Hand function outcomes following surgical treatment of complete neonatal brachial plexus palsy.

PURPOSE: Although re-innervation of the hand is considered a priority in the treatment of infants with complete brachial plexus injury, there is currently a paucity of publications investigating hand function outcomes following primary nerve reconstruction in infants with neonatal brachial plexus palsy (NBPP). This study therefore aimed to evaluate hand function outcomes in a series of patients with complete NBPP. METHODS: This retrospective case series included all patients who underwent primary nerve surgery for complete neonatal brachial plexus palsy over an 8-year period. Outcomes were assessed using the Raimond Hand Scale. Classification of grade 3 or higher indicates a functional hand (assistance in bimanual activity). RESULTS: Nineteen patients with a complete NBPP underwent primary nerve reconstruction at a mean age of 3.7 months. Periodic clinical evaluations were performed until at least 4 years of age. According to the Raimondi hand scale, one patient did not recover (grade 0), three patients attained grade 1, four grade 2, ten grade 3, and in one grade 4. Overall hand functional recovery was achieved in 57.8% (11/19) of patients. CONCLUSION: Sufficient recovery of hand function to perform bimanual activity tasks in patients with complete NBPP lesions is possible and should be a priority in the surgical treatment of these infants.

Self-biting behavior in patients with neonatal brachial plexus palsy.

PURPOSE: Self-biting behavior in patients with neonatal brachial plexus palsy (NBPP) has been associated with finger amputation. Our objective is to describe the incidence of this complication, risk factors, and clinical management. METHODS: We retrospectively analyzed 612 patients with NBPP. There were 303 males and 309 females. 51.8% of patients had C5-C6 lesions, 28.9% had C5-C7, 18.9% had C5-T1, and 0.3 had C7-T1 involvement. RESULTS: We identified 15 patients with self-biting behavior (2.5%). Ten patients had C5-T1 lesions, and five had C5-C7 lesions. Eight patents were submitted to brachial plexus surgery and seven were not. This behavior appeared between 8 and 46 months of life (mean 23.5), and it was always temporary. There was no difference between operated and non-operated patients (p > 0.05), and no correlation between age at surgery and age of appearance of self-biting behavior (p > 0.05). Physical restriction was effective in treating this complication and we had no case of finger amputation. CONCLUSION: Self-biting behavior is a rare complication of NBPP, and it is usually associated with severe motor involvement. The behavior duration is limited to a few months. This condition can be effectively treated with physical restriction to prevent hand biting.

Distal nerve transfer versus supraclavicular nerve grafting: comparison of elbow flexion outcome in neonatal brachial plexus palsy with C5-C7 involvement.

PURPOSE: Ulnar and median nerve transfers to arm muscles have been used to recover elbow flexion in infants with neonatal brachial plexus palsy, but there is no direct outcome comparison with the classical supraclavicular nerve grafting approach. METHODS: We retrospectively analyzed patients with C5-C7 neonatal brachial plexus palsy submitted to nerve surgery and recorded elbow flexion recovery using the active movement scale (0-7) at 12 and 24 months after surgery. We compared 13 patients submitted to supraclavicular nerve grafting with 21 patients submitted to distal ulnar or median nerve transfer to biceps motor branch. We considered elbow flexion scores of 6 or 7 as good results. RESULTS: The mean elbow flexion score and the proportion of good results were better using distal nerve transfers than supraclavicular grafting at 12 months (p < 0.01), but not at 24 months. Two patients with failed supraclavicular nerve grafting at 12 months showed good elbow flexion recovery after ulnar nerve transfers. CONCLUSION: Distal nerve transfers provided faster elbow flexion recovery than supraclavicular nerve grafting, but there was no significant difference in the outcome after 24 months of surgery. Patients with failed supraclavicular grafting operated early can still benefit from late distal nerve transfers. Supraclavicular nerve grafting should remain as the first line surgical treatment for children with neonatal brachial plexus palsy.

Treatment of traumatic acute posterior fossa subdural hematoma: report of four cases with systematic review and management algorithm.

BACKGROUND: Traumatic posterior fossa subdural hematomas (SDHs) are rare lesions. Despite improvements in intensive care and surgical management of traumatic brain injuries over the last decades, the outcome for posterior fossa subdural hematomas remains poor. METHODS: We conduct a retrospective study over a 2-year period of patients sustaining traumatic brain injury and posterior fossa SDH. Additionally, a systematic review of case series published to date was performed. RESULTS: The incidence of posterior fossa SDH was 0,01% (4/326). All patients in this current series had poor prognosis. Three out of four exhibited ischemic/edema lesions in postoperative CT scans leading to fourth ventricle effacement and persistent brainstem compression. Our literature review retrieved 57 patients from only seven case series. Unfavorable outcomes were seen in 63% of patients. CONCLUSIONS: Our data and data from the literature do not provide sufficient evidence to establish an optimal treatment strategy for posterior fossa SDH. However, based on lessons learned with these four cases, together with results from review of the literature, we propose an algorithm for the management of this rare condition.

Balloon compression vs radiofrequency for primary trigeminal neuralgia: a randomized, controlled trial.

ABSTRACT: Surgical procedures are necessary in up to 50% of trigeminal neuralgia patients. Although radiofrequency (RF) is more widely used, it is associated with high intraprocedural costs and long technical learning time. Other simpler procedures such as balloon compression (BC) require a lower training period and have significant lower costs. We evaluated the effects of BC and RF in pain control in primary trigeminal neuralgia in a randomized, double-blinded, head-to-head trial. Individuals were randomly allocated in 1 of 2 groups: BC and RF. Throughout pain, psychological and quality of life measurements were performed at baseline and after surgery. The main outcome was the worst pain in the last 24 hours (0-10) at 6 months postoperatively. After the inclusion of half of the estimated sample, a preplanned interim analysis was performed when 33 patients (62.1 ± 9.4 y.) completed the study. Pain intensity (confidence interval [CI] 95% 0.6 to 3.8, and -0.6 to 2.2, for BC and RF) did not significantly differ. Complications, interference of pain in daily life (CI 95% -0.1 to 2.3 and -0.4 to 2.3, for BC and RF), neuropathic pain symptoms (CI 95% 1.7 to 3.6 and 3.0 to 5.7, for BC and RF), mood (CI 95% 4.8 to 11.5 and 5.5 to 15.1, BC and RF, respectively), medication use, and quality of life (CI 95% 80.4 to 93.1 and 83.9 to 94.2, for BC and RF) were also not different. Radiofrequency presented more paresthetic symptoms than BC at 30 days after intervention. Based on these results, the study was halted due to futility because BC was not superior to RF.

Short-term survival in extensive craniofacial resections.

OBJECTIVES: Craniofacial resection (CFR) procedures for craniofacial tumors with cranial extension are often extensive. Although CFRs may yield good oncological results, there are concerns about high perioperative morbidity and mortality. This study aimed to determine risk factors for perioperative mortality after open CFR in terms of deaths occurring during index hospitalizations. METHODS: We conducted a retrospective analysis of CFRs conducted at a tertiary oncology hospital from May 2009 through December 2018. RESULTS: Our analysis included data from the medical records of 102 patients, the majority of whom were male (n=74, 72.5%). The mean age was 61 years (±18.3 years). Skin malignancies (n=64, 63.4%) accounted for nearly two-thirds of the treated tumors, and most of these were squamous cell carcinoma. Postoperative medical complications occurred in 33 patients (33%), and surgical complications occurred in 48 (47%). Multivariate analysis revealed the only independent risk factors for perioperative deaths to be the presence of intracranial tumor extension on preoperative imaging (hazard ratio [HR]=4.56; 95% confidence interval [CI]: 1.74-11.97; p=0.002) and the unexpected emergence of postoperative neurological dysfunction (HR=10.9; 95% CI: 2.21-54.3; p=0.003). CONCLUSIONS: In our study, factors related to tumor extension were associated with a higher risk of perioperative death.

Short-term survival in extensive craniofacial resections

OBJECTIVES: Craniofacial resection (CFR) procedures for craniofacial tumors with cranial extension are often extensive. Although CFRs may yield good oncological results, there are concerns about high perioperative morbidity and mortality. This study aimed to determine risk factors for perioperative mortality after open CFR in terms of deaths occurring during index hospitalizations. METHODS: We conducted a retrospective analysis of CFRs conducted at a tertiary oncology hospital from May 2009 through December 2018. RESULTS: Our analysis included data from the medical records of 102 patients, the majority of whom were male (n=74, 72.5%). The mean age was 61 years (±18.3 years). Skin malignancies (n=64, 63.4%) accounted for nearly two-thirds of the treated tumors, and most of these were squamous cell carcinoma. Postoperative medical complications occurred in 33 patients (33%), and surgical complications occurred in 48 (47%). Multivariate analysis revealed the only independent risk factors for perioperative deaths to be the presence of intracranial tumor extension on preoperative imaging (hazard ratio [HR]=4.56; 95% confidence interval [CI]: 1.74-11.97; p=0.002) and the unexpected emergence of postoperative neurological dysfunction (HR=10.9; 95% CI: 2.21-54.3; p=0.003). CONCLUSIONS: In our study, factors related to tumor extension were associated with a higher risk of perioperative death.

Good sensory recovery of the hand in brachial plexus surgery using the intercostobrachial nerve as the donor / Boa recuperação da sensibilidade da mão usando o nervo intercostobraquial como doador em cirurgia do plexo braquial

ABSTRACT Objective: Restoration of the sensitivity to sensory stimuli in complete brachial plexus injury is very important. The objective of our study was to evaluate sensory recovery in brachial plexus surgery using the intercostobrachial nerve (ICBN) as the donor. Methods: Eleven patients underwent sensory reconstruction using the ICBN as a donor to the lateral cord contribution to the median nerve, with a mean follow-up period of 41 months. A protocol evaluation was performed. Results: Four patients perceived the 1-green filament. The 2-blue, 3-purple and 4-red filaments were perceptible in one, two and three patients, respectively. According to Highet's scale, sensation recovered to S3 in two patients, to S2+ in two patients, to S2 in six patients, and S0 in one patient. Conclusion: The procedure using the ICBN as a sensory donor restores good intensity of sensation and shows good results in location of perception in patients with complete brachial plexus avulsion.

RESUMO Objetivo: A restauração da sensibilidade em pacientes com lesão completa do plexo braquial é muito importante. O objetivo desse estudo foi avaliar a recuperação sensitiva em cirurgia do plexo braquial utilizando o nervo intercostobraquial (NICB) como doador. Métodos: Onze pacientes foram submetidos a reconstrução sensitiva usando o NICB como doador para a contribuição lateral do nervo mediano, com tempo de acompanhamento pós-operatório médio de 41 meses. Um protocolo de avaliação foi realizado. Resultados: Quatro pacientes perceberam o filamento 1-verde. Os filamentos 2-azul, 3-roxo e 4-vermelho foram percebidos por um, dois e três pacientes, respectivamente. Um paciente não apresentou recuperação sensitiva. Dois pacientes obtiveram recuperação S3, dois S2+, seis S2 e um S0, pela escala de Highet. Conclusão: O procedimento usando o NICB como doador promove boa intensidade de recuperação sensitiva e bons resultados são obtidos quanto ao local de percepção em pacientes com avulsão completa do plexo braquial.

Computed Tomographic Angiography for Cerebral Aneurysms in Spontaneous Subarachnoid Hemorrhage

Computed tomographic angiography (CTA) has recently gained popularity as an initial imaging test for spontaneous subarachnoid hemorrhage (SAH). This study evaluated 59 patients presenting aneurysmal SAH who underwent microsurgical clipping based on CTA findings alone and digital subtraction angiography (DSA) at postoperative follow-up. Multiple aneurysms were identified by CTA in 27% of patients and in 10% of patients, DSA identified aneurysms in addition to those diagnosed with CTA. The time between CTA and surgical treatment ranged from 0­4 days. Postoperative DSA revealed that 24% of patients had residual neck. The use of CTA alonemay not be enough to detect small unruptured aneurysms in patients with multiple lesions or aneurysm remnants adjacent to an aneurysm clip. However, the advantages of CTA compared with DSA include its rapidity, reduced invasiveness, and lower cost, which allow us to proceed to ruptured aneurysm repair entirely on the basis of good-quality CTA studies.

Angiotomografia computadorizada (ATC) ganhou popularidade como exame de imagem inicial na hemorragia subaracnoide (HSA). Este estudo retrospectivo, descritivo e observacional, avaliou 59 pacientes com HSA aneurismática. Todos foram submetidos à clipagem microcirúrgica apenas com base na ATC e no seguimento realizou-se avaliação com angiografia digital (AD). Em 27% dos pacientes encontramos múltiplos aneurismas na ATC e 10% tinham outros diferentes aneurismas diagnosticados pela AD. O intervalo entre ATC e tratamento cirúrgico variou de 0­4 dias. AD pós-operatória mostrou 24% dos pacientes com colo residual. A detecção de pequenos aneurismas não rotos em pacientes com múltiplos aneurismas e colo residual pós clipagem cirúrgica continuam a ser um problema quando a ATC é realizada isoladamente. No entanto, as vantagens da ATC incluem sua rapidez, menor invasão e custo, o que nos permite realizar o tratamento cirúrgico de aneurismas rotos apenas com os achados da ATC de boa qualidade.

The clip-wrap technique in the treatment of intracranial unclippable aneurysms.

UNLABELLED: Fusiform and dolichoectatic aneurysms are challenging lesions to treat with direct clipping. Treatment of these aneurysms often requires alternative surgical strategies, including extracranial-intracranial bypass, wrapping, or clip-wrap techniques. Nonetheless, these alternatives methods of treatment have been underused and frequently overlooked. OBJECTIVE: To report a series of nine cases of otherwise untreatable aneurysms managed using the clip-wrap technique and discuss its surgical nuances. METHOD: In the last four years, 9 cases of ruptured aneurysms treated by the clip-wrap techniques were identified in the Division of Neurological Surgery, University of São Paulo, School of Medicine. RESULTS: The aneurysms were located at middle cerebral artery (2), anterior choroidal artery (1), anterior communicating artery (1), carotid ophthalmic (3), posterior cerebral artery (1) and posterior-inferior cerebellar artery (1). Three were dolichoectatic, 4 were unsuitable to complete surgical clipping because parent or efferent vessels arises from the aneurysm sac (1 MCA, 1 AcomA, 1 CO, 1 PICA aneurysms) and two, although ruptured aneurysms, were too small (<2mm) to be directly clipped. No early or late rebleeding was observed after 2 years mean follow-up. One patient deceased due to pulmonary tromboembolism. CONCLUSION: Clip-wrap techniques for the treatment of fusiform and otherwise unclippable aneurysms seem to be safe and it can be associated with a low rate of acute or delayed postoperative complications. It can prevent rebleeding and represents an improvement when compared with the natural history.

Compressão do nervo ulnar na região do cotovelo ­ síndrome do túnel cubital: revisão da literatura / Compression of the Ulnar Nerve in the Elbow Region - Cubital Tunnel Syndrome: Review of the Literature

A síndrome do túnel cubital é responsável pela neuropatia do nervo ulnar, sendo superada em frequência apenas pela síndrome do túnel do carpo. O nervo ulnar apresenta anatomia complexa podendo sofrer compressão em distintos pontos ao longo de seu trajeto, por isso o entendimento das nuances clínicas e da anatomia pormenorizada assim como da técnica cirúrgica meticulosa torna-se essencial no tratamento desta patologia.

The cubital tunnel syndrome is responsible for the ulnar nerve neuropathy, this condition is surpassed in frequency only by carpal tunnel syndrome. The ulnar nerve has complex anatomy andmay suffer compression at different points along its path, so understanding the clinical nuances and detailed anatomy as well asmeticulous surgical technique becomes essential in the treatment of this pathology.

The clip-wrap technique in the treatment of intracranial unclippable aneurysms / Técnica de "clip-wrap" no tratamento de aneurismas rotos não clipáveis

Fusiform and dolichoectatic aneurysms are challenging lesions to treat with direct clipping. Treatment of these aneurysms often requires alternative surgical strategies, including extracranial-intracranial bypass, wrapping, or clip-wrap techniques. Nonetheless, these alternatives methods of treatment have been underused and frequently overlooked. Objective: To report a series of nine cases of otherwise untreatable aneurysms managed using the clip-wrap technique and discuss its surgical nuances. Method: In the last four years, 9 cases of ruptured aneurysms treated by the clip-wrap techniques were identified in the Division of Neurological Surgery, University of São Paulo, School of Medicine. Results: The aneurysms were located at middle cerebral artery (2), anterior choroidal artery (1), anterior communicating artery (1), carotid ophthalmic (3), posterior cerebral artery (1) and posterior-inferior cerebellar artery (1). Three were dolichoectatic, 4 were unsuitable to complete surgical clipping because parent or efferent vessels arises from the aneurysm sac (1 MCA, 1 AcomA, 1 CO, 1 PICA aneurysms) and two, although ruptured aneurysms, were too small (<2mm) to be directly clipped. No early or late rebleeding was observed after 2 years mean follow-up. One patient deceased due to pulmonary tromboembolism. Conclusion: Clip-wrap techniques for the treatment of fusiform and otherwise unclippable aneurysms seem to be safe and it can be associated with a low rate of acute or delayed postoperative complications. It can prevent rebleeding and represents an improvement when compared with the natural history.

Aneurismas fusiformes são lesões de difícil tratamento e frequentemente necessitam de técnicas alternativas de tratamento, incluindo anastomose extra-intracranial ou técnicas de "clip-wrap". Contudo o uso destas técnicas é frequentemente esquecido e negligenciado. Objetivo: Descrever retrospectivamente casuística de nove casos de aneurismas não clipáveis tratados com a técnicas de "clip-wrap" e discutir as nuances cirúrgicas. Resultados: Revisão dos últimos quatro anos da casuística da Divisão de Clínica Neurocirúrgica do HCFMUSP mostrou que 384 casos eram de aneurismas rotos. Destes, 9 eram de aneurismas não clipáveis tratados com a técnica de "clip-wrap". Destes, 2 aneurismas eram de artéria cerebral media, 1 de artéria coroidéia anterior, 1 de artéria comunicante anterior, 3 de artéria oftálmica, 1 de artéria cerebral posterior e 1 de PICA. Três eram lesões ectásicas, 4 não puderam ser completamente clipados devido a relação de aneurismas com vasos eferentes, aferentes ou perfurantes, e dois, apesar de rotos eram pequenos demais para serem clipados (<2,0 mm). Sangramento precoce ou tardio não foram observados, em um seguimento médio de 2 anos. Conclusão: A técnica descrita é segura e está associada com baixa incidência de complicações agudas ou tardias. Ela previne ressangramanto e representa um avanço em relação à história natural destas lesões.