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1.
Neurosurgery ; 2020 Mar 20.
Artigo em Inglês | MEDLINE | ID: mdl-32195549

RESUMO

Milton Dave Heifetz (1921-2013) was a pioneer American neurosurgeon who spent the majority of his career at Cedars-Sinai Hospital in California. Heifetz greatly influenced the field of neurosurgery as an innovator, leader, and academic neurosurgeon. His redesign of the aneurysm clip addressed the long-standing issue of a fatiguing spring. Heifetz's innovation allowed the spring to maintain adequate closing force despite repetitive opening and closing. This clip was recognized as one of the most effective aneurysm clips for approximately 15 yr. While he was best known for this eponymous aneurysm clip, Heifetz also developed other various microsurgical instruments and tools for stereotactic approaches. Beyond neurosurgery, he was an influential figure and well-published author in fields such as medical ethics, philosophy, astronomy, and poetry. In 1975, he published The Right to Die: A Neurosurgeon Speaks of Death With Candor, a book which played a major role in our modern-day advanced directives. Throughout his life, Heifetz was an inspirational individual who consistently worked towards solutions to surgical and ethical problems. We present a historical vignette on his life, career, and contributions to neurosurgery.

2.
Neurosurg Focus ; 48(3): E20, 2020 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-32114557

RESUMO

OBJECTIVE: Engagement in research and scholarship is considered a hallmark of neurosurgical training. However, the participation of neurosurgical trainees in this experience has only recently been analyzed and described in the United States, with little, if any, data available regarding the research environment in neurosurgical training programs across the globe. Here, the authors set out to identify requirements for research involvement and to quantify publication rates in leading neurosurgical journals throughout various nations across the globe. METHODS: The first aim was to identify the research requirements set by relevant program-accrediting and/or board-certifying agencies via query of the literature and published guidelines. For the second part of the study, the authors attempted to determine each country's neurosurgical research productivity by quantifying publications in the various large international neurosurgical journals-World Neurosurgery, Journal of Neurosurgery, and Neurosurgery-via a structured search of PubMed. RESULTS: Data on neurosurgical training requirements addressing research were available for 54 (28.1%) of 192 countries. Specific research requirements were identified for 39 countries, partial requirements for 8, and no requirements for 7. Surprisingly, the authors observed a trend of increased average research productivity with the absence of designated research requirements, although this finding is not unprecedented in the literature. CONCLUSIONS: A variety of countries of various sizes and neurosurgical workforce densities across the globe have instituted research requirements during training and/or prior to board certification in neurosurgery. These requirements range in intensity from 1 publication or presentation to the completion of a thesis or dissertation and occur at various time points throughout training. While these requirements do not correlate directly to national research productivity, they may provide a foundation for developing countries to establish a culture of excellence in research.

3.
World Neurosurg ; 2020 Mar 09.
Artigo em Inglês | MEDLINE | ID: mdl-32165344

RESUMO

OBJECTIVES: Management of incidental asymptomatic brain tumors in children is controversial due to lack of clear evidence-based guidelines. We present this systematic review in an attempt to highlight an optimal treatment paradigm. METHODS: This systematic review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Databases were searched up to August 2019 using the keywords "incidental", "brain tumor" and "pediatric". Our main focus was on brain lesions suspected for neoplasm, diagnosed incidentally on neuroimaging in an otherwise asymptomatic patient <18 years old. Cystic, vascular, and inflammatory brain lesions were excluded. RESULTS: Fourteen studies comprising 308 patients were included. All cases were diagnosed using MRI. The most common indications for imaging were headache (93; 30%) and trauma (72; 23%). Lesion distribution was supratentorial (179; 58%), infratentorial (121; 40%), and intraventricular (8; 3%). Out of 308 cases, 243 (79%) were managed with neuroradiological surveillance and 57 (19%) by upfront surgical excision. Of those managed conservatively, 177 (73%) remained stable within a mean follow-up of 30 months, 54 (22%) progressed, and 12 (5%) spontaneously regressed. Meanwhile, upfront excision achieved complete remission in all 57 cases over a mean follow-up of 68.3 months. CONCLUSION: A small body of evidence has emerged, highlighting the marked heterogeneity and contradictory results between the available studies, limiting our ability to draw solid conclusions. At this point, the decision between surgery and "watchful waiting" should be tailored on an individual patient basis depending on suspicion of malignancy, clinical or radiologic progression, and parental preference.

4.
World Neurosurg ; 2020 Mar 13.
Artigo em Inglês | MEDLINE | ID: mdl-32179192

RESUMO

Intracranial pressure (ICP) monitoring has become an important tool in neurocritical care. Despite being used in ICUs all over the world, many are unfamiliar with its origins and the people and events that shaped the development of this technique. Herein, we provide a comprehensive historical review of the evolution of ICP monitoring, beginning with the earliest descriptions of the cerebrospinal fluid. We conducted a database search in PubMed, Google Scholar, and Google Books for relevant articles using the keywords "cerebrospinal fluid", "intracranial pressure" and "monitoring". Articles were further snowballed using reference lists of relevant papers. Although the earliest descriptions of the CSF date back several hundred years B.C., the history of ICP monitoring itself is not a long one. Alexander Monro and his student George Kellie laid the foundation of CSF physiology in the early 1800s through the Monro-Kellie doctrine. Their principles were later consolidated by John Abercrombie and Harvey Cushing. However, ten years earlier than Cushing's work on CSF physiology, Hans Queckenstedt's utilization of a lumbar needle to measure the pressure in the CSF marked the beginning of the era of ICP monitoring. Thenceforward, ICP monitoring technology underwent progressive improvements through the contributions of French scientists Guillaume and Janny, Swedish neurosurgeon Nils Lundberg, among others. Nowadays, ICP monitoring can be performed via direct and indirect methods using a potpourri of devices such as, but not limited to, subarachnoid bolts, microtransducer catheters and telemetric monitors. Nevertheless, despite advancements in ICP monitoring technology, the gold standard remains an extra-ventricular drain catheter connected to an external pressure transducer.

5.
Clin Neurol Neurosurg ; 194: 105798, 2020 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-32222653

RESUMO

When an incapacitated Jehovah's Witness neurologically deteriorates and requires immediate craniectomy, institutional protocols may delay surgery if the patient's refusal of blood products is ambiguous. We are among the first to describe such an ethically contentious case in emergency neurosurgery, review the morbidity of operative delays, discuss medicolegal concerns raised, and provide a detailed guide to hemostasis in patients who refuse blood products. We discuss the case of a 46-year-old woman presented with nausea, vomiting, and right-sided weakness, progressing to stupor over several hours. When an initial Computed Tomography (CT) scan showed a large, left-sided intraparenchymal hematoma with significant midline shift, she was booked for an emergency hemicraniectomy. According to the family, she was a Jehovah's Witness and would have refused blood consent, but was without the proper documentation. Despite her worsening neurological status, an indeterminate blood consent delayed surgery for more than two hours. Her neurological exam did not improve postoperatively, and she later expired. The ethical, legal, and operative concerns that arise in the emergency neurosurgical treatment of Jehovah's Witness patients pose unique management challenges. Since operative delay is a preventable cause of mortality in patients requiring urgent craniectomy, and the likelihood of requiring a transfusion from hemorrhage is minimal, an ambiguous blood consent should not postpone a potentially life-saving treatment. For the beneficence and autonomy of Jehovah's Witness patients, institutional policies should respect the family's wishes in order to expedite surgical decompression. In addition to discussing the nuances of such ethical considerations, we also provide a detailed list of commonly used, topical and parenteral hemostatic agents from the neurosurgical operating room which, depending on whether they are blood-derived, either should or should not be used when treating a Jehovah's Witness.

6.
World Neurosurg ; 137: 78-83, 2020 Feb 03.
Artigo em Inglês | MEDLINE | ID: mdl-32028002

RESUMO

BACKGROUND: Brainstem cavernous malformations (CMs) represent dangerous clinical entities associated with high rates of rebleeding and morbidity compared with those in other locations. Particularly rare are those located within the fourth ventricle. Although fourth ventricular CMs are favorable from a surgical standpoint, there are no defined guidelines on definitive indications and optimal timing of surgery. In addition, the surgical approaches, anatomic considerations, and general observations regarding these lesions are not well reported in the literature. CASE PRESENTATION: A 27-year-old man with a known history of a CM on the floor of the fourth ventricle presented with new cranial nerve deficits and signs of increased intracranial pressure. Imaging revealed acute bleeding from a fourth ventricular CM. The patient was urgently taken to surgery for resection. Despite a noneventful surgery which resulted in gross total resection, the patient developed a unique constellation of cranial nerve deficits postoperatively, most notably of which was eight-and-a-half syndrome. CONCLUSIONS: CMs of the fourth ventricle are rare clinical entities that can be treated successfully with surgery. The indications for surgery may not always be clear-cut; therefore, the neurosurgeon's decision to proceed with surgery must reside on a case-by-case basis using a multifactorial approach. The location of these lesions presents unique challenges given their proximity to vital structures and the technical difficulty required. For these reasons, the resection of these lesions often results in new or persistent neurologic deficits. However, despite the associated risks, the potential benefits of surgery oftentimes outweigh the risks of the alternative.

7.
Artigo em Inglês | MEDLINE | ID: mdl-32067926

RESUMO

BACKGROUND: Physician health and wellness can be negatively impacted by burnout, which, in turn, can lead to medical errors and early retirement. Burnout issues can start in medical school and progress during residency, fellowship, and throughout a physician's career. Previous studies have reported burnout rates between 45% and 54% for US physicians in general. However, there is currently little data regarding health and wellness specifically in the field of allergy and immunology. OBJECTIVE: This workgroup report was developed to assess health and wellness in our specialty. METHODS: The American Academy of Allergy, Asthma, and Immunology (AAAAI) electronically distributed an anonymous questionnaire using the validated mini-Z survey to a random sample of 1035 fellows and members. In addition to the mini-Z items, the survey queried personal and professional demographic characteristics, and included open-ended wellness questions. RESULTS: A total of 138 fellows and members of the AAAAI completed the survey, yielding a 13% response rate. The burnout rate was 35%, which is lower than the national average among US physicians, and is overall encouraging. However, there is room for improvement. Limitations of the study include a small sample size as well as evolving definitions of burnout. CONCLUSIONS: Our results identify specialty specific concerns and can be used to inform the development of tailored interventions to improve wellness and minimize burnout. However, future surveys with a larger sample size are needed to obtain a more robust data set on allergy and immunology specific wellness challenges.

8.
Acta Neurochir (Wien) ; 162(4): 923-928, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31997070

RESUMO

Extravasation of Onyx is a rare complication during embolization of arteriovenous malformations (AVM). We present a case of embolization that was complicated by leakage of Onyx into the cerebellum which was later encountered during surgical excision of the AVM. Our goal is to report this rare event and to outline successful treatment of this complication. The patient's records were reviewed for medical history, laboratory and radiologic workup, and outpatient clinical follow-up. A 62-year-old female presented with Hunt Hess grade 2 and modified Fisher grade 2 subarachnoid hemorrhage (SAH) secondary to ruptured left posterior inferior cerebellar artery (PICA) aneurysm associated with a superior cerebellar vermian AVM. Following endovascular intervention, the aneurysm was completely embolized; however, only 75% of the AVM could be safely obliterated. Extravasation of Onyx from the ruptured aneurysm was noted on her initial angiogram. Elective suboccipital craniectomy was subsequently planned for resection of the residual AVM where the extravasated Onyx posed an operative nuisance during resection. Post-op angiogram confirmed complete resection of the AVM, as well as the bulk of the extravasated Onyx. Patient did well post-operatively, remaining neurologically intact throughout her hospital course. Although infrequently reported in the literature, Onyx extravasation is a potential complication that neurosurgeons should be ready to face. Adherence of Onyx to surrounding parenchyma could hinder optimal surgical resection of AVM and increase complications. Therefore, careful surgical dissection should be performed with special care to delicate neurovasculature. In this case, complete resection of the AVM and Onyx mass was safely achieved.

9.
Acta Neurochir (Wien) ; 162(3): 499-507, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31900658

RESUMO

INTRODUCTION: Refractory or chronic subdural hematomas (cSDH) constitute a challenging entity that neurosurgeons face frequently nowadays. Middle meningeal artery embolization (MMAE) has emerged in the recent years as a promising treatment option. However, solid evidence that can dictate management guidelines is still lacking. METHODS: We conducted a systematic review and meta-analysis (MA) in compliance with the PRISMA guidelines to evaluate the efficacy and safety of MMAE compared with conventional treatments for refractory or cSDH. Databases were searched up to March 2019. Using a random-effects model, meta-analyses of proportions and risk difference were conducted recurrence, need for surgical rescue, and complications. RESULTS: Eleven studies (177 patients) were included. Majority (116, 69%) were males with a weighted mean age of 71 + -19.5 years. Meta-analysis of proportions showed treatment failure to be 2.8%, need for surgical rescue 2.7%, and embolization-related complications 1.2%. Meta-analysis of risk-difference between embolized and non-embolized patients showed a 26% (p < 0.001, 95% CI 21%-31%, I2 = 0) lower risk of hematoma recurrence in MMAE. Similarly, in the embolized group, the need for surgical rescue was 20% less (p < 0.001, 95% CI = 12%-27%, I2 = 12.4), and complications were 3.6% less (p = 0.008, 95% CI 1%-6%, I2 = 0) compared to conventional groups. CONCLUSIONS: Although MMAE appears to be a promising treatment for refractory or cSDH, drawing definitive conclusions remains limited by paucity of data and small sample sizes. Multicenter, randomized, prospective trials are needed to compare embolization to conventional treatments like watchful waiting, medical management, or surgical evacuation. More extensive research on MMAE could begin a new era in the minimally invasive management of cSDH.

10.
World Neurosurg ; 134: 518-531, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31542444

RESUMO

Aneurysm clips are indispensable tools in the armamentarium of vascular neurosurgeons. The history of the development of aneurysm clips is witness to ingenuity and tenacity in treating a potentially devastating disease. Few know the stories of their innovators and the inspiration behind their designs. Hence, we present this historical vignette in an attempt to shed more light on the pioneers who shaped the evolution of aneurysm clips as we know them. A comprehensive literature search was performed using PubMed, Google Scholar, Google Books, and library historical archives, as well as personal communications with relatives, colleagues, and institutions of the surgeon-designers. We present the following aneurysm clip innovators and chronicle their biographies and contributions: Herbert Olivecrona (1891-1980), Frank Mayfield (1908-1991), Charles Drake (1920-1998), Joseph McFadden (1920-present), Thoralf Sundt Jr. (1930-1992), William M. Lougheed (1923-2004), William B. Scoville (1906-1984), Milton D. Heifetz (1921-2015), Gazi Yasargil (1925-present), Kenichiro Sugita (1932-1994), and Robert Spetzler (1944-present). Although this compilation of eponymous clips is by no means complete, we hope that it provides an informative historical perspective and an inspiration for aspiring neurosurgeons. The history of aneurysm surgery, an entity once deemed inoperable, teaches us the importance of innovation in medicine.

11.
J Asthma ; 57(3): 241-252, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30656998

RESUMO

Objective: The older adult population is increasing worldwide, and a significant percentage has asthma. This review will discuss the challenges to diagnosis and management of asthma in older adults. Data Sources: PubMed was searched for multiple terms in various combinations, including asthma, older adult, elderly, comorbid conditions, asthma diagnosis, asthma treatment, biologics and medication side effects, and adverse events. From the search, the data sources that were utilized included peer reviewed scholarly review articles, peer reviewed scientific research articles, and peer reviewed book chapters. Study Selections: Study selections that were utilized included peer reviewed scholarly review articles, peer reviewed scientific research articles, and peer reviewed book chapters. Results: Asthma in older adults is frequently underdiagnosed and has higher morbidity and mortality rates compared to their younger counterparts. A detailed history and physical examination as well as judicious testing are essential to establish the asthma diagnosis and exclude alternative ones. Medical comorbidities, such as cardiovascular disease, cognitive impairment, depression, arthritis, gastroesophageal reflux disease (GERD), rhinitis, and sinusitis are common in this population and should also be assessed and treated. Non-pharmacologic management, including asthma education on inhaler technique and self-monitoring, is vital. Pharmacologic management includes standard asthma therapies such as inhaled corticosteroids (ICS), inhaled corticosteroid-long acting ß-agonist combinations (ICS-LABA), leukotriene antagonists, long acting muscarinic antagonists (LAMA), and short acting bronchodilators (SABA). Newly approved biologic agents may also be utilized. Older adults are more vulnerable to polypharmacy and medication adverse events, and this should be taken into account when selecting the appropriate asthma treatment. Conclusions: The diagnosis and management of asthma in older adults has certain challenges, but if the clinician is aware of them, the morbidity and mortality of this condition can be improved in this growing population.

12.
Med Clin North Am ; 104(1): 95-108, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31757240

RESUMO

Asthma affects approximately 300 million people worldwide and approximately 7.5% of adults in the United States. Asthma is characterized by inflammation of the airways, variable airflow obstruction, and bronchial hyperresponsiveness. The diagnosis of asthma is a clinical one with the history and physical examination being significant, but objective measures, such as pulmonary function testing, can be used to aid in the diagnosis. There are multiple associated comorbidities with asthma, including rhinitis, sinusitis, gastroesophageal reflux disease, obstructive sleep apnea, and depression. There is often an allergic component of asthma, and patient education is vital.


Assuntos
Asma/epidemiologia , Adulto , Asma/diagnóstico , Depressão/epidemiologia , Refluxo Gastroesofágico/epidemiologia , Humanos , Testes de Função Respiratória , Rinite/epidemiologia , Sinusite/epidemiologia , Apneia Obstrutiva do Sono/epidemiologia , Estados Unidos/epidemiologia
13.
J Clin Sleep Med ; 15(12): 1839-1848, 2019 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-31839111

RESUMO

STUDY OBJECTIVES: The role of obstructive sleep apnea (OSA) in the overall outcome of ruptured intracranial aneurysms (RIAs) is unknown. We have investigated the role of OSA in overall outcome of RIAs. METHODS: Data from 159 consecutive patients were retrospectively reviewed. A chi-square test and regression analysis were performed to determine the significant difference. A value of P < .05 was considered significant. RESULTS: The prevalence of OSA in RIAs was fivefold higher in the nonaneurysm patient group, P = .002. The number of patients with hypertension (P < .0001), body mass index ≥ 30 (P < .0001), hyperlipidemia (P = .018), chronic heart disease (P = .002) or prior ischemic stroke (P = .001) was significantly higher in the OSA group. Similarly, the number of wide-neck aneurysms (P < .0001) and aneurysm > 7 mm (P = .004), poor Hunt and Hess grade IV-V (P = .005), vasospasms, (P = .03), and patients with poor Modified Rankin Scale scores (3-6) was significantly higher in the OSA group (P < .0001). Interestingly, for the first time in univariate (P = .01) and multivariate (P = .003) regression analysis, OSA was identified as an individual predictor of unfavorable outcome of RIAs. In addition, hypertension (P = .04), smoking (P = .049), chronic heart disease (P = .01), and Hunt and Hess grade IV-V (P = .04) were revealed as predictors of poor outcome of RIAs. CONCLUSIONS: This is a novel study to determine the association between OSA and ruptured cerebral aneurysm in terms of comorbidities, size of aneurysm, severity of symptoms, and outcomes after treatment. In addition, for the first time, OSA is identified as a positive predictor of unfavorable outcome of RIAs.

14.
Neuroimage Clin ; 24: 102072, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31734529

RESUMO

Epilepsy, including the type with focal onset, is increasingly viewed as a disorder of the brain network. Here we employed the functional connectivity (FC) metrics estimated from the resting state functional MRI (rsfMRI) to investigate the changes of brain network associated with focal epilepsy caused by single cerebral cavernous malformation (CCM). Eight CCM subjects and 21 age and gender matched controls were enrolled in the study. Seven of 8 CCM subjects underwent surgical resection of the CCM and became seizure free and 4 of the surgical subjects underwent a repeat rsfMRI study. We showed that there was both regional and global disruption of the FC values among the CCM subjects including decreased in homotopic FC (HFC) and global FC (GFC) in the regions of interest (ROIs) where the CCMs were located. There was also the disruption of the default mode network (DMN) especially the FC between the middle prefrontal cortex (MPFC) and the right lateral parietal cortex (LPR) among these individuals. We observed the trend of alleviation of these disruptions after the individual has become seizure free from the surgical resection of the CCM. Using a voxel-based approach, we found the disruption of the HFC and GFC in the brain tissue immediately adjacent to the CCM and the severity of the disruption appeared inversely proportional to the distance of the brain tissue to the lesion. Our findings confirm the disruption of normal brain networks from focal epilepsy, a process that may be reversible with successful surgical treatments rendering patients seizure free. Some voxel-based metrics may help identify the epileptogenic zone and guide the surgical resection.

15.
Neurosurg Focus ; 47(2): E18, 2019 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-31370021

RESUMO

Central nervous system infections in immunosuppressed patients are rare but potentially lethal complications that require swift diagnoses and intervention. While the differential diagnosis for new lesions on neuroradiological imaging of immunosuppressed patients typically includes infections and neoplasms, image-based heuristics to differentiate the two has been shown to have variable reliability.The authors describe 2 rare CNS infections in immunocompromised patients with atypical physical and radiological presentations. In the first case, a 59-year-old man, who had recently undergone a renal transplantation, was found to have multifocal Nocardia amikacinitolerans abscesses masquerading as neoplasms on diffusion-weighted imaging (DWI); in the second case, a 33-year-old man with suspected recurrent Hodgkin's lymphoma was found to have a nonpyogenic abscess with cytomegalovirus (CMV) encephalitis.As per review of the literature, this appears to be the first case of brain abscess caused by N. amikacinitolerans, a recently isolated superbug. Despite confirmation through brain biopsy later on in case 1, the initial radiological appearance was atypical, showing subtle diffusion restriction on DWI. Similarly, the authors present a case of CMV encephalitis that presented as a ring-enhancing lesion, which is extremely rare. Both cases draw attention to the reliability of neuroimaging in differentiating an abscess from a neoplasm.

16.
Neurosurg Rev ; 2019 Aug 05.
Artigo em Inglês | MEDLINE | ID: mdl-31385110

RESUMO

The management of posterior cranial fossa meningioma [PCFM] is challenging and many neurosurgeons advise gamma knife radiosurgery [GKRS] as a modality for its upfront or adjuvant treatment. Due to the varying radiosurgical response based on lesion location, tumor biology, and radiation dosage, we performed a pioneer attempt in doing a systematic review analyzing the treatment efficacy and safety profile of GKRS for PCFM based on current literature. A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA] guidelines. A thorough literature search was conducted on PubMed, Web of science, and Cochrane data base; articles were selected systematically based on PRISMA protocol, reviewed completely, and relevant data was summarized and discussed. A total of 18 publications pertaining to GKRS for PCFM were included with a pooled sample size of 2131 patients. The median pre-GKRS tumor volume ranged from 2.28 to 10.5 cm [3]. Primary GKRS was administered in 61.1% of the pooled study cohorts, adjuvant treatment in 32.9%, and salvage therapy in 6.5% patients. Majority of the meningiomas were WHO grade 1 tumors (99.7%). The pooled mean marginal dose in the studies was 13.6 Gy (range 12-15.2 Gy) while the mean of maximum doses was 28.6 Gy (range 25-35 Gy). Most studies report an excellent radiosurgical outcome including the tumor control rate and the progression-free survival [PFS] of over 90%. The tumor control, PFS, and adverse radiation effect [ARE] rates in author's series were 92.3%, 91%, and 9.6%, respectively. The favorable radiosurgical outcome depends on multiple factors such as small tumor volume, absence of previous radiotherapy, tumor location, elderly patients, female gender, longer time from symptom onset, and decreasing maximal dose. GKRS as primary or adjuvant treatment modality needs to be considered as a promising management strategy for PCFM in selected patients in view of the growing evidence of high tumor control rate, improved neurological functions, and low incidence of ARE. The use of multiple isocenters, 3-D image planning, and limit GKRS treatment to tumors less than 3.5 cm help to avoid complications and achieve the best results. The treatment decisions in PCFM cases must be tailored and should consider the factors such as radiological profile, symptom severity, performance level, and patient preference for a good outcome.

17.
World Neurosurg ; 130: 192-200, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31295601

RESUMO

BACKGROUND: The need for neurosurgical care across the globe remains a public health issue. The creation of sustainable neurological surgery departments and training programs will be indispensable in alleviating the burden of neurological disease in low to middle income countries (LMICs). METHODS: We reviewed the history of the neurological surgery department and residency program of Santarém in the state of Pará, Brazil, from 1999 to the present. We have described the epidemiology unique to the region and provided evidence of a sustainable practice in a LMIC. The challenges, limitations, and resources were explored. RESULTS: We have provided a historical vignette of the evolution of neurological surgery in the Brazilian Amazon, including the creation of a sustainable neurological surgery practice and accredited residency program. In addition, we assessed the neurological surgery burden and epidemiology unique to the region, with an emphasis on the community and indigenous health in this remote area. We also explored the future directions of this example, which could affect the international neurological surgery community. CONCLUSION: A sustainable neurosurgery practice and training program is possible in a LMIC. Training neurosurgeons in developing regions of LMICs is a sustainable method to decrease the morbidity and mortality of neurological diseases and prevent the misdistribution of physicians in a country. We encourage adaptation of sustainable neurological surgery practices in similar regions across the world to increase access to necessary neurosurgical care.


Assuntos
Internato e Residência , Neurocirurgiões , Neurocirurgia , Procedimentos Neurocirúrgicos/educação , Brasil , Países em Desenvolvimento , Saúde Global/educação , Humanos , Internato e Residência/estatística & dados numéricos , Neurocirurgiões/estatística & dados numéricos , Saúde Pública
18.
World Neurosurg ; 127: e179-e185, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30878750

RESUMO

BACKGROUND: In the management of meningiomas invading the major venous sinuses, balance between tumor control and complication prevention is desirable. The aim of this study was to describe an institutional experience in management of meningiomas involving major venous sinuses. METHODS: A retrospective study was carried out over 18 years, between 1999 and 2017, in patients with meningiomas involving major venous sinuses. Clinical features, operative strategy, histology, postoperative complications, adjuvant therapy, and long-term follow-up were studied. RESULTS: The study included 84 patients. Neurologic deficits were seen in 26 (31%) patients at presentation. The recurrence rates in Simpson grade I, II, and III excision were 7.6%, 25%, and 29.4% at a mean follow-up of 45.4 months (range, 1-192 months). No intervention of the involved sinus was done in 64 (76%) cases, venotomy was done in 3 (3.5%) cases, sinus resection without graft was done in 14 (16.6%) cases, and sinus reconstruction with patch was done in 3 (3.5%) cases. There were 53 (67.0%) patients with World Health Organization grade I histology and 25 (31.6%) patients with World Health Organization grade II histology. Fifteen recurrences were treated with Gamma Knife radiosurgery. In univariate analysis using Cox proportional hazards model, World Health Organization grade (P = 0.036, hazard ratio 2.90, 95% confidence interval = 1.07-7.87) and Simpson grade (P = 0.017, hazard ratio 2.90, 95% confidence interval = 1.18-5.29) were found to be significant factors to predict tumor recurrence. CONCLUSIONS: Management of meningiomas involving major venous sinus with microsurgical techniques and adjuvant Gamma Knife radiosurgery achieves a good tumor control rate with an acceptable complication rate.


Assuntos
Cavidades Cranianas/cirurgia , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Idoso , Idoso de 80 Anos ou mais , Transplante Ósseo , Terapia Combinada , Cavidades Cranianas/patologia , Gerenciamento Clínico , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Masculino , Neoplasias Meníngeas/radioterapia , Meningioma/radioterapia , Microcirurgia , Pessoa de Meia-Idade , Invasividade Neoplásica , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/cirurgia , Complicações Pós-Operatórias , Intervalo Livre de Progressão , Modelos de Riscos Proporcionais , Radiocirurgia , Radioterapia Adjuvante , Procedimentos Cirúrgicos Reconstrutivos , Reoperação , Estudos Retrospectivos
20.
J Neurosurg Spine ; : 1-6, 2019 Feb 22.
Artigo em Inglês | MEDLINE | ID: mdl-30797203

RESUMO

In 1961, President John F. Kennedy declared that the United States would send a man to the moon and safely bring him home before the end of the decade. Astronaut Michael Collins was one of those men. He flew to the moon on the historic flight of Apollo 11 while Neil Armstrong and Buzz Aldrin walked on its surface. However, this was not supposed to be the case.Astronaut Collins was scheduled to fly on Apollo 8. While training, in 1968, he started developing symptoms of cervical myelopathy. He underwent evaluation at Wilford Hall Air Force Hospital in San Antonio and was noted to have a C5-6 disc herniation and posterior osteophyte on myelography. Air Force Lieutenant General (Dr.) Paul W. Myers performed an anterior cervical discectomy with placement of iliac bone graft. As a result, Astronaut James Lovell took his place on Apollo 8 flying the uncertain and daring first mission to the moon. This had a cascading effect on the rotation of astronauts, placing Michael Collins on the Apollo 11 flight that first landed men on the moon. It also placed Astronaut James Lovell in a rotation that exposed him to be the Commander of the fateful Apollo 13 flight.Here, the authors chronicle the history of Astronaut Collins' anterior cervical surgery and the impact of his procedure on the rotation of astronaut flight selection, and they review the pivotal historic nature of the Apollo 8 spaceflight. The authors further discuss the ongoing issue of cervical disc herniation among astronauts.

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