristics, treatment, and evolution of patients with occipital condyle fracture (OCF) at one of the largest referral trauma centers in Latin America. Methods: this was a retrospective observational study of OCF identified from trauma cases admitted between December 2011 and December 2019 by the neurosurgery team at a Type 3 trauma center. Results: a total of twenty-eight occipital condyle fractures were identified in twenty-six patients. The incidence was less than 0.2% per year and more common in male patients (4:1 ratio) involved in traffic accidents. The mean age was 42.08 years. Anderson and Montesano type II and Tuli type 1 were the most frequent (67.9% and 89.3%, respectively) and no case presented C0-C1-C2 instability. All patients were treated with a cervical collar for 3 to 6 months. About 65% of the patients exhibited good progression (Glasgow Outcome Scale equal to 4), and the severity of traumatic brain injury was the main determinant for negative outcomes. Conclusion: the findings of this study are in accordance with available literature data. The use of external stabilization with a cervical collar is reinforced for the treatment of stable lesions, even when these are bilateral. Assessment of the patients' follow-up results in the studied sample may contribute with useful information for the treatment of occipital condyle fractures.

RESUMO Objetivo: avaliar o perfil clínico-epidemiológico, o tratamento e a evolução de pacientes com fraturas do côndilo occipital (FCO) em um dos maiores centros especializados em trauma na América Latina. Método: este é um estudo observacional retrospectivo de FCO identificadas em casos de trauma que foram atendidos no período de Dezembro de 2011 a Dezembro de 2019 pela equipe de trauma de centro de trauma Tipo 3. Resultados: um total de vinte e oito fraturas do côndilo occipital foram identificadas em 26 pacientes. A incidência foi inferior a 0.2% ao ano e mais comum em pacientes do sexo masculino (proporção 4:1) envolvidos em acidentes de trânsito. A idade média foi de 42.08 anos. O Tipo II de Anderson e Montesano e o Tipo 1 de Tuli foram os mais frequentes (67.9% e 89.3%, respectivamente) e nenhum caso teve instabilidades C0C1C2. Todos os pacientes foram tratados com colar cervical por período de 3 a 6 meses. Cerca de 65% dos pacientes apresentaram boa evolução (Escala de Resultados de Glasgow maior ou igual a 4), e a gravidade da lesão cerebral foi o principal determinante para os resultados negativos. Conclusão: os achados deste estudo são similares a dados disponíveis na literatura. O uso de colar cervical para estabilização externa é reforçado para o tratamento de lesões estáveis, mesmo quando bilaterais. A avaliação dos resultados do acompanhamento dos pacientes na amostra estudada pode contribuir com informações úteis para o tratamento de fraturas de côndilo occipital.

"Whiplash" cervical trauma with fracture and migration of carotid stent fragments.

BACKGROUND: Angioplasty using a carotid stent is a treatment modality for carotid stenosis, with results similar to those obtained with endarterectomy, as demonstrated by important studies. The increasing use of this procedure has also led to a larger number of reports of complications, stent fractures among those. Stent fracture is a rare manifestation and hence needs further studying so that its actual prevalence can be determined, as well as its associated risk factors and proper clinical management. The current study reports the case of a patient who had previously undergone angioplasty with a carotid stent and, after an automobile accident, presented with a stent fracture and distal embolization of fragments thereof with neurological manifestation. CASE DESCRIPTION: A male patient, 40 years old, presented with a history of previously stent carotid angioplasty. He had been involved in an automobile accident and suffered a stent fracture with distal fragment migration. As he was an asymptomatic patient (NIHSS 0, Rankin zero), we opted for a conservative treatment with oral anticoagulant. CONCLUSION: Angioplasty is an effective treatment for extracranial atherosclerosis and, albeit rare, stent fractures can result in the migration of fragments thereof. This occurrence should be suspected in patients who have sustained severe neck injuries due to sudden deceleration and may be associated with thromboembolism.

Residual lesions in patients undergoing microsurgical clipping of cerebral aneurysms in a reference university hospital.

OBJECTIVES: This study aimed to analyze the incidence and epidemiological, angiographic, and surgical aspects associated with incomplete clipping of brain aneurysms in a cohort of patients undergoing microsurgical treatment. METHODS: The medical record data of patients who underwent microsurgery for cerebral aneurysm treatment and postoperative digital subtraction angiography, treated at the same teaching hospital between 2014 and 2019, were retrospectively analyzed. The studied variables involved epidemiological and clinical data, as well as neurological status and findings on neuroimaging. The time elapsed between hemorrhage and microsurgical treatment, data on the neurosurgical procedure employed for aneurysm occlusion, and factors associated with the treated aneurysm, specifically location and size, were also evaluated. RESULTS: One hundred and seventeen patients were submitted to 139 neurosurgical procedures, in which 167 aneurysms were clipped. The overall rate of residual injury was 23%. Smoking (odds ratio [OR]: 3.38, 95% confidence interval [CI95%]: 1.372-8.300, p=0.008), lesion size >10 mm (OR: 5.136, CI95%: 2.240-11.779, p<0.001) and surgery duration >6 h (OR: 8.667, CI95%: 2.713-27.681, p<0.001) were found to significantly impact incomplete aneurysm occlusion in the univariate analyses. CONCLUSION: Incomplete microsurgical aneurysm occlusion is associated with aneurysm size, complexity, and current smoking status. Currently, there is no consensus on postoperative assessment of clipped aneurysms, hindering the correct assessment of treatment outcomes.