Comparing surgical clipping with endovascular treatment for unruptured middle cerebral artery aneurysms: a systematic review and updated meta-analysis.

OBJECTIVE: Unruptured middle cerebral artery aneurysm (uMCAA) has traditionally been treated with open surgical clipping (SC). Endovascular treatments (EVTs) were designed to reduce surgical risks in these cases. Nevertheless, despite its potential benefits, many surgeons favor SC for uMCAA. This updated meta-analysis aimed to compare the safety, efficacy, and clinical outcomes of SC and EVT for uMCAA. METHODS: The authors searched the Medline, Embase, and Cochrane Library databases according to the Cochrane and PRISMA guidelines. Eligible studies included those with ≥ 4 patients with uMCAA reporting comparative data of SC and EVT. The endpoints were the complete occlusion rate (Raymond class I and II), good clinical outcomes (modified Rankin Scale score ≤ 2 or Glasgow Outcome Scale score ≥ 4), procedure-related complications (further divided into major and minor), and mortality. The authors pooled OR with 95% CI values with a random-effects model. I2 statistics were used to assess heterogeneity, and sensitivity analysis was conducted to address high heterogeneity. Publication bias was assessed with funnel plot analysis and the Egger's test. RESULTS: The analysis included data from 10 studies. Regarding the complete occlusion assessment, the comparative analysis revealed OR 0.17 (95% CI 0.08-0.40, p < 0.01), favoring SC. In terms of achieving good clinical outcomes, OR 0.44 (95% CI 0.20-0.97, p < 0.05) was determined, favoring SC. No differences regarding total procedure-related complications, major complications, or mortality were identified. However, a higher likelihood of minor complications was identified for EVT, with OR 4.68 (95% CI 2.01-10.92, p < 0.01). CONCLUSIONS: This systematic review and meta-analysis identified a lower likelihood of complete occlusion at last follow-up and lower likelihood of good clinical outcomes in patients treated with EVT when compared with SC. Furthermore, a higher likelihood of minor complications was identified in patients who underwent EVT when compared with SC. The findings reinforce that, based on the currently available data, SC should be considered the primary approach for treating uMCAA. However, EVT is an evolving approach, and this study's findings represent a synthesis of observational studies. Randomized trials are warranted to elucidate which approach should be the mainstay for uMCAA and to identify the nuances that determine whether SC or EVT is more or less indicated for addressing uMCAA with consideration of the individuality of each patient and aneurysm.

Effects of antenatal corticosteroids on fetal hemodynamics: a longitudinal study.

Objective: To study the effect of antenatal corticosteroid administration on fetal hemodynamics using longitudinal analysis of Doppler waveforms in the umbilical artery (UA) and middle cerebral artery (MCA). Materials and Methods: This was a retrospective study that included 30 fetuses at risk for preterm birth. Twenty-eight pregnant women were treated with betamethasone for fetal lung maturation. Doppler examinations of the UA and MCA were performed once before and three or eight times after corticosteroid administration. We used a Bayesian hierarchical linear model. Reference ranges were constructed, and associations between variables (gestational age and pre-eclampsia) were tested. Results: The mean maternal age, gestational age at betamethasone administration, and gestational age at delivery were 32.6 ± 5.89 years, 30.2 ± 2.59 weeks, and 32.9 ± 3.42 weeks, respectively. On UA Doppler, there was a significant decrease in the pulsatility index (PI) after corticosteroid administration, with a mean of 0.1147 (credibility interval: 0.03687-0.191) in three observations and a median of 0.1437 (credibility interval: 0.02509-0.2627) in eight observations. However, there was no significant change in the Doppler MCA PI, regardless of gestational age and the presence or absence of pre-eclampsia. Conclusion: Although antenatal corticosteroid administration induced a significant decrease in the Doppler UA PI, we observed no change in the cerebral vasculature.

Objetivo: Estudar o efeito da administração antenatal de corticosteroides na hemodinâmica fetal mediante análise longitudinal do Doppler na artéria umbilical (AU) e artéria cerebral média (ACM). Materiais e Métodos: Este foi um estudo retrospectivo que incluiu 30 fetos com risco de nascimento pré-termo. Vinte e oito gestantes foram tratadas com betametasona para maturação pulmonar fetal. Os exames de Doppler da AU e da ACM foram realizados uma vez antes e depois da administração de corticosteroides, num total de três ou oito observações. Utilizamos o modelo linear hierárquico com abordagem Bayesiana. Foram construídos os intervalos de referência e testadas associações entre variáveis (idade gestacional e pré-eclâmpsia). Resultados: A média ± desvio-padrão da idade materna, idade gestacional na administração de betametasona e idade gestacional no parto foram 32,6 ± 5,89 anos, 30,2 ± 2,59 semanas e 32,9 ± 3,42 semanas, respectivamente. No Doppler da AU, verificou-se diminuição significativa do índice de pulsatilidade (IP) com a terapêutica com corticosteroides (média: 0,1147 [0,03687-0,191]; em três observações) (mediana: 0,1437 [0,02509-0,2627]; em oito observações). No entanto, não foi observada alteração significativa no IP do Doppler da ACM, independentemente da idade gestacional e do diagnóstico de pré-eclâmpsia. Conclusão: Os corticosteroides pré-natais induziram diminuição significativa no IP do Doppler da AU, mas não houve alteração na vasculatura cerebral.

Microsurgical management of a ruptured intracranial mycotic aneurysm in infancy.

INTRODUCTION: During infancy, infectious aneurysms are uncommon and potentially fatal lesions with an imminent risk of intracranial hemorrhage development. CASE PRESENTATION: A 1-month-old infant presented with loss of consciousness and clonic movements of the right superior limb after a work-up for Hirschsprung's disease. His physical exam revealed stupor, miosis, anterior fontanelle swelling, and hyperreflexia of the right superior limb. Blood cultures were positive for Candida albicans. In addition, brain imaging revealed an intraparenchymal hematoma in the left temporal lobe and a saccular aneurysm at the M3 segment of the left middle cerebral artery. Upon careful discussion with the patient's family, he underwent evacuation of the hematoma and aneurysm repair. His postoperative clinical course was uneventful. At the 5-month follow-up, a brain MRI showed encephalomalacia in the area of prior hemorrhage. Furthermore, he had preserved motor function and adequate psychomotor development on subsequent pediatric evaluations. CONCLUSION: Microsurgical management of ruptured mycotic aneurysms demands a systematic work-up and nuanced appraisal of clinical and aneurysmal factors. Operating in a confined space and considering the fragile nature of aneurysms are of utmost relevance for effectively treating these lesions.

Reading and writing from right to left after anterior cerebral artery stroke.

This is the case report of a woman who started to write and read from right to left after anterior cerebral artery stroke, affecting the left supplementary motor area. No cases were found in the literature with exactly the same characteristics. She has been able to read and write faster after rehabilitation approach at Sarah Network of Rehabilitation Hospitals, in the Belo Horizonte city unit, Brazil, despite the maintenance of the inversion. She returned to her previous activities in an adaptive way. It was discussed how the dysfunction in this cerebral area and its connections may disturb the reading strategy and direction.

Relato do caso de uma mulher que passou a escrever e ler da direita para a esquerda após um acidente vascular encefálico isquêmico de artéria cerebral anterior, acometendo área motora suplementar esquerda. Não foram encontrados casos na literatura exatamente com as mesmas características. Durante a participação da paciente no programa de reabilitação neurológica da Rede Sarah de Hospitais de Reabilitação, unidade Belo Horizonte, foram observados ganhos na agilidade de leitura e escrita, ainda que mantendo a inversão, e retorno às suas atividades de forma adaptada. Realizou-se discussão de como o comprometimento dessa área e de suas conexões pode perturbar a estratégia de leitura e sua direção.

Valores de referencia del Doppler fetal en el Instituto Nacional de Parinatología Isidro Espinosa de los Reyes / Reference values of fetal Doppler at the Instituto Nacional de Perinatología Isidro Espinosa de los Reyes

Resumen OBJETIVO: Establecer los valores de referencia del índice de pulsatilidad con Doppler pulsado en la valoración materna y fetal de los embarazos en seguimiento entre las 18 y 39 semanas de gestación. MATERIALES Y MÉTODOS: Estudio descriptivo y transversal, efectuado en pacientes con embarazo único, entre las 18 a 40 semanas, que acudieron al Departamento de Medicina Materno Fetal del Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, entre los meses de septiembre de 2017 a mayo de 2018. La evaluación Doppler se practicó con medición del índice de pulsatilidad de las arterias uterinas, umbilical, cerebral media y conducto venoso en cada semana del embarazo. Se crearon tablas de referencia para cada semana de la gestación y se establecieron los percentiles 3, 5, 10, 90 y 95. RESULTADOS: Se registraron 862 pacientes. Los valores del índice de pulsatilidad de la arteria umbilical reportaron 17% en semanas tempranas de la gestación y 21% en edades gestacionales mayores. Los valores de la arteria umbilical fueron 3% menores en edades gestacionales tempranas y 10% menores al término del embarazo; 20% para la arteria umbilical, 15% para el conducto venoso y 10% para la arteria cerebral media. Los valores del índice de pulsatilidad medio de las arterias uterinas fueron mayores un 3% en edades gestacionales tempranas y 28% menores al término del embarazo. CONCLUSIONES: Los hallazgos de este estudio sugieren diferencias significativas con las poblaciones de Europa y Norteamérica; incluso difieren de los valores de referencia utilizados en la actualidad en la población mexicana, lo que supone una subestimación de las condiciones fetales o maternas al hacer las evaluaciones de la unidad fetoplacentaria.

Abstract OBJECTIVE: Establish the reference values for the pulsatility index using pulsed Doppler in the maternal and fetal assessment of pregnancies followed at 18 and 39 weeks of gestation. MATERIALS AND METHODS: Descriptive and cross-sectional study, carried out in patients with a singleton pregnancy, between 18 and 40 weeks, who attended the Department of Maternal Fetal Medicine of the National Institute of Perinatology, from September 2017 to May 2018. The Doppler evaluation was performed, with measurement of the pulsatility index of the uterine, umbilical, middle cerebral arteries, and venous duct in each week of pregnancy. Reference tables were created for each gestational age, establishing percentiles 3, 5, 10, 90 and 95. RESULTS: A total of 862 patients were registered. The umbilical artery pulsatility index values were reported to be 17% at early gestational ages and 21% at older gestational ages; Umbilical artery values were 3% lower at early gestational ages and 10% lower at term of pregnancy; 20% for the umbilical artery, 15% for the ductus venosus and 10% for the middle cerebral artery. The values of the mean pulsatility index of the uterine arteries were 3% higher at early gestational ages and 28% lower at the end of pregnancy. CONCLUSIONS: The findings of this study suggest significant differences with the populations of Europe and North America; They even differ from the reference values currently used in the Mexican population, which represents an underestimation of fetal and/or maternal conditions when carrying out evaluations of the feto-placental unit.

Reading and writing from right to left after anterior cerebral artery stroke / Escrita e leitura da direita para a esquerda após lesão cerebral

ABSTRACT. This is the case report of a woman who started to write and read from right to left after anterior cerebral artery stroke, affecting the left supplementary motor area. No cases were found in the literature with exactly the same characteristics. She has been able to read and write faster after rehabilitation approach at Sarah Network of Rehabilitation Hospitals, in the Belo Horizonte city unit, Brazil, despite the maintenance of the inversion. She returned to her previous activities in an adaptive way. It was discussed how the dysfunction in this cerebral area and its connections may disturb the reading strategy and direction.

RESUMO. Relato do caso de uma mulher que passou a escrever e ler da direita para a esquerda após um acidente vascular encefálico isquêmico de artéria cerebral anterior, acometendo área motora suplementar esquerda. Não foram encontrados casos na literatura exatamente com as mesmas características. Durante a participação da paciente no programa de reabilitação neurológica da Rede Sarah de Hospitais de Reabilitação, unidade Belo Horizonte, foram observados ganhos na agilidade de leitura e escrita, ainda que mantendo a inversão, e retorno às suas atividades de forma adaptada. Realizou-se discussão de como o comprometimento dessa área e de suas conexões pode perturbar a estratégia de leitura e sua direção.

Effects of antenatal corticosteroids on fetal hemodynamics: a longitudinal study / Efeitos do corticoide antenatal na hemodinâmica fetal: um estudo longitudinal

Abstract Objective: To study the effect of antenatal corticosteroid administration on fetal hemodynamics using longitudinal analysis of Doppler waveforms in the umbilical artery (UA) and middle cerebral artery (MCA). Materials and Methods: This was a retrospective study that included 30 fetuses at risk for preterm birth. Twenty-eight pregnant women were treated with betamethasone for fetal lung maturation. Doppler examinations of the UA and MCA were performed once before and three or eight times after corticosteroid administration. We used a Bayesian hierarchical linear model. Reference ranges were constructed, and associations between variables (gestational age and pre-eclampsia) were tested. Results: The mean maternal age, gestational age at betamethasone administration, and gestational age at delivery were 32.6 ± 5.89 years, 30.2 ± 2.59 weeks, and 32.9 ± 3.42 weeks, respectively. On UA Doppler, there was a significant decrease in the pulsatility index (PI) after corticosteroid administration, with a mean of 0.1147 (credibility interval: 0.03687-0.191) in three observations and a median of 0.1437 (credibility interval: 0.02509-0.2627) in eight observations. However, there was no significant change in the Doppler MCA PI, regardless of gestational age and the presence or absence of pre-eclampsia. Conclusion: Although antenatal corticosteroid administration induced a significant decrease in the Doppler UA PI, we observed no change in the cerebral vasculature.

Resumo Objetivo: Estudar o efeito da administração antenatal de corticosteroides na hemodinâmica fetal mediante análise longitudinal do Doppler na artéria umbilical e artéria cerebral média (ACM). Materiais e Métodos: Este foi um estudo retrospectivo que incluiu 30 fetos com risco de nascimento pré-termo. Vinte e oito gestantes foram tratadas com betametasona para maturação pulmonar fetal. Os exames de Doppler da AU e da ACM foram realizados uma vez antes e depois da administração de corticosteroides, num total de três ou oito observações. Utilizamos o modelo linear hierárquico com abordagem Bayesiana. Foram construídos os intervalos de referência e testadas associações entre variáveis (idade gestacional e pré-eclâmpsia). Resultados: A média ± desvio-padrão da idade materna, idade gestacional na administração de betametasona e idade gestacional no parto foram 32,6 ± 5,89 anos, 30,2 ± 2,59 semanas e 32,9 ± 3,42 semanas, respectivamente. No Doppler da AU, verificou-se diminuição significativa do índice de pulsatilidade (IP) com a terapêutica com corticosteroides (média: 0,1147 [0,03687-0,191]; em três observações) (mediana: 0,1437 [0,02509-0,2627]; em oito observações). No entanto, não foi observada alteração significativa no IP do Doppler da ACM, independentemente da idade gestacional e do diagnóstico de pré-eclâmpsia. Conclusão: Os corticosteroides pré-natais induziram diminuição significativa no IP do Doppler da AU, mas não houve alteração na vasculatura cerebral.

Maternal, obstetric, and fetal Doppler characteristics in a high-risk population: prediction of adverse perinatal outcomes and of cesarean section due to intrapartum fetal compromise.

Objective: To evaluate the capacity of fetal Doppler, maternal, and obstetric characteristics for the prediction of cesarean section due to intrapartum fetal compromise (IFC), a 5-min Apgar score < 7, and an adverse perinatal outcome (APO), in a high-risk population. Materials and Methods: This was a prospective cohort study involving 613 singleton pregnant women, admitted for labor induction or at the beginning of spontaneous labor, who underwent Doppler ultrasound within the last 72 h before delivery. The outcome measures were cesarean section due to IFC, a 5-min Apgar score < 7, and any APO. Results: We found that maternal characteristics were neither associated with nor predictors of an APO. Abnormal umbilical artery (UA) resistance index (RI) and the need for intrauterine resuscitation were found to be significant risk factors for cesarean section due to IFC (p = 0.03 and p < 0.0001, respectively). A UA RI > the 95th percentile and a cerebroplacental ratio (CPR) < 0.98 were also found to be predictors of cesarean section due to IFC. Gestational age and a UA RI > 0.84 were found to be predictors of a 5-min Apgar score < 7 for newborns at < 29 and ≥ 29 weeks, respectively. The UA RI and CPR presented moderate accuracy in predicting an APO, with areas under the ROC curve of 0.76 and 0.72, respectively. Conclusion: A high UA RI appears to be a significant predictor of an APO. The CPR seems to be predictive of cesarean section due to IFC and of an APO in late preterm and term newborns.

Objetivo: Avaliar a capacidade do Doppler fetal e características materno-obstétricas na predição de cesariana por comprometimento fetal intraparto (CFI), índice de Apgar de 5º min < 7 e desfecho perinatal adverso (DPA) em uma população de alto risco. Materiais e Métodos: Estudo de coorte prospectivo envolvendo 613 parturientes admitidas para indução ou em início de trabalho de parto espontâneo que realizaram ultrassonografia Doppler nas 72 horas anteriores ao parto. Os desfechos foram cesariana por CFI, índice de Apgar de 5º min < 7 e DPA. Resultados: As características maternas não foram associadas nem preditoras de DPA. Índice de resistência (IR) da artéria umbilical (AU) anormal (p = 0,03) e necessidade de medidas de ressuscitação intrauterina (p < 0,0001) permaneceram como fatores de risco significativos para cesariana por CFI. IR AU > 95º e razão cerebroplacentária (RCP) < 0,98 foram preditores de cesariana. Idade gestacional e IR AU > 0,84 foram os preditores de índice de Apgar de 5º min < 7 para recém-nascidos < 29 e ≥ 29 semanas, respectivamente. IR AU e RCP apresentaram acurácia moderada na predição de DPA (área sob a curva ROC de 0,76 e 0,72, respectivamente). Conclusão: IR UA mostrou-se preditor significativo de DPA. RCP revelou-se possível preditora de cesariana por CFI e DPA em recémnascidos prematuros tardios e a termo.

Morphometry of the Middle Cerebral Arteries: A Radio-Anatomical Study Based on Computed Tomography Angiography Findings / Morfometría de las Arterias Cerebrales Medias: Un Estudio Anátomo-Radiológico Basado en los Hallazgos de la Angiografía por Tomografía Computada

SUMMARY: Middle cerebral artery (MCA), which has the largest irrigation area of the arteries that feed the brain, is an important artery whose microanatomy should be well known because of its vascular variation. In pathologies which are known to affect the cerebrovascular system such as type 2 diabetes mellitus (T2DM) and hypertension, morphometric characteristics of MCA gain importance. The aim of this study is to compare the morphometric characteristics of M1 segment of MCA in T2DM and hypertensive patients with those of healthy control group by using computed tomographic angiography (CTA). The study was carried out with retrospective morphometric analysis of CTA images of 200 individuals between 40 and 65 years of age. The individuals were grouped in four as hypertensive patients (group 1), patients with T2DM (group 2), patients with hypertension and T2DM (group 3) and healthy control group (group 4). Length and diameter measurements of M1 segment were performed and recorded by using 3D CTA images. While statistically significant difference was found between bilateral M1 segment diameters of both women and men (p0.05). As a result of the post hoc analysis performed, it was concluded that right and left M1 segment diameter of group 1, group 2 and group 3 was found to be different from group 4 in both sexes (p<0.05). We believe that this study will both be a guide in radio-anatomic assessments to be performed and also increase microanatomic level of information in the surgical treatment of the artery by showing the morphometric changes that occur in M1 segment of MCA in T2DM diseases.

La arteria cerebral media (ACM), que otorga la mayor área de irrigación de las arterias que alimentan el cerebro, es un vaso importante cuya microanatomía debe ser bien conocida por su variación vascular. En patologías que afectan al sistema cerebrovascular, como la diabetes mellitus tipo 2 (DM2) y la hipertensión, las características morfométricas de la ACM cobran importancia. El objetivo de este estudio fue comparar las características morfométricas del segmento M1 de la ACM en pacientes con DM2 e hipertensos con las del grupo control sano mediante el uso de angiografía por tomografía computada (TC). El estudio fue realizado através de análisis morfométrico retrospectivo de imágenes de TC de 200 individuos entre 40 y 65 años de edad. Los individuos fueron divididos en cuatro grupos, como pacientes hipertensos (grupo 1), pacientes con DM2 (grupo 2), pacientes con hipertensión y DM2 (grupo 3) y grupo control sano (grupo 4). Las mediciones de longitud y diámetro del segmento M1 se realizaron y registraron utilizando imágenes 3D TC. Si bien se encontraron diferencias estadísticamente significativas entre los diámetros bilaterales de los segmentos M1 de mujeres y hombres (p0,05). Como resultado del análisis post hoc realizado, se concluyó que el diámetro de los segmentos M1 derecho e izquierdo del grupo 1, grupo 2 y grupo 3 fue diferente del grupo 4 en ambos sexos (p<0.05). Creemos que este estudio será una guía en las evaluaciones anátomo-radiológicas y también mejorará el nivel de información microanatómica en el tratamiento quirúrgico al mostrar los cambios morfométricos que ocurren en el segmento M1 de la ACM en las enfermedades con DM2.

Radiodensidad de la arteria cerebral media y su correlación con el nivel de hemoglobina en pacientes con y sin infarto cerebral residentes a gran altitud

Introducción. El signo de la arteria cerebral media (ACM) hiperdensa evaluada por tomografía simple permite predecir la enfermedad vascular cerebral isquémica (EVCi) con oclusión de un gran vaso, sin embargo, es frecuente identificar este signo en pobladores con niveles altos de hemoglobina sin clínica de EVCi. Objetivos. Evaluar la correlación entre la radiodensidad de la ACM y el nivel de hemoglobina en pacientes con y sin EVCi, residentes en una ciudad a gran altitud. Métodos. Estudio observacional analítico, se incluyeron personas residentes de Cusco (ubicada a 3300 msnm) que acudían al servicio de emergencia y se les realizó una tomografía cerebral, presentando o no clínica de EVCi. Se realizó la medición de la radiodensidad de la ACM y se correlacionó con el nivel de hemoglobina. Resultados. Se incluyeron 279 pacientes, el promedio de hemoglobina fue de 15,1 mg/dL y desviación estándar (DE) de 2,5 mg/dL, en los controles se identificó una correlación significativa (r = 0,425, p<0,01) entre la radiodensidad de la ACM con el nivel de hemoglobina. En los casos con EVCi derechos, la radiodensidad de la ACM derecha fue de 46,9 (DE = 7,7 UH) y de la izquierda fue de 46,1 (DE = 6,6 UH), sin que existan diferencias estadísticas (p = 0,24). Tampoco se encontró diferencias en los casos con EVCi izquierdos. Conclusión. Sí existe una correlación entre la radiodensidad de la ACM con el nivel de hemoglobina en los pobladores que viven a gran altitud, sin embargo, no se logró demostrar diferencias significativas entre la radiodensidad entre las ACM afectada y la contralateral en los casos de un EVCi.

Introduction. The sign of the hyperdense middle cerebral artery (MCA) evaluated by simple tomography allows predicting ischemic cerebrovascular disease (ICD) with occlusion of a large vessel, however, it is common to identify this sign in residents with high hemoglobin levels without symptoms of ICD. Objectives. To evaluate the correlation between the radiodensity of the MCA and the hemoglobin level in patients with and without ICD, residing in a high-altitude city. Methods. Analytical observational study, including people residing in Cusco (located at 3300 masl) who attended the emergency service and underwent a brain tomography, presenting or not ICD symptoms. ACM radiodensity was measured and correlated with the hemoglobin level. Results. 279 patients were included, the average hemoglobin was 15.1 and standard deviation (DE) of 2.5 mg/dL, in the controls a significant correlation was identified (r = 0.425, p<0.01) between the radiodensity of the MCA with the hemoglobin level. In the cases with right ICD, the radiodensity of the right MCA was 46.9 (DE = 7.7 HU) and of the left it was 46.1 (DE = 6.6 HU), with no statistical differences (p=0 ,24). No differences were found in the cases with left ICD either. Conclusion. There is a correlation between the radiodensity of the MCA with the hemoglobin level in the inhabitants who live at high altitudes, however, it is not possible to demonstrate significant differences between the radiodensity between the affected MCA and the contralateral one in the cases of an ICD.

Outcomes of decompressive craniectomy for malignant middle cerebral artery stroke in an academic hospital in Brazil / Desfechos da craniectomia descompressiva para infarto maligno da artéria cerebral média em um hospital acadêmico no Brasil

Abstract Background Ischemic stroke is an important cause of death in the world. The malignant middle cerebral artery infarction (MMCAI) has mortality as high as 80% when clinically treated. In this setting, decompressive craniectomy is a life-saving measure, in spite of high morbidity among survivors. Objective To evaluate the outcomes of patients with MMCAI treated with decompressive craniectomy in a Brazilian academic tertiary stroke center. Methods A prospective stroke database was retrospectively evaluated, and all patients treated with decompressive craniectomy for MMCAI between January 2014 and December 2017 were included. The demographics and clinical characteristics were evaluated. The functional outcome, measured by the modified Rankin Scale (mRS), was assessed at hospital discharge, after 3-months and 1-year of follow-up. Results We included 53 patients on the final analysis. The mean age was 54.6 ± 11.6 years and 64.2% were males. The median time from symptoms to admission was 4.8 (3-9.7) hours and the mean time from symptoms to surgery was 36 ± 17 hours. The left hemisphere was the affected in 39.6%. The median NIHSS at admission was 20 (16-24). The in-hospital mortality was 30.2%. After a median of 337 [157-393] days, 47.1% of patients had achieved favorable outcome (mRS ≤ 4) and 39.6% had died. Conclusion Decompressive craniectomy is a life-saving measure in the setting of MMCAI, and its effects remains important in the scenario of a middle-income country in real-world situations.

Resumo Antecedentes O acidente vascular cerebral (AVC) isquêmico é uma causa importante da morte em todo o mundo. O infarto maligno da artéria cerebral média (IMACM) tem mortalidade de até 80% quando tratado clinicamente. Nesse contexto, a craniectomia descompressiva é uma medida salvadora de vidas, apesar da alta morbidade entre os sobreviventes. Objetivo Avaliar os desfechos dos pacientes com IMACM tratados com craniectomia descompressiva em um centro acadêmico terciário de AVC no Brasil. Métodos Um banco de dados prospectivo de AVC foi avaliado retrospectivamente e todos os pacientes tratados com craniectomia descompressiva para IMACM entre janeiro de 2014 e dezembro de 2017 foram incluídos. As características clínicas e demográficas foram avaliadas. Os desfechos funcionais, medidos pela escala modificada da Rankin (mRS), foram avaliados na alta hospitalar, após 3 meses e após 1 ano de seguimento. Resultados Foram incluídos 53 pacientes na análise final. A idade média foi 54,6 ± 11,6 anos e 64,2% eram homens. A mediana do tempo dos sintomas à admissão foi 4,8 (3-9,7) horas e o tempo médio dos sintomas à cirurgia foi 36 ± 17 horas. O hemisfério esquerdo foi o afetado em 39,6%. A pontuação na escala de AVC do National Institute of Health (NIHSS) à admissão foi 20 (16-24). A mortalidade hospitalar foi 30,2%. Após uma mediana de 337 (157-393) dias, 47,1% dos pacientes tinham atingido um desfecho favorável (mRS ≤ 4) e 39,6% tinham morrido. Conclusão Craniectomia descompressiva é uma medida salvadora de vidas no contexto do IMACM e seus efeitos permanecem importantes no cenário de um país em desenvolvimento em situação de vida real.

Limitation of fenestrated clips during clipping of middle cerebral artery aneurysm: Technical note.

Background: The middle cerebral artery (MCA) is a common site of cerebral aneurysms and 82.6% occur at the bifurcation. When surgery is selected as a therapeutic option, it intends to clip the neck completely because if some remnant occurs, there exists the possibility of regrowth and bleeding in the short- or long-term. Methods: We analyzed one drawback of the fenestrated clips of Yasargil and Sugita types to occlude the neck totally at a specific point formed by the union of the fenestra with the blades, creating a triangular space where the aneurysm can protrude, giving place to a remnant that can lead to a future recurrence and rebleeding. We show two cases of ruptured MCA aneurysms in which a cross-clipping technique occluded a broad base and dysmorphic aneurysm using straight fenestrated clips. Results: In both cases (one using a Yasargil clip and the other with a Sugita clip), a small remnant was visualized when fluorescein videoangiography (FL-VAG) was used. In both cases, the small remnant was clipped with a 3 mm straight miniclip. Conclusion: We should be aware of this drawback when clipping aneurysms using fenestrated clips to ensure a complete obliteration of the aneurysm's neck.

Numerical simulation of flow-diverting stent: comparison between branches in bifurcation brain aneurysm.

The usage of flow-diverting stents in the treatment of intracranial aneurysms is widespread due to their high success and low complication rates. However, their use is still not officially recommended for bifurcation aneurysms, as there is a risk of generating ischemic complications due to the reduced blood flow to the jailed branch. Many works utilize computational fluid dynamics (CFD) to study how hemodynamic variables respond to flow diverter placement, but few seem to use it to verify flow variation between branches of bifurcation aneurysms and to aid in the choice of the best ramification for device placement. This investigation was performed in the present work, by comparing wall shear stress (WSS) and flowrates for a patient-specific scenario of a middle cerebral artery (MCA) aneurysm, considering device placement on each branch. A secondary objective was to follow a methodology that provides fast results, envisioning application to daily medical practice. The device was simplified as a homogeneous porous medium, and extreme porosity values were simulated for comparison. Results suggest that stent placement on either branch is both safe and effective, significantly reducing WSS and flow into the aneurysm while maintaining flow to the different ramifications within acceptable thresholds.

Time course of hemispheric cerebral volume after decompressive craniectomy in malignant middle cerebral artery stroke / Evolução temporal do volume hemisférico cerebral após craniectomia descompressiva em infarto maligno de artéria cerebral média

Abstract Background Brain edema is the leading cause of death in patients with malignant middle cerebral artery (MCA) infarction. Midline shift (MLS) has been used as a monohemispheric brain edema marker in several studies; however, it does not precisely measure brain edema. It is now possible to directly measure hemisphere brain volume. Knowledge about the time course of brain edema after malignant middle cerebral artery infarction may contribute to the condition's management. Objective Therefore, our goal was to evaluate the course of brain edema in patients with malignant MCA infarction treated with decompressive craniectomy (DC) using hemispheric volumetric measurements. Methods Patients were selected consecutively from a single tertiary hospital between 2013 and 2019. All patients were diagnosed with malignant middle cerebral artery infarction and underwent a decompressive craniectomy (DC) to treat the ischemic event. All computed tomography (CT) exams performed during the clinical care of these patients were analyzed, and the whole ischemic hemisphere volume was calculated for each CT scan. Results We analyzed 43 patients (197 CT exams). Patients' mean age at DC was 51.72 [range: 42-68] years. The mean time between the ischemic ictus and DC was 41.88 (range: 6-77) hours. The mean time between the ischemic event and the peak of hemisphere volume was 168.84 (95% confidence interval [142.08, 195.59]) hours. Conclusion In conclusion, the peak of cerebral edema in malignant MCA infarction after DC occurred on the 7th day (168.84 h) after stroke symptoms onset. Further studies evaluating therapies for brain edema even after DC should be investigated.

Resumo Antecedentes O edema cerebral é a principal causa de morte em pacientes com infarto maligno de artéria cerebral média. O desvio da linha média tem sido utilizado como marcador de edema cerebral mono-hemisférico em alguns estudos; porém, ele não mede de forma precisa o edema cerebral. Atualmente é possível mensurar diretamente o volume do hemisfério cerebral. O conhecimento sobre a evolução temporal do edema cerebral após infartos malignos da artéria cerebral média pode contribuir para o cuidado clínico desta condição. Objetivo Nosso objetivo é avaliar o edema hemisférico ao longo do tempo, em pacientes com infarto maligno da artéria cerebral média, tratados com craniectomia descompressiva. Métodos Os pacientes foram selecionados de forma consecutiva, em um hospital terciário, entre 2013 e 2019. Todos os pacientes apresentavam diagnóstico de infarto maligno de artéria cerebral média e foram submetidos a craniectomia descompressiva. Todas as tomografias computadorizadas de crânio destes pacientes foram analizadas, e o volume do hemisfério cerebral infartado foi mensurado. Resultados Analisamos 43 pacientes (197 tomografias de crânio). A idade média dos pacientes na craniectomia descompressiva foi 51,72 (42-68) anos. O tempo médio entre o ictus e a craniectomia descompressiva foi 41,88 (6-77) horas. O tempo médio entre o ictus e o pico do volume hemisférico foi 168,84 (142,08-195,59) horas. Conclusão O pico do volume cerebral em pacientes com infarto maligno de artéria cerebral média submetidos a craniectomia descompressiva ocorreu no 7o dia (168,84 horas) após o infarto. Mais estudos avaliando terapêuticas direcionadas ao edema cerebral seriam úteis neste contexto.

Newborns with a Congenital Heart Defect and Diastolic Steal Have an Altered Cerebral Arterial Doppler Profile.

OBJECTIVES: To compare trends in the anterior cerebral artery (ACA) Doppler markers of vascular flow for neonates with a congenital heart defect (CHD) with and without diastolic systemic steal during the first 7 days of life. METHODS: Prospective study recruiting newborns (≥35 weeks of gestation) with a CHD. Doppler ultrasound and echocardiography were performed daily from day 1 to 7. The cohort was divided into the presence/absence of holo-diastolic retrograde flow in the postductal aorta ("retrograde") on the last-available echocardiogram. Data extractors were masked to retrograde status. Mixed effect models (random slope/intercept) were constructed using RStudio. RESULTS: We enrolled 38 neonates with CHD. Retrograde aortic flow was present on the last echocardiogram in 23 (61%). Peak systolic velocity and mean velocity increased significantly over time, independent of retrograde status. However, having a "retrograde" flow status conferred a significant decrease over time of their ACA-end-diastolic velocity (ß = -5.75 cm/s, 95% CI -8.38 to -3.12, P < .001, when compared with the nonretrograde group), and a significant increase in the ACA resistive (ß = 0.16, 95% CI 0.10-0.22, P < .001) and pulsatility (ß = 0.49, 95% CI 0.28-0.69, P < .001) indexes. No subject presented retrograde diastolic flow in the ACA. CONCLUSIONS: In neonates with CHD in the first week of life, infants with echocardiographic signs of systemic diastolic steal within the pulmonary circulation have Doppler signs of cerebrovascular steal in the ACA.

Rectangular method: a modified technique for sampling the ischemic border zone in a rat model of transient middle cerebral artery occlusion

To date, there have been three common methods for sampling the cerebral ischemic border zone in a rat model of transient middle cerebral artery occlusion (tMCAO): the "two o'clock method", the "diagonal method", and the "parallel line method". However, these methods have their own advantages and limitations. Here, we propose a modified technique (the "rectangular method") for sampling the ischemic border zone. A rat tMCAO model was prepared under the support of a compact small animal anesthesia machine. Cerebral blood flow was monitored by high-resolution laser Doppler to control the quality of modeling, and 2,3,5-triphenyl tetrazolium chloride (TTC) staining was used for cerebral infarction location assessment. Superoxide dismutase 2 (SOD2), cysteinyl aspartate specific proteinase (caspase)-3, caspase-9, and heat shock protein 70 (HSP70) were used to verify the reliability and reproducibility of the rectangular method. The expression of biomarkers (SOD2, caspase-3, caspase-9, and HSP70) in the traditional (two o'clock method after TTC staining) and modified (rectangular method) groups were increased. There were no significant differences between the groups. The rectangular method proposed herein is based on a modification of the diagonal method and parallel line method, which could provide a directly observable infarct borderline and a sufficient sampling area for subsequent experimental operations regardless of the cerebral infarct location. The assessed biomarkers (SOD2, caspase-3, caspase-9, and HSP70) demonstrated the reliability and reproducibility of the rectangular method, which may facilitate inter-laboratory comparisons.

Maternal, obstetric, and fetal Doppler characteristics in a high-risk population: prediction of adverse perinatal outcomes and of cesarean section due to intrapartum fetal compromise / Características maternas, obstétricas e do Doppler fetal em uma população de alto risco: predição de desfechos perinatais adversos e de cesariana por comprometimento fetal intraparto

Abstract Objective: To evaluate the capacity of fetal Doppler, maternal, and obstetric characteristics for the prediction of cesarean section due to intrapartum fetal compromise (IFC), a 5-min Apgar score < 7, and an adverse perinatal outcome (APO), in a high-risk population. Materials and Methods: This was a prospective cohort study involving 613 singleton pregnant women, admitted for labor induction or at the beginning of spontaneous labor, who underwent Doppler ultrasound within the last 72 h before delivery. The outcome measures were cesarean section due to IFC, a 5-min Apgar score < 7, and any APO. Results: We found that maternal characteristics were neither associated with nor predictors of an APO. Abnormal umbilical artery (UA) resistance index (RI) and the need for intrauterine resuscitation were found to be significant risk factors for cesarean section due to IFC (p = 0.03 and p < 0.0001, respectively). A UA RI > the 95th percentile and a cerebroplacental ratio (CPR) < 0.98 were also found to be predictors of cesarean section due to IFC. Gestational age and a UA RI > 0.84 were found to be predictors of a 5-min Apgar score < 7 for newborns at < 29 and ≥ 29 weeks, respectively. The UA RI and CPR presented moderate accuracy in predicting an APO, with areas under the ROC curve of 0.76 and 0.72, respectively. Conclusion: A high UA RI appears to be a significant predictor of an APO. The CPR seems to be predictive of cesarean section due to IFC and of an APO in late preterm and term newborns.

Resumo Objetivo: Avaliar a capacidade do Doppler fetal e características materno-obstétricas na predição de cesariana por comprometimento fetal intraparto (CFI), índice de Apgar de 5º min < 7 e desfecho perinatal adverso (DPA) em uma população de alto risco. Materiais e Métodos: Estudo de coorte prospectivo envolvendo 613 parturientes admitidas para indução ou em início de trabalho de parto espontâneo que realizaram ultrassonografia Doppler nas 72 horas anteriores ao parto. Os desfechos foram cesariana por CFI, índice de Apgar de 5º min < 7 e DPA. Resultados: As características maternas não foram associadas nem preditoras de DPA. Índice de resistência (IR) da artéria umbilical anormal (p = 0,03) e necessidade de medidas de ressuscitação intrauterina (p < 0,0001) permaneceram como fatores de risco significativos para cesariana por CFI. IR AU > 95º e razão cerebroplacentária (RCP) < 0,98 foram preditores de cesariana. Idade gestacional e IR AU > 0,84 foram os preditores de índice de Apgar de 5º min < 7 para recém-nascidos < 29 e ≥ 29 semanas, respectivamente. IR AU e RCP apresentaram acurácia moderada na predição de DPA (área sob a curva ROC de 0,76 e 0,72, respectivamente). Conclusão: IR UA mostrou-se preditor significativo de DPA. RCP revelou-se possível preditora de cesariana por CFI e DPA em recémnascidos prematuros tardios e a termo.

Cognitive-communication disorder following right hemisphere damage: Narrative production.

Background: Cognitive-communication disorder (CCD) results from the association of language and cognition impairment that may follow right hemisphere (RH) damage and impair the quality of life of affected persons. Objective: We studied a set of 1,625 narratives produced by a cohort of 125 individuals (50 with a single right vascular lesion in the MCA territory and 75 cognitively healthy controls) using a task of picture-based discourse production. Discourse production was analyzed in its macro-and microlinguistic aspects to characterize better the linguistic mechanisms underlying RH patients' performance. Results: The RH group produced more words and elocutions than controls, with a lower rate of informational content and a higher percentage of global coherence errors (all p-values <0.0001). Conclusion: Individuals with RH lesions showed formal lexical and syntactic aspects of discourse mostly preserved. Alterations in the macrostructure of discourse prevailed over microstructural alterations in our sample, according to most literature studies. The group of individuals with RH lesions produced narratives containing more words and utterances, with a lesser degree of lexical information and more global coherence errors.

Ruptured aneurysm associated with a twig-like middle cerebral artery: An illustrative case report.

Background: Anomalies of the middle cerebral artery (MCA) are rare; among the different types of anomalies, the aplastic or twig-like (Ap/T) MCA is extremely rare and has been reported under various names, including aplastic, unfused, or rete type anomaly. The occurrence of a brain aneurysm associated with this anatomic variant is an even rare event, and probably their development and rupture are related to hemodynamic stress of the tinny wall of vessels forming the network. Case Description: We present a 43-year-old male patient with an explosive and persistent right orbitofrontal headache. A computed tomography showed a right frontobasal hematoma with intraventricular disruption. Magnetic resonance angiography showed a right MCA aneurysm and what seems to be a MCA trunk stenosis. Cerebral digital subtraction angiography demonstrated a plexiform arterial network and one aneurysm arising from the network. The patient was successfully treated by surgical clipping to evacuate the hematoma and to prevent further intracranial hemorrhages. Conclusion: The Ap/T-MCA may be associated with hemodynamic stress with a significant effect through the tinny wall of the vessels causing hemorrhage or leading to the formation and rupture of cerebral aneurysms. Based on a correct diagnosis of the anomaly, treatment can be completed successfully through different standard methods.

Dataset of middle cerebral artery blood flow stability in response to high-definition transcranial electrical stimulation.

This supplementary dataset is supportive of the randomized sham-controlled, double-blind, crossover clinical trial investigating polarity- and intensity-dependent effects of high-definition transcranial electrical stimulation (HD-tDCS) applied over the right temporo-parietal junction on mean middle cerebral artery blood flow velocity (MCA-BFv) bilaterally. Data of eleven healthy right-handed adults (6 women, 5 men; mean age 31 ± 5.6 years old) were analyzed for MCA-BFv, assessed using transcranial doppler ultrasound on the stimulated and the contralateral hemisphere concomitantly, during and after 3 blocks of 2 min HD-tDCS at 1, 2, and 3 mA. Participants received three electrical stimulation conditions (anode center, cathode center, and sham) randomly ordered across different days. The collected data is publicly available at Mendeley Data. This article and the data will inform future related investigations and safety analysis of transcranial non-invasive brain stimulation.