RESUMO
BACKGROUND AND PURPOSE: MCA aneurysms are still commonly clipped surgically despite the recent development of a number of endovascular tools and techniques. We measured clinical uncertainty by studying the reliability of decisions made for patients with middle cerebral artery (MCA) aneurysms. MATERIALS AND METHODS: A portfolio of 60 MCA aneurysms was presented to surgical and endovascular specialists who were asked whether they considered surgery or endovascular treatment to be an option, whether they would consider recruitment of the patient in a randomized trial, and whether they would provide their final management recommendation. Agreement was studied using κ statistics. Intrarater reliability was assessed with the same, permuted portfolio of cases of MCA aneurysm sent to the same specialists 1 month later. RESULTS: Surgical management was the preferred option for neurosurgeons (n = 844/1320; [64%] responses/22 raters), while endovascular treatment was more commonly chosen by interventional neuroradiologists (1149/1500 [76.6%] responses/25 raters). Interrater agreement was only "slight" for all cases and all judges (κ = 0.094; 95% CI, 0.068-0.130). Agreement was no better within specialties or with more experience. On delayed requestioning, 11 of 35 raters (31%) disagreed with themselves on at least 20% of cases. Surgical management and endovascular treatment were always judged to be a treatment option, for all patients. Trial participation was offered to patients 65% of the time. CONCLUSIONS: Individual clinicians did not agree regarding the best management of patients with MCA aneurysms. A randomized trial comparing endovascular with surgical management of patients with MCA aneurysms is in order.
Assuntos
Embolização Terapêutica , Procedimentos Endovasculares , Aneurisma Intracraniano , Humanos , Tomada de Decisão Clínica , Reprodutibilidade dos Testes , Incerteza , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Procedimentos Neurocirúrgicos/métodos , Resultado do Tratamento , Estudos RetrospectivosRESUMO
Inherited factor VII (FVII) deficiency is a rare autosomal-recessive bleeding disorder. There are no clear guidelines regarding therapy in such patients when intracerebral surgery is performed. We report the use of recombinant activated FVII (rFVIIa) for the prophylaxis of bleeding in a female with FVII deficiency (8% of activity) undergoing urgent removal of a right fronto-rolandic intracerebral haematoma secondary to a bleeding from a cavernous angioma. To assist haemostasis during and after surgery, rFVIIa boluses were administered during the procedure and continued every 12 h during 3 days after operation to maintain a prothrombin time <15 s. Using this approach, no abnormal bleeding or thromboembolic complications were observed and rFVIIa appeared safe in this context.
Assuntos
Deficiência do Fator VII/tratamento farmacológico , Fator VIIa/uso terapêutico , Hemostáticos/uso terapêutico , Hemorragias Intracranianas/cirurgia , Neoplasias Encefálicas/complicações , Neoplasias Encefálicas/cirurgia , Emergências , Feminino , Hemangioma Cavernoso/complicações , Hemangioma Cavernoso/cirurgia , Hemostasia Cirúrgica/métodos , Humanos , Hemorragias Intracranianas/etiologia , Pessoa de Meia-Idade , Proteínas Recombinantes/uso terapêuticoRESUMO
OBJECTIVE: Mini-open transforaminal lumbar interbody fusion (oTLIF), previously described by Mummaneni et al., is a well-established technique that uses tubular dilators and retractors for treatment of single-level lumbar spinal stenosis. TECHNIQUE: We describe eight patients with two-level spinal stenosis who were operated on with minimally invasive spinal arthrodesis via a transforaminal route with the use of tubular retractors. This approach allowed us to obtain double-level cages insertion in all patients, with direct visualization of pedicular entry points and no screw malpositioning. CONCLUSION: The oTLIF represents a good compromise in patients with two-level lumbar degenerative disease deserving surgery. Compared to standard open TLIF, it is associated with less postoperative muscular trauma, and faster recovery. This seems to be more evident in that category of patients in whom open approaches need longer incisions and more muscular fiber splitting. Compared to percutaneous TLIF (pTLIF), it allows for bilateral root decompression in every case. Bilateral cage insertion was also possible with this technique.
Assuntos
Vértebras Lombares/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Fusão Vertebral/métodos , Estenose Espinal/cirurgia , Idoso , Parafusos Ósseos , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Fusão Vertebral/instrumentaçãoRESUMO
Brain metastases account for 30 to 40% of all brain tumors in adults. Even if urological carcinomas are not very common, anti-angiogenic drugs have transformed their prognosis, leading physicians to consider their specific treatment. For the majority of cases, surgery is quite simple with low associated morbidity. Depending on the size and the location, surgery or stereotaxic radiotherapy should be discussed. As soon as the metastasis is suspected a neurosurgerical opinion must be sought before beginning any treatment to coordinate the global management.
Assuntos
Neoplasias Encefálicas/secundário , Neoplasias Urológicas/patologia , Neoplasias Encefálicas/diagnóstico , Neoplasias Encefálicas/terapia , HumanosRESUMO
The improved survival rate in urologic carcinoma notably due to anti-angiogenic drugs is directly associated with increased incidence of spinal metastases. During spinal metastasis cord compression it has been proved that surgery associated with radiotherapy gives better results that radiotherapy alone. The neurotoxic risk of the spine metastasis must be evaluated before neurological signs appear in order to propose, if necessary decompressive surgery with stabilisation of the lesion. The choices of therapeutic approach are quite large ranging from percutaneous cimentoplasty to vertebral replacement. It is essential that the initial treatment of metastasis be discussed before neurologic signs appear.
Assuntos
Neoplasias da Coluna Vertebral/secundário , Neoplasias da Coluna Vertebral/cirurgia , Neoplasias Urológicas/patologia , HumanosRESUMO
BACKGROUND: Since it was first described in 2005 by Kassam et al., the technique of endoscopic resection of the odontoid by the transnasal route has gained broad acceptance. Its advantages over the transoral approach are currently well-demonstrated. METHOD: The authors present the surgical technique developed by the senior author in a series of 12 patients, specifying the planning, complications avoidance and showing a film of the operating technique. CONCLUSION: Endoscopic endonasal odontoidectomy is an effective procedure with low morbidity. This technique has a place in the treatment of complex pathologies of the craniovertebral junction and has many advantages over the transoral route.
Assuntos
Descompressão Cirúrgica/instrumentação , Endoscopia , Nariz/cirurgia , Processo Odontoide/cirurgia , Idoso , Idoso de 80 Anos ou mais , Descompressão Cirúrgica/métodos , Endoscopia/métodos , Feminino , Humanos , Masculino , Procedimentos Neurocirúrgicos/instrumentação , Nariz/diagnóstico por imagem , Processo Odontoide/diagnóstico por imagemRESUMO
INTRODUCTION: Hirayama disease is a rare cervical myelopathy predominantly affecting young adults and mainly found in Asia. It results in a pure motor distal lesion of the upper limbs with slow progression. Dynamic magnetic resonance imaging (MRI), which allows the diagnosis to be made, shows a typical appearance of anterior compression of the cervical spinal cord associated with enlargement of the posterior epidural spaces due to a dilated venous plexus. Surgery is considered when conservative treatment has failed. However, the type of surgery is not well standardized in this compressive myelopathy. METHODS: We report on three patients with Hirayama disease operated using an original method: cervical decompressive laminectomy and coagulation of the posterior epidural plexus without fixation. The clinical, radiological and surgical data of these three patients were analyzed. Each patient underwent postoperative MR imaging. RESULTS: The mean age at diagnosis was 18.6 years (16-20 years) with a history of progressive symptoms lasting 1 to 4 years before treatment. Follow-up was 21 to 66 months after surgery. Neurological and electrophysiological improvement was noted in two patients; the third had stabilized. Postoperative MRI confirmed normalization of flexion imaging on MRI. None of the three patients complained of disabling neck pain. CONCLUSION: Posterior cervical decompression with coagulation of epidural venous plexus is a technique that seems effective in Hirayama disease in young subjects. It effectively treats patients by avoiding permanent cervical fixation.
Assuntos
Vértebras Cervicais/cirurgia , Laminectomia , Compressão da Medula Espinal/cirurgia , Atrofias Musculares Espinais da Infância/cirurgia , Adolescente , Descompressão Cirúrgica/métodos , Humanos , Laminectomia/efeitos adversos , Imageamento por Ressonância Magnética/métodos , Masculino , Pescoço/patologia , Doenças da Medula Espinal/cirurgia , Atrofias Musculares Espinais da Infância/diagnóstico , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND AND PURPOSE: Osteoarticular manifestations of beta-2 microglobulin amyloidosis are often diagnosed in long-term dialyzed patients. However, spinal involvement is rare (10-25% of patients), and generally not associated with neurological deterioration. Compression of the spinal cord or roots is extremely rare, and probably under-recognized. METHODS: The authors describe three cases of spinal stenosis presenting with neurological signs in long-term dialyzed patients, prospectively collected over 2 years in two different institutions and treated by surgical decompression. In all three cases, the main cause of neural compression was amyloid deposition in the spine, either extradurally in the ligamentum flavum or intradurally. RESULTS: All patients improved after surgery and did not present any postoperative complications. However, two out of three patients with amyloid in the cervical spine required surgical revision to obtain a satisfactory decompression of the spinal cord. DISCUSSION: The authors discuss spinal amyloidosis which is a well-known complication of long-term dialysis. However, neurological complications such as spinal cord or radicular symptoms have been rarely reported and, when present in dialyzed patients, are symptoms that are often attributed to other causes. To our knowledge, this is the first case series that demonstrates the relationship between neurological deterioration and amyloid depositions in the spinal canal that occur in long-term dialyzed patients. The prevalence of spinal stenosis related to the presence of amyloid in this specific subgroup of patients is probably underestimated.
Assuntos
Amiloidose/cirurgia , Falência Renal Crônica/terapia , Diálise Renal/efeitos adversos , Estenose Espinal/cirurgia , Idoso de 80 Anos ou mais , Amiloidose/diagnóstico por imagem , Amiloidose/etiologia , Amiloidose/patologia , Descompressão Cirúrgica , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Compressão da Medula Espinal/diagnóstico por imagem , Compressão da Medula Espinal/etiologia , Compressão da Medula Espinal/patologia , Compressão da Medula Espinal/cirurgia , Estenose Espinal/diagnóstico por imagem , Estenose Espinal/etiologia , Estenose Espinal/patologia , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Metastatic disease of the spine is an increasingly common public health problem. Surgery should be an integral component of the overall cancer treatment plan and, importantly, must neither delay not jeopardize any of the other components. The prognosis governs the choice of the surgical strategy. Tokuhashi et al. developed a prognostic score in 1990, then revised it in 2000 and 2005. Here, our objective was to evaluate the performance of the Tokuhashi score in a cohort of 260 patients and to look for other variables that might improve preoperative outcome prediction. MATERIAL AND METHOD: We retrospectively established a single-centre cohort of 260 patients who underwent spinal metastasis surgery between 1998 and 2008. For each patient, the following data were collected prospectively: socio-demographic features, history of the malignancy, variables needed to determine the Tokuhashi score, and treatments used. SAS 9.0 software was chosen for the statistical analysis. Variables were described as mean ± SD, overall survival was estimated using the Kaplan-Meier method, and survivals in subgroups were compared by the log-rank test. To assess agreement between survival predicted by the Tokuhashi score and observed survival, we computed Cohen's kappa and interpreted the results according to Landis and Koch. RESULTS: There were 143 females and 117 males with a mean age of 59 years and overall median survival of 10 months. Median observed survivals in the three Tokuhashi score categories (< 6, 6-12, and > 12 months predicted survival) were 5, 10, and 36 months, respectively. These survival times differed significantly (P < 0.0001). Cohen's kappa indicated moderate agreement between predicted and observed survivals. Other factors associated with significant survival differences were time from cancer diagnosis to metastasis diagnosis (synchronous, < 2 years, 2-5 years, or > 5 years; P < 0.0001) and age (< 70 years or ≥ 70 years, P = 0.0053). CONCLUSION: Our cohort study supports the validity and reproducibility of the Tokuhashi score. Our finding that shorter time to metastasis diagnosis and age ≥ 70 years were also significantly associated with survival in our population invites further efforts to improve and update the Tokuhashi score.
Assuntos
Procedimentos Neurocirúrgicos/métodos , Neoplasias da Coluna Vertebral/secundário , Adulto , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Metástase Neoplásica , Prognóstico , Estudos Retrospectivos , Índice de Gravidade de Doença , Neoplasias da Coluna Vertebral/diagnóstico , Neoplasias da Coluna Vertebral/cirurgia , Adulto JovemRESUMO
We report on a case of migration inside the liver of the distal end of a ventriculoperitoneal shunt catheter in an adult patient. A simple laparotomy permitted the surgical removal with no haemorrhagic complication. We discuss the other cases reported in the literature and we outline the need to perform an abdominal CT scan in patients carrying a VP shunt with digestive symptoms.
Assuntos
Dor Abdominal/etiologia , Fígado/lesões , Falha de Prótese , Derivação Ventriculoperitoneal/efeitos adversos , Adulto , Remoção de Dispositivo , Falha de Equipamento , Humanos , Hidrocefalia/cirurgia , Laparotomia , Fígado/diagnóstico por imagem , Fígado/patologia , Fígado/cirurgia , Imageamento por Ressonância Magnética , Masculino , Ajuste de Prótese , Tomografia Computadorizada por Raios X , VentriculostomiaRESUMO
We report on two cases of spontaneous resorption of a calcified thoracic hernia. This phenomenom is widely recognised in lumbar and cervical hernia, but is exceptional at the thoracic level. The potential mechanisms underlying this resorption are discussed trough a review of the literature. We think this could be another argument for a "wait and watch" period before a surgical decision in the patients who have few symptoms.
Assuntos
Calcinose/fisiopatologia , Deslocamento do Disco Intervertebral/fisiopatologia , Vértebras Torácicas/patologia , Calcinose/diagnóstico por imagem , Calcinose/patologia , Eletrofisiologia , Feminino , Humanos , Deslocamento do Disco Intervertebral/diagnóstico por imagem , Deslocamento do Disco Intervertebral/patologia , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Remissão Espontânea , Vértebras Torácicas/diagnóstico por imagem , Vértebras Torácicas/fisiopatologia , Tomografia Computadorizada por Raios X , Conduta ExpectanteRESUMO
BACKGROUND: Hereditary multiple exostosis (HME) is an hereditary disease, characterized by the presence of multiple osteochondromas; 7% of patients with HME have a spinal disease. Through this observation, the authors discuss the diagnostic and therapeutic aspects of this rare lesion. CASE REPORT: A 45-year-old woman, operated 10 years ago for an exostosis of the right fibula and left femur. She has since few years paresthesia of all four limbs with distal predominance, walking fatigability kind of spinal claudication. The MRI shows a voluminous osteoma at the second cervical vertebra compressing the spinal cord. The patient was operated with macroscopically complete resection of the exostosis and C2 laminectomy. CONCLUSION: The cervical exostosis associated with HME is a rare disease. The clinical symptomatology is dominated by spinal cord compression and surgical treatment allows excellent clinical results.
Assuntos
Exostose Múltipla Hereditária/complicações , Compressão da Medula Espinal/etiologia , Vértebras Cervicais , Feminino , Humanos , Pessoa de Meia-IdadeRESUMO
Osteocartilaginous exostoses are benign bone tumors frequently found in the metaphysis of long bones but rarely in the spine. Four patients with acute spinal cord decompensation due to vertebral exostoses spinal cord compression have been previously described in the literature. We report an additional case of rapidly evolving spinal cord compression due to a cervical osteochondroma in a patient with hereditary multiple exostoses (HME), also known as Bessel Hagen disease. Careful analysis of the 5 cases suggested to us that patients with HME should have a systematic spinal imaging screening, in order to prevent rapid neurological decompensation. A minimal risk surgical procedure can be performed at a time of election.
Assuntos
Vértebras Cervicais/patologia , Exostose Múltipla Hereditária/complicações , Compressão da Medula Espinal/etiologia , Medula Espinal/patologia , Neoplasias da Coluna Vertebral/complicações , Adulto , Vértebras Cervicais/irrigação sanguínea , Vértebras Cervicais/fisiopatologia , Exostose Múltipla Hereditária/diagnóstico , Exostose Múltipla Hereditária/fisiopatologia , Feminino , Transtornos Neurológicos da Marcha/etiologia , Transtornos Neurológicos da Marcha/fisiopatologia , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Paraparesia/etiologia , Paraparesia/fisiopatologia , Reflexo de Babinski/etiologia , Reflexo de Babinski/fisiopatologia , Transtornos de Sensação/etiologia , Transtornos de Sensação/fisiopatologia , Fatores Sexuais , Medula Espinal/fisiopatologia , Compressão da Medula Espinal/diagnóstico , Compressão da Medula Espinal/fisiopatologia , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Neoplasias da Coluna Vertebral/diagnóstico , Neoplasias da Coluna Vertebral/fisiopatologia , Veias/patologia , Veias/fisiopatologiaRESUMO
Vasotocin/mesotocin (VT/MT) producing neurons are known to migrate extensively during development of the hypothalamus. Birthdating studies as well as immunohistochemical studies suggested the possibility that VT/MT producing neurons originate from specific sites of the neural tube. Furthermore, a relationship between the site of origin and the eventual fate of VT/MT cells has been suggested. This study proposes to identify the sites of origin of VT/MT cells and to establish whether magnocellular and parvocellular VT/MT, and neuromodulatory and neurosecretory VT/MT arise from common or different areas of the developing neural tube. To do so, the embryological distribution of VT/MT producing neurons of the chick was studied with immunohistochemistry. Analysis of the youngest brains in which VT/MT cells could be detected (embryonic day 7.25, E7.25) suggested the presence of two separate sites of origin. The first site was located in the hypothalamic anlage, next to the third ventricle, and the second in the mesencephalon, next to the fourth ventricle. Three-dimensional reconstructions of the location of VT/MT cells throughout development substantiated the hypothesis that diencephalic VT/MT cells originate from the first site while mesencephalic ones originate from the second site. Mesencephalic VT/MT producing cells were confined to the nucleus of Edinger-Westphal and were only detectable during a brief period in development (E7.25-E10). Diencephalic VT/MT producing neurons were noted to form two main paths from their sites of origin to the rostral diencephalon. Quantitative analysis confirmed this caudal to rostral displacement. Magnocellular and parvocellular VT/MT+ cells were intermingled at the diencephalic site of origin as well as in the migratory paths. Neuromodulatory and neurosecretory VT/MT cells of the diencephalon appeared to be derived from a common diencephalic site of origin. These studies support the hypothesis that while specific groups of progenitors may be important in allowing their offspring to produce VT/MT, they do not appear to influence the morphological attributes (magnocellular vs. parvocellular), nuclear locations, or functional characteristics of these cells.
Assuntos
Encéfalo/metabolismo , Movimento Celular/fisiologia , Neurônios/metabolismo , Ocitocina/análogos & derivados , Vasotocina/biossíntese , Animais , Especificidade de Anticorpos , Encéfalo/citologia , Encéfalo/embriologia , Tamanho Celular , Embrião de Galinha , Diencéfalo/química , Diencéfalo/citologia , Processamento de Imagem Assistida por Computador , Imuno-Histoquímica , Mesencéfalo/química , Mesencéfalo/citologia , Proteínas do Tecido Nervoso/análise , Neurônios/citologia , Ocitocina/análise , Ocitocina/biossíntese , Vasotocina/análise , Vimentina/análiseRESUMO
To identify patterns of cell generation and migration during early development of the hypothalamus, clones were marked with a library of retroviral vectors. The majority of clones analyzed at Embryonic Days 8-10 were simple radial columns. A small number of clones had one of three unusual patterns of dispersion. One unusual clone type was bilaterally symmetric across the ventral forebrain. Another was composed of four or more columns of cells arranged in a line along the ventricular surface, and a third was composed of cells that appeared to disperse from the typical radial columns in a plane parallel to the ventricular surface. The appearance of the rare clones suggests that there are different mechanisms of clonal dispersion during early development of the ventral forebrain that could play a role in patterning the hypothalamus.
Assuntos
Movimento Celular , Hipotálamo/embriologia , Animais , Sequência de Bases , Biomarcadores , Embrião de Galinha , Células Clonais , Vetores Genéticos , Hipotálamo/citologia , Dados de Sequência Molecular , Morfogênese , Prosencéfalo/citologia , Prosencéfalo/embriologia , Retroviridae/genéticaRESUMO
Treatment with prostaglandin synthesis inhibitors has been associated with oligohydramnios in the fetus. The presumed mechanism is a reduction in fetal renal blood flow. We examined the effect of meclofenamate administration on renal blood flow in chronically catheterized fetal sheep during normoxia and during moderate and severe hypoxia. Ten fetal sheep were made hypoxic twice at least 4 days after surgery: once in the presence and once in the absence of meclofenamate infusion. Renal blood flow and combined ventricular output were measured with radioactive microspheres. Prostaglandin synthesis blockade with meclofenamate caused no significant change in blood pressure, combined ventricular output, renal blood flow, or renal vascular resistance in either the normoxic or hypoxic animals. These data challenge the contention that prostaglandin activity protects the renal vascular bed of the fetus from vasoconstriction during hypoxia and they also do not support the hypothesis that prostaglandin synthesis inhibition causes oligohydramnios through reduction of fetal renal blood flow.
Assuntos
Feto/fisiologia , Ácido Meclofenâmico/farmacologia , Antagonistas de Prostaglandina/farmacologia , Circulação Renal/efeitos dos fármacos , Animais , Débito Cardíaco/efeitos dos fármacos , Feto/efeitos dos fármacos , Hipóxia/fisiopatologia , Valores de Referência , OvinosRESUMO
Multipotent neural cell lines were generated via retrovirus-mediated v-myc transfer into murine cerebellar progenitor cells. When transplanted back into the cerebellum of newborn mice, these cells integrated into the cerebellum in a nontumorigenic, cytoarchitecturally appropriate manner. Cells from the same clonal line differentiated into neurons or glia in a manner appropriate to their site of engraftment. Engrafted cells, identified by lacZ expression and PCR-mediated detection of a unique sequence arrangement, could be identified in animals up to 22 months postengraftment. Electron microscopic and immunohistochemical analysis demonstrated that some engrafted cells were similar to host neurons and glia. Some transplant-derived neurons received appropriate synapses and formed normal intercellular contacts. These data indicate that generating immortalized cell lines for repair of, or transport of genes into, the CNS may be feasible. Such lines may also provide a model for commitment and differentiation of cerebellar progenitor cells.