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OBJECTIVE: Several pathologies either invade or arise within the orbit. These include meningiomas, schwannomas, and cavernous hemangiomas among others. Although several studies describing various approaches to the orbit are available, no study describes all cranio-orbital and orbitocranial approaches with clear, surgically oriented anatomical descriptions. As such, this study aimed to provide a comprehensive guide to the microsurgical and endoscopic approaches to and through the orbit. METHODS: Six formalin-fixed, latex-injected cadaveric head specimens were dissected in the surgical anatomy laboratory at the authors' institution. In each specimen, the following approaches were modularly performed: endoscopic transorbital approaches (ETOAs), including a lateral transorbital approach and a superior eyelid crease approach; endoscopic endonasal approaches (EEAs), including those to the medial orbit and optic canal; and transcranial approaches, including a supraorbital approach, a fronto-orbital approach, and a 3-piece orbito-zygomatic approach. Each pertinent step was 3D photograph-documented with macroscopic and endoscopic techniques as previously described. RESULTS: Endoscopic endonasal approaches to the orbit afforded excellent access to the medial orbit and medial optic canal. Regarding ETOAs, the lateral transorbital approach afforded excellent access to the floor of the middle fossa and, once the lateral orbital rim was removed, the cavernous sinus could be dissected and the petrous apex drilled. The superior eyelid approach provides excellent access to the anterior cranial fossa just superior to the orbit, as well as the dura of the lesser wing of the sphenoid. Craniotomy-based approaches provided excellent access to the anterior and middle cranial fossa and the cavernous sinus, except the supraorbital approach had limited access to the middle fossa. CONCLUSIONS: This study outlines the essential surgical steps for major cranio-orbital and orbitocranial approaches. Endoscopic endonasal approaches offer direct medial access, potentially providing bilateral exposure to optic canals. ETOAs serve as both orbital access and as a corridor to surrounding regions. Cranio-orbital approaches follow a lateral-to-medial, superior-to-inferior trajectory, progressively allowing removal of protective bony structures for proportional orbit access.
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Procedimentos Neurocirúrgicos , Órbita , Humanos , Procedimentos Neurocirúrgicos/métodos , Órbita/cirurgia , Endoscopia/métodos , Fossa Craniana Média/cirurgia , Craniotomia/métodos , CadáverRESUMO
OBJECTIVE: Idiopathic normal pressure hydrocephalus (iNPH) represents an insidious type of dementia considered reversible after shunt placement. Although the clinical outcome has been widely studied, few studies have reported on quality of life (QOL) after surgery. This study evaluated the long-term clinical and QOL outcomes of iNPH patients after ventriculoperitoneal shunt (VPS) implantation. Factors influencing QOL in iNPH were also investigated. METHODS: From 2009 to 2020, a single-institution retrospective study was conducted to compare shunted iNPH patients with a homogeneous control group. QOL was analyzed using the SF-36 questionnaire with yearly follow-up for as long as 11 years. Severity of symptoms, comorbidities, and clinical data were also recorded. RESULTS: Among 187 treated patients, 15 had died at the time of the authors' evaluation, and 45 did not match the inclusion criteria. The mean ± SD (range) follow-up was 118.5 ± 4.2 (18-132) months. QOL improved in 103/130 (79%) patients through 5 years after shunt surgery, although it remained lower than that of the control group (p < 0.0001). The SF-36 score reduced progressively, reaching baseline at 5-7 years of follow-up and decreased to below baseline at 7-11 years of follow-up (p < 0.0001). Predictors of improved QOL were younger age (p < 0.001), lower body mass index (BMI) (p < 0.001), and better Mini-Mental State Examination (MMSE) performance (p < 0.001) before surgery. Decreased postoperative QOL was associated with cerebrovascular disease, diabetes, and severity of symptoms (gait and cognition) at presentation (p < 0.001). CONCLUSIONS: VPS implantation, along with a strict and comprehensive follow-up, has been shown to improve QOL in iNPH patients for as long as 5 years after surgery. Younger age, lower BMI, and better MMSE score are positive predictors of improved QOL after shunt placement.
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Hidrocefalia de Pressão Normal , Humanos , Hidrocefalia de Pressão Normal/cirurgia , Hidrocefalia de Pressão Normal/diagnóstico , Hidrocefalia de Pressão Normal/etiologia , Qualidade de Vida , Resultado do Tratamento , Estudos Retrospectivos , Derivação Ventriculoperitoneal/efeitos adversosRESUMO
Although the therapeutic armamentarium for brain metastases (BMs) has been expanded from innovative surgical techniques and radiotherapy to include targeted therapies and immunotherapy, the prognosis of BMs remains poor. Despite the proven efficacy of numerous compounds in preclinical studies, the limited penetration of promising therapeutic agents across the blood-brain barrier (BBB) remains an unaddressed issue. Recently, low-intensity magnetic resonance-guided focused ultrasound (MRgFUS) in combination with microbubbles has been shown to overcome vascular and cellular transport barriers in the brain and tumor microenvironment, resulting in increased drug diffusion and preliminary effective results. Preclinical studies have investigated the increased penetration of many therapeutic agents including doxorubicin, trastuzumab, and ipilimumab into the CNS with promising results. Furthermore, anticancer drugs combined with MRgFUS-induced BBB opening have been demonstrated to improve animal survival and slow tumor progression. Accordingly, the first clinical trial has recently been launched and hopefully the results will provide evidence for the safety and efficacy of drug delivery enhanced by MRgFUS-induced BBB opening in BMs. This review aims to provide an overview of transcranial low-intensity MRgFUS application for BBB disruption and a comprehensive overview of the most relevant evidence in the treatment of BMs.
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Antineoplásicos , Neoplasias Encefálicas , Animais , Barreira Hematoencefálica , Encéfalo/diagnóstico por imagem , Neoplasias Encefálicas/diagnóstico por imagem , Neoplasias Encefálicas/tratamento farmacológico , Antineoplásicos/uso terapêutico , Ultrassonografia/métodos , Sistemas de Liberação de Medicamentos/métodos , Imageamento por Ressonância Magnética/métodos , Microambiente TumoralRESUMO
BACKGROUND AND PURPOSE: Patients with cervical spondylosis often present with concurrent 'atypical symptoms' of unknown etiology that have been associated with cervical spondylotic disease, including dizziness, headache, nausea, tinnitus, blurred vision, palpitations, and memory and gastrointestinal disturbances. Few studies have addressed whether surgical intervention to treat classic symptoms of cervical spondylosis can also effectively alleviate atypical symptoms. Accordingly, the purpose of this study is to compare the ability of cervical arthroplasty (CA) and anterior cervical discectomy and fusion (ACDF) to alleviate atypical symptoms associated with cervical spondylosis. MATERIALS AND METHODS: A retrospective analysis of 140 patients with cervical spondylosis and associated atypical symptoms was performed. Atypical symptoms were defined vertigo, headache, nausea and vomiting, tinnitus, blur vision, palpitation, hypomnesia, and gastroenteric disturbances not otherwise explained by medical comorbidities. Seventy-eight patients (55.7%) underwent ACDF and 62 (44.3%) patients underwent CA. Demographics, surgical characteristics, patient reported outcome measures (PROMs), radiographs, complication rates, and resolution in atypical symptoms were recorded and compared between groups. Atypical symptoms were assessed using a 20-point system. All the patients had a minimum of five years follow-up. RESULTS: VAS, SF-36, JOA, and NDI scores improved significantly in all the patients (p < 0.001). At the last follow-up, the fusion rate was 97% in the ACDF group. Atypical symptoms improved in both groups (p < 0.001), although the ACDF group demonstrated greater improvement in headache and vertigo resolution compared to the CA group (p < 0.0001). CONCLUSIONS: While both ACDF and CA are effective in alleviating atypical symptoms associated with cervical spondylosis, ACDF demonstrated greater improvements in atypical symptoms.
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Fusão Vertebral , Espondilose , Zumbido , Humanos , Estudos Retrospectivos , Zumbido/etiologia , Zumbido/cirurgia , Resultado do Tratamento , Vértebras Cervicais/cirurgia , Fusão Vertebral/efeitos adversos , Discotomia/efeitos adversos , Artroplastia/efeitos adversos , Vertigem/complicações , Vertigem/cirurgia , Náusea , Espondilose/complicações , Espondilose/cirurgia , Cefaleia/etiologia , Transtornos da Visão/etiologiaRESUMO
Brain edema after severe traumatic brain injury (TBI) plays an important role in the outcome and survival of injured patients. It is also one of the main targets in the therapeutic approach in the current clinical practice. To date, the pathophysiology of traumatic brain swelling is complex and, being that it is thought to be mainly cytotoxic and vasogenic in origin, not yet entirely understood. However, based on new understandings of the hydrodynamic aspects of cerebrospinal fluid (CSF), an additional mechanism of brain swelling can be considered. An increase in pressure into the subarachnoid space, secondary to traumatic subarachnoid hemorrhage, would result in a rapid shift of CSF from the cisterns, through the paravascular spaces, into the brain, resulting in an increase of brain water content. This mechanism of brain swelling would be termed as "CSF-shift edema." This "CSF-shift," promoted by a pressure gradient, leads to increased pressure inside the paravascular spaces and the interstitium of the brain, disturbing the functions of the paravascular system, with implications of secondary brain injury. Cisternostomy, an emerging surgical treatment, would reverse the direction of the CSF-shift, allowing for a decrease in brain swelling. In addition, this technique would reduce the pressure in the paravascular spaces and interstitium, leading to a recovery of the functionality of the paravascular system.
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Edema Encefálico/líquido cefalorraquidiano , Lesões Encefálicas Traumáticas/líquido cefalorraquidiano , Lesões Encefálicas Traumáticas/cirurgia , Espaço Extracelular/metabolismo , HumanosRESUMO
Idiopathic normal pressure hydrocephalus (iNPH) is a neurological disorder characterized by the triad of gait disturbance, cognitive impairment, and urinary incontinence. The condition is diagnosed mainly in older adults and is associated with ventricular enlargement without an increase in cerebrospinal fluid pressure. The clinical assessment involves a detailed medical history, physical examination, and cognitive testing. Neuroimaging is an essential part of the diagnostic workup for iNPH. However, to determine the suitability of patients for shunt surgery, a range of invasive preoperative investigations are employed. This narrative review aims to provide a comprehensive analysis of the current literature on invasive preoperative investigations in iNPH, focusing primarily on the lumbar infusion test, cerebrospinal fluid drainage tests, and continuous intracranial pressure monitoring. The strengths and limitations of each method, as well as their potential impact on treatment outcomes, are discussed.
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Hidrocefalia de Pressão Normal , Doenças do Sistema Nervoso , Humanos , Idoso , Hidrocefalia de Pressão Normal/diagnóstico por imagem , Hidrocefalia de Pressão Normal/cirurgia , Resultado do Tratamento , Doenças do Sistema Nervoso/cirurgia , Derivações do Líquido Cefalorraquidiano/métodosRESUMO
OBJECTIVE: One of the pressing constraints in the treatment of arteriovenous malformations (AVM) is the potential development of new neurologic deficits, mainly when the AVM is in an eloquent area. The risk of ischemia when an en passage arterial supply is present is not negligible. In this regard, awake surgery holds promise in increasing the safety of low-grade AVM resection. METHODS: We conducted a pilot trial on 3 patients with low-grade AVMs affecting speech areas to evaluate the safety of awake craniotomy using Conscious Sedation. Each feeder was temporarily clipped before the section. Also, we performed a systematic review to analyze the existing data about the impact of awake surgery in eloquent AVM resection. RESULTS: None of the 3 patients presented with neurologic deficits after the procedure. Awake craniotomy was useful in 1 case, as it allowed the detection of speech arrest during the temporal clipping of 1 of the feeders. This vessel was identified as an en passage vessel, closer to the nidus. The second attempt revealed the feeder of the AVM, which was sectioned. Systematic review yielded 7 studies meeting our inclusion criteria. Twenty-six of 33 patients included in these studies presented with AVM affecting speech area. Only 2 studies included the motor evoked potentials. Six studies used direct cortical and subcortical stimulation. In all studies the asleep-awake-asleep technique was used. CONCLUSIONS: Awake craniotomies are safe procedures and may be helpful in avoiding ischemic complications in low-grade AVMs, either affecting eloquent areas and/or when en passage feeders are present.
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BACKGROUND: Enhanced recovery after surgery (ERAS) is a multidisciplinary approach aimed at reducing the length of hospital stay, improving patient outcomes, and reducing the overall cost of care. Although ERAS protocols have been widely adopted in various surgical fields, their application in cranial surgery remains relatively limited. METHODS: Considering that the aging of the population presents significant challenges to healthcare systems, and there is currently no ERAS protocol available for geriatric patients over the age of 65 requiring cranial surgery, this article proposes a new ERAS protocol for this population by analyzing successful ERAS protocols and optimal perioperative care for geriatric patients described in the literature. RESULTS: Our aim is to develop a feasible, safe, and effective protocol for geriatric patients undergoing elective craniotomy, which includes preoperative, intraoperative, and postoperative assessments and management, as well as outcome measures. CONCLUSIONS: This multidisciplinary and evidence-based ERAS protocol has the potential to reduce perioperative morbidity, improve functional recovery, and enhance postoperative outcomes after cranial surgery in elderly. Further research will be necessary to establish strict guidelines.
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Recuperação Pós-Cirúrgica Melhorada , Humanos , Idoso , Craniotomia/métodos , Assistência Perioperatória/métodos , Recuperação de Função Fisiológica , Idoso de 80 Anos ou mais , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/epidemiologia , Procedimentos Neurocirúrgicos/métodos , Tempo de InternaçãoRESUMO
The leading cause of trigeminal neuralgia (TGN) relies on the microvascular conflict between the superior cerebellar artery (SCA) loop and the dorsal root entry zone of the trigeminal nerve (TN). However, lesions along the TN have been described as a possible cause of TGN for direct mass effect or indirect vascular transposition. Thus, the surgical approach to TGN in patients harboring cerebellopontine angle or Meckel's cave tumor should be methodically chosen. The retrosigmoid (RS) approach with suprameatal extension offers direct access to the TN in both its cisternal and Meckel's cave segment, allowing optimal TN decompression from vascular and tumoral components. Although the RS approach with suprameatal extension has been described in numerous studies,1-4 videos detailing its key steps in addressing a multicomponent TGN are lacking. In this video, we highlight the case of a 46 year-old woman with 6 months of medically refractory typical TGN with a right en plaque meningioma involving the petrous bone, petroclival junction, Meckel's cave, and tentorium. In addition, magnetic resonance imaging was suspicious for a compressive SCA loop over the dorsal root entry zone. The patient underwent a RS approach with suprameatal extension for subtotal resection of the tumor and microvascular decompression of the TGN. The patient recovered with no complications and TGN resolved.
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BACKGROUND AND OBJECTIVES: The retrosigmoid approach with transtentorial extension (RTA) allows us to address posterior cranial fossa pathologies that extend through the tentorium into the supratentorial space. Incision of the tentorium cerebelli is challenging, especially for the risk of injury of the cranial nerve (CN) IV. We describe a tentorial incision technique and relevant anatomic landmarks. METHODS: The RTA was performed stepwise on 5 formalin-fixed (10 sides), latex-injected cadaver heads. The porus trigeminus's midpoint, the lateral border of the suprameatal tubercle (SMT)'s base, and cerebellopontine fissure were assessed as anatomic landmarks for the CN IV tentorial entry point, and relative measurements were collected. A clinical case was presented. RESULTS: The tentorial opening was described in 4 different incisions. The first is curved and starts in the posterior aspect of the tentorium. It has 2 limbs: a medial one directed toward the tentorium's free edge and a lateral one that extends toward the superior petrosal sinus (SPS). The second incision turns inferiorly, medially, and parallel to the SPS down to the SMT. At that level, the second incision turns perpendicular toward the tentorium's free edge and ends 1 cm from it. The third incision proceeds posteriorly, parallel to the free edge. At the cerebellopontine fissure, the incision can turn toward and cut the tentorium-free edge (fourth incision). On average, the CN IV tentorial entry point was 12.7 mm anterior to the SMT base's lateral border and 20.2 mm anterior to the cerebellopontine fissure. It was located approximately in the same coronal plane as the porus trigeminus's midpoint, on average 1.9 mm anterior. CONCLUSION: The SMT and the cerebellopontine fissure are consistently located posterior to the CN IV tentorial entry point. They can be used as surgical landmarks for RTA, reducing the risk of injury to the CN IV.
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Procedimentos Neurocirúrgicos , Humanos , Procedimentos Neurocirúrgicos/métodos , Fossa Craniana Posterior/cirurgia , Fossa Craniana Posterior/anatomia & histologia , Cadáver , Traumatismos dos Nervos Cranianos/prevenção & controle , Traumatismos dos Nervos Cranianos/etiologia , Craniotomia/métodos , Masculino , Nervo Troclear/anatomia & histologia , Nervo Troclear/cirurgiaRESUMO
BACKGROUND AND OBJECTIVES: The trans-sinus transglabellar and bifrontal approaches offer direct access to the anterior cranial fossa. However, these approaches present potential drawbacks. We propose the biportal endoscopic transfrontal sinus (BETS) approach, adapting endoscopic endonasal approach (EEA) techniques for minimally invasive access to the anterior fossa, reducing tissue manipulation, venous sacrifice, and brain retraction. METHODS: Six formalin specimens were used. BETS approach involves 2 incisions over the medial aspect of both eyebrows from the supraorbital notch to the medial end of the eyebrow. A unilateral pedicled pericranial flap is harvested. A craniotomy through the anterior table of the frontal sinus (FS) and a separate craniotomy through the posterior table are performed. Two variants of the approach (preservative vs cranialization) are described for opening and reconstruction of the FS based on the desired pathology to access. Bone flap replacement can be performed with titanium plates and filling of the external table defect with bone cement. RESULTS: Like in EEA, this approach provides access for endoscope and multiple working instruments to be used simultaneously. The approach allows wide access to the anterior cranial fossa, subfrontal, and interhemispheric corridors, all the way up to the suprachiasmatic corridor and through the lamina terminalis to the third ventricle. BETS provides direct access to the anterior fossa, minimizing the level of frontal lobe retraction and providing potentially less tissue disruption and improved cosmesis. Cerebrospinal fluid fistula risk remains one of the major concerns as the narrow corridor limits achieving a watertight closure which can be mitigated with a pedicled flap. Mucocele risk is minimized with full cranialization or reconstruction of the FS. CONCLUSION: The BETS approach is a minimally invasive approach that translates the concepts of EEA to the FS. It allows excellent access to the anterior cranial fossa structures with minimal frontal lobe retraction.
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Introduction: Imposter syndrome (IS), characterized by persistent doubts about one's abilities and fear of exposure as a fraud, is a prevalent psychological condition, particularly impacting physicians. In neurosurgery, known for its competitiveness and demands, the prevalence of IS remains high. Research question: Recognizing the limited literature on IS within the neurosurgical community, this European survey aimed to determine its prevalence among young neurosurgeons and identify associated factors. Material and methods: The survey, conducted by the Young Neurosurgeon Committee of the European Association of Neurosurgical Societies, gathered responses from 232 participants. The survey included demographics, the Clance Imposter Phenomenon Survey (CIPS), and an analysis of potential compensatory mechanisms. Results: Nearly 94% of respondents exhibited signs of IS, with the majority experiencing moderate (36.21%) or frequent (40.52%) symptoms. Analyses revealed associations between IS and factors such as level of experience, sex, and board-certification. Discussion and conclusion: The findings suggest a significant prevalence of IS among young neurosurgeons, with notable associations with sex and level of experience. Compensatory mechanisms, such as working hours, article reading, and participation in events, did not show significant correlations with IS. Notably, male sex emerged as an independent protective factor against frequent/intense IS, while reading more than five articles per week was identified as a risk factor. The identification of protective and risk factors, particularly the influence of gender and reading habits, contributes valuable insights for developing targeted interventions to mitigate IS and improve the well-being of neurosurgeons.
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BACKGROUND: Nondysraphic intramedullary lipomas of the cervical spine are extremely rare, and only a few cases have been reported. We aimed to provide a thorough review of the literature regarding patient characteristics, treatment options, and outcomes in these patients. We also provided an illustrative case from our institution, which we added to the pool of patients identified by our review. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the literature in PubMed/Medline, Web of Science, and Scopus databases was searched. Nineteen studies were included in the final quantitative analysis. The Joanna Briggs Institute critical appraisal tool was used to assess the risk of bias. RESULTS: We identified 24 patients with nondysraphic cervical intradural intramedullary lipoma of the spinal cord. The patients were predominantly male (70.8%) with a mean age of 30.3 years. Quadriparesis was observed in 33.3% of the cases, while paraparesis occurred in 25% of the patients. Sensory disturbances were observed in 8.3% of the cases. In some patients, the presenting symptoms were neck pain (4.2%) and headache (4.2%). Surgical treatment was performed in 22 cases (91.7%). In 13 cases (54.2%) a subtotal removal was reached, and in 8 cases (33.3%) partial tumor removal was feasible. In 1 case (4.2%) a simple laminectomy was performed. Fourteen patients (58.3%) improved, 6 (25%) were unvaried, and 2 (8.3%) worsened. The mean follow-up was 30.8 months. CONCLUSIONS: Overall, surgical treatment can provide substantial spinal cord decompression improving or stabilizing the neurologic deficits. Experience from our case, along with analysis of reports from the literature, suggests that careful and controlled resection may provide benefits and avoid serious complications otherwise that result from aggressive resection.
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Lipoma , Neoplasias da Medula Espinal , Humanos , Masculino , Adulto , Feminino , Neoplasias da Medula Espinal/diagnóstico por imagem , Neoplasias da Medula Espinal/cirurgia , Vértebras Cervicais/cirurgia , Vértebras Cervicais/patologia , Laminectomia , Lipoma/diagnóstico por imagem , Lipoma/cirurgia , Lipoma/patologia , Procedimentos Neurocirúrgicos , Imageamento por Ressonância MagnéticaRESUMO
OBJECTIVE: Although shunting has been shown to ameliorate symptoms in idiopathic normal pressure hydrocephalus (iNPH), its impact on health-related quality of life (HRQoL) has yet to be fully elucidated. Patient and caregiver subjective life satisfaction and HRQoL represent crucial indicators for assessing the well-being of individuals facing chronic illnesses, including iNPH. This study aimed to systematically analyze the existing data about HRQoL in iNPH-treated patients to evaluate the role of surgical treatment in such a scenario. METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the literature in the PubMed/Medline, Web of Science, and Scopus databases was searched. Fourteen studies met our inclusion criteria. The Joanna Briggs Institute critical appraisal tool was used to assess the risk of bias. RESULTS: Overall, HRQoL improved significantly within 1 year after shunt placement although patients with iNPH reported worse HRQoL values compared with healthy-matched individuals. Up to 5 years after shunting, a sustained heterogeneity exists on published data showing improved scores across all domains for at least 21 months after shunting. Further, although surgical treatment can improve HRQoL, long-term follow-up showed that it remained lower than that of healthy controls. These data suggest a significant decrease of HRQoL in patients with iNPH over time after shunting, probably due to aging, comorbidities, and disease progression. CONCLUSIONS: Despite that iNPH has been recognized as a potentially reversible neurological disorder, the available data about the impact of shunting on the HRQoL are unsatisfactory. To improve the well-informed clinical decision-making, it is essential to reach additional high-quality evidence regarding the effect of shunting on HRQoL. New prospective studies, using validated instruments specifically tailored for assessing HRQoL in patients with iNPH, and improved reporting standards are needed. Current evidence suggests that although shunting can provide initial benefits, affected patients may experience long-term impairment in HRQoL.
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Hidrocefalia de Pressão Normal , Humanos , Hidrocefalia de Pressão Normal/diagnóstico , Qualidade de Vida , Estudos Prospectivos , Derivações do Líquido Cefalorraquidiano , Derivação Ventriculoperitoneal/efeitos adversos , Resultado do TratamentoRESUMO
Glioblastoma multiforme (GBM) represents the most common and aggressive central nervous system tumor associated with a poor prognosis. The aim of this study was to depict the role of intraoperative imaging techniques in GBM surgery and how they can ensure the maximal extent of resection (EOR) while preserving the functional outcome. The authors conducted a systematic review following PRISMA guidelines on the PubMed/Medline and Scopus databases. A total of 1747 articles were identified for screening. Studies focusing on GBM-affected patients, and evaluations of EOR and functional outcomes with the aid of advanced image-guided techniques were included. The resulting studies were assessed for methodological quality using the Risk of Bias in Systematic Review tool. Open Science Framework registration DOI 10.17605/OSF.IO/3FDP9. Eighteen studies were eligible for this systematic review. Among the selected studies, eight analyzed Sodium Fluorescein, three analyzed 5-aminolevulinic acid, two evaluated IoMRI imaging, two evaluated IoUS, and three evaluated multiple intraoperative imaging techniques. A total of 1312 patients were assessed. Gross Total Resection was achieved in the 78.6% of the cases. Follow-up time ranged from 1 to 52 months. All studies assessed the functional outcome based on the Karnofsky Performance Status scale, while one used the Neurologic Assessment in Neuro-Oncology score. In 77.7% of the cases, the functional outcome improved or was stable over the pre-operative assessment. Combining multiple intraoperative imaging techniques could provide better results in GBM surgery than a single technique. However, despite good surgical outcomes, patients often present a neurocognitive decline leading to a marked deterioration of the quality of life. Advanced intraoperative image-guided techniques can allow a better understanding of the anatomo-functional relationships between the tumor and the surrounding brain, thus maximizing the EOR while preserving functional outcomes.
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OBJECTIVE: The objective of this study was to summarize and assess the current literature evaluating nonoperative treatments for patients with Modic changes (MCs) and low back pain (LBP). METHODS: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The PubMed database was searched from its inception until May 1, 2022 for studies evaluating MC and clinical outcomes. Key findings, treatment details, and patient information were extracted from included studies. Study quality was assessed using the Newcastle-Ottawa Scale. RESULTS: Eighteen studies were included in this review, encompassing a total of 2452 patients, 1713 of whom displayed baseline MC. Seventy-eight percent of studies were high quality. Of included studies, 2 evaluated antibiotics, 5 evaluated steroid injections, 6 evaluated conservative therapies, and 5 evaluated other treatment modalities. Antibiotics and bisphosphonates improved treatment in patients with MC. Patients with MC without disc herniation benefited from conservative therapy, while those with Type I Modic changes and disc herniation experienced poorer improvement. Significant variability exists in reported outcomes following steroid injections. CONCLUSIONS: Nonoperative therapy may provide patients with MC with significant benefits. Patients may benefit from therapies not traditionally utilized for LBP such as antibiotics or bisphosphonates, but conservative therapy is not recommended for patients with concomitant MC and disc herniation. The large variation in follow-up times and outcome measures contributes to significant heterogeneity in studies and inability to predict long-term patient outcomes. More long-term studies are needed to assess nonoperative treatments for LBP in patients with MC.
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Deslocamento do Disco Intervertebral , Dor Lombar , Humanos , Dor Lombar/tratamento farmacológico , Deslocamento do Disco Intervertebral/cirurgia , Vértebras Lombares/cirurgia , Antibacterianos/uso terapêutico , Esteroides/uso terapêutico , Imageamento por Ressonância MagnéticaRESUMO
Aneurysmal subarachnoid hemorrhage (aSAH) is a severe subtype of stroke occurring at a relatively young age with a significant socioeconomic impact. Treatment of aSAH includes early aneurysm exclusion, intensive care management, and prevention of complications. Once the aneurysm rupture occurs, blood spreading within the subarachnoid space triggers several molecular pathways causing early brain injury and delayed cerebral ischemia. Pathophysiologic mechanisms underlying brain injury after aSAH are not entirely characterized, reflecting the difficulties in identifying effective therapeutic targets for patients with aSAH. Although the improvements of the last decades in perioperative management, early diagnosis, aneurysm exclusion techniques, and medical treatments have increased survival, vasospasm and delayed cerebral infarction are associated with high mortality and morbidity. Clinical practice can rely on a few specific therapeutic agents, such as nimodipine, a calcium-channel blocker proved to reduce severe neurologic deficits in these patients. Therefore, new pharmacologic approaches are needed to improve the outcome of this life-threatening condition, as well as a tailored rehabilitation plan to maintain the quality of life in aSAH survivors. Several clinical trials are investigating the efficacy and safety of emerging drugs, such as magnesium, clazosentan, cilostazol, interleukin 1 receptor antagonists, deferoxamine, erythropoietin, and nicardipine, and continuous lumbar drainage in the setting of aSAH. This narrative review focuses on the most promising therapeutic interventions after aSAH.
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Lesões Encefálicas , Isquemia Encefálica , Hemorragia Subaracnóidea , Vasoespasmo Intracraniano , Lesões Encefálicas/complicações , Isquemia Encefálica/etiologia , Infarto Cerebral/complicações , Humanos , Nimodipina/uso terapêutico , Qualidade de Vida , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/diagnóstico , Hemorragia Subaracnóidea/terapia , Vasoespasmo Intracraniano/tratamento farmacológico , Vasoespasmo Intracraniano/terapiaRESUMO
Preventing possible complications during brain aneurysm surgery is mandatory to ensure a better outcome for patients. Currently, it is possible to rely on some technologic innovations such as motor evoked potential, endoscope-assisted surgery, dye with indocyanine green, and video angiography capable of supporting the surgeon's work. The innovation process has mainly assisted the endovascular technique compared with surgery. The latter, apart from some new technical expedients, always requires anatomic knowledge and optimal technical preparation. A careful patient selection, adequate surgical exposure, use of microsurgical techniques in expert hands, and meticulous postoperative management represent the key to success for the surgical treatment of cerebral aneurysms.
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Aneurisma Intracraniano , Angiografia/efeitos adversos , Angiografia Cerebral/métodos , Endoscopia/efeitos adversos , Humanos , Verde de Indocianina , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Microcirurgia/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/cirurgiaRESUMO
A large body of evidence has suggested that the natural biology for symptomatic cerebral cavernous malformations (CCMs) is dynamic. These lesions exhibit a temporal clustering epiphenomenon and usually manifest with multispectral clinical patterns, the most relevant being hemorrhagic and seizurogenic events. Most patients with cerebral cavernous malformations are asymptomatic, and the lesions are detected as incidentalomas. However, association with the CCM3 gene, Zabramski type I and II lesions, and brainstem location have the propensity to increase the bleeding events. The rebleeding risk is 20%/year per lesion, which supports the need for surgical strategies for brainstem cavernous malformations; paradoxically, almost 50% of these patients develop new deficits postoperatively. A navigation-aided approach through safe entry zones is therefore of paramount importance in mitigating the surgical risks. Radiosurgery is currently reserved for biologically aggressive lesions that are not amenable for excision. Similarly, antiepileptic drug treatment is advised following the index seizure event. Early resection of the astrogliotic tissue, barring tissues within the brainstem, following detailed seizure semiology may be beneficial to patients with mesiotemporal lesions and in patients with noncompliance and severe adverse reactions to antiepileptic drug treatment. The proper dichotomization of symptomatic and high-risk cohorts and implementation of stringent surgical strategies performed by experienced surgeons result in good surgical outcomes. The guidelines from the Angioma Alliance Scientific Advisory Board Clinical Experts Panel greatly facilitate in formulating the proper management algorithm.