Preliminary Study on Application of Combined Monitoring of Neuroelectrophysiology-Intracranial Pressure-Cerebral Perfusion Pressure in Craniotomy for Intracranial Aneurysm Clipping: An Anatomical and Clinical Study

SUMMARY: Intracranial aneurysm is a common cerebrovascular disease with high mortality. Neurosurgical clipping for the treatment of intracranial aneurysms can easily lead to serious postoperative complications. Studies have shown that intraoperative monitoring of the degree of cerebral ischemia is extremely important to ensure the safety of operation and improve the prognosis of patients. Aim of this study was to probe the application value of combined monitoring of intraoperative neurophysiological monitoring (IONM)-intracranial pressure (ICP)-cerebral perfusion pressure (CPP) in craniotomy clipping of intracranial aneurysms. From January 2020 to December 2022, 126 patients in our hospital with intracranial aneurysms who underwent neurosurgical clipping were randomly divided into two groups. One group received IONM monitoring during neurosurgical clipping (control group, n=63), and the other group received IONM-ICP-CPP monitoring during neurosurgical clipping (monitoring group, n=63). The aneurysm clipping and new neurological deficits at 1 day after operation were compared between the two groups. Glasgow coma scale (GCS) score and national institutes of health stroke scale (NIHSS) score were compared before operation, at 1 day and 3 months after operation. Glasgow outcome scale (GOS) and modified Rankin scale (mRS) were compared at 3 months after operation. All aneurysms were clipped completely. Rate of new neurological deficit at 1 day after operation in monitoring group was 3.17 % (2/63), which was markedly lower than that in control group of 11.11 % (7/30) (P0.05). Combined monitoring of IONM-ICP-CPP can monitor the cerebral blood flow of patients in real time during neurosurgical clipping, according to the monitoring results, timely intervention measures can improve the consciousness state of patients in early postoperative period and reduce the occurrence of early postoperative neurological deficits.

El aneurisma intracraneal es una enfermedad cerebrovascular común con alta mortalidad. El clipaje neuroquirúrgico para el tratamiento de aneurismas intracraneales puede provocar complicaciones posoperatorias graves. Los estudios han demostrado que la monitorización intraoperatoria del grado de isquemia cerebral es extremadamente importante para garantizar la seguridad de la operación y mejorar el pronóstico de los pacientes. El objetivo de este estudio fue probar el valor de la aplicación de la monitorización combinada de la monitorización neurofisiológica intraoperatoria (IONM), la presión intracraneal (PIC) y la presión de perfusión cerebral (CPP) en el clipaje de craneotomía de aneurismas intracraneales. Desde enero de 2020 hasta diciembre de 2022, 126 pacientes de nuestro hospital con aneurismas intracraneales que se sometieron a clipaje neuroquirúrgico se dividieron aleatoriamente en dos grupos. Un grupo recibió monitorización IONM durante el clipaje neuroquirúrgico (grupo de control, n=63) y el otro grupo recibió monitorización IONM-ICP-CPP durante el clipaje neuroquirúrgico (grupo de monitorización, n=63). Se compararon entre los dos grupos el recorte del aneurisma y los nuevos déficits neurológicos un día después de la operación. La puntuación de la escala de coma de Glasgow (GCS) y la puntuación de la escala de accidentes cerebrovasculares de los institutos nacionales de salud (NIHSS) se compararon antes de la operación, 1 día y 3 meses después de la operación. La escala de resultados de Glasgow (GOS) y la escala de Rankin modificada (mRS) se compararon 3 meses después de la operación. Todos los aneurismas fueron cortados por completo. La tasa de nuevo déficit neurológico 1 día después de la operación en el grupo de seguimiento fue del 3,17 % (2/63), que fue notablemente inferior a la del grupo de control del 11,11 % (7/30) (P 0,05). La monitorización combinada de IONM-ICP-CPP puede controlar el flujo sanguíneo cerebral de los pacientes en tiempo real durante el corte neuroquirúrgico; de acuerdo con los resultados de la monitorización, las medidas de intervención oportunas pueden mejorar el estado de conciencia de los pacientes en el período postoperatorio temprano y reducir la aparición de problemas postoperatorios tempranos y déficits neurológicos.

Hemorragia subaracnoidea asociada a aneurisma cerebral con malformación arteriovenosa / Subarachnoid hemorrhage related to a cerebral aneurysm with arteriovenous malformation

Los aneurismas asociados a las malformaciones arteriovenosas son lesiones vasculares que suelen encontrarse hasta en el 15 % de los pacientes que las presentan, lo que incrementa el riesgo global de hemorragia. Se presenta una paciente de 53 años de edad que sufrió un cuadro agudo de hemorragia subaracnoidea; en el estudio se evidenció la presencia de un aneurisma de comunicante anterior y malformación arteriovenosa distal de la arteria cerebral anterior izquierda, el cual requirió procedimiento quirúrgico debido al sangramiento. La evolución de la paciente fue satisfactoria y sin complicaciones.

Aneurysms associated with arteriovenous malformations are vascular lesions that are usually found in up to 15% of the patients who present them, which increases the overall risk of bleeding. We present a 53-year-old female patient who suffered from an acute subarachnoid hemorrhage; the study revealed the presence of an anterior communicating aneurysm and a distal arteriovenous malformation of the left anterior cerebral artery, which required surgical procedure due to bleeding. The evolution of the patient was satisfactory and without complications.

Factores predictivos de rotura de aneurismas intracraneales / Rupture Predictive Factors for Intracranial Aneurysms

Introducción: Un aneurisma intracraneal roto provoca una hemorragia subaracnoidea. La enfermedad presenta una alta mortalidad y morbilidad. Sin embargo, no todos se rompen. Mejorar la predicción de rotura permitirá un tratamiento quirúrgico preventivo en un grupo de pacientes y evitará una intervención quirúrgica con riesgos en otro grupo de enfermos. Es necesario identificar factores predictivos para mejorar la estratificación del riesgo de rotura y optimizar el tratamiento de los aneurismas intracraneales incidentales. Objetivo: Identificar factores predictivos de rotura de aneurismas intracraneales. Métodos: En una muestra de 152 pacientes espirituanos con aneurismas intracraneales saculares rotos (n = 138) y no rotos (n = 22) y 160 imágenes de angiografía por tomografía computarizada, se realizaron mensuraciones de los índices o factores morfológicos, los cuales se combinaron mediante análisis de regresión logística con variables demográficas y clínicas. Resultados: El grupo de edad con mayor frecuencia de presentación de aneurismas fue el de mayor de 65 años. La muestra estuvo representada, en su gran mayoría, por el sexo femenino. Se identificaron tres factores clínicos y cuatro factores morfológicos estadísticamente significativos, asociados con la rotura. El índice de no esfericidad (p = 0,002 y el sexo femenino (p = 0,02) fueron los de mayor significación estadística. Conclusiones: Se detectaron siete factores predictivos de rotura de aneurismas intracraneales estadísticamente significativos, de los cuales el índice de no esfericidad resultó el de mayor significación(AU)

Introduction: A ruptured intracranial aneurysm causes a subarachnoid hemorrhage. The disease has high mortality and morbidity. However, not all of them break. Improving the rupture prediction will allow preventive surgical treatment in a group of patients and it will avoid risky surgical intervention in another group of patients. It is necessary to identify predictive factors to improve rupture risk stratification and to optimize treatment of incidental intracranial aneurysms. Objective: To identify rupture predictive factors for intracranial aneurysms. Methods: Measurements of the morphological indices or factors were performed in a sample of 152 patients from Sancti Spiritus with ruptured (n = 138) and unruptured (n = 22) saccular intracranial aneurysms and 160 computed tomography angiography images. They were combined using logistic regression analysis with demographic and clinical variables. Results: The age group with the highest frequency of aneurysm presentation was older than 65. The sample was represented, in its vast majority, by the female sex. Three clinical factors and four statistically significant morphological factors associated with rupture were identified. The non-sphericity index (p = 0.002) and the female sex (p = 0.02) were the most statistically significant. Conclusions: Seven statistically significant predictors of intracranial aneurysm rupture were detected, the non-sphericity index being the most significant(AU)

Manejo ultra temprano del aneurisma cerebral roto. Reporte de caso y revisión de la literatura / Ultra-early management of ruptured brain aneurysm. A case report and literature review

Introducción : Los aneurismas intracraneales representan el 85% de casos de hemorragias subaracnoideas, dentro de las cuales las no traumáticas tienen una alta tasa de mortalidad (40-60%). En el manejo endovascular y microquirúrgico de esta enfermedad, el debate ha sido siempre intenso respecto a si el tratamiento temprano produce un beneficioso resultado funcional y reduce la morbi-mortalidad del paciente. Caso Clínico : Paciente mujer de 54 años, admitida con cefalea súbita y cuadro neurológico que cursó con rápido deterioro. La tomografía mostró hemorragia subaracnoidea por ruptura aneurísmica del complejo comunicante anterior; fue sometida a microcirugía dentro de las primeras 24 horas y transferida luego a UCI, sin complicaciones. Discusión : El tiempo de resolución, sea mediante clipaje microquirúrgico o tratamiento endovascular es tema de intensos debates. Las guías actuales señalan la necesidad del manejo más temprano posible de la patología. Conclusión : En nuestro caso, se obtuvo un buen resultado funcional debido a varios factores uno de ellos el ingreso precoz a cirugía. La actualización de las guías y nuevos estudios ayudarán a mejorar el conocimiento de la enfermedad y protocolos hospitalarios adecuados a la realidad clínica ayudarán a reducir su tiempo de resolución.

SUMMARY Introduction : Intracranial aneurysms account for 85% of all subarachnoid hemorrhages. Non-traumatic SAH has a high mortality rate (40-60%). Regarding the microsurgical and endovascular management for this pathology, there has been intense debate on whether early action is beneficial in terms of functional outcome and reduction of morbi-mortality. Clinical case : A 54-year-old woman admitted with a sudden, severe headache and a rapidly deteriorating neurological state at baseline, and with deterioration at the next hour. Tomography showed a subarachnoid hemorrhage due to ruptured aneurysm of the anterior communicating artery; the patient underwent surgery within the first 24 hours, with subsequent ICU management without complications. Discussion : The resolution time of this condition, either by micosurgery or endovascular management is a matter of intense debate. International guidelines point out the need of an earliest possible treatment. Conclusion : In our case, a good functional result was obtained due to several factors, one of which was early admission to surgery. The updating of guidelines and new studies will help to better understand the pathophysiology of SAH, and the creation of hospital protocols adapted to clinical realities will assist to reduce the resolution time of this pathology.

Clinical application of Neuroform Atlas stent-assisted coiling in the treatment of unruptured wide-neck intracranial aneurysms / 北京大学学报(医学版)

OBJECTIVE@#To assess the safety and efficacy of Neuroform Atlas stent used in treatment of unruptured wide-neck intracranial aneurysms.@*METHODS@#Clinical data of 62 patients with unruptured wide-neck intracranial aneurysms undergoing Neuroform Atlas stent-assisted coiling from August 2020 to September 2021 were retrospectively analyzed. There were 64 aneurysms in those 62 patients. Among them, 25 aneurysms were located at the bifurcation of M1 segment on middle cerebral artery, 16 at the anterior communicating artery, 10 at the C7 segment of internal carotid artery, 5 at the C6 segment of internal carotid artery, 4 at the apex of basilar artery, 3 at the A3 segment of anterior cerebral artery, and 1 at the M2 segment of middle cerebral artery. All the patients underwent Neuroform Atlas stent-assisted coiling, including 49 patients with single stent assisted coiling and 15 patients with dual stents assisted coiling (14"Y"style and 1"X"style). After the procedure, the immediate DSA was performed to evaluate the status of aneurysm occlusion and the parent artery patency. The clinical follow-up was performed 3 months after the operation and evaluated based on the modified Rankin Scale(mRS).DSA image was reviewed at 6 months after operation and Raymond grading scale was used to assess the status of aneurysm occlusion and the parent artery patency.@*RESULTS@#A total of 62 patients with 64 aneurysms were all achieved technical success(100%).The immediate post-procedural Raymond scale was assessed, including Raymond Ⅰ in 57 aneurysms(89.1%, 57/64), Raymond Ⅱ in 6 aneurysms(9.3%, 6/64) and Raymond Ⅲ in 1 aneurysm(1.6%, 1/64). The peri-procedural complications rate was 4.8%(3/62), 2 patients developed intraoperative thrombosis and 1 patient suffered from local subarachnoid hemorrhage. Among them, 55 patients obtained 3 months clinical follow-up after operation and all the patients had good outcomes (mRS≤2), 50 patients with 52 aneurysms were followed up with DSA 6 months after operation, including Raymond Ⅰ in 45 aneurysms(86.5%, 45/52), Raymond Ⅱ in 4 aneurysms(7.7%, 4/52) and Raymond Ⅲ in 3 aneurysms(5.8%, 3/52).@*CONCLUSION@#Neuroform Atlas stent for the treatment of unruptured wide-neck intracranial aneurysms has high safety and good efficacy, and has its advantages over other traditional stents.

Effect of sugammadex on postoperative nausea and vomiting after surgery for intracranial aneurysm / 中华外科杂志

Objective: To investigate the effect of sugammadex on postoperative nausea and vomiting(PONV) after intracranial aneurysm surgery. Methods: Data from intracranial aneurysms patients who met the inclusion and exclusion criteria and underwent interventional surgery in the Department of Neurosurgery, Peking University International Hospital from January 2020 to March 2021 were prospectively included. According to the random number table method, the patients were divided by 1∶1 into the neostigmine+atropine group (group N) and the sugammadex group (group S). Use an acceleration muscle relaxation monitor for muscle relaxation monitoring, and administer neostigmine+atropine and sugammadex to block residual muscle relaxation drugs after surgery. The incidence rates of PONV and severity, the appearance of anesthesia, and the correlation between PONV and postoperative complications were recorded in both groups during five periods after surgery: 0-0.5 hours (T1),>0.5-2.0 hours(T2),>2.0-6.0 hours (T3),>6.0-12.0 hours (T4) and >12.0-24.0 hours (T5). Group comparisons of quantitative data were performed by the independent sample t-test, and categorical data was performed by the χ2 or rank sum test. Results: A total of 66 patients were included in the study, including 37 males and 29 female, aged (59.3±15.4) years (range: 18 to 77 years). The incidence rates of PONV of 33 patients in group S at different time periods of T1, T2, T3, T4, and T5 after surgery were respectively 27.3%(9/33),30.3%(10/33),12.1%(4/33),3.0%(1/33),0(0/33),and the incidence rates of PONV of 33 patients in the group N at different time periods of T1, T2, T3, T4 and T5 after surgery were respectively 36.4%(12/33),36.4%(12/33),33.3%(11/33),6.1%(2/33) and 0(0/33).The incidence of PONV was lower in the group S only in the T3 period after reversal than in the group N (χ2=4.227, P=0.040).However, there was no statistically significant difference in the incidence of PONV between the two groups of patients in other periods (all P>0.05). The recovery time for spontaneous breathing in patients in group S was (7.7±1.4) minutes, the extubation time was (12.4±5.3) minutes, and the safe exit time for anesthesia recovery was (12.3±3.4) minutes; the N groups were (13.9±2.0) minutes, (18.2±6.0) minutes, and (18.6±5.2) minutes, respectively; three time periods in group S were shorter than those in group N, and the differences were statistically significant (all P<0.05). The results regarding the occurrence of complications in patients with different levels of PONV at different time intervals after surgery in the two groups were as follows: in the T3 time period of group N, a significant difference was observed only in the occurrence of postoperative complications among patients with different levels of PONV (χ2=24.786, P<0.01). However, in the T4 time period, significant differences were found in the occurrence of postoperative complications among both the same level and different level PONV patients (χ2=15.435, 15.435, both P<0.01). Significant differences were also observed in the occurrence of postoperative complications among the same level and different level PONV patients in both the T3 and T4 time periods of group S (all P<0.01). Conclusion: Sugammadex can be used to reverse muscle relaxation in patients undergoing intracranial aneurysm intervention surgery,and it does not have a significant impact on the incidence of PONV, it can also optimize the quality of anesthesia recovery and reduce the incidence of complications after intracranial aneurysm embolization surgery.

Prise en charge anesthésiologique de l'anévrisme cérébral au Mali / Anesthesiological management of cerebral aneurysm in Mali

Objectif : Décrire la prise en charge anesthésiologique de l'anévrisme cérébral au Mali. Patients et Méthodes : étude descriptive à recueil historique de 8 ans (Novembre 2012 à Octobre 2020) au CHU « Hôpital du Mali ¼ des patients opérés pour anévrisme cérébral avec un dossier médical complet. La saisie et l'analyse ont été effectuées par SSPS version 25. Résultats : Durant la période d'étude, 32 patients répondaient à nos critères soit une prévalence de 2,1%. L'âge moyen était de 45,2 ± 12,5 ans. Le ratio femme-homme était de 2,55. Les patients résidaient à Bamako dans 71,9 %. L'HTA était l'antécédent médical le plus fréquent. Les patients étaient de grade I de WFNS dans 87,5%. La classe ASA II représentait 84,4%. Une prémédication a été faite dans 96,9%. Une anesthésie générale a été faite chez tous les patients. Une antibioprophylaxie a été faite chez tous les patients. La perte sanguine moyenne était de 737,3 ± 460,5 ml. Une transfusion per opératoire a été prescrite dans 46,8%. L'évènement indésirable per opératoire était cardiovasculaire dans 96,9 %. La durée moyenne de la chirurgie était de 267,1±77,1 minute. Celle de l'anesthésie était de 427,9 minutes. En réanimation, une complication a été observée dans 34,4%. La mortalité était de 25%. La durée moyenne de séjour était de 6,3 jours. Conclusion: Au Mali la prise en charge de l'anévrysme cérébral est en progrès malgré une mortalité encore élevée.

Objective: To Describe the anesthesiological management of cerebral aneurysm in Mali. Patients and Methods: This was an observational study, descriptive with historical collection of 8 years (November 2012 to October 2020) at the department of the university hospital "Hôpital du Mali" concerning 32 patients operated for cerebral aneurysm with a complete medical file. Input and analysis were performed by SSPS version 25. Results: During the study period, 32 patients met our criteria, a prevalence of 2.1%. The median age was 45.2 ± 12.5 years. The female-to-male ratio was 2.55. Patients resided in Bamako in 71.9%. High blood pressure was the most common medical history. Patients were grade I WFNS in 87.5o_ièvg%. ASA class II accounted for 84.4%. Premedication was done in 96.9%. General anesthesia was applied to all patients. Antibiotic prophylaxis was given to all patients. The average blood loss was 737.3 ± 460.5 ml. An intraoperative transfusion was prescribed in 46.8%. The intraoperative adverse event was cardiovascular in 96.9%. The average duration of surgery was 267.1±77.1 minutes. That of anesthesia was 427.9 minutes. In intensive care, a complication was observed in 34.4%. Mortality was 25%. The average length of stay was 6.3 days. Conclusion: In Mali, the management of cerebral aneurysm is progressing despite still high mortality.

Role of temporary arterial occlusion in subarachnoid hemorrhage outcomes: a prospective cohort study

Purpose: Temporary arterial occlusion (TAO) is a widespread practice in the surgical treatment of intracranial aneurysms. This study aimed to investigate TAO's role during ruptured aneurysm clipping as an independent prognostic factor on short- and long-term outcomes. Methods: This prospective cohort included 180 patients with ruptured intracranial aneurysms and an indication of microsurgical treatment. Patients who died in the first 12 hours after admission were excluded. Results: TAO was associated with intraoperative rupture (IOR) (odds ratio ­ OR = 10.54; 95% confidence interval ­ 95%CI 4.72­23.55; p < 0.001) and surgical complications (OR = 2.14; 95%CI 1.11­4.07; p = 0.01). The group with TAO and IOR had no significant difference in clinical (p = 0.06) and surgical (p = 0.94) complications compared to the group that had TAO, but no IOR. Among the 111 patients followed six months after treatment, IOR, number of occlusions, and total time of occlusion were not associated with Glasgow Outcome Scale (GOS) in the follow-up (respectively, p = 0.18, p = 0.30, and p = 0.73). Among patients who underwent TAO, IOR was also not associated with GOS in the follow-up (p = 0.29). Conclusions: TAO was associated with IOR and surgical complications, being the latter independent of IOR occurrence. In long-term analysis, neither TAO nor IOR were associated with poor clinical outcomes.

Uso de asistolía inducida por adenosina de aneurismas cerebrales / Asystole induce by adenosine for management of cerebral aneurysms

The treatment of cerebral aneurysms can currently be performed through endovascular technique and/or surgical treatment by clipping the aneurysm. The decision to use a particular technique will depend on the location, morphology and other characteristics. The techniques described are aimed to facilitate the surgical procedure, allowing to improve the approach, visualization and definitive clipping. Some of these techniques include temporary clipping of the proximal blood vessel, proximal control of the carotid artery at the cervical level, extracranial to intracranial bypass, and cardiac pause or arres

El tratamiento de los aneurismas cerebrales actualmente puede ser realizado a través de técnicas endovasculares y/o tratamiento quirúrgico con clipaje del aneurisma, la decisión de utilizar una técnica en particular dependerá de la localización, morfología y otras características. Las técnicas descritas están orientadas a facilitar el procedimiento quirúrgico, permitiendo mejorar el abordaje, la visualización y el clipaje definitivo. Algunas de estas técnicas incluyen clipaje transitorio de vaso sanguíneo proximal, control proximal de arteria carótida a nivel cervical, bypass extracraneal a intracraneal y la pausa o paro cardíaco

Aneurismas intracraneales, no rotos en pacientes de la provincia Sancti Spíritus / Non-ruptured intracranial aneurysms in patients from Sancti Spíritus province

Fundamento: Los aneurismas intracraneales cuando se fisuran provocan una hemorragia subaracnoidea. No obstante, no todos se rompen y algunos pueden ser encontrados de manera casual en un estudio imaginológico y se les denomina incidentales o asintomáticos según el paciente presente, o no, historia previa de otro saco que se haya roto con anterioridad. Tratar un aneurisma intracraneal no roto es un desafío para líderes clínicos y quirúrgicos. Objetivo: Describir las características y evolución de una serie de 91 aneurismas intracraneales incidentales y asintomáticos en pacientes atendidos en el Hospital General Camilo Cienfuegos de Sancti Spíritus entre los años 2010 y 2020. Metodología: Estudio descriptivo y cuantitativo con una muestra no probabilística de 91 aneurismas incidentales y asintomáticos encontrados en 72 pacientes mediante estudios imaginológicos. Las variables estudiadas fueron: edad, sexo, dimensiones, forma irregular, sitio de localización, método de tratamientos empleados, mortalidad y morbilidad. Resultados: Predominaron los pacientes con edad entre 45 y 65 años y hubo un predominio del sexo femenino. Fue mayoritario el aneurisma de mediano tamaño y la localización más frecuente fue la comunicante anterior. Se detectaron variables clínicas y morfológicas predictivas de complicaciones. Los pacientes no intervenidos quirúrgicamente evolucionaron mejor. Se detectaron varios pacientes con familiares de primer y segundo grado afectados por aneurismas intracraneales. Conclusiones: Los aneurismas intracraneales no rotos predominan en mujeres de la quinta y sexta década de la vida. Factores morfológicos como el tamaño del saco, la altura máxima del domo y la razón de aspecto se relacionaron con la aparición de complicaciones en los pacientes operados. El síndrome de aneurisma intracraneal familiar debe tenerse en cuenta en pacientes con antecedentes de familiares de primer y segundo grado con aneurismas intracraneales.

Background: Intracranial aneurysms when ruptured cause subarachnoid hemorrhage. However, not always they rupture and some may be found by chance in an imaging study and they are called incidental or asymptomatic depending on whether or not the patient has a prior event of additional ruptured sac formerly. Treating a non-ruptured intracranial aneurysm is a challenge for foremost clinical physicians and surgeons. Objective: To describe the characteristics and evolution of a series of 91 incidental and asymptomatic intracranial aneurysms in patients treated at the General Hospital Camilo Cienfuegos in Sancti Spíritus between 2010 and 2020. Methodology: Descriptive and quantitative study with a non-probabilistic sample of 91 incidental and asymptomatic aneurysms found in 72 patients through imaging studies. The variables studied were: age, sex, dimensions, irregular shape, site of location, method of treatment used, mortality and morbidity. Results: Patients aged between 45 and 65 years predominated with a predominance of female sex. The majority were medium-sized aneurysms and the most frequent location was the anterior connecting aneurysm. Clinical and morphological variables predictive of complications were detected. Patients who did not undergo surgery had a better evolution. Several patients with first and second relatives' degree affected by intracranial aneurysms were detected. Conclusions: Non-ruptured intracranial aneurysms predominate in women in the fifth and sixth decade of life. Morphological factors such as sac size, maximum dome height and aspect ratio were related to the happening of complications in operated patients. Family intracranial aneurysm syndrome should be considered in patients with a history of first and second relatives' degree affected by intracranial aneurysms.

Desfechos clínicos e funcionais de pacientes com hemorragia subaracnóidea aneurismática em UTI / Clinical and functional outcomes of patients with aneurysmatic subarachnoid hemorrhage in the ICU

INTRODUCTION: Rehabilitation has recently been discussed in patients with subarachnoid hemorrhage (SAH) caused by a ruptured aneurysm. OBJECTIVE: To compare clinical and functional outcomes of surviving and non-surviving patients with aneurysmal SAH in a neurosurgical ICU. METHODS: This is a retrospective documentary study. Medical records of patients with SAH admitted to the neurosurgical ICU of a teaching hospital between July 2014 and July 2019 were analyzed. Data were divided according to the outcomes into survivors group (SG) and non-survivors group (NG). RESULTS: 103 patients were analyzed, 72% female, mean age 55 years, 62% had high ICU outcome. The SG had significantly lower age, SAPS III score, Fisher and Hunt-Hess scales and time on mechanical ventilation (MV) than the NG, in addition, they had a Glasgow Coma Scale (GCS), on admission and discharge from the ICU and length of hospital stay, significantly higher (p≤0.05) than NG. The SG showed significantly higher functionality (p≤0.05) than the NG on admission and a significant increase (p≤0.05) in functionality between admission and discharge from the ICU. CONCLUSION: Surviving patients with aneurysmal SAH had lower age, SAPS III score, neurological scales and time on MV, higher GCS scores at ICU admission and discharge, and longer hospital stay than non-survivors. Surviving patients had better functionality than non-survivors on admission, and, evolved with functional improvement from admission to discharge from the ICU.

INTRODUÇÃO: Recentemente tem sido discutido quanto à reabilitação em pacientes com hemorragia subaracnóidea (HSA) causada pelo rompimento de um aneurisma. OBJETIVO: Comparar desfechos clínicos e funcionais de pacientes com HSA aneurismática, sobreviventes e não sobreviventes em uma UTI neurocirúrgica. MÉTODOS: Trata-se de um estudo documental retrospectivo. Foram analisados prontuários de pacientes com HSA internados na UTI neurocirúrgica de um hospital escola, entre julho de 2014 e julho de 2019. Os dados foram divididos de acordo com os desfechos em grupo sobreviventes (GS) e grupo não sobreviventes (GN). RESULTADOS: Foram analisados 103 pacientes, 72% do sexo feminino, idade média de 55 anos, 62% apresentaram alta da UTI como desfecho. O GS apresentou idade, escore SAPS III, escalas de Fisher e Hunt-Hess e tempo de ventilação mecânica (VM) significativamente menores (p≤0,05) que o GN, além disso, apresentaram escala de coma de Glasgow (ECG), na admissão e na alta da UTI e tempo de internação hospitalar, significativamente maiores (p≤0,05) que o GN. O GS apresentou funcionalidade significativamente maior (p≤0,05) que o GN na admissão e incremento significativo (p≤0,05) da funcionalidade entre a admissão e alta da UTI. CONCLUSÃO: Pacientes com HSA aneurismática sobreviventes apresentaram menores idades, escore SAPS III, escalas neurológicas e tempo de VM, maiores escores de ECG, na admissão e na alta da UTI e maior tempo de internação hospitalar que os não sobreviventes. Os pacientes sobreviventes apresentaram melhor funcionalidade que os não sobreviventes na admissão, e, evoluíram com melhora funcional da admissão até a alta da UTI.

Analysis of serum cholesterol, statins and atherosclerotic plaque in ruptured and unruptured intracranial aneurysm / Análise de colesterol sérico, estatina e placa aterosclerótica em aneurisma intracraniano roto e não roto

Introduction Intracranial aneurysm (IA) is a major healthcare concern. The use of statin to reduce serum cholesterol has shown evidence to reduce cardiovascular risk in various diseases, but the impact on IA has not been described. This study aims to determine whether statin use, and serum cholesterol levels interfere with outcomes after IA event. Methods A cohort of patients with IA was analyzed. Patients social and demographics data were collected.Modified Rankin scale (mRS) score after 6months of follow-up was the endpoint. The data regarding statins use, presence or not of atherosclerotic plaque in radiological images and serum cholesterol of 35 patients were included in our study. Linear regression models were used to determine the influence of those 6 variables in the clinical outcome. Results The prevalence of atherosclerotic plaque, high cholesterol and use of statins was 34.3%, 48.5%, and 14.2%, respectively. Statins and serum cholesterol did not impact the overall outcome,measured by mRS after 6 months (p>0.05), but did show different tendencies when separated by IA rupture status. Serum cholesterol shows na important association with rupture of aneurysm (p»0.0382). High cholesterol and use of statins show a tendency for worse outcome with ruptured aneurysm, and the opposite is true for unruptured aneurysm. The presence of atherosclerotic plaques was not related with worse outcomes. Conclusions Multiple and opposite mechanisms might be involved in the pathophysiology of IA. Ruptured aneurysms are associated with higher levels of serum cholesterol. Serum cholesterol and statins use were not correlated with worse outcomes, but further studies are important to clarify these relationships.

Introdução Aneurisma intracranial (AI) é uma grande preocupação para a saúde. Evidências apontam que o uso de estatina para reduzir o colesterol sérico diminui o risco cardiovascular em diversas doenças, mas o impacto em AI ainda não foi descrito. Este estudo almeja determinar se o uso de estatina e o nível sérico de colesterol interferem no desfecho clínico após a ocorrência de AIs. Métodos Uma coorte de pacientes com AI foi analisada. Os dados sociodemográficos dos pacientes foram coletados. Ao final de 6 meses de acompanhamento, aplicou-se a escala modificada de Rankin (mRS). Os dados sobre uso de estatina, existência de placa aterosclerótica em imagens radiológicas, e colesterol sérico de 35 pacientes foram incluídos no estudo. Modelos de regressão linear foram usados para determinar a influência dessas 6 variáveis nos desfechos clínicos. Resultados A prevalência de placa aterosclerótica, colesterol elevado, e uso de estatina foram respectivamente 34,3%, 48,5% e 14,2%. Estatina e colesterol sérico não impactaram nos desfechos medidos pela mRS em 6 meses (p > 0,05), mas mostraram diferentes tendências quando separados pelo estado de ruptura do AI. Colesterol sérico apresenta uma importante associação com ruptura de aneurisma (p » 0,0382). Colesterol elevado e uso de estatinas representam uma tendência a piores desfechos para aneurismas rompidos, e o oposto é verdade para os não rompidos. A presença de placa aterosclerótica não está relacionada com piores resultados. Conclusões Mecanismos múltiplos e opostos podem estar envolvidos na patofisio logia do AI. Aneurismas rompidos estão associados com maiores níveis de colesterol sérico. Colesterol sérico e estatinas não foram correlacionados com piores desfechos, mas mais estudos são importantes para clarificar a relação entre esses fatores

Outcomes of patients experiencing cardiovascular adverse events within 1 year following craniotomy for intracranial aneurysm clipping: a retrospective cohort study / 南方医科大学学报

OBJECTIVE@#To investigate the impact of postoperative serious cardiovascular adverse events (CAE) on outcomes of patients undergoing craniotomy for intracranial aneurysm clipping.@*METHODS@#This retrospective cohort study was conducted among the patients undergoing craniotomy for intracranial aneurysm clipping during the period from December, 2016 to December, 2017, who were divided into CAE group and non-CAE group according to the occurrence of Clavien-Dindo grade ≥II CAEs after the surgery. The perioperative clinical characteristics of the patients, complications and neurological functions during hospitalization, and mortality and neurological functions at 1 year postoperatively were evaluated. The primary outcome was mortality within 1 year after the surgery. The secondary outcomes were Glasgow outcome scale (GOS) score at 1 year, lengths of postoperative hospital and intensive care unit (ICU) stay, and Glasgow coma scale (GCS) score at discharge.@*RESULTS@#A total of 361 patients were enrolled in the final analysis, including 20 (5.5%) patients in CAE group and 341 in the non-CAE group. No significant differences were found in the patients' demographic characteristics, clinical history, or other postoperative adverse events between the two groups. The 1-year mortality was significantly higher in CAE group than in the non-CAE group (20.0% vs 5.6%, P=0.01). Logistics regression analysis showed that when adjusted for age, gender, emergency hospitalization, subarachnoid hemorrhage, volume of bleeding, duration of operation, aneurysm location, and preoperative history of cardiovascular disease, postoperative CAEs of Clavien-Dindo grade≥II was independently correlated with 1-year mortality rate of the patients with an adjusted odds ratio of 3.670 (95% CI: 1.037-12.992, P=0.04). The patients with CEA also had a lower GOS score at 1 year after surgery than those without CEA (P=0.002). No significant differences were found in the occurrence of other adverse events, postoperative hospital stay, ICU stay, or GCS scores at discharge between the two groups (P > 0.05).@*CONCLUSION@#Postoperative CAEs may be a risk factor for increased 1-year mortality and disability in patients undergoing craniotomy for intracranial aneurysms.

Internações hospitalares para tratamento de aneurismas cerebrais rotos e não rotos no Sistema Único de Saúde do Brasil, 2009-2018: um estudo descritivo / Ingresos hospitalarios para el tratamiento de aneurismas cerebrales rotos y no rotos en el Sistema Único de Salud de Brasil, 2009-2018: un estudio descriptivo / Hospital admissions for treatment of ruptured and unruptured cerebral aneurysms within the Brazilian National Health System, 2009-2018: a descriptive study

Objetivo: Analisar internações para tratamento de aneurismas cerebrais rotos e não rotos com realização de embolização e de microcirurgia cerebral no Sistema Único de Saúde (SUS), Brasil, 2009-2018. Métodos: Estudo descritivo, utilizando dados do Sistema de Informações Hospitalares do SUS. Descreveu-se a frequência das internações, procedimentos, utilização de unidade de tratamento intensivo (UTI), letalidade e gastos. Resultados: Das 43.927 internações, 22.622 (51,5%) resultaram em microcirurgia. Embolização e microcirurgia foram mais frequentes no sexo feminino. A duração das internações com embolização foi de 7,7 dias (±9,0), e com microcirurgia, 16,2 (±14,2) dias, a frequência de admissão em UTI, 58,6% e 85,3%, e a letalidade, 5,9% e 10,9%, respectivamente. Do gasto total, US$ 240 milhões, 66,3% corresponderam às internações com embolização. Conclusão: As internações com embolização para tratamento de aneurismas cerebrais no SUS apresentaram menor duração, menor frequência de utilização de UTI e menor letalidade, porém maior gasto em relação à microcirurgia cerebral.

Objetivo: Analizar las internaciones para tratamiento de aneurismas cerebrales rotos y no rotos en cuanto a embolización y microcirugía cerebral en el Sistema Único de Salud (SUS), Brasil, de 2009 a 2018. Métodos: Estudio descriptivo utilizando datos del Sistema de Información Hospitalaria (SIH)/SUS relacionados con la frecuencia de hospitalizaciones, procedimientos, uso de la unidad de cuidados intensivos (UCI), letalidad y gastos. Resultados: De los 43.927 ingresos, 22.622 (51,5%) correspondieron a microcirugía. Hubo una mayor frecuencia de procedimientos de embolización y microcirugía entre las personas del sexo femenino. De las hospitalizaciones con embolización y microcirugía, respectivamente, la duración de la estadía fue de 7,7 (±9,0) y 16,2 (±14,2) días, la frecuencia de ingreso en la UCI fue del 58,6% y el 85,3% y la letalidad del 5,9% y el 10,9%. El gasto total fue de US$ 240 millones, de los cuales el 66,3% correspondió a hospitalizaciones con embolización. Conclusión: Las hospitalizaciones con embolización, para el tratamiento de aneurismas cerebrales en el SUS, tuvieron menor tiempo de estadía, menor frecuencia de uso de la UCI y menor letalidad, pero mayores gastos en relación a la microcirugía cerebral.

Objective: To analyze hospital admissions for treatment of ruptured and unruptured cerebral aneurysms with embolization and brain microsurgery performed within the Brazilian National Health System (SUS), 2009-2018. Methods: This was a descriptive study, using data from the SUS's Hospital Information System. Frequency of hospital admissions, procedures, use of intensive care unit (ICU), case fatality ratio and expenditures were described. Results: Of the 43,927 hospital admissions, 22,622 (51.5%) resulted in microsurgery. Embolization and cerebral microsurgery were more frequent among females. Length of hospital stay with embolization procedure was 7.7 days (±9.0), and with microsurgery, 16.2 (±14.2) days, frequency of ICU admission, 58.6% and 85.3%, and case fatality ratio, 5.9% and 10.9% respectively. Of the total expenditure, USD 240 million, 66.3% corresponded to hospitalizations with embolization procedure. Conclusion: Hospital admissions with embolization procedure for treatment of cerebral aneurysms within the SUS showed a shorter length of stay, less frequent use of ICU and lower case fatality ratio, but higher expenditure when compared to brain microsurgery.

Manifestações oftalmológicas em paciente com aneurisma gigante de carótida interna / Ophthalmological manifestation in patient with gigantic aneurysm of the internal carotid

RESUMO Os aneurismas intracranianos são dilatações em segmentos arteriais que irrigam o sistema nervoso central. Acometem 2% da população e as alterações oftalmológicas podem ser as primeiras manifestações do quadro. O objetivo deste relato foi descrever um caso de aneurisma de artéria carótida interna que cursou com restrição da movimentação ocular, alteração do reflexo fotomotor, ptose palpebral, dor facial e cervical. O diagnóstico foi confirmado pela identificação do aneurisma por meio do exame de angiografia cerebral. Foi realizado teste de oclusão por balão, cujo resultado positivo possibilitou a oclusão total da artéria carótida interna por meio de ligadura cirúrgica, procedimento este realizado com sucesso.

ABSTRACT Intracranial aneurysms are dilations in segments of the arteries that irrigate the central nervous system. They affect 2% of the population and the ophthalmologic disorders may be the first evidence in the clinical examination. The aim of the report is to describe a case of an internal carotid artery aneurysm that showed restrictions of ocular movements, change of pupillary light reflex, palpebral ptosis, facial, and cervical pain. This diagnosis was confirmed by the identification of the aneurysm through angiography. A balloon occlusion test was performed, and its positive result made a complete occlusion of the Internal Carotid Artery possible through surgery ligation, procedure that was successful.

Could outcomes of intracranial aneurysms be better predict using serum creatinine and glomerular filtration rate?

Purpose: To analyze the role of serum creatinine levels as a biomarker of intracranial aneurysm outcomes. Methods: This is a prospective analysis of outcomes of patients with intracranial aneurysm. One hundred forty-seven patients with serum creatinine at admission and 6 months follow up were included. Linear and logistic regressions were used to analyze the data. Modified Rankin scale (mRS) was used to assess outcome. Results: Creatinine level was not directly related to aneurysm outcome nor aneurysm rupture (p > 0.05). However, patients with a glomerular filtration rate (GFR) lower than 72.50 mL·min­1 had an odds ratio (OR) of 3.049 (p = 0.006) for worse outcome. Similarly, aneurysm rupture had an OR of 2.957 (p = 0.014) for worse outcomes. Stepwise selection model selected 4 variables for outcomes prediction: serum creatinine, sex, hypertension and treatment. Hypertensive patients had, on average, an increase in 0.588 in mRS (p = 0.022), while treatment with microsurgery had a decrease in 0.555 (p = 0.038). Conclusions: Patients with higher GFR had better outcomes after 6 months. Patients with higher GFR had better outcomes after 6 months. Creatinine presented an indirect role in GFR values and should be included in models for outcome prediction.

Anatomy of the Middle Meningeal Artery

Introduction The middle meningeal artery (MMA) is an important artery in neurosurgery. As the largest branch of the maxillary artery, it provides nutrition to the meninges and to the frontal and parietal regions. Diseases, including dural arteriovenous fistula (DAVF), pseudoaneurysm, true aneurysm, traumatic arteriovenous fistula (TAVF), Moya-Moya disease (MMD), recurrent chronic subdural hematoma (CSDH), migraine, and meningioma,may be related to the MMA. The aim of the present study is to describe the anatomy of the MMA and to correlate it with brain diseases. Methods A literature review was performed using the PubMed, Scielo, Scientific Direct, Ebsco, LILACS, TripDataBase and Cochrane databases, with the following descriptors: neurosurgery, neuroanatomy, meninges and blood supply. Discussion The MMA is embedded in a cranial groove, and traumatic or iatrogenic factors can result in MMA-associated pseudoaneurysms or arteriovenous fistulas (AVFs). In hemodynamic stress, true aneurysms can develop. Arteriovenous fistulas, pseudoaneurysms, and true aneurysms can be effectively treated by endovascular or surgical removal. In MMD, the MMA plays a role in the development and in the improvement of collateral circulation. Finally, in cases of CSDH, when standard surgery and drainage fail, MMA embolization can constitute a great alternative. Conclusion The MMA is a relevant structure for the understanding of neurosurgical diseases. In conclusion, every neurosurgeon must know the anatomy of the MMA sufficiently to correlate it with the diagnosed pathology, thus obtaining treatment effectiveness and preventing brain lesion.