Association between preoperative serum lactate concentrate with tumor cell proliferative index in primary brain tumor.

BACKGROUND: Elevated preoperative lactate levels have been reported in patients admitted for resection of brain tumors. As histologic type and tumor grade have also been linked to lactate concentration, we hypothesized that preoperative lactate concentration in patients with brain tumors may be associated with tumor proliferation. We describe the relationship between preoperative plasma lactate levels, and the cell proliferation marker Ki-67 in brain tumor surgery. METHODS: In this cross-sectional study, records of patients who underwent craniotomy between June 2017 and February 2018 at our Hospital were reviewed to select glioma and meningioma cases in which lactate concentrations in plasma and degree of cell proliferation were registered. Bivariable and linear regression analyses were used to assess the association between lactate concentrations and the Ki-67 Index. RESULTS: Lactate concentrations in plasma and Ki-67 Index were available in 55 patients. Meningioma cases had a mean concentration of 1.2 (0.1) mmol/L compared to diffuse astrocytic and oligodendroglial tumors cases with 1.7 (0.1) mmol/L (P<0.01). Both variables had a low positive correlation in meningiomas (Spearman's r, 0.29; 95% CI, -0.10-0.61; P=0.13) and a high correlation in gliomas (Spearman's r, 0.64; 95% CI, 0.33-0.82; P<0.01). The pooled analysis showed a high correlation index (Spearman's r, 0.61; 95% CI, 0.40-0.76; P<0.01). A linear regression model showed that the Ki-67 Index explained 43% of the variation in lactate (P<0.01). CONCLUSIONS: Brain tumors with higher rates of cell proliferation have higher plasma lactate levels. In this scenario, lactate concentrations may not only reflect systemic perfusion.

Hemodynamic Response, Coughing and Incidence of Cerebrospinal Fluid Leakage on Awakening with an Endotracheal Tube or Laryngeal Mask Airway in Place after Transsphenoidal Pituitary Surgery: A Randomized Clinical Trial.

We aimed to compare systemic and cerebral hemodynamics and coughing during emergence after pituitary surgery after endotracheal tube (ETT) extubation or after replacing ETT with a laryngeal mask airway (LMA). Patients were randomized to awaken with an ETT in place or after replacing it with an LMA. We recorded mean arterial pressure (MAP), heart rate, middle cerebral artery (MCA) flow velocity, regional cerebral oxygen saturation (SrO2), cardiac index, plasma norepinephrine, need for vasoactive drugs, coughing during emergence, and postoperative cerebrospinal fluid (CSF) leakage. The primary endpoint was postoperative MAP; secondary endpoints were SrO2 and coughing incidence. Forty-five patients were included. MAP was lower during emergence than at baseline in both groups. There were no significant between-group differences in blood pressure, nor in the number of patients that required antihypertensive drugs during emergence (ETT: 8 patients (34.8%) vs. LMA: 3 patients (14.3%); p = 0.116). MCA flow velocity was higher in the ETT group (e.g., mean (95% CI) at 15 min, 103.2 (96.3-110.1) vs. 89.6 (82.6-96.5) cm·s-1; p = 0.003). SrO2, cardiac index, and norepinephrine levels were similar. Coughing was more frequent in the ETT group (81% vs. 15%; p < 0.001). CSF leakage occurred in three patients (13%) in the ETT group. Placing an LMA before removing an ETT during emergence after pituitary surgery favors a safer cerebral hemodynamic profile and reduces coughing. This strategy may lower the risk for CSF leakage.

Use of second generation supraglottic airway device for endovascular treatment of unruptured intracranial aneurysms: a retrospective cohort.

BACKGROUND: We aimed to assess the feasibility of using supraglottic devices as an alternative to orotracheal intubation for airway management during anesthesia for endovascular treatment of unruptured intracranial aneurisms in our department over a nine-year period. METHODS: Retrospective single center analysis of cases (2010-2018). Primary outcomes: airway management (supraglottic device repositioning, need for switch to orotracheal intubation, airway complications). SECONDARY OUTCOMES: aneurysm complexity, history of subarachnoid hemorrhage, hemodynamic monitoring, and perioperative complications. RESULTS: We included 187 patients in two groups: supraglottic device 130 (69.5%) and orotracheal intubation 57 (30.5%). No adverse incidents were recorded in 97% of the cases. Three supraglottic device patients required supraglottic device repositioning and 1 supraglottic device patient required orotracheal intubation due to inadequate ventilation. Three orotracheal intubation patients had a bronchospasm or laryngospasm during awakening. Forty-five patients (24.1%) had complex aneurysms or a history of subarachnoid hemorrhage. Thirty-three of them (73.3%) required orotracheal intubation compared to 24 of the 142 (16.9%) with non-complex aneurysms. Two patients in each group died during early postoperative recovery. Two in each group also had intraoperative bleeding. A post-hoc analysis showed that orotracheal intubation was used in 55 patients (44%) in 2010 through 2014 and 2 (3.2%) in 2015 through 2018, parallel to a trend toward less invasive blood pressure monitoring from the earlier to the later period from 34 (27.2%) cases to 5 (8.2%). CONCLUSION: Supraglottic device, like other less invasiveness protocols, can be considered a feasible alternative airway management approach in selected patients proposed for endovascular treatment of unruptured intracranial aneurisms.

Effects on cerebral blood flow of position changes, hyperoxia, CO2 partial pressure variations and the Valsalva manoeuvre: A study in healthy volunteers.

BACKGROUND: Maintaining adequate blood pressure to ensure proper cerebral blood flow (CBF) during surgery is challenging. Induced mild hypotension, sitting position or unavoidable intra-operative circumstances such as haemorrhage, added to variations in carbon dioxide and oxygen tensions, may influence perfusion. Several of these circumstances may coincide and it is unclear how these may affect CBF. OBJECTIVE: To describe the variation in transcranial Doppler and regional cerebral oxygen saturation (rSO2), as a surrogate of CBF, after cardiac preload and gravitational positional changes. DESIGN: Observational study. SETTING: Operating room at Hospital Clínic de Barcelona. VOLUNTEERS: Ten healthy volunteers, white, both sexes. INTERVENTIONS: Measurements were performed in the supine, sitting and standing positions during hyperoxia, hypocapnia and hypercapnia protocols and after a Valsalva manoeuvre. MAIN OUTCOME MEASURES: Cardiac index (CI), haemodynamic and respiratory variables, maximal and mean velocities (Vmax, Vmean) (transcranial Doppler) and rSO2 were acquired. Results were analysed using a generalised estimating equation technique. RESULTS: CI increases more than 16% after a preload challenge were not accompanied by differences in rSO2 or Vmax - Vmean. With positional changes, Vmean decreased more than 7% (P = 0.042) from the supine to the seated position. Hyperoxia induced a cerebral rSO2 increase more than 6% (P = 0.0001) with decreases in Vmax, Vmean and CI values more than 3% (P = 0.001, 0.022 and 0.001) in the supine and standing position. During hypocapnia, CI rose more than 20% from supine to seated and standing (P = 0.0001) with a 4.5% decrease in cerebral rSO2 (P = 0.001) and a decrease of Vmax - Vmean more than 24% in all positions (P = 0.001). Hypercapnia increased cerebral rSO2 more than 17% (P = 0.001), Vmax - Vmean more than 30% (P = 0.001) with no changes in CI. After a Valsalva manoeuvre, rSO2 decreased more than 3% in the right hemisphere in the upright position (P = 0.001). Vmax - Vmean decreased more than 10% (P = 0.001) with no changes in CI. CONCLUSION: CBF changes in response to cerebral vasoconstriction and vasodilatation were detected with rSO2 and transcranial Doppler in healthy volunteers during cardiac preload and in different body positions. Acute hypercapnia had a greater effect on recorded brain parameters than hypocapnia.

Rescue Surgery in the Flow Diverter Era: Partial Trapping Plus Revascularization Technique for a Giant Carotid-Ophthalmic Aneurysm.

BACKGROUND: Flow diverters (FDs) are an excellent option for the management of giant carotid artery aneurysms. However, in a nonnegligible percent of cases, the aneurysm may continue to grow despite multiple endovascular treatments and apparent occlusion on the angiogram. Due to the recent introduction of FDs, surgical experience after their failure is scarce and neurosurgeons have to face these challenging cases without much previous reference. Here we describe a giant ophthalmic-carotid aneurysm that presented with new severe mass effect 5 years after initially successful treatment with FDs and coils. We investigate the likely advantages of partial trapping versus complete trapping in this particular type of case. CASE DESCRIPTION: A 63-year-old patient with a subarachnoid hemorrhage from a 26-mm left carotid-ophthalmic aneurysm was initially embolized with coils. One year later a recanalization was observed and treated with an FD. Five years afterward, the patient's mild cognitive impairment prompted a magnetic resonance image that showed significant aneurysm growth despite apparent occlusion on angiogram. Rescue surgery consisted of partial trapping + extracranial-intracranial bypass and aneurysm debulking. The patient recovered from his deficits and remains asymptomatic 2 years later. CONCLUSIONS: In selected patients with previous long-term FDs, partial trapping may be a choice even if aneurysm debulking is needed. After years of stent placement, some endothelialization and neointimal membrane formation could have a summing effect to facilitate surgical exclusion and enable a safe thrombectomy. Classic revascularization techniques must be rethought and retested in this new FD era scenario.

Predictors of severe asthma attack re-attendance in Ecuadorian children: a cohort study.

Asthma is a common cause of emergency care attendance in low- and middle-income countries (LMICs). While few prospective studies of predictors for emergency care attendance have been undertaken in high-income countries, none have been performed in a LMIC.We followed a cohort of 5-15-year-old children treated for asthma attacks in emergency rooms of public health facilities in Esmeraldas City, Ecuador. We collected blood and nasal wash samples, and performed spirometry and exhaled nitric oxide fraction measurements. We explored potential predictors for recurrence of severe asthma attacks requiring emergency care over 6 months' follow-up.We recruited 283 children of whom 264 (93%) were followed-up for ≥6 months or until their next asthma attack. Almost half (46%) had a subsequent severe asthma attack requiring emergency care. Predictors of recurrence in adjusted analyses were (adjusted OR, 95% CI) younger age (0.87, 0.79-0.96 per year), previous asthma diagnosis (2.2, 1.2-3.9), number of parenteral corticosteroid courses in previous year (1.3, 1.1-1.5), food triggers (2.0, 1.1-3.6) and eczema diagnosis (4.2, 1.02-17.6). A parsimonious Cox regression model included the first three predictors plus urban residence as a protective factor (adjusted hazard ratio 0.69, 95% CI 0.50-0.95). Laboratory and lung function tests did not predict recurrence.Factors independently associated with recurrent emergency attendance for asthma attacks were identified in a low-resource LMIC setting. This study suggests that a simple risk-assessment tool could potentially be created for emergency rooms in similar settings to identify higher-risk children on whom limited resources might be better focused.

Aumento de la detección de eventos tromboembólicos en pacientes neuroquirúrgicos tras la actualización del protocolo de tromboprofilaxis perioperatoria / Increased detection of thromboembolic events in neurosurgical patients after updating the perioperative thromboprophylaxis protocol

No disponible

Divertículo uretral en la mujer: diagnóstico y resección quirúrgica temprana / Female urethral diverticulum: early diagnosis and surgical resection

Resumen ANTECEDENTES El divertículo uretral es la formación de un saco entre la uretra y la vagina. El tratamiento, dependiente de los síntomas, puede ser conservador o quirúrgico. El primero consiste en la descompresión por aspiración, antibióticos profilácticos y dilatadores uretrales. Para el tratamiento quirúrgico existen diversas técnicas, su elección dependerá de la ubicación del divertículo. OBJETIVO Reportar el caso clínico de un padecimiento infrecuente y describir cómo se trató. CASO CLÍNICO Paciente de 59 años que acudió a consulta debido a una disuria severa de varios meses de evolución, asociada con aumento del volumen de la uretra distal, goteo postmiccional y dolor severo en la región vaginal. Se estableció el diagnóstico de divertículo uretral, se efectuó la escisión de la lesión y la evolución fue favorable. CONCLUSIONES El divertículo uretral es un diagnóstico poco frecuente y sospechado, por lo que debe haber un alto grado de sospecha en los cirujanos que intervienen esta área para evitar diagnósticos erróneos, reoperaciones innecesarias y complicaciones. Los tratamientos son variados según el tipo, lugar anatómico y síntomas de la lesión.

Abstract BACKGROUND The urethral diverticulum is the formation of a sac between the urethra and the vagina. The treatment, dependent on the symptoms, can be conservative or surgical. The first consists of aspiration decompression, prophylactic antibiotics and urethral dilators. For surgical treatment there are several techniques, their choice will depend on the location of the diverticulum. OBJECTIVE To report the clinical case of an infrequent condition that generates ignorance of the health professional to detect, treat and refer this type of patients. DESCRIBE The management of an uncommon case, reporting a favorable mediate and long-term postoperative evolution. CLINICAL CASE A 59-year-old patient attended the clinic due to a severe dysuria lasting several months, associated with an increase in the volume of the distal urethra, post-voiding drip, and severe pain in the vaginal region. Diagnosis of urethral diverticulum was made, and excision of the lesion was performed with favorable evolution. CONCLUSIONS The urethral diverticulum is a rare and suspected diagnosis, so there should be a high degree of suspicion in surgeons who address this area to avoid poor diagnosis, unnecessary reoperations and complications. The treatments are varied according to the type, anatomical location and symptomatology of the lesion.

Laryngeal Mask Ventilation During Lumbar Spine Neurosurgery in Knee-Chest Position is Feasible.

BACKGROUND: This study describes our experience with laryngeal mask (LM) inserted after anesthetic induction in patients already in knee-chest position for lumbar neurosurgery. METHODS: Airway management (need for LM repositioning, orotracheal intubation because of failed LM insertion), anticipated difficult airway, and airway complications were registered. Statistics were compared between groups with the t test or the χ test, as appropriate. RESULTS: A total of 358 cases were reviewed from 2008 to 2013. Tracheal intubation was performed in 108 patients and LM was chosen for 250 patients (69.8%). Intubated patients had a higher mean age and rate of anticipated difficult airway; duration of surgery was longer (P<0.001, all comparisons). LM insertion and anesthetic induction proved effective in 97.2% of the LM-ventilated patients; 7 patients (2.8%) were intubated because of persistent leakage. Incidences with airway management were resolved without compromising patient safety. CONCLUSION: LM airway management during lumbar neurosurgery in knee-chest position is feasible for selected patients when the anesthetist is experienced.

Experience with "Fast track" postoperative care after deep brain stimulation surgery / Experiencia con el cuidado postoperatorio "Fast-Track" después de la cirugía de estimulación cerebral profunda

Background: A 24-h-stay in the post-anesthesia care unit (PACU) is a common postoperative procedure after deep brain stimulation surgery (DBS). Objective: We evaluated the impact of a fast-track (FT) postoperative care protocol. Methods: An analysis was performed on all patients who underwent DBS in 2 periods: 2006, overnight monitored care (OMC group), and 2007-2013, FT care (FT group). Results: The study included 19 patients in OMC and 95 patients in FT. Intraoperative complications occurred in 26.3% patients in OMC vs. 35.8% in FT. Post-operatively, one patient in OMC developed hemiparesis, and agitation in 2 patients. In FT, two patients with intraoperative hemiparesis were transferred to the ICU. While on the ward, 3 patients from the FT developed hemiparesis, two of them 48h after the procedure. Thirty eight percent of FT had an MRI scan, while the remaining 62% and all patients of OMC had a CT-scan performed on their transfer to the ward. One patient in OMC had a subthalamic hematoma. Two patients in FT had a pallidal hematoma, and 3 a bleeding along the electrode. Conclusions: A FT discharge protocol is a safe postoperative care after DBS. There are a small percentage of complications after DBS, which mainly occur within the first 6 h

Introducción: La estancia durante 24 h en una unidad de recuperación post-anestésica es una estrategia común de control post-operatorio después de la cirugía de estimulación cerebral profunda (DBS). Objetivo: Evaluamos el impacto de un protocolo Fast-track (FT) en el cuidado postoperatorio. Métodos: Analizamos todos los pacientes que se sometieron a cirugía DBS en 2 periodos: 2006, monitorización durante la noche (grupo OMC) y entre 2007 y 2013 (grupo FT). Resultados: Incluimos 19 pacientes en el grupo OMC y 95 pacientes en el FT. Se registraron incidentes intraoperatorios en el 26,3% de pacientes del grupo OMC vs. 35,8% del grupo FT. Postoperatoriamente, un paciente en el grupo OMC desarrollo hemiparesia y 2 pacientes agitación. En el grupo FT, 2 pacientes con hemiparesia intraoperatoria fueron trasladados a la UCI. Durante su ingreso en planta, 3 pacientes del grupo FT desarrollaron hemiparesia, 2 de ellos 48h después del procedimiento. Al 38% del FT se les realizó una resonancia, mientras que al 62% restante y a todos los pacientes del grupo OMC se les realizó un escáner antes del traslado a sala: un paciente del grupo OMC tuvo un hematoma subtalámico; 2 pacientes del grupo FT tuvieron un hematoma en el pálido y 3, sangrado en el trayecto del electrodo. Conclusiones: El protocolo FT es seguro después de la cirugía de DBS. Hay un pequeño porcentaje de complicaciones y la mayoría suceden en las primeras 6 h

Experience with "Fast track" postoperative care after deep brain stimulation surgery.

BACKGROUND: A 24-h-stay in the post-anesthesia care unit (PACU) is a common postoperative procedure after deep brain stimulation surgery (DBS). OBJECTIVE: We evaluated the impact of a fast-track (FT) postoperative care protocol. METHODS: An analysis was performed on all patients who underwent DBS in 2 periods: 2006, overnight monitored care (OMC group), and 2007-2013, FT care (FT group). RESULTS: The study included 19 patients in OMC and 95 patients in FT. Intraoperative complications occurred in 26.3% patients in OMC vs. 35.8% in FT. Post-operatively, one patient in OMC developed hemiparesis, and agitation in 2 patients. In FT, two patients with intraoperative hemiparesis were transferred to the ICU. While on the ward, 3 patients from the FT developed hemiparesis, two of them 48h after the procedure. Thirty eight percent of FT had an MRI scan, while the remaining 62% and all patients of OMC had a CT-scan performed on their transfer to the ward. One patient in OMC had a subthalamic hematoma. Two patients in FT had a pallidal hematoma, and 3 a bleeding along the electrode. CONCLUSIONS: A FT discharge protocol is a safe postoperative care after DBS. There are a small percentage of complications after DBS, which mainly occur within the first 6h.

Binding Selectivity of Macrocycle Ionophores in Ionic Liquids versus Aqueous Solution and Solvent-free Conditions.

The understanding of supramolecular recognition in room-temperature ionic liquids (RTILs) is key to develop the full potential of these materials. In this work, we provide insights into the selectivity of the binding of alkali metal cations by standard cyclodextrin and calixarene macrocycles in RTILs. A direct laser desorption/ionization mass spectrometry approach is employed to determine the relative abundances of the inclusion complexes formed through competitive binding in RTIL solutions. The results are compared with the binding selectivities measured under solvent-free conditions and in water/methanol solutions. Cyclodextrins and calixarenes in which the peripheral OH groups are substituted by bulkier side groups preferentially bind to Cs(+) . Such specific ionophoric behavior is substantially enhanced by solvation effects in the RTIL. This finding is rationalized with the aid of quantum mechanical calculations, in terms of the conformational features and steric interactions that drive the solvation of the inclusion complexes by the bulky RTIL counterions.

Eficacia diagnóstica y manejo posoperatorio de los pacientes sometidos a biopsia cerebral en un hospital universitario / Diagnostic yield and postoperative management of patients submitted to brain biopsy in a university hospital

Objetivo: Determinar la eficacia diagnóstica y la incidencia de complicaciones perioperatorias en pacientes sometidos a biopsia cerebral cerrada o por craneotomía, y valorar la duración de la vigilancia intensiva, para el diagnóstico precoz y el manejo de las complicaciones posoperatorias. Material y método: Estudio observacional retrospectivo, incluyendo todos los pacientes sometidos a biopsia cerebral entre enero de 2006 y julio de 2012. Se recogieron los datos demográficos, enfermedad asociada, tipo de biopsia, datos relevantes del intraoperatorio, el resultado de la anatomía patológica, la realización de prueba de imagen cerebral y su resultado, y la presencia, tipo y momento de aparición de las complicaciones posoperatorias. Resultados: Se analizaron un total de 76 biopsias (51 «cerradas», 25 «abiertas») en 75 pacientes. La efectividad diagnóstica fue del 98% en las «cerradas» y del 96% en las «abiertas». La mortalidad relacionada con el procedimiento fue de 3,9 y 4%, respectivamente. La incidencia de complicaciones mayores fue del 3,9% en biopsias «cerradas» y del 8% en biopsias «abiertas», apareciendo la mitad de ellas dentro de las primeras 24 h del posoperatorio, durante el ingreso en la Unidad de Cuidados Intensivos. La edad fue el único factor de riesgo para la aparición de complicaciones (p = 0,04). No encontramos diferencias de morbimortalidad entre los 2 grupos analizados. Conclusiones: La eficacia diagnóstica de nuestra serie ha sido muy alta. Dada la importancia del diagnóstico precoz de las complicaciones, recomendamos una vigilancia monitorizada en las primeras 24 h tras la realización de una biopsia cerebral tanto «abierta» como «cerrada»

Objective: To assess the diagnostic yield and the incidence of perioperative complications in patients undergoing an open or closed cerebral biopsy and to determine the length of intensive care monitoring, for early diagnosis and fast management of perioperative complications. Material and method: This was a retrospective analysis of all the patients that underwent brain biopsy between January 2006 and July 2012. We recorded demographic data, comorbidities, modality of biopsy, intraoperative clinical data, histological results, computed tomography scanning findings and occurrence, and type of perioperative complications and moment of appearance. Results: Seventy-six brain biopsies in 75 consecutive patients (51 closed and 25 open) were analysed. Diagnostic yield was 98% for closed biopsies and 96% for open biopsies. Mortality related to the procedures was 3.9 and 4%, respectively. The incidence of major complications was 3.9% for closed biopsies and 8% for open biopsies; half of these appeared within the first 24 postoperative hours, during patient stay in the Intensive Care Unit. Age was the only risk factor for complications (P = .04) in our study. No differences in morbimortality were found between the studied groups. Conclusions: Diagnostic yield was very high in our series. Because the importance of early diagnosis of complications for preventing long-term sequelae, we recommend overnight hospital stay for observation after open or closed brain biopsy

Anestesia para Neurocirugía Mínimamente Invasiva / Anesthesia for minimally invasive neurosurgery

Introduction: Advances in imaging, computing and optics have encouraged the application of minimally invasive surgical approach to a variety of neurosurgical procedures. The advantages include accurate localization of lesions usually inaccessible to conventional surgery, less trauma to healthy brain, blood vessels and nerves, shorter operating time, reduced blood loss, and early recovery and discharge. Nevertheless minimally invasive neurosurgical (MIN) procedures still have potential intra-and post-operative complications that can cause morbidity and mortality. Objectives: The aim of this study was to review and analyze published literature describing experiences in the anesthetic management of the most commonly performed MIN procedures. Materials and methods: Neurosurgical and neuroanesthesia literature (1990-2013) was reviewed and description of anesthetic technique/management and perioperative morbidity/mortality was reported. We also compared the different authors' experience with MIN procedures. Results: The neurosurgical literature dealing with MIN has expanded, but there are few references in relation to anesthetic management. Anesthesia goals remain the same: careful pre-operative assessment and planning, and meticulous cerebral hemodynamic control to ensure adequate cerebral perfusion pressure. The degree of postoperative care depends on local practice, patient factors and postoperative brain imaging.

Introducción: Los avances en la formación de imágenes, la computación y la óptica han alentado la aplicación del enfoque quirúrgico mínimamente invasivo a una variedad de procedimientos neuroquirúrgicos. Las ventajas incluyen la localización exacta de las lesiones generalmente inaccesibles a la cirugía convencional, menos trauma al cerebro sano, vasos sanguíneos y nervios, más corto el tiempo de funcionamiento, la reducción de la pérdida de sangre, la recuperación temprana y el alta. Sin embargo los procedimientos neuroquirúrgicos mínimamente invasivos (NMI) todavía tienen potencial complicaciones intra y post-operatorias que pueden causar morbilidad y mortalidad. Objetivos: El objetivo de este estudio fue revisar y analizar la literatura publicada que describe las experiencias en el manejo anestésico de los procedimientos más comúnmente realizados en NMI. Materiales y métodos: Literatura sobre neurocirugía y neuroanestesia (1990-2013). Revisión y descripción de la técnica anestésica/gestión y morbilidad perioperatoria/mortalidad notificada. Comparación de la experiencia de los diferentes autores en procedimientos de NMI. Resultados: La literatura sobre NMI se ha expandido, pero hay pocas referencias en relación con el manejo anestésico. Las metas anestésicas siguen siendo las mismas: la evaluación preoperatoria cuidadosa y la planificación, el meticuloso control de hemodinámica cerebral para asegurar la presión de perfusión cerebral adecuada. El grado de cuidado postoperatorio depende de la práctica local, factores del paciente y de imagen cerebral postoperatoria.

ProSeal Laryngeal Mask Airway Attenuates Systemic and Cerebral Hemodynamic Response During Awakening of Neurosurgical Patients: A Randomized Clinical Trial.

BACKGROUND: Extubation and emergence from anesthesia may lead to systemic and cerebral hemodynamic changes that endanger neurosurgical patients. We aimed to compare systemic and cerebral hemodynamic variables and cough incidence in neurosurgery patients emerging from general anesthesia with the standard procedure (endotracheal tube [ETT] extubation) or after replacement of the ETT with a laryngeal mask airway (LMA). MATERIALS AND METHODS: Forty-two patients undergoing supratentorial craniotomy under general anesthesia were included in a randomized open-label parallel trial. Patients were randomized (sealed envelopes labeled with software-generated randomized numbers) to awaken with the ETT in place or after its replacement with a ProSeal LMA. We recorded mean arterial pressure as the primary endpoint and heart rate, middle cerebral artery flow velocity, regional cerebral oxygen saturation, norepinephrine plasma concentrations, and coughing. RESULTS: No differences were found between groups at baseline. All hemodynamic variables increased significantly from baseline in both groups during emergence. The ETT group had significantly higher mean arterial pressure (11.9 mm Hg; 95% confidence interval [CI], 2.1-21.8 mm Hg) (P=0.017), heart rate (7.2 beats/min; 95% CI, 0.7-13.7 beats/min) (P=0.03), and rate-pressure product (1045.4; 95% CI, 440.8-1650) (P=0.001). Antihypertensive medication was administered to more ETT-group patients than LMA-group patients (9 [42.9%] vs. 3 [14.3%] patients, respectively; P=0.04). The percent increase in regional cerebral oxygen saturation was greater in the ETT group by 26.1% (95% CI, 9.1%-43.2%) (P=0.002), but no between-group differences were found in MCA flow velocity. Norepinephrine plasma concentrations rose in both groups between baseline and the end of emergence: LMA: from 87.5±7.1 to 125.6±17.3 pg/mL; and ETT: from 118.1±14.1 to 158.1±24.7 pg/mL (P=0.007). The differences between groups were not significant. The incidence of cough was higher in the ETT group (87.5%) than in the LMA group (9.5%) (P<0.001). CONCLUSIONS: Replacing the ETT with the LMA before neurosurgical patients emerge from anesthesia results in a more favorable hemodynamic profile, less cerebral hyperemia, and a lower incidence of cough.

[Diagnostic yield and postoperative management of patients submitted to brain biopsy in a university hospital]. / Eficacia diagnóstica y manejo posoperatorio de los pacientes sometidos a biopsia cerebral en un hospital universitario.

OBJECTIVE: To assess the diagnostic yield and the incidence of perioperative complications in patients undergoing an open or closed cerebral biopsy and to determine the length of intensive care monitoring, for early diagnosis and fast management of perioperative complications. MATERIAL AND METHOD: This was a retrospective analysis of all the patients that underwent brain biopsy between January 2006 and July 2012. We recorded demographic data, comorbidities, modality of biopsy, intraoperative clinical data, histological results, computed tomography scanning findings and occurrence, and type of perioperative complications and moment of appearance. RESULTS: Seventy-six brain biopsies in 75 consecutive patients (51 closed and 25 open) were analysed. Diagnostic yield was 98% for closed biopsies and 96% for open biopsies. Mortality related to the procedures was 3.9 and 4%, respectively. The incidence of major complications was 3.9% for closed biopsies and 8% for open biopsies; half of these appeared within the first 24 postoperative hours, during patient stay in the Intensive Care Unit. Age was the only risk factor for complications (P=.04) in our study. No differences in morbimortality were found between the studied groups. CONCLUSIONS: Diagnostic yield was very high in our series. Because the importance of early diagnosis of complications for preventing long-term sequelae, we recommend overnight hospital stay for observation after open or closed brain biopsy.

Detección de embolismo aéreo venoso y de foramen oval permeable en pacientes neuroquirúrgicos intervenidos en posición de sedestación / Detection of venous air embolism and patent foramen ovale in neurosurgery patients in sitting position

INTRODUCCIÓN: La detección precoz del embolismo aéreo venoso (EAV) durante las intervenciones neuroquirúrgicas en sedestación disminuye la gravedad de sus complicaciones. OBJETIVOS: Analizar la detección de EAV y sus repercusiones en pacientes intervenidos en sedestación. Comprobar la frecuencia de aspiración de aire a través de una vía venosa central. Valorar la viabilidad del uso del Doppler transcraneal (DTC) en quirófano para el diagnóstico del foramen oval permeable (FOP). MATERIAL Y MÉTODOS: Estudio prospectivo de intervenciones neuroquirúrgicas consecutivas realizadas durante 5 años en sedestación. Como método diagnóstico del EAV se empleó el Doppler precordial y el CO2 espirado. El FOP se exploró tras la inducción anestésica mediante DTC. RESULTADOS: Ciento treinta y seis pacientes fueron intervenidos en sedestación, 93 craneotomías y 43 cirugías de columna cervical. Veintidós pacientes (16,2%) fueron diagnosticados de EAV (21,5% de las craneotomías y 4,7% de las cirugías de columna; p = 0,013). En el 59% de los casos se aspiró aire a través del catéter venoso central. Hubo afectación hemodinámica en 3 pacientes, alteración de la oxigenación en 4 y neumoencéfalo clínicamente relevante en 5. Dos pacientes (1,4%) fueron diagnosticados de FOP, pero no presentaron episodios de EAV ni embolia aérea paradójica. CONCLUSIONES: Confirmamos una mayor incidencia de EAV en craneotomías que en cirugía de columna cervical en sedestación. Obtuvimos aire a través del catéter venoso central en más de la mitad de los casos. Con nuestra sistemática, ningún paciente presentó complicaciones críticas intraoperatorias. La baja incidencia de FOP detectada con DTC requerirá modificar nuestro protocolo realizado con el paciente anestesiado

INTRODUCTION: Early detection of venous air embolism (VAE) during neurosurgical procedures in sitting position decreases the severity of its complications. OBJECTIVES: our aim was to analyse the detection of VAE and its impact on patients operated in a sitting position, verify air aspiration through a central venous catheter and assess the feasibility of the routine use of transcranial Doppler (TCD) for intraoperative diagnosis of patent foramen ovale (PFO). MATERIAL AND METHODS: We performed a prospective study of consecutive neurosurgical procedures performed in the sitting position for 5 years. Precordial Doppler and end-tidal carbon dioxide were the diagnostic methods for VAE. PFO was explored by TCD after anaesthetic induction. RESULTS: 136 patients were operated in the sitting position, 93 craniotomies and 43 cervical spine procedures. Twenty-two patients (16.2%) were diagnosed with VAE (21.5% of craniotomies and 4.7% of spinal surgeries; p = .013). In 59% of cases, air was aspirated through the central venous catheter. There was haemodynamic involvement in 3 patients, impaired oxygenation in 4 and clinically relevant pneumocephalus in 5 of them. Two patients (1.4%) were diagnosed with PFO, but did not present episodes of VAE or paradoxical air embolism. CONCLUSIONS: The series analysed confirmed a higher incidence of VAE in craniotomies than in cervical spine surgery in a sitting position. We were able to aspirate air through the central venous catheter in more than half the cases. No patients suffered critical intraoperative complications following our approach. The low incidence of PFO detected with TCD will imply a modification of our protocol performed on anaesthetised patients

[Detection of venous air embolism and patent foramen ovale in neurosurgery patients in sitting position]. / Detección de embolismo aéreo venoso y de foramen oval permeable en pacientes neuroquirúrgicos intervenidos en posición de sedestación.

INTRODUCTION: Early detection of venous air embolism (VAE) during neurosurgical procedures in sitting position decreases the severity of its complications. OBJECTIVES: our aim was to analyse the detection of VAE and its impact on patients operated in a sitting position, verify air aspiration through a central venous catheter and assess the feasibility of the routine use of transcranial Doppler (TCD) for intraoperative diagnosis of patent foramen ovale (PFO). MATERIAL AND METHODS: We performed a prospective study of consecutive neurosurgical procedures performed in the sitting position for 5 years. Precordial Doppler and end-tidal carbon dioxide were the diagnostic methods for VAE. PFO was explored by TCD after anaesthetic induction. RESULTS: 136 patients were operated in the sitting position, 93 craniotomies and 43 cervical spine procedures. Twenty-two patients (16.2%) were diagnosed with VAE (21.5% of craniotomies and 4.7% of spinal surgeries; p=.013). In 59% of cases, air was aspirated through the central venous catheter. There was haemodynamic involvement in 3 patients, impaired oxygenation in 4 and clinically relevant pneumocephalus in 5 of them. Two patients (1.4%) were diagnosed with PFO, but did not present episodes of VAE or paradoxical air embolism. CONCLUSIONS: The series analysed confirmed a higher incidence of VAE in craniotomies than in cervical spine surgery in a sitting position. We were able to aspirate air through the central venous catheter in more than half the cases. No patients suffered critical intraoperative complications following our approach. The low incidence of PFO detected with TCD will imply a modification of our protocol performed on anaesthetised patients.

Carbohydrate-aromatic interactions: vibrational spectroscopy and structural assignment of isolated monosaccharide complexes with p-hydroxy toluene and N-acetyl l-tyrosine methylamide.

The nature of carbohydrate binding first to p-hydroxy toluene and then the capped amino acid, N-acetyl l-tyrosine methyl amide (AcTyrNHMe), has been investigated in a solvent-free environment under molecular beam conditions. A combination of double resonance IR-UV spectroscopy and quantum chemical calculations has established the structures of complexes with the α and ß anomers of methyl d-gluco- and d-galacto- and l-fucopyranosides (α/ßMeGlc, MeGal, MeFuc). The new results, when combined with dispersion-corrected DFT calculations, reveal gas phase structures which are dominated by hydrogen bonding but also with evidence of CH-π bonded interactions in complexes with α/ßMeGal. These adopt stacked intermolecular structures in marked contrast to those with α/ßMeGlc; p-OH → O bonds linking AcTyrNHMe, or p-hydroxy toluene, to the carbohydrate provide an anchor that facilitates further binding, both through OH → O and NH → O hydrogen bonds to the peptide backbone and through CH-π dispersion interactions with the aromatic side group. "Stacked" structures associated with dispersion interactions with the aromatic ring are not detected in the corresponding complexes of capped phenylalanine, despite their common occurrence in bound carbohydrate-protein structures.