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1.
J Clin Neurosci ; 92: 67-74, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34509265

RESUMO

Errors in communication are a major source of preventable medical errors. Neurosurgical patients frequently present to the neuro-intensive care unit (NICU) postoperatively, where handoffs occur to coordinate care within a large multidisciplinary team. A multidisciplinary working group at our institution started an initiative to improve postoperative neurosurgical handoffs using validated quality improvement methodology. Baseline handoff practices were evaluated through staff surveys and serial observations. A formalized handoff protocol was implemented using the evidence based IPASS format (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, Synthesis by receiver). Cycles of objective observations and surveys were employed to track practice improvements and guide iterative process changes over one year. Surveys demonstrated improved perceptions of handoffs as organized (17.1% vs 69.7%, p < 0.001), efficient (27.0% vs. 72.7%, p < 0.001), comprehensive (17.1% vs. 66.7%, p < 0.001), and safe (18.0% vs. 66.7%, p < 0.001), noting improved teamwork (31.5% vs. 69.7%, p < 0.001). Direct observations demonstrated improved communication of airway concerns (47.1% observed vs. 92.3% observed, p < 0.001), hemodynamic concerns (70.6% vs. 97.1%, p = 0.001), intraoperative events (52.9% vs. 100%, p < 0.001), neurological examination (76.5% vs. 100%, p < 0.001), vital sign goals (70.6% vs. 100%, p < 0.001), and required postoperative studies (76.5% vs. 100%, p < 0.001). Receiving teams demonstrating improved rates of summarization (47.1% vs. 94.2%, p = 0.005) and asking questions (76.5% vs 98.1%, p = 0.004). The mean handoff time during long-term follow-up was 4.4 min (95% confidence interval = 3.9-5.0 min). Standardization of handoff practices yields improvements in communication practices for postoperative neurosurgical patients.

2.
J Stroke Cerebrovasc Dis ; 30(7): 105796, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33887664

RESUMO

INTRODUCTION: Novel machine learning (ML) methods are being investigated across medicine for their predictive capabilities while boasting increased adaptability and generalizability. In our study, we compare logistic regression with machine learning for feature importance analysis and prediction in first-pass reperfusion. METHODS: We retrospectively identified cases of ischemic stroke treated with mechanical thrombectomy (MT) at our institution from 2012-2018. Significant variables used in predictive modeling were demographic characteristics, medical history, admission NIHSS, and stroke characteristics. Outcome was binarized TICI on first pass (0-2a vs 2b-3). Shapley feature importance plots were used to identify variables that strongly affected outcomes. RESULTS: Accuracy for the Random Forest and SVM models were 67.1% compared to 65.8% for the logistic regression model. Brier score was lower for the Random Forest model (0.329 vs 0.342) indicating better predictive capability. Other supervised learning models performed worse than the logistic regression model, with accuracy of 56.2% for Naïve Bayes and 61.6% for XGBoost. Shapley plots for the Random Forest model showed use of aspiration, hyperlipidemia, hypertension, use of stent retriever, and time between symptom onset and catheterization as the top five predictors of first pass reperfusion. CONCLUSION: Use of machine learning models, such as Random Forest, for the study of MT outcomes, is more accurate than logistic regression for our dataset, and identifies new factors that contribute to achieving first pass reperfusion. The benefits of machine learning, such as improved predictive capabilities, integration of new data, and generalizability, establish ML as the preferred model for studying outcomes in stroke.


Assuntos
AVC Isquêmico/terapia , Aprendizado de Máquina , Reperfusão , Trombectomia , Circulação Cerebrovascular , Feminino , Humanos , AVC Isquêmico/diagnóstico , AVC Isquêmico/fisiopatologia , Masculino , Reperfusão/efeitos adversos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Trombectomia/efeitos adversos , Resultado do Tratamento
3.
Oper Neurosurg (Hagerstown) ; 21(1): E3-E7, 2021 06 15.
Artigo em Inglês | MEDLINE | ID: mdl-33571372

RESUMO

BACKGROUND: The transradial access (TRA) is rapidly gaining popularity for neuroendovascular procedures as there is strong evidence for its benefits compared to the traditional transfemoral access (TFA). However, the transition to TRA bears some challenges including optimization of the interventional suite set-up and workflow as well as its impact on fellowship training. OBJECTIVE: To compare the learning curves of TFA and TRA for diagnostic cerebral angiograms in neuroendovascular fellowship training. METHODS: We prospectively collected diagnostic angiogram procedural data on the performance of 2 neuroendovascular fellows with no prior endovascular experience who trained at our institution from July 2018 until June 2019. Metrics for operator proficiency were minutes of fluoroscopy time, procedure time, and volume of contrast used. RESULTS: A total of 293 diagnostic angiograms were included in the analysis. Of those, 57.7% were TRA and 42.3% were TFA. The median contrast dose was 60 cc, and the median radiation dose was 14 000 µGy. The overall complication rate was 1.4% consisting of 2 groin hematomas, 1 wrist hematoma, and 1 access-site infection using TFA. The crossover rate to TFA was 2.1%. Proficiency was achieved after 60 femoral and 95 radial cases based on fluoroscopy time, 52 femoral and 77 radial cases based on procedure time, and 53 femoral and 64 radial cases based on contrast volume. CONCLUSION: Our study demonstrates that the use of TRA can be safely incorporated into neuroendovascular training without causing an increase in complications or significantly prolonging procedure time or contrast use.


Assuntos
Bolsas de Estudo , Curva de Aprendizado , Angiografia , Artéria Femoral/diagnóstico por imagem , Humanos , Artéria Radial/diagnóstico por imagem , Artéria Radial/cirurgia
4.
Sci Rep ; 11(1): 1089, 2021 01 13.
Artigo em Inglês | MEDLINE | ID: mdl-33441762

RESUMO

Neuroangiography has seen a recent shift from transfemoral to transradial access. In transradial neuroangiography, the right dominant hand is the main access used. However, the left side may be used specifically for left posterior circulation pathologies and when right access cannot be used. This study describes our initial experience with left radial access for diagnostic neuroangiography and assesses the feasibility and safety of this technique. We performed a retrospective review of a prospective database of consecutive patients between April 2018 and January 2020, and identified 20 patients whom a left radial access was used for neurovascular procedures. Left transradial neuroangiography was successful in all 20 patients and provided the sought diagnostic information; no patient required conversion to right radial or femoral access. Pathology consisted of anterior circulation aneurysms in 17 patients (85%), brain tumor in 1 patient (5%), and intracranial atherosclerosis disease involving the middle cerebral artery in 2 patients (10%). The left radial artery was accessed at the anatomic snuffbox in 18 patients (90%) and the wrist in 2 patients (10%). A single vessel was accessed in 7 (35%), two vessels in 8 (40%), three vessels in 4 (20%), and four vessels in 1 (5%). Catheterization was successful in 71% of the cases for the right internal carotid artery and in only 7.7% for the left internal carotid artery. There were no instances of radial artery spasm, radial artery occlusion, or procedural complications. Our initial experience found the left transradial access to be a potentially feasible approach for diagnostic neuroangiography even beyond the left vertebral artery. The approach is strongly favored by patients but has significant limitations compared with the right-sided approach.


Assuntos
Angiografia Cerebral , Idoso , Cateterismo , Angiografia Cerebral/métodos , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Radial/cirurgia , Estudos Retrospectivos
5.
World Neurosurg ; 146: e607-e617, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33130285

RESUMO

BACKGROUND: Aneurysms associated with fenestrations of intracranial arteries are exceptionally rare findings. Management strategies for these aneurysms are not well-defined, especially regarding endovascular treatment. We sought to investigate the strategies and feasibility of endovascular treatment approaches for various fenestration-associated intracranial aneurysms. METHODS: We performed a retrospective chart review of 2000 aneurysms treated endovascularly, identifying 8 aneurysms located at arterial fenestrations. The technical details and procedural outcomes were reviewed to identify common management approaches, technical nuances, and treatment outcomes. RESULTS: There were 3 (37.5%) aneurysms associated with fenestrations of the basilar artery or vertebrobasilar junction. All 3 were successfully treated with a previously undescribed coil-assisted flow-diversion technique, resulting in complete obliteration. Three (37.5%) aneurysms were associated with fenestrations of the anterior communicating artery. Of those, 2 were successfully treated with stent-assisted coil embolization and 1 with coil embolization alone. One (12.5%) aneurysm was associated with a fenestration of the paraclinoid internal carotid artery and 1 (12.5%) aneurysm found was at the takeoff of the posterior inferior cerebellar artery at a fenestration of the vertebral artery. Both were successfully treated with coil-assisted flow diversion. There were no permanent procedural complications. Major considerations for endovascular management of these aneurysms were the dominance of fenestration trunks, aneurysms arising from the fenestration apex or a fenestration limb, amenability to flow diversion, and anticipation of vascular remodeling. CONCLUSIONS: Fenestration-associated aneurysms are very rare. We have identified common factors to help guide decision-making for endovascular approaches and demonstrate successful aneurysm treatment using these methods.


Assuntos
Artéria Carótida Interna/cirurgia , Angiografia Cerebral , Embolização Terapêutica , Aneurisma Intracraniano/terapia , Adulto , Idoso , Angiografia Cerebral/efeitos adversos , Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Feminino , Humanos , Imageamento Tridimensional/métodos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Artéria Vertebral/cirurgia
6.
J Neurosurg ; : 1-6, 2020 Nov 13.
Artigo em Inglês | MEDLINE | ID: mdl-33186909

RESUMO

OBJECTIVE: In this study, the authors aimed to investigate procedural and clinical outcomes between radial and femoral artery access in patients undergoing thrombectomy for acute stroke. METHODS: The authors conducted a single-institution retrospective analysis of 104 patients who underwent mechanical thrombectomy, 52 via transradial access and 52 via traditional transfemoral access. They analyzed various procedural and clinical metrics between the two patient cohorts. RESULTS: There was no difference between patient demographics or presenting symptoms of stroke severity between patients treated via transradial or transfemoral access. The mean procedural time was similar between the two treatment cohorts: 60.35 ± 36.81 minutes for the transradial group versus 65.50 ± 29.92 minutes for the transfemoral group (p = 0.451). The mean total fluoroscopy time for the procedure was similar between the two patient cohorts (20.31 ± 11.68 for radial vs 18.49 ± 11.78 minutes for femoral, p = 0.898). The majority of patients underwent thrombolysis in cerebral infarction score 2b/3 revascularization, regardless of access site (92.3% for radial vs 94.2% for femoral, p = 0.696). There was no significant difference in the incidence of access site or periprocedural complications between the transradial and transfemoral cohorts. CONCLUSIONS: Acute stroke intervention performed via transradial access is feasible and effective, with no significant difference in procedural and clinical outcomes compared with traditional transfemoral access. Larger studies are required to further validate the efficacy and limitations of transradial access for neurointerventional procedures.

7.
J Neurol Neurosurg Psychiatry ; 91(8): 846-848, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32354770

RESUMO

BACKGROUND: Emergence of the novel corona virus (severe acute respiratory syndrome (SARS)-CoV-2) in December 2019 has led to the COVID-19 pandemic. The extent of COVID-19 involvement in the central nervous system is not well established, and the presence or the absence of SARS-CoV-2 particles in the cerebrospinal fluid (CSF) is a topic of debate. CASE DESCRIPTION: We present two patients with COVID-19 and concurrent neurological symptoms. Our first patient is a 31-year-old man who had flu-like symptoms due to COVID-19 and later developed an acute-onset severe headache and loss of consciousness and was diagnosed with a Hunt and Hess grade 3 subarachnoid haemorrhage from a ruptured aneurysm. Our second patient is a 62-year-old woman who had an ischaemic stroke with massive haemorrhagic conversion requiring a decompressive hemicraniectomy. Both patients' CSF was repeatedly negative on real-time PCR analysis despite concurrent neurological disease. CONCLUSION: Our report shows that patients' CSF may be devoid of viral particles even when they test positive for COVID-19 on a nasal swab. Whether SARS-CoV-2 is present in CSF may depend on the systemic disease severity and the degree of the virus' nervous tissue tropism and should be examined in future studies.


Assuntos
Betacoronavirus/isolamento & purificação , Infecções por Coronavirus/líquido cefalorraquidiano , Infecções por Coronavirus/complicações , Pneumonia Viral/líquido cefalorraquidiano , Pneumonia Viral/complicações , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/virologia , Adulto , COVID-19 , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , SARS-CoV-2 , Acidente Vascular Cerebral/líquido cefalorraquidiano
8.
J Neurointerv Surg ; 12(4): 345-349, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32115436

RESUMO

BACKGROUND: Robots in surgery aid in performing delicate, precise maneuvers that humans, with inherent physical abilities, may be limited to perform. The CorPath 200 system is FDA approved and is being implemented in the US for interventional cardiology procedures. CorPath GRX robotic-assisted platform is the next-generation successor of CorPath 200. OBJECTIVE: To discuss the feasibility and early experience with the use of the CorPath GRX robotic-assisted platform for neuroendovascular procedures, including transradial diagnostic cerebral angiograms and transradial carotid artery stenting. METHODS: The cases of 10 consecutive patients who underwent neuroendovascular robotic-assisted procedures between December 1, 2019 and December 30, 2019, are presented. RESULTS: Seven patients underwent elective diagnostic cerebral angiography, and three patients underwent carotid artery angioplasty and stenting using the CorPath GRX robotic-assisted platform. All procedures were performed successfully, and no complications were encountered. Conversion to manual control occurred in three diagnostic cases because of a bovine arch that was previously not known. The fluoroscopy time and the procedure time continued to improve with subsequent procedures as we streamlined the workflow. CONCLUSION: This series demonstrates the early use of this technology. It could potentially be used in the near future for acute stroke interventions in remote geographic locations and in places where a neurointerventionalist is not available.


Assuntos
Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/cirurgia , Angiografia Cerebral/métodos , Procedimentos Endovasculares/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Artéria Carótida Primitiva/diagnóstico por imagem , Artéria Carótida Primitiva/cirurgia , Angiografia Cerebral/instrumentação , Procedimentos Endovasculares/instrumentação , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Robóticos/instrumentação , Stents , Resultado do Tratamento
9.
J Neurosurg ; : 1-6, 2019 Sep 13.
Artigo em Inglês | MEDLINE | ID: mdl-31518981

RESUMO

OBJECTIVE: The advent of mechanical thrombectomy (MT) has become an effective option for the treatment of acute ischemic stroke in addition to tissue plasminogen activator (tPA). With recent advances in device technology, MT has significantly altered the hospital course and functional outcomes of stroke patients. The authors' goal was to establish the most up-to-date reperfusion and functional outcomes with the evolution of MT technology. METHODS: The authors conducted a retrospective study of 403 patients who underwent MT for ischemic stroke at their institution from 2010 to 2017. They collected data on patient comorbidities, National Institutes of Health Stroke Scale (NIHSS) score on arrival, tPA administration, revascularization outcomes, and functional outcomes on discharge. RESULTS: In 403 patients, the mean NIHSS score on presentation was 15.8 ± 6.6, with 195 (48.0%) of patients receiving tPA prior to MT. Successful reperfusion (thrombolysis in cerebral infarction score 2B or 3) was achieved in 84.4%. Hemorrhagic conversion with significant mass effect was noted in 9.9% of patients. The median lengths of ICU and hospital stay were 3.0 and 7.0 days, respectively. Functional independence (modified Rankin Scale score 0-2) was noted in 125 (31.0%) patients, while inpatient mortality occurred in 43 (10.7%) patients. CONCLUSIONS: As MT has established acute ischemic stroke as a neurosurgical disease, there is a pressing need to understand the hospital course, hospital- and procedure-related complications, and outcomes for this new patient population. The authors provide a detailed account of key metrics for MT with the latest device technology and identify the predictors of unfavorable outcomes and inpatient mortality.

12.
Brain Res ; 1718: 231-241, 2019 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-31034813

RESUMO

BACKGROUND: The sphenopalatine ganglion (SPG) is a vasoactive mediator of the anterior intracranial circulation in mammals. SPG stimulation has been demonstrated to alter blood-brain barrier (BBB) permeability, although this phenomenon is not well characterized. OBJECTIVE: To determine the effect of SPG stimulation on the BBB using rat models. METHODS: Extravasation of fluorescent tracer 70 kDa FITC-dextran into rat brain specimens was measured across a range of stimulation parameters to assess BBB permeability. Tight junction (TJ) morphology was compared by assessing differences in the staining of proteins occludin and ZO-1 and analyzing ultrastructural changes on transmission electron microscopy (TEM) between stimulated and unstimulated specimens. RESULTS: SPG stimulation at 10 Hz maximally increased BBB permeability, exhibiting a 6-fold increase in fluorescent traceruptake (1.66% vs 0.28%, p < 0.0001). This effect was reversed 4-hours after stimulation (0.36% uptake, p = 0.99). High-frequency stimulation at 20 Hz and 200 Hz did not increase tracer extravasation, (0.26% and 0.28% uptake, p = >0.999 and p = 0.998, respectively). Stimulation was associated a significant decrease in the colocalization of occludin and ZO-1 with endothelial markers in stimulated brains compared to control (74.6% vs. 39.7% and 67.2% vs. 60.4% colocalization, respectively, p < 0.0001), and ultrastructural changes in TJ morphology associated with increased BBB permeability were observed on TEM. CONCLUSION: This study is the first to show a reversible, frequency-dependent increase in BBB permeability with SPG stimulation and introduces a putative mechanism of action through TJ disruption. Bypassing the BBB with SPG stimulation could enable new paradigms in delivering therapeutics to the CNS. Further study of this technology is needed.


Assuntos
Barreira Hematoencefálica/metabolismo , Fossa Pterigopalatina/inervação , Fossa Pterigopalatina/metabolismo , Animais , Estimulação Elétrica/métodos , Feminino , Ocludina/metabolismo , Permeabilidade/efeitos dos fármacos , Ratos , Ratos Sprague-Dawley , Proteínas de Junções Íntimas/metabolismo , Junções Íntimas/efeitos dos fármacos , Proteína da Zônula de Oclusão-1/metabolismo
14.
World Neurosurg ; 110: e585-e592, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29175567

RESUMO

OBJECTIVE: Stereoelectroencephalography (sEEG) requires extensive preoperative planning to optimize placement of electrodes and limit the potential for complications. Flat-detector computed tomography (FD-CT) has previously been used for perioperative vascular imaging to guide the treatment of vascular lesions. This imaging modality provides a detailed depiction of cerebrovascular and bony cranial anatomy, which can be used to guide intracranial electrode implantation. We have developed a novel method to improve preoperative planning for sEEG electrode implantation and limit the potential for postoperative complications by using FD-CT imaging merged with preoperative magnetic resonance imaging (MRI). METHODS: All patients underwent preoperative FD-CT with selective intra-arterial iodinated contrast dye injection through the late arterial and capillary phases for evaluation of cerebrovascular anatomy. These results were merged with thin-cut MRI for trajectory planning of intracranial sEEG electrodes. All patients underwent routine CT and MRI after electrode placement. RESULTS: 39 patients have undergone sEEG implantation according to this protocol, with a total of 541 electrodes placed. Additionally, 25 (64.1%) patients underwent implantation of 70 oblique insular electrodes. There were no clinically significant complications after the implantations. Thirty-six (92.3%) patients underwent operative intervention, including surgical resection in 27 (69.2%) patients. CONCLUSION: FD-CT imaging allows for a detailed depiction of cortical cerebrovascular anatomy through the capillary phase, in addition to bony cranial anatomy. This enables the safe planning of complex trajectories, including high-obliquity insular electrodes and transsulcal trajectories through "empty sulci" while also providing concurrent imaging of bony anatomy to allow for preoperative planning of drill depth and anchor placement.


Assuntos
Angiografia Cerebral , Eletrodos Implantados , Eletroencefalografia , Procedimentos Neurocirúrgicos , Técnicas Estereotáxicas , Tomografia Computadorizada por Raios X , Adolescente , Adulto , Córtex Cerebral/irrigação sanguínea , Córtex Cerebral/diagnóstico por imagem , Córtex Cerebral/fisiopatologia , Córtex Cerebral/cirurgia , Meios de Contraste , Epilepsia Resistente a Medicamentos/diagnóstico por imagem , Epilepsia Resistente a Medicamentos/fisiopatologia , Epilepsia Resistente a Medicamentos/cirurgia , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/métodos , Crânio/diagnóstico por imagem , Crânio/fisiopatologia , Crânio/cirurgia , Cirurgia Assistida por Computador , Tomografia Computadorizada por Raios X/métodos , Adulto Jovem
15.
J Clin Neurosci ; 36: 59-63, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27815027

RESUMO

Teratomas of the spinal cord are incredibly rare, comprising less than 0.5% of all spinal cord tumors. These tumors are exceptionally rare in adults, with only a handful of cases reported in the literature. We present the case of a 49-year-old gentleman with new onset urinary incontinence who presented with a large intradural tumor of the thoracolumbar spine. The patient underwent a laminectomy with midline durotomy for subtotal tumor resection. Surgical pathology diagnosed the tumor as a mature teratoma, exhibiting the presence of all three germ layers. These tumors tend to present with an indolent onset of symptoms characteristic of the tumor location within the spinal cord and the affected surrounding nerve roots. Magnetic resonance imaging (MRI) is useful in determining the location and nature of these tumors, but final diagnosis ultimately rests on histopathological analysis. Surgical resection is the preferred treatment, with subtotal resection being favored if there is a high risk of intraoperative neurological damage due to adherent or infiltrative tumor. In general, the prognosis for these tumors is good, with most patients exhibiting stable or improved neurological status after resection.


Assuntos
Neoplasias da Medula Espinal/patologia , Teratoma/patologia , Humanos , Laminectomia , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Neoplasias da Medula Espinal/diagnóstico por imagem , Neoplasias da Medula Espinal/cirurgia , Teratoma/diagnóstico por imagem , Teratoma/cirurgia
16.
Epilepsia ; 57(10): 1697-1708, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27549686

RESUMO

OBJECTIVE: Intracranial monitoring is fundamental to epilepsy surgery, with reported complication rates of 3-17%. We aimed to assess the differences in complication rates between subdural and depth electrodes. METHODS: We conducted a retrospective review of 317 electrode implantation procedures. All documented abnormal postoperative findings were recorded in our study. Those that resulted in a significant alteration of treatment course, including neurologic deficit, long-term medication use, reoperation, or hospital readmission, were deemed clinically significant. When possible, findings were attributed to a particular electrode type based on relative location to each electrode. RESULTS: Postoperative abnormalities were associated with SDE placement in 152 (47.9%) procedures and 40 (25.2%) DE placements (p < 0.001). Twenty-nine (9.1%) clinically significant complications were seen in the subdural electrode (SDE) group compared to 10 associated with DEs (6.3%, p = 0.37). SDEs were associated with increased rates of any postoperative hemorrhage (p < 0.001) or extraaxial collection (p = 0.007). Subdural grid placement was associated with an increased risk of any extraaxial collection (odds ratio [OR 2.42), as well as clinically significant collections (OR 9.47). Previous craniotomy was found to be associated with any abnormal postoperative finding (OR 1.71) as well as radiographic hemorrhage (OR 1.99). Concurrent resection is also associated with abnormal findings (OR 1.83) and extraaxial collections (OR 2.37). The overall complication rate was 9.1%, with 13 procedures (4.1%) resulting in neurologic deficit. However, only two patients (0.6%) had permanent neurologic sequelae resulting from lead placement. SIGNIFICANCE: Subdural electrodes appear to have an increased rate of abnormal postoperative findings, including hemorrhage and extraaxial collections; however, there was no difference in clinically significant findings. Subdural grids also appear to be associated with symptomatic extraaxial collections, and previous craniotomy increases the risk of hemorrhage. Overall, intracranial monitoring remains a safe and effective procedure for localization of operative seizure foci. Patient selection and risk education for various modalities is an essential aspect of preoperative evaluation.


Assuntos
Eletrodos Implantados/efeitos adversos , Epilepsia/cirurgia , Procedimentos Neurocirúrgicos/métodos , Complicações Pós-Operatórias/fisiopatologia , Espaço Subdural/cirurgia , Adolescente , Adulto , Idoso , Criança , Eletroencefalografia/métodos , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Estudos Retrospectivos , Tomógrafos Computadorizados , Adulto Jovem
17.
Int Forum Allergy Rhinol ; 4(7): 577-82, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24574271

RESUMO

Unrepaired orbital floor defects after sinonasal and skull-base tumor resection can lead to herniation of orbital contents into the maxillary or ethmoidal sinuses, possibly resulting in infection and significant cosmetic and functional deficits. Orbital floor defects are usually repaired using prosthetic implants or autogenous material. Nasal septal cartilage has been used previously as a free graft for reconstruction. However, its reliance on local vascular supply can result in ischemia and necrosis in the postoperative period. The vascularized pedicled nasoseptal flap, consisting of mucoperichondrium and mucoperiosteum, is routinely used as an effective reconstruction method for endoscopic repair of cerebrospinal fluid leaks arising from skull base dural defects. However, this flap does not provide rigid structural reconstruction when used alone. We report a case of an orbital floor defect repaired using a pedicled mucochondral-osteal nasoseptal flap. This technique incorporates the structural component of the nasal septal cartilage and bone with the vascularized pedicled nasoseptal flap. This repair technique may be useful in patients requiring postoperative radiotherapy.


Assuntos
Neoplasias do Seio Maxilar/cirurgia , Órbita/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Neoplasias da Base do Crânio/cirurgia , Retalhos Cirúrgicos/estatística & dados numéricos , Humanos , Processamento de Imagem Assistida por Computador , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Cartilagens Nasais/transplante , Septo Nasal/patologia , Septo Nasal/cirurgia , Neoplasias da Base do Crânio/patologia
18.
J Clin Neurosci ; 20(9): 1193-9, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-23810386

RESUMO

Central neurocytomas are rare benign tumors of the central nervous system that are typically located in the lateral ventricles. Since they were first reported in the early 1980s, many advancements have been made in terms of their diagnosis and treatment. Despite the progress made, the origin of these rare tumors and effective newer treatment strategies remain elusive. Central neurocytomas represent 0.1-0.5% of all primary brain tumors. Since they are typically intraventricular, these tumors tend to present clinically with hydrocephalus. CT scanning and MRI are useful in localizing these tumors; however, due to their numerous ambiguous features, the ultimate diagnosis relies on immunohistochemistry and electron microscopy studies of sampled tissue. Currently, surgical removal with a gross-total resection of these tumors is the treatment of choice. Various radiotherapy techniques, including both conventional radiotherapy and stereotactic radiosurgery, have been shown to be useful in cases of residual tumor after sub-total resection and tumor recurrence. The benign nature of these tumors tends to offer a favorable outcome for most patients; however, recurrence rates are relatively high and tumors with high-grade features or extraventricular location tend to have a less favorable prognosis. We present a comprehensive review of these rare tumors, including their epidemiology, clinical presentation, radiological presentation, histopathological findings, and options for intervention including surgery, radiation therapy, stereotactic radiosurgery, and chemotherapy.


Assuntos
Neoplasias Encefálicas , Neoplasias do Ventrículo Cerebral , Neurocitoma , Animais , Antineoplásicos/administração & dosagem , Neoplasias Encefálicas/diagnóstico , Neoplasias Encefálicas/etiologia , Neoplasias Encefálicas/terapia , Neoplasias do Ventrículo Cerebral/diagnóstico , Neoplasias do Ventrículo Cerebral/etiologia , Neoplasias do Ventrículo Cerebral/terapia , Humanos , Neurocitoma/diagnóstico , Neurocitoma/etiologia , Neurocitoma/terapia , Radiocirurgia/métodos , Resultado do Tratamento
19.
J Clin Neurosci ; 20(11): 1599-603, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-23706185

RESUMO

Acromegaly is a relatively rare neuroendocrine disorder associated with diffuse hypertrophy of bony and soft tissues due to growth hormone hypersecretion from a pituitary adenoma. Acromegaly can also cause numerous pathological changes in the spine, including degenerative osteoarticular disease, axial arthropathy, spinal stenosis, vertebral fracture and diffuse idiopathic skeletal hyperostosis (Forestier's disease). Ossified ligamentum flavum (OLF) is a rare disorder that often presents as thoracic spinal stenosis, but to our knowledge has never been described in patients with acromegaly. Previously, no link has been established between these two entities. We present, to our knowledge, the first reported case of OLF in a patient with acromegaly who presented with thoracic spinal cord compression. OLF is a potential spinal manifestation of acromegaly and should be considered in the differential diagnosis of spinal stenosis or spinal cord compression in the context of growth hormone hypersecretion.


Assuntos
Acromegalia/complicações , Ligamento Amarelo/patologia , Ossificação Heterotópica/complicações , Compressão da Medula Espinal/etiologia , Comorbidade , Feminino , Infecções por HIV/epidemiologia , Humanos , Pessoa de Meia-Idade , Ossificação Heterotópica/cirurgia
20.
Neurosurg Focus ; 34(3): E5, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-23451818

RESUMO

OBJECT: Malignant peripheral nerve sheath tumors (MPNSTs) are a rare form of malignancy arising from the Schwann cells of peripheral nerves. MPNSTs of the trigeminal nerve are exceptionally rare, with only a handful of reports in the literature. These tumors are typically very aggressive, resulting in significant patient morbidity and a generally grim prognosis. Most current reports suggest that radical resection with radiation therapy offers the best benefit. In this study, the authors systematically reviewed the world English-language literature on MPNSTs of the trigeminal nerve to analyze the presentations, treatment options, and outcomes for patients with this disease. METHODS: A literature search for MPNSTs of the trigeminal nerve confined to nonanimal, English-language articles was conducted utilizing the PubMed database, with additional cases chosen from the references of selected articles. Only cases of confirmed MPNSTs of the trigeminal nerve or its peripheral branches, based upon surgical, pathological, or radiological analysis, were included. RESULTS: From the literature search, 29 articles discussing 35 cases of MPNSTs of the trigeminal nerve were chosen. With the addition of 1 case from their own institution, the authors analyzed 36 cases of trigeminal MPNSTs. The average age of onset was 44.6 years. These tumors were more commonly seen in male patients (77.1%). The gasserian ganglion was involved in 36.1% of the cases. Of the cases in which the nerve distribution was specified (n = 25), the mandibular branch was most commonly involved (72.0%), followed by the maxillary branch (60.0%) and the ophthalmic branch (32.0%), with 44.0% of patients exhibiting involvement of 2 or more branches. Altered facial sensation and facial pain were the 2 most commonly reported symptoms, found in 63.9% and 52.8% of patients, respectively. Mastication difficulty and diplopia were seen in 22.2% of patients, facial weakness was seen in 19.4%, and hearing loss was present in 16.7%. With regard to the primary treatment strategy, 80.6% underwent resection, 16.7% underwent radiation therapy, and 2.9% received chemotherapy alone. Patients treated with complete resection followed by postoperative radiation therapy had the most favorable outcomes, with no patients showing evidence of disease recurrence with a mean follow-up of 34.6 months. Patients treated with incomplete resection followed by postoperative radiation therapy had more favorable outcomes than patients treated with incomplete resection without radiation therapy or radiation therapy alone. CONCLUSIONS: Trigeminal MPNSTs most commonly present as altered facial sensation or facial pain, although they exhibit a number of other clinical manifestations, including the involvement of other cranial nerves. While a variety of treatment options exist, due to their highly infiltrative nature, aggressive resection followed by radiation therapy appears to offer the greatest chance of recurrence-free survival.


Assuntos
Neoplasias dos Nervos Cranianos/cirurgia , Neoplasias da Bainha Neural/cirurgia , Doenças do Nervo Trigêmeo/cirurgia , Adolescente , Adulto , Idade de Início , Idoso , Idoso de 80 Anos ou mais , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Criança , Terapia Combinada , Neoplasias dos Nervos Cranianos/tratamento farmacológico , Neoplasias dos Nervos Cranianos/epidemiologia , Neoplasias dos Nervos Cranianos/patologia , Neoplasias dos Nervos Cranianos/radioterapia , Diplopia/etiologia , Neuralgia Facial/etiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Neoplasias da Bainha Neural/tratamento farmacológico , Neoplasias da Bainha Neural/epidemiologia , Neoplasias da Bainha Neural/patologia , Neoplasias da Bainha Neural/radioterapia , Neurocirurgia/métodos , Prognóstico , Radioterapia Adjuvante , Resultado do Tratamento , Doenças do Nervo Trigêmeo/tratamento farmacológico , Doenças do Nervo Trigêmeo/epidemiologia , Doenças do Nervo Trigêmeo/patologia , Doenças do Nervo Trigêmeo/radioterapia , Adulto Jovem
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