Outcome following phrenic nerve transfer to musculocutaneous nerve in patients with traumatic brachial palsy: a qualitative systematic review.

BACKGROUND: The phrenic nerve can be transferred to the musculocutaneous nerve in patients with traumatic brachial plexus palsy in order to recover biceps strength, but the results are controversial. There is also a concern about pulmonary function after phrenic nerve transection. In this paper, we performed a qualitative systematic review, evaluating outcomes after this procedure. METHOD: A systematic review of published studies was undertaken in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Data were extracted from the selected papers and related to: publication, study design, outcome (biceps strength in accordance with BMRC and pulmonary function) and population. Study quality was assessed using the "strengthening the reporting of observational studies in epidemiology" (STROBE) standard or the CONSORT checklist, depending on the study design. RESULTS: Seven studies were selected for this systematic review after applying inclusion and exclusion criteria. One hundred twenty-four patients completed follow-up, and most of them were graded M3 or M4 (70.1 %) for biceps strength at the final evaluation. Pulmonary function was analyzed in five studies. It was not possible to perform a statistical comparison between studies because the authors used different parameters for evaluation. Most of the patients exhibited a decrease in pulmonary function tests immediately after surgery, with recovery in the following months. Study quality was determined using STROBE in six articles, and the global score varied from 8 to 21. CONCLUSIONS: Phrenic nerve transfer to the musculocutaneous nerve can recover biceps strength ≥M3 (BMRC) in most patients with traumatic brachial plexus injury. Early postoperative findings revealed that the development of pulmonary symptoms is rare, but it cannot be concluded that the procedure is safe because there is no study evaluating pulmonary function in old age.

Giant pericallosal artery aneurysm ? Literature review and report of a rare case / Aneurisma gigante de artéria pericalosa ? Revisão da literatura e relato de um caso raro

Giant pericallosal artery aneurysms are extremely rare. Aneurismatic lesions involving this artery are usually small, tend to early bleeding and might be associated with other lesions. Differential diagnosis of giant aneurysms are not easy and includes tumoral, infectious and vascular mass effect lesions. We report a case of a giant and partially thrombosed left pericallosal artery aneurysm. A 58-year-old man, presented with progressive headaches, seizures and speech alterations initially misdiagnosed as a falx cerebri meningioma. As clinical status continue to worsen, magnetic resonance imaging and digital cerebral angiography were performed and a vascular etiology was considered. The patient was then referred to our hospital for surgical treatment. The peculiarity of this case concerns the difficulty of surgical treatment once the surgeon was not able to obtain control of the afferent artery and the aneurysm neck could not be visualized. Also, the aneurysm adhered to the medial surfaces of the frontal lobes and covered the anterior cerebral arteries. Treatment by means of microsurgical thrombectomy, clipping and resection of the lesion was successfully performed. Microsurgical treatment may provide good results when carefully planned with the help of imaging studies of the lesion. It is essential to keep in mind that flexible approach is of great importance when dealing with giant aneurysmatic lesions of pericallosal artery due to its variety of intraoperative presentation.

Aneurismas gigantes da artéria pericalosa são raros. Lesões aneurismáticas acometendo essa artéria são, geralmente, pequenas, tendem a sangrar precocemente e associam-se a outras lesões.O diagnóstico diferencial dos aneurismas gigantes é complexo, uma vez que inclui diversas lesões que cursam com efeito de massa, entre elas, as tumorais, infecciosas e vasculares. Relatamos o caso de um aneurisma gigante, parcialmente trombosado, acometendo a artéria pericalosa esquerda. Tratase de um paciente de 58 anos de idade, sexo masculino, apresentando quadro de cefaleia, crises convulsivas e alterações na fala. O achado de uma massa inter-hemisférica de característica hiperdensaà tomografia computadorizada de crânio levou ao diagnóstico errôneo de meningioma da foice cerebral. Uma vez que o quadro clínico do paciente continuou a piorar, optou-se por submetê-lo à ressonância nuclear magnética e à angiografia cerebral digital. A hipótese de etiologia vascular foi então aventada. O paciente foi encaminhado ao nosso serviço para ser submetido a tratamento cirúrgico. A peculiaridade desse caso deve-se à dificuldade de acesso à artéria aferente e de visualização do colo para controle da lesão. Além disso, o aneurisma encontrava-se aderido às faces mediais dos lobos frontais e cobria as artérias cerebrais anteriores. O tratamento cirúrgico por meio de trombectomia microcirúrgica,clipagem e ressecção da lesão pôde ser realizado com sucesso. O tratamento microcirúrgico, quando cuidadosamente planejado por meio de exames de imagem, pode viabilizar a obtenção de resultadossatisfatórios. No entanto, deve-se atentar para o fato de que lesões aneurismáticas gigantes de artéria pericalosa podem se apresentar de diversas formas durante o ato operatório, sendo, portanto, essencialuma abordagem flexível, adaptada às peculiaridades de cada lesão.

Anatomia cirúrgica do nervo acessório espinhal: comoevitar lesões em procedimentos cirúrgicos no trígonocervical posterior / Surgical anatomy of the spinal accessory nerve: how to avoid injuries to the posterior cervical triangle during surgical procedures

Introdução: A síndrome resultante da lesão iatrogênica do nervo acessório espinhal (NAE) secaracteriza por dor, paralisia e escápula alada, estando relacionada a morbidade considerável. Opresente estudo investiga o grau de variação na ramificação e no curso do NAE no trígono cervicalposterior (TCP). Método: A região cervical de oito cadáveres foi dissecada bilateralmente paraexpor o NAE. A ramificação e as variações no curso do NAE no TCP foram registradas. Medidasrelacionadas a estruturas anatômicas do Músculo Esternocleidomastóideo (MEC) e do MúsculoTrapézio (MTZ) foram analisadas. Resultados: As 16 dissecções demonstraram padrão de ramificaçãodo NAE como: nenhum ramo em 25%, um ramo em 37,5% e dois ramos em 37,5%dos casos. Considerável variação foi observada na anatomia regional do NAE no TCP. Medidasrevelaram que o NAE tem relação relativamente constante com o nervo auricular magno (NAM)e esta é uma importante referência anatômica para identificação do NAE no TCP. Conclusões:O NAM é uma referência anatômica útil para a identificação do NAE no TCP. Essa abordagemsugere uma possibilidade para diminuição de lesão iatrogênica do NAE, frequentemente relacionadaà manipulação cervical de estruturas anatômicas adjacentes sem exposição direta do nervo.

Background: The resulting syndrome from iatrogenic injury to the spinal accessory nerve (SAN)is characterized by pain, paralysis and winging of the scapula are often the source of considerablemorbidity. This study analyses the degree of ramification and variations of the SAN at the posteriortriangle (PT). Method: The necks of 8 adult cadavers were dissected bilaterally to expose the SAN.The ramifications and variations of the SAN at the PT were recorded. Measurements related toanatomical landmarks of the Sternocleidomastoid Muscle (SM) and the Trapezius Muscle (TM)were analyzed. Results: The sixteen dissections performed showed the ramification pattern ofthe SAN as: no ramus in 25%, one ramus in 37.5% and 2 ramus in 37.5% of cases. Considerablevariation was seen in regional anatomy of the SAN at the PT. Measurements revealed that the SANhas a relatively constant relationship with the great auricular nerve (GAN) and this is a importantlandmark for the identification of the SAN at the PT. Conclusions: The GAN is a useful landmarkfor identification of the SAN at the PT. This approach suggests a possibility to decrease theincidence of iatrogenic injury of the SAN, that is frequently related to dissection of surroundinganatomical structures and reduced direct exposure of the nerve.

Dificuldades no tratamento microcirúrgico dos aneurismas gigantes e complexos da circulacao anterior do polígono de Willis: proposta de escala técnica prognóstica / Dificulties in the microsurgical treatment of giant and complex aneurysms of the anterior circulation of the circle of Willis: proposal of a technical and prognostic scale

Para desenvolver e avaliar a aplicabilidade de uma escala técnica prognostica das dificuldades no tratamento microcirúrgico dos aneurismas gigantes e complexos da circulação anterior do polígono de Willis, 50 lesões foram operadas. Um valor numérico foi dado a cada uma das 8 variáveis da escala / In order to develop and verify the applicability of a technical and prognostic scale of the difficulties in the microsurgical treatment of giant and complex aneurysms of the anterior circulation of the Cicle of Willis, 50 lesions were operated. A numeric amount was given for each of 8 variants of the scale. By adding each amount for each variant a score(from 1 to 14) was achieved, for each of the 50 surgeries. Two groups, therefore, were established...