Detection of Trypanosoma cruzi DNA in lizards: Using non-lethal sampling techniques in a sylvatic species with zoonotic reservoir potential in Chile.

Several reptile species have been described as hosts of Trypanosoma cruzi, the causative agent of Chagas disease, and therefore, they have become vertebrates of epidemiological interest. In recent decades, there has been a growing interest in animal welfare, especially in populations with small numbers where lethal sampling could have catastrophic consequences, and non-lethal methodologies have been developed for detecting zoonotic parasites. In this study, we compared three non-lethal sampling methodologies for detecting T. cruzi DNA in 21 captured specimens of the native lizard Liolaemus monticola, collected from the semiarid Mediterranean ecosystem of Chile. Specimens were subjected to xenodiagnosis (XD), tail clipping, and living syringe sampling procedures to evaluate whether lizards could serve as sentinel species for T. cruzi in endemic regions. To detect the protozoan, real-time PCR (qPCR) was performed on the DNA extracted from the samples (intestinal contents, tail tissues, and blood from living syringes). Trypanosoma cruzi DNA was detected in 12 of 21 lizards, considering all three methodologies. By XD, 12 specimens showed infection (57.1 %), and both living syringe and tail sampling methodologies detected only one infected lizard (4.8 %). Therefore, T. cruzi can be detected in lizards by qPCR using the three methodologies but XD is by far the most effective non-lethal detection methodology. The use of tail and living syringe methodologies showed a large underestimation; however, they might be options for monitoring the presence of T. cruzi in lizard populations when large sample sizes are available.

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.

Clip versus coil shift for aneurysm treatment in Brazil: an exploratory analysis of trends in a 10-year time-series.

Regarding intracranial aneurysm treatment, the clip versus coil debate remains inconclusive and lacking studies in Brazil. To examine trends in the management of intracranial aneurysms in Brazil over time, both ruptured and unruptured. A descriptive and exploratory study was conducted based on data of neurovascular procedures for aneurysm treatment using the Brazilian Public Health System database (DATASUS). The variables analyzed were the number of procedures, mortality rates, length of hospital stays, and global costs of hospitalization, from 2010 to 2019. Temporal trend analysis and statistical comparisons were conducted to assess changes over time and differences between the treatment options. The mean annual number of aneurysm treatments with endovascular embolization was 2206.30 (± 309.5), with a non-significant increasing trend (B = 55.66; p = 0.104). Conversely, microsurgical clipping exhibited a significant decreasing trend (B = -69.97; p < 0.001) with a mean of 1133.1 (± 223.12) procedures. The mortality rate associated with clipping procedure was higher in the period, with a mean difference of 5.23 (± 0.39); ([CI95%: 4.36; 6.10]; p < 0.001) and showed an increase trend, while embolization showed a stable trend. The length of in-hospital stay remained stable for clipping but increased for embolization. Costs associated with clipping increased over time, whereas costs for embolization decreased. This study highlights a significant shift in the treatment of aneurysm towards Endovascular Embolization. Despite higher costs, endovascular procedures were associated with lower mortality rates and shorter hospital stays. These findings provide valuable insights into aneurysm treatment patterns and indicators in a middle-income country's Public Health System.

Surgical clipping and endovascular treatments for small or very small anterior communicating artery aneurysms: A comparative pooled analysis.

INTRODUCTION: Small and very small anterior communicating artery (ACoA) aneurysms pose a complex challenge in neurosurgery and interventional neuroradiology due to their critical location and potential for severe consequences upon rupture. Surgical clipping has been a traditional approach, but it presents challenges requiring precision and expertise. Endovascular treatment has emerged as an alternative, offering minimally invasive techniques with potential advantages. This study aims to comprehensively compare outcomes and efficacy between surgical clipping and endovascular treatment for small or very small ACoA aneurysms. OBJECTIVES: We aimed to perform a meta-analysis of small or very small anterior communicating artery aneurysms comparing surgical clipping and endovascular treatments. METHODS: A systematic review and meta-analysis were conducted, including studies reporting on both treatment modalities. Eligible studies were identified through PubMed, Cochrane Library, and Embase databases. Pooled analyses with 95% confidence intervals were used to compare treatment effects, and statistical analysis followed PRISMA guidelines. RESULTS: Thirteen studies with 637 patients were included. Endovascular treatment, predominantly coiling, was performed in 60.3% of patients, while 39.7% underwent surgical management. Endovascular treatment exhibited an 18% retreatment rate, contrasting with 0% in the surgery group. Mortality rates were 3% and 6% for endovascular and surgical treatments, respectively. Overall complications occurred in 1.8% of patients, with intraoperative rupture and cerebral infarction being the most common. CONCLUSION: In summary, our study indicates a comparable outcome between surgical clipping and endovascular treatment for small ACoA aneurysms, with the former showing a lower retreatment rate. Decision factors include surgeon expertise, healthcare context, and patient age. Further research is needed to refine treatment strategies, considering variations in aneurysm status and evolving techniques.

Efficacy and safety of adenosine, rapid ventricular pacing and hypothermia in cerebral aneurysms clipping: a systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: Cerebral aneurysms in complex anatomical locations and intraoperative rupture can be challenging. Many methods to reduce blood flow can facilitate its exclusion from the circulation. This study evaluated the safety and efficacy of using adenosine, rapid ventricular pacing, and hypothermia in cerebral aneurysm clipping. METHODS: Databases (PubMed, Embase, and Web of Science) were systematically searched for studies documenting the use of adenosine, rapid ventricular pacing, and hypothermia in cerebral aneurysm clipping and were included in this single-arm meta-analysis. The primary outcome was 30-day mortality. Secondary outcomes included neurological outcomes by mRs and GOS, and cardiac outcomes. We evaluated the risk of bias using ROBIN-I, a tool developed by the Cochrane Collaboration. OpenMetaAnalyst version 2.0 was used for statistical analysis and I2 measured data heterogeneity. Heterogeneity was defined as an I2 > 50%. RESULTS: Our systematic search yielded 10,100 results. After the removal of duplicates and exclusion by title and abstract, 64 studies were considered for full review, of which 29 were included. The overall risk of bias was moderate. The pooled proportions of the adenosine analysis for the different outcomes were: For the primary outcome: 11,9%; for perioperative arrhythmia: 0,19%; for postoperative arrhythmia: 0,56%; for myocardial infarction incidence: 0,01%; for follow-up good recovery (mRs 0-2): 88%; and for neurological deficit:14.1%. In the rapid ventricular pacing analysis, incidences were as follows: peri operative arrhythmia: 0,64%; postoperative arrhythmia: 0,3%; myocardial infarction: 0%. In the hypothermia analysis, the pooled proportion of 30-day mortality was 11,6%. The incidence of post-op neurological deficits was 35,4% and good recovery under neurological analysis by GOS was present in 69.2%. CONCLUSION: The use of the three methods is safe and the related complications were very low. Further studies are necessary, especially with comparative analysis, for extended knowledge.

Neuropsychological outcomes in patients with ruptured anterior communicating artery aneurysms treated by clipping versus coiling: a systematic review and meta-analysis.

Ruptured anterior communicating artery (ACoA) aneurysms are frequently associated with neuropsychological deficits. This review aims to compare neuropsychological outcomes between surgical and endovascular approaches to ACoA. We systematically searched PubMed, Embase, and Web of Science for studies comparing the endovascular and surgical approaches to ruptured ACoA aneurysms. Outcomes of interest were the cognitive function, covered by memory, attention, intelligence, executive, and language domains, as well as motor and visual functions. Nine studies, comprising 524 patients were included. Endovascularly-treated patients showed better memory than those treated surgically (Standardized Mean Difference (SMD) = -2; 95% CI: -3.40 to -0.61; p < 0.01). Surgically clipped patients had poorer motor ability than those with coiling embolization (p = 0.01). Executive function (SMD = -0.20; 95% CI: -0.47 to 0.88; p = 0.55), language (SMD = -0.33; 95% CI: -0.95 to 0.30; p = 0.30), visuospatial function (SMD = -1.12; 95% CI: -2.79 to 0.56; p = 0.19), attention (SMD = -0.94; 95% CI: -2.79to 0.91; p = 0.32), intelligence (SMD = -0.25; 95% CI: -0.73 to 0.22; p = 0.30), and self-reported cognitive status (SMD = -0.51; 95% CI: -1.38 to 0.35; p = 0.25) revealed parity between groups. Patients with ACoA treated endovascularly had superior memory and motor abilities. Other cognitive domains, including executive function, language, visuospatial function, attention, intelligence and self-reported cognitive status revealed no statistically significant differences between the two approaches. Trial Registration PROSPERO (International Prospective Register of Systematic Reviews) CRD42023461283; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=461283.

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.

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.

Endoscopic endonasal clipping of a medial paraclinoid aneurysm with roadmapping assistance: Two-dimensional operative video.

Background: Advancements in endoscopic endonasal approaches (EEAs) allow the treatment of a wide variety of diseases including vascular pathology. Case Description: A 56-year-old woman presented with thunderclap headache due to two aneurysms: Communicating segment of left internal carotid artery (ICA) and medial paraclinoid (Baramii IIIB). The ICA aneurysm was clipped through a conventional transcranial approach; the paraclinoid aneurysm was successfully clipped using an EEA guided with roadmapping assistance. Conclusion: EEA is useful to treat aneurysms in selected cases and the use of adjuvant angiographical techniques such as roadmapping or proximal balloon control allow excellent control during the procedure.

Transcatheter resolution of an aneurism of the pulmonary trunk with residual ductus arteriosus after thoracoscopic clipping: a new approach.

Patent ductus arteriosus is the most common cardiac anomaly in our country. In the last few decades, there has been a lot of interest in developing less invasive techniques like video-assisted thoracoscopic clipping; nevertheless, this also has some complications. We present an 8-year-old female, which had been treated with video-assisted thoracoscopic clipping of patent ductus arteriosus. Five years later, she presented with a large aneurysm of the ductus arteriosus extending to the pulmonary trunk and a residual patent ductus arteriosus. A Cardia ASD occluder of 24 mm was placed in the aneurysm, and the residual ductus arteriosus was then closed with an Amplatzer Plug vascular II device of 10 mm, with a good outcome. The development of an aneurysm after video-assisted patent ductus arteriosus closure is apparently a non-reported complication; therefore, there are also no reports for its treatment. That is why we present this case as an option for its resolution.

Dual Microscope Indocyanine Green Video Angiography and Endoscopic Review to Treat Intracranial Aneurysm: A Review of the Literature Regarding a Case.

The use of the indocyanine green video angiography (ICG-VA) both endoscope and microscope has become popular in recent decades thanks to the safety, efficacy, and added value that they have provided for cerebrovascular surgery. The dual use of these technologies is considered complementary and has helped cerebrovascular surgeons in decision-making, especially for aneurysm clipping surgery; however, its use has been described for both aneurysm surgery, resection of arteriovenous malformations, or even for bypass surgeries. We conducted a review of the literature with the MeSH terms "microscope indocyanine green video angiography (mICG-VA)," "endoscopic review," AND/OR "intracranial aneurysm." A total of 97 articles that included these terms were selected after a primary review to select a total of 26 articles for the final review. We also present a case to exemplify its use, in which we use both technological tools for the description of the aneurysm, as well as for decision-making at the time of clipping and for reclipping. Both tools, both the use of the endoscope and the mICG-VA, have helped decision-making in neurovascular surgery. A considerable clip replacement rate has been described with the use of these technologies, which has helped to reduce the complications associated with poor clipping. One of the main advantages of their usefulness is that they are tools for intraoperative use, which is why they have shown superiority compared to digital subtraction angiography, which takes longer to use and has a higher risk of complications associated with the contrast medium. On the other hand, a very low rate of complications has been described with the use of the endoscope and mICG-VA, which is why they are considered safe tools to use. In some cases, mention has been made of the use of one or the other technology; however, we consider that its dual use provides more information about the status of the clip, its anatomy, its relationship with other vascular structures, and the complete occlusion of the aneurysm. We consider that the use of both technologies is complementary, so in case of having them both should be used, since both the endoscope and the mICG-VA provide additional and useful information.

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

Intra-aneurysmatic thrombectomy in a distal anterior cerebral artery aneurysm.

Thrombectomy procedures following intra-aneurysmatic lesions are extremely rare, and few cases have been reported. This article describes a microsurgical intra-aneurysmatic thrombectomy (MIaT) for a distal anterior cerebral artery (DACA) aneurysm. We present the case of a 48-year-old female that was admitted to the emergency room, showing neurologic deterioration with focal deficits. A computed tomography angiography (CTA) scan revealed an aneurysm located in the distal segment of the left anterior cerebral artery. During the surgical procedure, after clipping, a wellformed clot was visualized through the aneurysm's wall obstructing the left DACA flow. We proceeded to open the aneurysm's dome to remove the thrombus and clip the aneurysm neck, re-establishing the flow of the left DACA. Intra-aneurysmatic thrombosis can occur as a complication during clipping, obstructing the distal flow of vital arteries and causing fatal results in the patient's postoperative status. MIaT is a good technique for restoring the flow of the affected vessel and allows a secure aneurysm clipping after thrombus removal.

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.

Surgical treatment of a ruptured internal carotid artery pseudoaneurysm following transsphenoidal surgery.

Development of Internal Carotid Artery pseudoaneurysms (ICAp) after transsphenoidal surgery is extremely rare, occurring only in 0.4% of cases. Surgical treatment of ICAp poses a real challenge to the neurosurgeon as treatment may require parent vessel sacrifice or artery reconstruction with bypass grafting. Furthermore, surgical resolution of these lesions is rarely reported in the literature. The internal carotid artery is prone to iatrogenic injury in transsphenoidal surgery due to its frequent involvement in pituitary adenomas. Intracranial pseudoaneurysms may be at high risk for rupture and increased morbidity and mortality. Here we present a case of a patient with an ICAp rupture two months after transsphenoidal surgery for a pituitary adenoma.

Long-term outcomes of ruptured saccular intracranial aneurysm clipping versus coiling: systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Previous meta-analyses comparing microsurgery and coiling that include BRAT may be inaccurate to compare the outcomes of ruptured saccular aneurysms. This study aims to evaluate 10-year efficiency, safety, and advantages of coiling compared with clipping in patients with spontaneous saccular aneurismal SAH as a primary outcome. Also analyzed secondary outcomes: no-occlusion, mortality, rebleeding, and retreatment. METHODS: A systematic search of the literature on microsurgical clipping versus coiling was done to identify RCTs with at least 10 years of follow-up published between 2000 and 2021. The primary outcome was favorable functional outcome, defined as a modified Rankin scale (mRS) score ≤ 2. Secondary outcomes were no-occlusion, mortality, rebleeding, and retreatment. Quality of the included trials was analyzed using the Risk of Bias 2.0 (RoB 2.0) tool. A random-effects meta-analysis was performed. RESULTS: Two studies reported 10-year follow-up results, and the meta-analysis did not demonstrate significant differences between groups (OR 0.9, 95%CI 0.66-1.24, I2 = 21%). No differences were observed compared clipping and coiling regarding occlusion rates (OR 5.3, 95%CI 0.8-36.3, I2 = 89%). Mortality rates did not show significant differences between treatment modalities (OR 0.97, 95%CI 0.77-1.21, I2 = 0%). Rebleeding rates were also similar between groups (OR 1.63, 95%CI 0.25-10.7, I2 = 37%); however, significantly higher retreatment rates were associated with coiling (OR 10.6, 95%CI 2.1-52.5, I2 = 80%). Overall, risk of bias was low. CONCLUSION: There are no long-term differences regarding no-occlusion, mortality, and rebleeding rates between coiling and clipping. Higher retreatment rates were associated with coiling.

Endoport-assisted microsurgical treatment for a ruptured posterior cerebral artery aneurysm: A technical note.

Posterior Cerebral Artery aneurysms are scarce, yet its territory is frequently associated to large and giant aneurysms. Treatment is mostly a binary option between microsurgical clipping and endovascular coiling. Hybrid approaches are an option too, whereas innovation with less frequent techniques such as endoscope-controlled and endoscope-assisted procedure may provide a safer surgical approach with same successful results. Hereby we report a case of a 53 years old male examined at the ER after presenting generalized seizures and altered state of consciousness. Upon arrival, neurological evaluation revealed homonymous right hemianopia. Computed tomography (CT) scan revealed a subarachnoid hemorrhage and left parieto-occipital intraparenchymal hemorrhage with intraventricular extension; computed tomography angiogram (CTA) revealed an aneurysm at the left posterior cerebral artery (PCA) in its P4 segment. We performed a vascular exploration with drainage of the occipital and intraventricular hematoma through a single endoscopic port through transulcal approach guided by neuronavigation, in addition to clipping and aneurysmectomy. The combination of microsurgical clipping with previous Endoport-guided endoscopic procedure may be a surgical-operative option that not only may facilitate the approach to the desired lesion, but also provides a safer surgical scenario.

Histological changes of vascular clipping in Wistar rats.

Background: During aneurysm microsurgery, the aneurysmal sac is excluded from circulation by placing one or more clips at the base of the aneurysm. In some cases of complex aneurysms or subarachnoid hemorrhage history, transient clipping before definitive clipping is necessary. The closing force of the transient clip is less than the permanent clip; however, it is sufficient to stop circulation to the aneurysmal sac. The aim of the following work is to analyze and describe histological changes caused by transient and permanent clipping of the abdominal aorta in Wistar-type rats, to study the correlation between the closing force of the clip and the time, it remains on the vascular tissue structures. Methods: Six groups were formed, with 10 rats each, whereby temporary clipping of the abdominal aorta was performed with subsequent sampling of the site where the vascular clip was placed. The groups were: control and temporary clipping with: 2, 5, 10, and 15 and permanent clipping with 5 min. Results: Resection samples of the 3 µm thick aorta were obtained through the routine histological technique and special histochemical techniques (Masson's Trichrome and orcein) from the six groups. Transmural changes were found from Group II-VI. Conclusion: There is a vascular histological effect after both transient and permanent clipping. The sum of time and strength of the clip induce vascular changes visible at 5 min.

Cerebral aneurysms in pediatrics: a case report and review of the literature.

BACKGROUND: Cerebral aneurysms in pediatrics represent < 4% of the total of this condition, and their rupture represents 10-23% mortality. Aneurysms have been associated with infections, head injuries, sickle cell anemia, cardiovascular diseases, autoimmune diseases, immunodeficiencies, and connective tissue diseases. Their clinical presentation includes severe headache, seizures, motor-sensory deficits, and death due to subarachnoid and intraparenchymal hemorrhage. CASE REPORT: We describe the case of a 12-year-old female patient who presented with a sudden intense headache; after 72 hours, generalized tonic-clonic seizures were observed. At the hospital, she was stabilized with antiepileptic drugs and analgesics. A simple head computed tomography scan showed intraparenchymal hemorrhage in the right frontal lobe and subarachnoid hemorrhage. The study was complemented with a cerebral angiotomography, which revealed an aneurysm of the anterior communicating artery. The pediatric neurosurgeon evaluated the case, and management in the pediatric intensive care unit was decided. Two weeks after the stroke, the aneurysm was clipped and excluded. The patient developed adequate clinical evolution and resolution of initial symptoms, resuming her daily activities. CONCLUSIONS: Pediatric cerebral aneurysms differ from their adult counterparts, mainly in their etiology and evolution. In addition, pediatric patients have a longer life expectancy. Aneurysm clipping and neurological endovascular therapy have shown similar results.

INTRODUCCIÓN: Los aneurismas cerebrales en pediatría representan menos del 4% del total de estos padecimientos, aunque su rotura tiene una mortalidad del 10-23%. Se han asociado con infecciones, traumatismos craneoencefálicos, anemia de células falciformes, enfermedades cardiovasculares, enfermedades autoinmunitarias, inmunodeficiencias y enfermedades del tejido conectivo. Su presentación clínica se manifiesta con cefalea intensa, crisis convulsivas, déficit motor-sensitivo y muerte debida a la hemorragia subaracnoidea e intraparenquimatosa. CASO CLÍNICO: Se describe el caso de una paciente de 12 años que presentó cefalea súbita intensa; a las 72 horas se agregaron crisis convulsivas tónico-clónicas generalizadas. En el hospital se estabilizó con fármacos antiepilépticos y analgésicos. Se le realizó una tomografía de cráneo simple que evidenció hemorragia intraparenquimatosa en el lóbulo frontal derecho y hemorragia subaracnoidea. El estudio se complementó con una angiotomografía cerebral, la cual reveló un aneurisma de la arteria comunicante anterior. Fue valorada por el neurocirujano pediatra y se decidió su manejo en la unidad de terapia intensiva pediátrica. A las 2 semanas de iniciado el evento se realizó clipaje y exclusión del aneurisma. La paciente tuvo una adecuada evolución clínica y resolución de los síntomas iniciales, retomando sus actividades de la vida diaria. CONCLUSIONES: Los aneurismas cerebrales en pediatría difieren de su contraparte en los adultos, principalmente en su etiología y evolución, ya que los pacientes pediátricos tienen mayor expectativa de vida. El clipaje del aneurisma y la terapia endovascular neurológica han mostrado resultados similares.

Endonasal clipping of unruptured right paraclinoid aneurysm. Case report in a third level center in Mexico City.

Paraclinoid aneurysms take importance due to the technical difficulty due to anatomical relationships, which is why different approaches have been sought for their proper management. This is a female patient with a finding of a paraclinoid aneurysm and treatment using an endonasal approach with adequate angiographic support. Knowledge of the anatomy and surgical skill are required for the management of these lesions, assisted by angiographic controls for successful treatment. The endoscopic endonasal approach is adequate if the anatomy allows it and the basic hospital infrastructure is available to obtain high success rates.

Los aneurismas paraclinoideos cobran importancia debido a la dificultad técnica por sus relaciones anatómicas, por lo que se han buscado diferentes abordajes para su adecuado manejo. Se presenta el caso de una paciente con un aneurisma paraclinoideo y tratamiento mediante abordaje endonasal con apoyo angiográfico adecuado. Se requieren conocimientos de la anatomía y habilidad quirúrgica para el manejo de estas lesiones, así como asistencia de controles angiográficos para el éxito del tratamiento. El abordaje endonasal endoscópico es adecuado en caso de que la anatomía lo permita y se tenga la infraestructura hospitalaria básica para obtener un alto índice de éxitos.