Suprapiamadre: Análisis Etimológico y Propuesta Terminológica para la Cuarta Meninge en Terminologia Anatomica, Terminologia Neuroanatomica y Terminologia Histologica / Suprapiamadre: Etymological Analysis and Terminological Proposal for the Fourth Meninge in Terminologia Anatomica, Terminologia Neuroanatomica and Terminologia Histologica

A lo largo de la historia, el conocimiento sobre las meninges ha evolucionado desde los primeros registros en el papiro de Edwin Smith hasta la actualidad, donde se ha descrito SLYM, una cuarta meninge que separa el espacio subaracnoideo en un compartimiento superficial y otro profundo, a la que se le atribuyen funciones de barrera semipermeable y de nicho de células inmunes para la vigilancia y protección del sistema nerviosos central. La FIPAT contiene un grupo de terminologías que son mundialmente aceptadas para la descripción de las estructuras del cuerpo humano, sin embargo, en Terminologia Anatomica, Ter- minologia Neuroanatomica y Terminologia Histologica, aún no se encuentra incluido el término SLYM para representar una cuarta meninge, quizás porque sea un reciente descubrimiento. El objetivo de este estudio fue sugerir un nuevo término que concuerde con los lineamientos de la FIPAT y con las reglas de Terminología Anatómica Regular (RAT) en reemplazo de SLYM, además de proponer su inclusión en Terminologia Anatomica, Terminologia Neuroanatomica y Terminologia Histologica, previa revisión y aprobación por parte del comité respectivo de la FIPAT. Se revisó el acrónimo SLYM y los elementos que lo conforman (membrana subaracnoidea de tipo linfática), desde un enfoque etimológico, este análisis estuvo acompañado de una revisión a las reglas RAT aceptadas por la FIPAT, que fueron consideradas para examinar su cumplimiento por parte del acrónimo SLYM. Se encontró que SLYM, al igual que los términos que lo componen no cumplen totalmente con las reglas RAT. El acrónimo SLYM no proporciona una descripción adecuada de la estructura que representa, lo que contradice las reglas RAT. Se propone el término Suprapiamater como alternativa, para su inclusión en Terminologia Anatomica, Terminologia Neuroanatomica y Terminologia Histologica, basado en elementos latinos que describen su ubicación y función, mejorando la precisión y claridad en la comunicación científica.

SUMMARY: Throughout history, knowledge about the meninges has evolved from the first records in the Edwin Smith papyrus to the present, where SLYM, a fourth meninge that separates the subarachnoid space into a superficial compartment and another, has been described deep, to which semipermeable barrier and immune cell niche functions are attributed for the surveillance and protection of the central nervous system. The FIPAT contains a group of terminologies that are globally accepted for the description of the structures of the human body, however, in Terminologia Anatomica, Terminologia Neuroanatomica and Terminologia Histologica, the term SLYM to represent a fourth meninge is not yet included, perhaps because be a recent discovery. The objective of this study was to suggest a new term that agrees with the FIPAT guidelines and with the Regular Anatomical Terminology (RAT) rules to replace SLYM, in addition to proposing its inclusion in Terminologia Anatomica, Terminologia Neuroanatomica and Terminologia Histologica, previously review and approval by the respective FIPAT committee. The acronym SLYM and the elements that make it up (Subarachnoid Lymphatic-like Membrane) were reviewed from an etymological approach. This analysis was accompanied by a review of the RAT rules accepted by FIPAT, which were considered to examine their compliance by the acronym SLYM. It was found that SLYM, like the terms that compose it, do not fully comply with the RAT rules. The SLYM acronym does not provide an adequate description of the structure it represents, which contradicts the RAT rules. The term suprapiamater is proposed as an alternative, for inclusion in Terminologia Anatomica, Terminologia Neuroanatomica and Terminologia Histologica, based on Latin elements that describe its location and function, improving precision and clarity in scientific communication.

Stellate ganglion block: what else is necessary to include in the treatment of subarachnoid hemorrhage patients?

Cerebral vasospasm is determined as a temporary narrowing of cerebral arteries a few days after an aneurysmal subarachnoid hemorrhage. The onset of this vascular event usually evolves with new neurological deficits or progression of ischemic areas. The success of interventions to treat or revert this condition is not satisfying. In addition to cerebral vasospasm, early brain injury plays an important role as a contributor to subarachnoid hemorrhage's mortality. In this sense, stellate ganglion block appears as an alternative to reduce sympathetic system's activation, one of the main pathophysiological mechanisms involved in brain injury. Over the past few years, there is growing evidence that stellate ganglion block can contribute to decline patient morbidity from subarachnoid hemorrhage. Is it time to include this procedure as a standard treatment after aneurysm rupture?

Silent Intruder: Unusual Presentation of Neurocysticercosis in an HIV-Infected Patient from the Far Northern Brazilian Amazon.

Neurocysticercosis, a parasitic infection of the central nervous system (CNS), is a significant public health issue globally, including in Brazil. This article presents a case report of a 44-year-old male patient residing in the rural area of Roraima, the northernmost region of Brazil within the Amazon Forest. The patient, with chronic HIV infection, acquired the Taenia solium helminth, resulting in neurocysticercosis development. Remarkably, the diagnosis of neurocysticercosis was not initially apparent but emerged through meticulous analysis following a motorcycle accident. The absence of seizures, a common clinical manifestation, complicated the diagnostic process, making it an uncommon case of NCC, which may be related to co-infection. As the patient's condition progressed, multiple complications arose, requiring additional medical attention and interventions. This case underscores the immense challenges faced by healthcare teams in managing neurocysticercosis effectively. It emphasizes the critical need for a comprehensive, multidisciplinary approach to provide optimal care for such complex cases. The study's findings underscore the importance of raising awareness and implementing improved strategies for tackling neurocysticercosis, particularly in regions where it remains a prevalent concern.

ICP wave morphology as a screening test to exclude intracranial hypertension in brain-injured patients: a non-invasive perspective.

Intracranial hypertension (IH) is a life-threating condition especially for the brain injured patient. In such cases, an external ventricular drain (EVD) or an intraparenchymal bolt are the conventional gold standard for intracranial pressure (ICPi) monitoring. However, these techniques have several limitations. Therefore, identifying an ideal screening method for IH is important to avoid the unnecessary placement of ICPi and expedite its introduction in patients who require it. A potential screening tool is the ICP wave morphology (ICPW) which changes according to the intracranial volume-pressure curve. Specifically, the P2/P1 ratio of the ICPW has shown promise as a triage test to indicate normal ICP. In this study, we propose evaluating the noninvasive ICPW (nICPW-B4C sensor) as a screening method for ICPi monitoring in patients with moderate to high probability of IH. This is a retrospective analysis of a prospective, multicenter study that recruited adult patients requiring ICPi monitoring from both Federal University of São Paulo and University of São Paulo Medical School Hospitals. ICPi values and the nICPW parameters were obtained from both the invasive and the noninvasive methods simultaneously 5 min after the closure of the EVD drainage. ICP assessment was performed using a catheter inserted into the ventricle and connected to a pressure transducer and a drainage system. The B4C sensor was positioned on the patient's scalp without the need for trichotomy, surgical incision or trepanation, and the morphology of the ICP waves acquired through a strain sensor that can detect and monitor skull bone deformations caused by changes in ICP. All patients were monitored using this noninvasive system for at least 10 min per session. The area under the curve (AUC) was used to describe discriminatory power of the P2/P1 ratio for IH, with emphasis in the Negative Predictive value (NPV), based on the Youden index, and the negative likelihood ratio [LR-]. Recruitment occurred from August 2017 to March 2020. A total of 69 patients fulfilled inclusion and exclusion criteria in the two centers and a total of 111 monitorizations were performed. The mean P2/P1 ratio value in the sample was 1.12. The mean P2/P1 value in the no IH population was 1.01 meanwhile in the IH population was 1.32 (p < 0.01). The best Youden index for the mean P2/P1 ratio was with a cut-off value of 1.13 showing a sensitivity of 93%, specificity of 60%, and a NPV of 97%, as well as an AUC of 0.83 to predict IH. With the 1.13 cut-off value for P2/P1 ratio, the LR- for IH was 0.11, corresponding to a strong performance in ruling out the condition (IH), with an approximate 45% reduction in condition probability after a negative test (ICPW). To conclude, the P2/P1 ratio of the noninvasive ICP waveform showed in this study a high Negative Predictive Value and Likelihood Ratio in different acute neurological conditions to rule out IH. As a result, this parameter may be beneficial in situations where invasive methods are not feasible or unavailable and to screen high-risk patients for potential invasive ICP monitoring.Trial registration: At clinicaltrials.gov under numbers NCT05121155 (Registered 16 November 2021-retrospectively registered) and NCT03144219 (Registered 30 September 2022-retrospectively registered).

The relationship between the level of vitamin D and ruptured intracranial aneurysms among patients with high sun exposure.

Non-traumatic subarachnoid hemorrhage (SAH) accounts for 3-5% of acute strokes. Intracranial aneurysm is the most common cause of non-traumatic SAH. Vitamin D influences the cardiovascular system, including the formation and rupture of cerebral aneurysms. To evaluate the serum vitamin D level in patients living in the tropical zone who suffered aneurysmal subarachnoid hemorrhage and its correlation with demographic and neurological characteristics. This is an analytical cross-sectional study to assess the serum level of vitamin D in a study population of 99 patients treated and diagnosed with aSAH in a public hospital in Recife-PE over a period of 12 months. In the study sample, composed of individuals with high sun exposure due to the lifestyle they lead in a tropical region, we observed hypovitaminosis D (85.9%), with a median of 19.9 ng/ml, although the majority of individuals are skin with high concentration of melanin (Fitzpatrick skin type IV and V). In addition, rates of sun exposure are high to all patients (Solar Index 9.03 P50). Most individuals were female (79.8%); there was no statistical difference in solar exposure/solar index between genders. As for the neurological repercussions, there was no statistical relevance in the clinical prognostic scales evaluated. As the sample was composed mainly of individuals whose economic activity is agriculture, the values of solar index found are vastly higher than those of other studies conducted in high latitude regions. In line with the literature review, some aspects were raised with the objective of justifying such findings that go from the base of the poor diet of these individuals, the increase of melanin in the skin and genetic alterations that directs us to possible mechanisms of natural photoprotection to high sun exposure. Thus, we had a vast majority (85%) of hypovitaminosis D, which in fact makes us wonder if there is any influence of calcitriol on vitamin D receptors in vascular walls and in the cardiovascular system as a whole, which influence bleeding events of this nature. As for the neurological repercussions, measured using assessment scales (Glasgow coma scale, WFNS scale, Hunt-Hess and Fisher's tomographic scale) there was no significant difference in the results. As it is only a descriptive study, the causal relationship of the facts cannot be established. However, in a population exposed to high sun exposure and affected by aneurysmal SAH, there is a significant rate of hypovitaminosis D, which supports the hypothesis that vitamin D plays a role in vascular pathologies, such as cerebral aneurysms and SAH.

The role of peritoneal dialysis in the treatment of acute kidney injury in neurocritical patients: a retrospective Brazilian study.

BACKGROUND: Acute kidney injury (AKI) occurs frequently in the neurocritical intensive care unit and is associated with greater morbidity and mortality. AKI and its treatment, including acute kidney replacement therapy, can expose patients to a secondary greater brain injury. This study aimed to explore the role of peritoneal dialysis (PD) in neurocritical AKI patients in relation to metabolic and fluid control, complications related to PD and outcome. METHODS: Neurocritical AKI patients were treated by PD (prescribed Kt/V = 0.40/session) using a flexible catheter and a cycler and lactate as a buffer. RESULTS: A total of 58 patients were included. The mean age was 61.8 ± 13.2 years, 65.5% were in the intensive care unit, 68.5% needed intravenous inotropic agents, 72.4% were on mechanical ventilation, APACHE II was 16 ± 6.67 and the main neurological diagnoses were stroke (25.9%) and intracerebral haemorrhage (31%). Ischaemic acute tubular necrosis (iATN) was the most common cause of AKI (51.7%), followed by nephrotoxic ATN AKI (25.8%). The main dialysis indications were uraemia and hypervolemia. Blood urea and creatinine levels stabilised after four sessions at around 48 ± 11 mg/dL and 2.9 ± 0.4 mg/dL, respectively. Negative fluid balance and ultrafiltration increased progressively and stabilised around 2.1 ± 0.4 L /day. Weekly delivered Kt/V was 2.6 ± 0.31. The median number of high-volume PD sessions was 6 (4-10). Peritonitis and mechanical complications were not frequent (8.6% and 10.3%, respectively). Mortality rate was 58.6%. Logistic regression identified as factors associated with death in neurocritical AKI patients: age (odds ratio (OR) = 1.14, 95% confidence interval (CI) = 1.09-2.16, p = 0.001), nephrotoxic AKI (OR = 0.78, 95% CI = 0.69- 0.95, p = 0.03), mechanical ventilation (OR = 1.54, 95% CI = 1.17-2.46, p = 0.01), intracerebral haemorrhage as main neurological diagnoses (OR = 1.15, 95% CI = 1.09-2.11, p = 0.03) and negative fluid balance after two PD sessions (OR = 0.94, 95% CI = 0.74-0.97, p = 0.009). CONCLUSION: Our study suggests that careful prescription may contribute to providing adequate treatment for most neurocritical AKI patients without contraindications for PD use, allowing adequate metabolic and fluid control, with no increase in the number of infectious, mechanical and metabolic complications. Mechanical ventilation, positive fluid balance and intracerebral haemorrhage were factors associated with mortality, while patients with nephrotoxic AKI had lower odds of mortality compared to those with septic and ischaemic AKI. Further studies are needed to investigate better the role of PD in neurocritical patients with AKI.

Cerebrovascular Complications Associated With Iatrogenic Fungal Meningitis Following Surgical Procedures in Mexico.

BACKGROUND: The current fungal meningitis outbreak caused by contaminated epidural anesthesia with Fusarium solani among patients who underwent surgical procedures in Matamoros, Mexico remains a cause of concern. Its association with an increased susceptibility for cerebrovascular complications (CVC) has not been reported. This single-center study describes 3 patients with a unique pattern of CVC attributed to fungal meningitis. METHODS: A retrospective case series of patients diagnosed with fungal meningitis following surgical procedures under contaminated epidural anesthesia who developed a unique pattern of CVC during their hospitalization. RESULTS: Three female patients (mean age, 35 years) with CVC due to iatrogenic fungal meningitis were included. Positive Fungitell ß-D-glucan assay in cerebrospinal fluid was documented in all cases, and F. solani was confirmed by polymerase chain reaction in case 3. All cases were complicated by severe vertebrobasilar circulation vasculopathy and arterial dissections with resultant subarachnoid hemorrhage and intraventricular hemorrhage, ultimately leading to patients' death. CONCLUSIONS: The death toll from the ongoing fungal meningitis outbreak keeps rising, underscoring the need for early recognition and aggressive treatment. We highlight the risk for vertebrobasilar circulation CVC among these patients. The angioinvasive nature of F. solani is yet to be clarified; however, a clear pattern has been observed. Public health awareness should be raised and a strong response should be pursued.

Prognostic value of scales for aneurysmal subarachnoid hemorrhage: Report of a reference center in Peru.

INTRODUCTION: Multiple scales have been designed to stratify the severity and predict the prognosis in the initial evaluation of patients with aneurysmal subarachnoid hemorrhage (aSAH). Our study aimed to validate the most commonly used prognostic scales for aSAH in our population: Hunt-Hess, modified Hunt-Hess, World Federation of Neurosurgical Societies (WFNS), Prognosis on Admission of Aneurysmal Subarachnoid Hemorrhage (PAASH), and Barrow Aneurysm Institute (BAI) scales. METHODS: This study includes all aSAH cases treated at our institution between June 2019 and December 2020. We developed a retrospective cohort by reviewing medical records and radiologic images performed during hospitalization. The outcome was evaluated using the modified Rankin scale (mRS). It was defined as a poor outcome (mRS 4-5) and mortality (mRS 6). The ROC curves and the area under the curve (AUC) of each of the prognostic scales were calculated to evaluate their prognostic prediction capacity. RESULTS: A total of 142 patients were diagnosed with aSAH. A poor outcome occurred in 52.1% of the patients, whereas mortality was 27.5%. The AUC of the scales studied was similar and no significant difference was found between them for predicting a poor outcome (P = .709) or mortality (P = .715). CONCLUSION: We determined that the prognostic scales for aSAH had a similar predictive value for poor clinical outcomes and mortality in our institution, with no significant difference. Thus, we recommend the most simple and well-known scale used institutionally.

Management of a ruptured posterior inferior cerebellar artery (PICA) aneurysm with end-to-end in situ bypass: Case report.

Dissecting posterior inferior cerebellar artery (PICA) aneurysms are uncommon lesions. Their anatomy and the location of the dissection are variable, however, they usually occurs at the origin of the PICA. Dissecting PICA aneurysms generally have non-vascular morphology involving an entire segment of the artery and cannot be cut. Nevertheless, the detection of these vascular lesions has increased latterly, so it is necessary to recognize it and take the appropriate management modalities for these injuries. In this report, we describe a case of a 73-year-old male patient, who presented a history of severe headache, associated with neck stiffness, nausea, vomiting, dizziness, hypoactivity, mental confusion, and walking difficulty. Radiographic investigation with brain computed tomography (CT) showed mild bleeding in a pre-medullary and pre-pontine cistern, and cerebral angiogram showed a dissecting PICA aneurysm. Despite being a challenging treatment, microsurgery management was the chosen modality. It was performed an end-to-end anastomosis between the p2/p3 segments, showing to be effective with good clinical and radiographic outcomes. We discussed an unusual case, reviewing the current literature on clinical presentations, the angiographic characteristics of the dissecting aneurysms of PICA, and evaluating the clinical and angiographic results of patients undergoing microsurgical treatment.

Homocysteine serum levels in patients with ruptured and unruptured intracranial aneurysms: a case-control study / Homocisteína sérica em pacientes com aneurismas rotos e não rotos: um estudo caso-controle

Abstract Background There is very few data regarding homocysteine's influence on the formation and rupture of intracranial aneurysms. Objective To compare homocysteine levels between patients with ruptured and unruptured intracranial aneurysms, and to evaluate possible influences of this molecule on vasospasm and functional outcomes. Methods This is a retrospective, case-control study. We evaluated homocysteinemia differences between patients with ruptured and unruptured aneurysms; and the association of homocysteine levels with vasospasm and functional outcomes. Logistic regressions were performed. Results A total of 348 participants were included: 114 (32.8%) with previous aneurysm rupture and 234 (67.2%) with unruptured aneurysms. Median homocysteine was 10.75μmol/L (IQR = 4.59) in patients with ruptured aneurysms and 11.5μmol/L (IQR = 5.84) in patients with unruptured aneurysms. No significant association was detected between homocysteine levels and rupture status (OR = 0.99, 95% CI = 0.96-1.04). Neither mild (>15μmol/L; OR = 1.25, 95% CI 0.32-4.12) nor moderate (>30μmol/L; OR = 1.0, 95% CI = 0.54-1.81) hyperhomocysteinemia demonstrated significant correlations with ruptured aneurysms. Neither univariate (OR = 0.86; 95% CI 0.71-1.0) nor multivariable age-adjusted (OR = 0.91; 95% CI = 0.75-1.05) models evidenced an association between homocysteine levels and vasospasm. Homocysteinemia did not influence excellent functional outcomes at 6 months (mRS≤1) (OR = 1.04; 95% CI = 0.94-1.16). Conclusion There were no differences regarding homocysteinemia between patients with ruptured and unruptured intracranial aneurysms. In patients with ruptured aneurysms, homocysteinemia was not associated with vasospasm or functional outcomes.

RESUMO Antecedentes Existem poucos dados sobre a influência da homocisteína na formação e rotura de aneurismas intracranianos (AI). Objetivo Comparar os níveis de homocisteína entre pacientes com AI rotos e não rotos e influências no vasoespasmo e resultados funcionais. Métodos Estudo caso-controle, que avaliou as diferenças de homocisteinemia entre pacientes com aneurismas rotos e não rotos, além da associação entre níveis de homocisteína, vasoespasmo e estado funcional. Regressões logísticas foram realizadas. Resultados Um total de 348 participantes foram incluídos: 114 (32,8%) com aneurismas rotos e 234 (67,2%) não rotos. A homocisteína mediana foi de 10,75μmol/L (IQR = 4,59) nos rotos e 11,5μmol/L (IQR = 5,84) nos não rotos. Não houve associação significativa entre os níveis de homocisteína e o status de ruptura (OR = 0,99, 95% CI = 0,96-1,04). Nem a hiperhomocisteinemia leve (>15μmol/L; OR = 1,25, 95% CI = 0,32-4,12) nem a moderada (>30μmol/L; OR = 1,0, 95% CI = 0,54-1,81) mostraram correlações significativas com aneurismas rotos. Modelos univariados (OR = 0,86; 95% CI = 0,71-1,0) e multivariados ajustados por idade (OR = 0,91; 95% CI = 0,75-1,05) não evidenciaram associação entre homocisteína e vasoespasmo. A homocisteinemia não influenciou resultados funcionais excelentes em seis meses (mRS ≤ 1) (OR = 1,04; 95% CI = 0,94-1,16). Conclusão Não houve diferenças em relação à homocisteinemia entre pacientes com aneurismas intracranianos rotos e não rotos. Em pacientes com aneurismas rotos, a homocisteinemia não foi associada ao vasoespasmo ou resultados funcionais.

Comparison of Prognostic Performance between Fisher and Modified Fisher Scales for Patients with Aneurysmal Subarachnoid Hemorrhage / Comparação do desempenho prognóstico entre as escalas Fisher e Fisher modificada para pacientes com hemorragia subaracnóidea aneurismática

Objective The present study aims to assess and compare the prognostic value of these two scales for predicting mortality. Method We reviewed 172 patients with aneurysmal subarachnoid hemorrhage, who were followed-up for 6 months. The Fisher and modified Fisher scales were evaluated for the prediction of mortality using logistic regressions. Results The Fisher scale was associated with mortality (odds ratio [OR]: 2; 95% confidence interval [CI]: 1.09­4.05) in the multivariate analysis. The modified Fisher scale was not associated with mortality in the multivariate analysis (OR: 1.39; 95% CI: 0.9­2.29), nor in the univariate analysis (OR: 1.24; 95%CI: 0.87­1.86). There was no significant association between Fisher score and unfavorable functional outcomes (mRS > 2) in the univariate analysis (OR: 1.33; 95%CI: 0.92­1.92), nor in the multivariate analysis (OR: 1.37; 95%CI: 0.92­2.05). There was no significant association between modified Fisher scores and unfavorable functional outcomes in the univariate analysis (OR: 1.16; 95%CI: 0.88­1.52). There was also no significant association in the multivariate analysis (OR: 1.18; 95%CI: 0.88­1.57). Conclusion Only the Fisher scale was associated with mortality. Neither of the two scales was associated with unfavorable functional outcomes (mRS > 2).

Objetivo O presente estudo tem como objetivo avaliar e comparar o valor prognós tico dessas duas escalas para predizer mortalidade. Método Revisamos 172 pacientes com hemorragia subaracnóidea aneurismática, acompanhados por 6 meses. As escalas de Fisher e modificada de Fisher foram avaliadas para a previsão de mortalidade usando regressões logísticas. Resultados A escala de Fisher foi associada à mortalidade (odds ratio [OR]: 2; intervalo de confiança [IC] 95%: 1.09­4.05) na análise multivariada. A escala Fisher modificada não foi associada à mortalidade na análise multivariada (OR: 1.39; IC95%: 0.9­2.29), nem na análise univariada (OR: 1.24; IC95%: 0.87­1.86). Não houve associação significativa entre o escore de Fisher e resultados funcionais desfavoráveis (mRS > 2) na análise univariada (OR: 1.33; IC95%: 0.92­1.92), nem na análise multivariada (OR: 1.37; IC95%: 0.92­2.05). Não houve associação significativa entre os escores modificados de Fisher e resultados funcionais desfavoráveis na análise univariada (OR: 1.16; IC95%: 0.88­1.52). Também não houve associação significativa na análise multivariada (OR: 1.18; IC95%: 0.88­1.57). Conclusão Apenas a escala de Fisher foi associada à mortalidade. Nenhuma das duas escalas foi associada a resultados funcionais desfavoráveis (mRS > 2).

Endovascular trends in the treatment of intracranial aneurysms in a Peruvian reference center.

Objectives: Endovascular treatment of intracranial aneurysms (IAs) has evolved in recent years and is currently the preferred treatment worldwide. We analyzed the trends in the number of patients, number of aneurysms, aneurysm characteristics, and techniques used in a pure endovascular cohort of patients treated in a reference center. Materials and Methods: Between 2010 and 2020, a retrospective data collection of patients who underwent endovascular intervention of IAs was performed. We used the Mann-Kendal test to evaluate the trends. In addition, the moving-average technique was used to assess smoother curves. Results: Eight hundred and forty-five aneurysms were treated in 765 patients, the mean age was 53.9 ± 14.6 years and 81% were women. The number of patients (P = 0.016) and aneurysms (P = 0.003) increased significantly. Unruptured (P = 0.029) and posterior communicating artery aneurysms increased their frequency of treatment (P = 0.042). Balloon remodeling (P = 0.01) and the use of flow diverters showed a positive trend (P = 0.016). Conclusion: There have been an increased number of patients and aneurysms treated endovascularly at our institution, including unruptured and posterior communicating aneurysms. Advanced endovascular techniques also increased. Comparative studies including surgical cases must be done in our region to determine the best approach.

Hemorragia Intracerebral Imprevisible en un Hombre Joven: La Importancia de la Tomografía computarizada craneal post-mortem / Unpredictable Intracerebral Hemorrhage in a Young Male: The Importance of Post-Mortem Cranial Computed Tomography

La muerte súbita es aquella que ocurre dentro de las 24 horas posteriores al inicio de los síntomas y se caracteriza por ser clínicamente inexplicable, inesperada y repentina. Debido a la naturaleza de la muerte súbita, no es posible llegar a un diagnóstico preciso sin una autopsia. En esta comunicación breve, evaluaremos el caso de un empleado de crucero de 33 años, sin historial médico/farmacológico previo, el cual falleció súbitamente mientras reposaba en su camarote. Debido a las sospechas iniciales de una posible muerte causada por una sobredosis de cocaína, se le realizó un panel toxicológico abarcador el cual resultó negativo. Empero, una tomografía computarizada (TC) craneal sin contraste revirtió la hipótesis inicial y la autopsia neuropatológica -sorpresivamente- confirmó que la verdadera causa de muerte fue la ruptura de un aneurisma sacular desconocido en el polígono de Willis.

Sudden death occurs within 24 hours after the onset of symptoms and is characterized by being clinically inexplicable, sudden, and unexpected. Due to the nature of sudden death, it is not possible an accurate diagnosis without performing an autopsy. In this brief communication, we will evaluate the case of a 33-year-old cruise employee, with no prior medical/pharmacological history, who suddenly died while resting in his cabin. Due to initial suspicions of a possible cocaine overdose death, a comprehensive toxicology panel was performed, although yielding a negative result. A cranial computed tomography without contrast reversed the initial hypothesis and the neuropathological autopsy -surprisingly- confirmed that the true cause of death was the rupture of an unknown saccular aneurysm in the Circle of Willis.

Complicaciones del tratamiento endovascular y quirúrgico en las hemorragias subaracnoideas aneurismáticas en Uruguay: análisis prospectivo de una serie de 211 casos / Complications of endovascular and surgical treatment in aneurysmal subarachnoid hemorrhages in Uruguay prospective analysis of a series of 211 cases / Complicações do tratamento endovascular e cirúrgico nas hemorragias subaracnóideas aneurismais no Uruguai: análise prospectiva de uma série de 211 casos

Introducción: si bien varios estudios han abordado la comparación entre el tratamiento endovascular y el clipado quirúrgico de aneurismas rotos, no existe aún evidencia firme respecto a la utilización de una u otra técnica en términos de seguridad y mejor pronóstico. El objetivo de este trabajo es analizar las distintas modalidades de tratamiento de la hemorragia subaracnoidea (HSA) implementadas en Uruguay y su impacto sobre la curación del aneurisma y el pronóstico de los pacientes. Material y método: estudio prospectivo y multicéntrico que incluyó a todos los pacientes mayores de 18 años que fueron asistidos por HSA espontánea aneurismática en Uruguay entre el 1 de noviembre de 2019 y el 31 de octubre de 2020. Fueron relevadas las características clínico-epidemiológicas y comorbilidades al momento del diagnóstico, el tipo de tratamiento recibido y variables de evolución clínica durante los siguientes seis meses. Los datos fueron procesados a través del software estadístico Statistical Package for Social Sciences (SPSS) y el nivel de significación utilizado en los test fue de 5%. Debido al carácter multicéntrico y nacional del estudio, debió ser sometido a evaluación por todos los comités de ética de las instituciones de salud participantes. Resultados: se observó un total de 211 casos en el período evaluado. La media de edad fue de 57 años con predominancia del sexo femenino (75%). En el 74% de los casos fue indicado algún tipo de tratamiento específico (43% cirugía abierta y 31% terapia endovascular), mientras al resto de los pacientes no se les pudo tratar el aneurisma por su grave situación neurológica; 52 pacientes tuvieron complicaciones vinculadas al tratamiento recibido, observándose una mayor proporción de estas en el caso de la cirugía abierta respecto a la terapia endovascular (42% vs 21,5%; p=0,008). Conclusiones: se observó una mayor tasa de complicaciones en el tratamiento quirúrgico, sin impacto en la morbimortalidad. De los factores predictores independientes de mala evolución clínica encontrados, el único vinculado al tipo de tratamiento fue la presencia de isquemia extensa.

Introduction: While several studies have addressed the comparison between endovascular treatment and surgical clipping of ruptured aneurysms, there is still no definitive evidence regarding the use of one or the other in terms of safety and improved prognosis. The objective of this study is to analyze the various modalities of subarachnoid hemorrhage (SAH) treatment implemented in Uruguay and their impact on aneurysm resolution and patient prognosis. Method: This is a prospective, multicenter study that includes all patients over 18 years of age who were treated for spontaneous aneurysmal subarachnoid hemorrhage in Uruguay between November 1, 2019, and October 31, 2020. We collected and examined clinical-epidemiological characteristics and comorbidities at the time of diagnosis, the type of treatment received, and clinical outcome variables over the following 6 months. The data were analysed using the Statistical Package for Social Sciences (SPSS) software, and a significance level of 5% was applied in the tests. Due to the multicenter and national nature of the study, it had to be submitted for evaluation to all the Ethics Committees of the participating healthcare institutions. Results: A total of 211 cases were observed during the evaluated period. The mean age was 57 years with a predominance of females (75%). In 74% of the cases, some form of specific treatment was recommended (43% open surgery and 31% endovascular therapy), while the remaining patients could not undergo aneurysm treatment due to their severe neurological condition. 52 patients experienced complications related to the treatment received, with a higher proportion of these in the case of open surgery compared to endovascular therapy (42% vs. 21,5%; p=0,008). Conclusions: A higher rate of complications was observed in the surgical treatment, with no impact on morbidity and mortality. Among the independent predictors of poor clinical outcomes identified, the only one related to the type of treatment was the presence of extensive ischemia.

As campanhas de prevenção e promoção da saúde, bem como os avanços na medidas terapêuticas voltadas para pacientes neurocríticos conseguiram reduzir a incidência de pacientes com lesão cerebral aguda que evoluem para morte encefálica (ME). No entanto, na maioria dos países latino-americanos, os órgãos que podem ser perfundidos adequados para transplante (TX) vêm de doadores falecidos em ME. A doação em assistolia e em particular a doação em assistolia controlada (DAC), é uma opção aceita e válida para a obtenção de órgãos, o que contribuiria para a redução das listas de espera para transplantes. Durante o processo DAC, são aplicados conceitos com forte cunho bioético, que são fundamentais na o momento da tomada de decisão. Este artigo tem como objetivo analisar esses conceitos, com o objetivo de oferecer ferramentas válidas à equipe de saúde, para os processos em que há deliberação moral como ocorre na doação de órgãos em assistolia controlada considerada parte integrante dos cuidados de fim de vida.

Topografía más frecuente de aneurismas rotos en Uruguay: presentación de un estudio prospectivo multicéntrico de una serie de 211 casos / Most Frequent Topography of Ruptured Aneurysms In Uruguay: Presentation of a multicentricprospective study of a series of 211 cases

Introducción. La hemorragia subaracnoidea (HSA) es más frecuente en el sexo femenino entre la cuarta y sexta década de vida6. El 80 a 85% de las HSA se deben a rotura de un aneurisma. Los aneurismas intracraneanos pueden ser clasificados de diferentes maneras según su etiología, tamaño, morfología o topografía. Objetivo. Describir las características topográficas y morfo-estructurales de los aneurismas en nuestro país. Materiales y Métodos. Fueron incluidos en el estudio todos los pacientes mayores de 18 años con diagnóstico de HSA, que consultaron a centros asistenciales del país entre el 01/11/2019 y el 31/10/2020. Fueron relevadas las características clínico-epidemiológicas y comorbilidades al momento del diagnóstico, el tipo de tratamiento recibido y variables de evolución clínica durante los siguientes 6 meses. El nivel de significación utilizado en los test fue del 5%. Debido al carácter multicéntrico y nacional del estudio, debió ser sometido a evaluación por todos los Comité de Ética de las instituciones de salud participantes, y por la Comisión Nacional de Ética en Investigación (CNEI). Resultados. Se observó un total de 211 casos en el período evaluado. La media de edad fue de 57 años con predominancia del sexo femenino (75%). En el 82% de los casos, el estudio vascular utilizado fue la angio-TC. La topografía aneurismática más frecuente fue: arteria comunicante anterior (27,5%), arteria cerebral media (27%), y arteria comunicante posterior (23%). Un 27% tuvieron aneurismas múltiples. En el 74% de los casos fue indicado algún tipo de tratamiento específico (43% cirugía abierta y 31% terapia endovascular) Conclusiones. Este trabajo aporta las primeras cifras sobre la topografía de los aneurismas rotos en el Uruguay, siendo ésta comparable a lo descrito en la literatura internacional

Background. Subarachnoid hemorrhage (SAH) is more common in females between the fourth and sixth decade of life6. 80 to 85% of SAH are due to ruptured aneurysm. Intracranial aneurysms can be classified in different ways according to their etiology, size, morphology or topography. Objectives. To describe the topographic and morpho-structural features of aneurysms in our country. Methods. All patients over 18 years old with a diagnosis of SAH, who consulted to a healthcare center in the country between 11/01/2019 and 10/31/2020, were included in the study. The clinical-epidemiological characteristics and comorbidities at the time of diagnosis, the type of treatment received and clinical evolution variables during the following 6 months were collected. The significance level of evidence used in the tests was 5%. Due to the multicenter and national nature of the study, it had to be subjected to an evaluation by all the Ethics Committees of the participating health institutions, and by the National Research Ethics Commission. Results. A total of 211 cases were observed in the evaluated period. The average age was 57 years with a predominance of the female sex (75%). In 82% of cases, the vascular study used was CT angiography. The most common aneurysmal topography was anterior communicating artery (27.5%), middle cerebral artery (27%), and posterior communicating artery (23%). 27% suffered multiple aneurysms. In 74% of cases, some type of specific treatment was indicated (43% open surgery and 31% endovascular therapy). Conclusions. This work provides the first figures on the topography of ruptured aneurysms in Uruguay, being this comparable to what is described in the international literature

Unilateral caudate infarct following pituitary adenoma resection.

Cerebral ischemic complications after pituitary surgery are not frequently reported. Multiple mechanisms have been proposed, including vasospasm, and delayed cerebral ischemia resulting from postoperative subarachnoid bleeding. Given the unknown etiology of vasospasm following these situations, little is known about its prevention. Through a case report and bibliographic review, the authors warn about the importance of recognizing key signs postoperatively that could indicate increased risk for cerebral vasospasm and must be recognized in a timely manner, with appropriate treatment strategies implemented once these symptoms present.

Predestinative role acidic cerebrospinal fluid on the destiny of central channel in spinal cord following subarachnoid hemorrhage: an experimental study.

OBJECTIVE: Acidosis is the most dangerous complication in subarachnoid hemorrhage (SAH). This study aimed to investigate the effect of acidic cerebrospinal fluid on central canal structures after SAH. MATERIALS AND METHODS: Twenty-eight hybrid rabbits were studied. Blood and cerebrospinal fluid pH values were recorded before/during/after the experimental procedures. The structures related to the central canals at the level of C5 of the cervical spinal cord were then examined histopathologically. The relationship between pH values of ependymal cells and degenerated epithelial cell densities was statistically analyzed. RESULTS: Mean blood pH values and degenerated ependymal cell density (n/mm2) were as follows: 7.351 ± 0.033/23 ± 7 in control, 7.322 ± 0.059/78 ± 13 in SHAM, and 7.261 ± 0.048/254 ± 62 in study animals. Gross examinations revealed swelling, edema, pia-arachnoid adhesions, ventral canal dilatation, arachnoiditis, central canal hemorrhage, occlusions, and dilatation in the spinal cord. CONCLUSION: Cerebrospinal fluid acidosis-induced central channel pathologies should be considered an important complication of SAH following SAH.

OBJETIVO: La acidosis es la complicación más peligrosa en la hemorragia subaracnoidea (HSA). El objetivo de este estudio fue investigar el efecto del líquido cefalorraquídeo ácido en las estructuras del canal central tras la HSA. MATERIALES Y MÉTODOS: Se estudiaron 28 conejos híbridos. Se registraron los valores de pH de la sangre y del líquido cefalorraquídeo antes, durante y después de los procedimientos experimentales. A continuación se examinaron histopatológicamente las estructuras relacionadas con los canales centrales a nivel de C5 de la médula espinal cervical. Se analizó estadísticamente la relación entre los valores de pH de las células ependimarias y las densidades de células epiteliales degeneradas. RESULTADOS: Los valores medios de pH en sangre y la densidad de células ependimarias degeneradas (n/mm2) fueron los siguientes: 7.351 ± 0.033/23 ± 7 en el control, 7.322 ± 0.059/78 ± 13 en el SHAM, 7.261 ± 0.048/254 ± 62 en los animales del estudio. Los exámenes macroscópicos revelaron hinchazón, edema, adherencias pia-aracnoideas, dilatación del canal ventral, aracnoiditis, hemorragia del canal central, oclusiones y dilatación en la médula espinal. CONCLUSIONES: Las patologías del canal central inducidas por la acidosis del líquido cefalorraquídeo deben considerarse como una complicación importante de la HSA tras una hemorragia subaracnoidea.

Blood Blister-Like Aneurysms of the Internal Carotid Artery.

Internal carotid artery blood blister-like aneurysms are challenging lesions that arise from the artery trunk at non-branching sites. They have been recognized since 1969 and are distinct from typical saccular aneurysms. Usually, these aneurysms are broad-based, with no clearly identifiable neck and have extremely friable and fragile walls, thus with a great propensity to cause subarachnoid hemorrhage and to rupture during treatment. Apparently, blister-like aneurysms are formed through an acquired defect of the inner layers (tunica intima and media) of the internal carotid artery wall, probably due to hemodynamic stress in the carotid siphon.Several surgical and endovascular techniques have been described for the treatment of these aneurysms, however, there is still no consensus on the best technique or method, exposing how challenging the treatment of internal carotid artery blister-like aneurysms is, for both neurosurgeons and neurointerventionists. In this chapter, we review the main aspects of the pathogenesis, diagnosis, and therapeutics and report our experience in the microsurgical treatment of these formidable lesions.