Effect of postoperative tranexamic acid on recurrence rate and complications in chronic subdural hematomas patients: preliminary results of a randomized controlled clinical trial.

Chronic subdural hematoma (CSDH) is a frequent neurosurgical disease which mainly affects elderly patients. Tranexamic acid (TXA) has been hypothesized as an oral agent to avoid CSDH progression and/or recurrence. We performed an evaluation to determine whether the postoperative use of TXA reduces recurrence rate. A prospective, randomized, and controlled trial. Patients with unilateral or bilateral chronic subdural hematoma undergoing surgical treatment by burr-hole were randomized as to whether or not to use TXA in the postoperative period. We evaluated image and clinical recurrence of CSDH at follow up of 6 months and potential clinical and/or surgical complications impact of TXA. Twenty-six patients were randomized to the control group (52%) and twenty-four patients to the TXA group (48%). Follow-up ranged from 3 to 16 months. There were no significant difference between baseline data in groups regarding to age, gender, use of antiplatelet or anticoagulants, smoking, alcoholism, systemic arterial hypertension, diabetes mellitus, hematoma laterality, hematoma thickness, and drain use. Clinical and radiological recurrence occurred in three patients (6%), being two cases in TXA group (8.3%) and 1 in control group (3.8%). Postoperative complications occurred in two patients during follow-up (4%), being both cases in TXA group (8.3%), and none in the control group. Although TXA group had a higher recurrence rate (8.3%), there was no statistically significant difference between the two groups. Moreover, TXA group had two complications while control group had no complications. Although limited by experimental nature of study and small sample, our current data suggest that TXA should not be used as a potential agent to avoid recurrences of CSDH and might increase complication odds.

Endoscopic resection of sellar and suprasellar epidermoid cyst: report of two cases and review of literature.

INTRODUCTION: Epidermoid cysts (EC) are lesions developing from neuroectodermal epithelial cells. They represent 1-2% of all intracranial tumors and are usually found in cerebellopontine angle and parasellar regions. To the best of our knowledge, only 27 cases have been reported of EC in sellar and suprasellar region. In 12 cases out of the 27, surgery was done by craniotomy means. The 7 most recent manuscripts (with 15 patients described) share in common the use of endoscopic endonasal approach (EEA) to perform surgical removal. RESULTS: In this paper, we report the safe removal of epidermoid cysts arising from the pituitary using an EEA in two patients, which should be the sixth such description in literature. In both cases, resection and evolution was favourable. DISCUSSION: Surgical resection is the treatment standard for epidermoid cysts, with total resection including the cyst wall to prevent recurrence when possible. The degree of resection obtained is limited by adherence to nearby neural and vascular structures. The advent of EEA approaches has allowed safe maximal resection especially in midline lesions nearby sellar and suprasellar compartiments.

Social determinants of health and survival on Brazilian patients with glioblastoma: a retrospective analysis of a large populational database.

Background: The majority of patients diagnosed with glioblastoma develop recurrent disease resulting in poor prognoses. The current study aimed to determine the survival rates of patients diagnosed with glioblastoma in Brazil accounting for the influence of age, treatment modalities, public and private practices, and educational level using a population-based national database. Methods: Patients diagnosed with glioblastoma from 1999-2020 were identified from The Fundação Oncocentro de São Paulo database to create a retrospective cohort. Patients were described according to age, education level treatment modalities and medical practice. In a Cox proportional hazards model, controlled for confounding factors for overall survival, the hazard ratio and 95% CI of overall survival in adults was evaluated. Findings: A total of 4,511 patients were included. The median lengths of survival for patients treated in the public and private settings were 8 and 17 months (p<0.001), respectively. Young patients had longer median overall survival (OS: 18 to 40 years, 41 to 60 years, 61 to 65 years, 66 to 70 years and over than 70 years was 22 months, 10 months, 6 months, 5 months, 4 months, respectively (p<0.001). In general, combined treatments were associated with higher median survival compared to monotherapy. The higher educational level, the higher median survival was observed (4 months for illiterate versus 14 months for university degree). In the multivariable analyses, the significant independent predictors for overall survival were practice setting, educational level, age and treatment modalities. Interpretation: Public practice, older patients, less intensive treatment, and lower educational level were associated with worse survival outcomes in Brazilian glioblastoma patients.

The Role of Neurophysiological Monitoring during Complex Aneurysm Surgery: Report of Two Cases and Review of the Literature

The surgical treatment of intracranial aneurysms is a routine operation in the neurosurgeon practice. Complex aneurysms are those with morphological irregularities, usually large or giant; thrombosed, partially thrombosed or calcified; with aberrant fundus/neck ratio and near eloquent neurological structures. These cases demand special skills by the surgical team. The present article is a report of two cases of complex aneurysms successfully treated, with a discussion on the role of neurophysiological monitoring. In these two cases of supra- and infratentorial complex giant aneurysms, intraoperative monitoring was extremely relevant. Thus, we believe that treating complex and giant aneurysms carries several pitfalls, and the use of multimodal intraoperative monitoring is mandatory to mitigate risks and deliver the best result to the patient.

Microsurgical treatment of basilar tip aneurysms: is it still acceptable?

OBJECTIVE: Basilar tip aneurysms (BTAs) have a complex anatomy, making them difficult to treat. We describe our surgical results for BTAs. METHODS: From 2004 to 2015 (12 years), a total of 25 small BTAs and two giant BTAs were treated in the Hospital do Servidor Público Estadual de São Paulo. RESULTS: In 23 patients harboring aneurysms positioned anteriorly or straight, all aneurysms were clipped (complete exclusion in all on follow-up angiography). In two patients with posteriorly positioned aneurysms, there was residual neck. All patients submitted to surgical treatment of small aneurysms presented with late Glasgow Outcome Scale scores of 4 or 5. Two patients with giant aneurysms died. CONCLUSION: Surgical treatment of these lesions may be accomplished with quite high success rates and low morbidity.

Microsurgical treatment of basilar tip aneurysms: is it still acceptable? / Tratamento cirúrgico dos aneurismas do topo da artéria basilar: ainda uma opção aceitável?

ABSTRACT Basilar tip aneurysms (BTAs) have a complex anatomy, making them difficult to treat. We describe our surgical results for BTAs. Methods: From 2004 to 2015 (12 years), a total of 25 small BTAs and two giant BTAs were treated in the Hospital do Servidor Público Estadual de São Paulo. Results: In 23 patients harboring aneurysms positioned anteriorly or straight, all aneurysms were clipped (complete exclusion in all on follow-up angiography). In two patients with posteriorly positioned aneurysms, there was residual neck. All patients submitted to surgical treatment of small aneurysms presented with late Glasgow Outcome Scale scores of 4 or 5. Two patients with giant aneurysms died. Conclusion: Surgical treatment of these lesions may be accomplished with quite high success rates and low morbidity.

RESUMO Os aneurismas do topo da artéria basilar (BTAs) têm anatomia complexa tornando-os tecnicamente difíceis de serem tratados. Nós descrevemos nossos resultados cirúrgicos em BTAs. Métodos: De 2004 a 2015 (12 anos), foram tratados no Hospital do Servidor Público Estadual de São Paulo um total de 25 BTAs pequenos e 2 BTAs gigantes. Resultados: Nos 23 pacientes portadores de aneurismas direcionados anteriormente ou neutros, cem por cento dos aneurismas foram tratados (oclusão de 100% na angiografia de seguimento). Em pacientes com aneurismas direcionados posteriormente (2 pacientes), houve colo residual. Todos os pacientes submetidos ao tratamento cirúrgico de pequenos aneurismas apresentaram Glasgow Outcome Scale (GOS) tardio de 4 ou 5. Nos 2 aneurismas gigantes, houve 2 casos de mortalidade (100%). Conclusão: Em mãos experientes, o tratamento cirúrgico destas lesões pode ser realizado com taxas de sucesso bastante elevadas e baixa morbidade.

Endoscopic endonasal management of cerebrospinal fluid rhinorrhea after anterior clinoidectomy for aneurysm surgery: changing the paradigm of complication management.

Resection of the anterior clinoid process results in the creation of the clinoid space, an important surgical step in the exposure and clipping of clinoidal and supraclinoidal internal carotid artery aneurysms. Cerebrospinal fluid rhinorrhea is an undesired and potentially serious complication. Conservative measures may be unsuccesful, and there is no consensus on the most appropriate surgical treatment. Two patients with persistent transclinoidal CSF rhinorrhea after aneurysm surgery were successfully treated with a combined endoscopic transnasal/transeptal binostril approach using a fat graft and ipsilateral mucosal nasal septal flap. Anatomical considerations and details of the surgical technique employed are discussed, and a management plan is proposed.

Endoscopic endonasal management of cerebrospinal fluid rhinorrhea after anterior clinoidectomy for aneurysm surgery: changing the paradigm of complication management / Endoscopia endonasal no tratamento da fístula liquórica após clinoidectomia anterior na cirurgia de aneurisma: mudando o paradigma no manejo desta complicação

ABSTRACT Resection of the anterior clinoid process results in the creation of the clinoid space, an important surgical step in the exposure and clipping of clinoidal and supraclinoidal internal carotid artery aneurysms. Cerebrospinal fluid rhinorrhea is an undesired and potentially serious complication. Conservative measures may be unsuccesful, and there is no consensus on the most appropriate surgical treatment. Two patients with persistent transclinoidal CSF rhinorrhea after aneurysm surgery were successfully treated with a combined endoscopic transnasal/transeptal binostril approach using a fat graft and ipsilateral mucosal nasal septal flap. Anatomical considerations and details of the surgical technique employed are discussed, and a management plan is proposed.

RESUMO A ressecção da clinóide anterior resulta na criação do espaço clinoideo, um passo cirúrgico importante na exposição e clipagem de aneurismas dos segmentos clinoideo e supraclinoideo da artéria carótida interna. Fístula liquórica é uma das complicaçoes mais indesejadas e é potencialmente grave. O manejo com medidas conservadoras pode ser bem sucedido, e não há consenso sobre o tratamento cirúrgico mais adequado. Dois pacientes com rinorréia persistente secundária a fistula liquórica transclinoidal após cirurgia de aneurisma foram tratados com sucesso por uma abordagem endoscópica combinada transnasal/transseptal binostril usando um enxerto de gordura e retalho de mucosa naso-septal ipsilateral. Considerações anatômicas e detalhes da técnica cirúrgica empregada são discutidos, e um plano de manejo destes tipo de fistula líquorica é proposto.

Surgical flow modification of the anterior cerebral artery-anterior communicating artery complex in the management of giant aneurysms of internal carotid artery bifurcation: An alternative for a difficult clip reconstruction.

BACKGROUND: Internal carotid artery bifurcation (ICAb) aneurysms account for about 2-15% of all intracranial aneurysms. In giant and complex cases, treatment may be difficult and dangerous, once some aneurysms have wide neck and anterior cerebral artery (ACA) and middle cerebral artery (MCA) may arise from the aneurysm itself. Clip reconstruction may be difficult in such cases. Whenever possible, the occlusion of ACA transform the bifurcation in a single artery reconstruction (ICA to MCA), much easier than a bifurcation reconstruction. METHODS: In patients with giant and complex ICAb aneurysms, we propose routine preoperative angiography with anatomical evaluation of anterior communicating artery (ACoA) patency during cervical common carotid compression with concomitant contralateral carotid artery injection. This allowed visualization of the expected reversal of flow in the A1 segment-ACoA complex. When test is positive, we can perform ipsilateral ACA (A1 segment) clip occlusion and flow modification of the ACA-ACoA complex transforming a three vessel (ICA, ACA, and MCA) reconstruction into a two vessel (ICA and MCA) reconstruction. RESULTS: Two patients were treated, with 100% of occlusion and good outcome. CONCLUSIONS: Surgical treatment of giant and complex ICAb may be achieved with acceptable morbidity.

Surgical clipping is still a good choice for the treatment of paraclinoid aneurysms.

UNLABELLED: Paraclinoid aneurysms are lesions located adjacent to the clinoid and ophthalmic segments of the internal carotid artery. In recent years, flow diverter stents have been introduced as a better endovascular technique for treatment of these aneurysms. METHOD: From 2009 to 2014, a total of 43 paraclinoid aneurysms in 43 patients were surgically clipped. We retrospectively reviewed the records of these patients to analyze clinical outcomes. RESULTS: Twenty-six aneurysms (60.5%) were ophthalmic artery aneurysms, while 17 were superior hypophyseal artery aneurysms (39.5%). The extradural approach to the clinoid process was used to clip these aneurysms. One hundred percent of aneurysms were clipped (complete exclusion in 100% on follow-up angiography). The length of follow-up ranged from 1 to 60 months (mean, 29.82 months). CONCLUSION: Surgical clipping continues to be a good option for the treatment of paraclinoid aneurysms.

Surgical clipping is still a good choice for the treatment of paraclinoid aneurysms / A clipagem cirúrgica é uma boa opção para o tratamento de aneurismas paraclinóideos

ABSTRACT Paraclinoid aneurysms are lesions located adjacent to the clinoid and ophthalmic segments of the internal carotid artery. In recent years, flow diverter stents have been introduced as a better endovascular technique for treatment of these aneurysms. Method From 2009 to 2014, a total of 43 paraclinoid aneurysms in 43 patients were surgically clipped. We retrospectively reviewed the records of these patients to analyze clinical outcomes. Results Twenty-six aneurysms (60.5%) were ophthalmic artery aneurysms, while 17 were superior hypophyseal artery aneurysms (39.5%). The extradural approach to the clinoid process was used to clip these aneurysms. One hundred percent of aneurysms were clipped (complete exclusion in 100% on follow-up angiography). The length of follow-up ranged from 1 to 60 months (mean, 29.82 months). Conclusion Surgical clipping continues to be a good option for the treatment of paraclinoid aneurysms.

RESUMO Aneurismas paraclinóideos são lesões localizadas adjacentes aos segmentos clinóideos e oftálmicos da artéria carótia interna. Os stents desviadores de fluxo tem sido crescentemente aplicados com sucesso. Métodos De 2009 a 2014, um total de 43 aneurismas paraclinóideos foram clipados em 43 pacientes. Analisamos retrospectivamente os dados dos pacientes e desfechos clínicos. Resultados Vinte seis aneurismas (60,5%) foram de artéria oftálmica e 17 de artéria hipofisária superior (39,5%). O acesso extradural à clinóide foi utilizado para todos aneurismas. Cem por cento dos aneurismas foram clipados com oclusão de 100% na angiografia controle. O tempo de follow-up oscilou de 1 a 60 meses, com media de 29 meses. Conclusão A clipagem cirúrgica é uma opção boa e segura para o tratamento de aneurismas paraclinóideos.

Blister-Like Aneurysms: Report of Successful Surgical Treatment of Consecutive Cases and Review of the Literature.

INTRODUCTION: Blister-like aneurysms (BAs) are usually defined as arterial lesions arising from nonbranching sites on intracranial arteries. Because of specific peculiarities such as different pathophysiology, fragility of the aneurysmal wall, high risk of intraoperative bleeding, and high probability of losing parent vessel patency, their treatment is controversial, and both endovascular and surgical options have been reported. METHODS: From 2006 to 2015 (10 years), 7 aneurysms in 6 patients were treated. We retrospectively reviewed the records of these patients to analyze clinical pictures and outcomes, which are expressed as modified Rankin Score. RESULTS: In our sample of 7 aneurysms in 6 patients, all BAs were successfully treated (complete exclusion in 100% on follow-up angiography). A good outcome (modified Rankin Score = 0) was achieved in all patients, with no difference related to aneurysm size and location. There was no mortality. CONCLUSIONS: Surgical treatment of BAs may be effective and have acceptable complications and outcomes.

Vasa Vasorum and the Growing of Thrombosed Giant Aneurysm of the Vertebral Artery: A Case Report.

BACKGROUND: Giant aneurysms arising from the vertebral artery (VA) are often associated with thrombosis and present as mass lesions with slow progression of symptoms and signs. A consensus is still to be established on the underlying growth mechanisms and surgical management of thrombosed giant aneurysms of the VA. CASE DESCRIPTION: Here, we report the case of a 54-year-old man who sought neurosurgical care after 3 months of progressive cervical axial pain. He underwent cervical magnetic resonance imaging and cerebral angiography, which revealed a giant VA aneurysm with thrombosed component. After failure of proximal and distal endovascular treatment, it was decided to adopt a surgical approach, which revealed a markedly developed vasa vasorum in the aneurysmal walls, raising the possibility of intra-aneurysmal nutrition from vasa vasorum. The patient recovered progressively and almost completely after surgery. CONCLUSIONS: Another report described the case of a 58-year-old woman harboring a partially thrombosed giant aneurysm of the VA. At the time of resection, a marked development of vasa vasorum on the occluded VA and the neck of the aneurysm was noted. We highlight the need to comprehend vasa vasorum as potential sources for aneurysmal growth.

Application of indocyanine green video angiography in surgical treatment of intracranial aneurysms.

Indocyanine green (ICG) video angiography has been used for several medical indications in the last decades. It allows a real time evaluation of vascular structures during the surgery. This study describes the surgical results of a senior vascular neurosurgeon. We retrospectively searched our database for all aneurysm cases treated with the aid of intraoperative ICG from 2009 to 2014. A total of 61 aneurysms in 56 patients were surgically clipped using intraoperative ICG. Clip reposition after ICG happened in 2 patients (3.2%). Generally, highly variable clip adjustment rates of 2%-38% following ICG have been reported since the introduction of this imaging technique. The application of ICG in vascular neurosurgery is still an emerging challenge. It is an adjunctive strategy which facilitates aneurismal evaluation and treatment in experienced hands. Nevertheless, a qualified vascular neurosurgeon is still the most important component of a high quality work.

Application of indocyanine green video angiography in surgical treatment of intracranial aneurysms / Aplicação da angiografia intraoperatória com indocianina verde no tratamento cirúrgico de aneurismas cerebrais

Indocyanine green (ICG) video angiography has been used for several medical indications in the last decades. It allows a real time evaluation of vascular structures during the surgery. This study describes the surgical results of a senior vascular neurosurgeon. We retrospectively searched our database for all aneurysm cases treated with the aid of intraoperative ICG from 2009 to 2014. A total of 61 aneurysms in 56 patients were surgically clipped using intraoperative ICG. Clip reposition after ICG happened in 2 patients (3.2%). Generally, highly variable clip adjustment rates of 2%–38% following ICG have been reported since the introduction of this imaging technique. The application of ICG in vascular neurosurgery is still an emerging challenge. It is an adjunctive strategy which facilitates aneurismal evaluation and treatment in experienced hands. Nevertheless, a qualified vascular neurosurgeon is still the most important component of a high quality work.

A angiografia intraoperatória com indocianina verde (ICG) já foi aplicada em diversas situações clínicas por vários anos. O ICG permite avaliação em tempo real de estruturas vasculares durante a cirurgia. Este artigo descreve os resultados cirúrgicos do autor sênior. Avaliamos retrospectivamente os casos de aneurismas intracranianos operados de 2009 a 2014. Um total de 61 aneurismas em 56 pacientes foram operados com ICG. O reposicionamento do clip ocorreu em 2 casos (3.2%). Geralmente, taxas variáveis de reposicionamento do clip têm sido descritas (2%–38%). A aplicação de ICG na neurocirurgia vascular ainda é um desafio crescente. É um artifício que auxilia na avaliação e tratamento de aneurismas intracranianos em mãos experientes. No entanto, um neurocirurgião vascular continua sendo o principal componente de um resultado cirúrgico de alto nível.

Natural course of subarachnoid hemorrhage is worse in elderly patients.

UNLABELLED: Aging is a major risk factor for poor outcome in patients with ruptured or unruptured intracranial aneurysms (IA) submitted to treatment. It impairs several physiologic patterns related to cerebrovascular hemodynamics and homeostasis. OBJECTIVE: Evaluate clinical, radiological patterns and prognostic factors of subarachnoid hemorrhage (SAH) patients according to age. METHOD: Three hundred and eighty nine patients with aneurismal SAH from a Brazilian tertiary institution (Hospital do Servidor Público Estadual de São Paulo) were consecutively evaluated from 2002 to 2012 according to Fisher and Hunt Hess classifications and Glasgow Outcome Scale. RESULTS: There was statistically significant association of age with impaired clinical, radiological presentation and outcomes in cases of SAH. CONCLUSION: Natural course of SAH is worse in elderly patients and thus, proper recognition of the profile of such patients and their outcome is necessary to propose standard treatment.

Natural course of subarachnoid hemorrhage is worse in elderly patients / A história natural da hemorragia subaracnóide é pior em pacientes idosos

Aging is a major risk factor for poor outcome in patients with ruptured or unruptured intracranial aneurysms (IA) submitted to treatment. It impairs several physiologic patterns related to cerebrovascular hemodynamics and homeostasis. Objective Evaluate clinical, radiological patterns and prognostic factors of subarachnoid hemorrhage (SAH) patients according to age. Method Three hundred and eighty nine patients with aneurismal SAH from a Brazilian tertiary institution (Hospital do Servidor Público Estadual de São Paulo) were consecutively evaluated from 2002 to 2012 according to Fisher and Hunt Hess classifications and Glasgow Outcome Scale. Results There was statistically significant association of age with impaired clinical, radiological presentation and outcomes in cases of SAH. Conclusion Natural course of SAH is worse in elderly patients and thus, proper recognition of the profile of such patients and their outcome is necessary to propose standard treatment. .

A idade é considerada fator de risco de mau prognóstico em pacientes com aneurismas intracranianos rotos ou não-rotos; com o aumento da idade, ficam prejudicados vários padrões fisiológicos relacionados à hemodinâmica cerebral e homeostase. Objetivo Estudar o quadro clínico, os dados radiológicos e o prognóstico nos pacientes com hemorragia subaracnóide aneurismática em relação à idade. Método Foram avaliados consecutivamente, de 2002 a 2012, 389 pacientes com hemorragia subaracnóide aneurismática oriundos de uma instituição terciária brasileira. Resultados Houve associação da idade com pior quadro clínico, radiológico e prognóstico nos pacientes com hemorragia subaracnóide aneurismática. Conclusão O curso natural da hemorragia subaracnoidea é pior em pacientes idosos. O reconhecimento adequado do perfil desses pacientes e seu prognóstico é importante para estabelecer um tratamento adequado. .

Spontaneous resolution of an isolated cervical anterior spinal artery aneurysm after subarachnoid hemorrhage.

BACKGROUND: Isolated cervical anterior spinal artery aneurysms are extremely rare. Subarachnoid hemorrhage (SAH) secondary to such lesions have been described only in six cases to the best of our knowledge. CASE DESCRIPTION: We describe an unusual clinical picture of SAH due to rupture of anterior spinal artery aneurysm in a patient with previous normal angiogram. Due to the location of the aneurysm and clinical status of the patient, conservative management was proposed, and she was discharged to further follow-up. Monthly routine angiograms revealed resolution of the aneurysm 90 days after bleeding, which was highly suggestive of vascular dissection. CONCLUSION: We highlight the need to consider these aneurysms in the differential diagnosis of SAH, especially when occurring in the posterior fossa and when angiography findings are inconclusive.

Perianeurysmal edema as a predictive sign of aneurysmal rupture.

Subarachnoid hemorrhage following intracranial aneurysmal rupture is a major cause of morbidity and mortality. Several factors may affect the probability of rupture, such as tobacco and alcohol use; size, shape, and location of the aneurysm; presence of intraluminal thrombus; and even the sex of the patient. However, few data correlate such findings with the timing of aneurysmal rupture. The authors report 2 cases of middle-age women with headache and MRI findings of incidental aneurysms. Magnetic resonance imaging showed evidence of surrounding parenchymal edema, and in one case there was a clear increase in edema during follow-up, suggesting a progressive inflammatory process that culminated with rupture. These findings raise the possibility that bleb formation and an enlargement of a cerebral aneurysm might be associated with an inflammatory reaction of the aneurysm wall resulting in perianeurysmal edema and subsequent aneurysmal rupture. There may be a temporal link between higher degree of edema and higher risk for rupture, including risk for immediate rupture.