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2.
Acta Neurochir (Wien) ; 161(11): 2233-2240, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31489530

RESUMO

BACKGROUND: Management of asymptomatic meningiomas represents a challenge due to the absence of a solid consensus on which is the best management strategy. There are various known factors predicting meningiomas growth risk. However, the Asian Intracranial Meningioma Scoring System (AIMSS) is the only described score to quantify such risk thus emerging as a potential tool for management decisions. This study aims to validate this score on our series of asymptomatic meningiomas. METHOD: We performed a retrospective review of asymptomatic meningiomas diagnosed at our institution between January 2008 and October 2016 and followed by an annual cerebral Magnetic Resonance Imaging (MRI). For each lesion, the AIMSS score was calculated thus classifying them in low (0-2), intermediate (3-6) or high risk (7-11) of rapid growth (>2cm3/year). We investigated the correlation between the expected Average Growth Rate (AGR) according to the score and the one obtained in our study. The mean growth velocity over the different risk groups was also compared. RESULTS: Overall, 69 asymptomatic meningiomas found incidentally in 46 patients were included in the study; 31 were assigned to the low-risk group, 34 to the intermediate-risk group and 4 to the high-risk group. Attending to the AGR, 0% showed rapid growth in the low-risk group, 12% in the intermediate-risk group, and 25% in the high-risk group. The mean growth velocity showed a significant difference over the different risk groups (p < 0,001). CONCLUSIONS: According to our finding, the AIMSS score is a valid tool to estimate the risk of rapid growth of asymptomatic meningiomas. It is especially useful distinguishing between low- and intermediate-risk meningiomas. This feature would allow physicians to adjust the periodicity of radiological and clinical controls. Adding more known risk factors of rapid growth to the score might improve its predictive capabilities with the high-risk group.

3.
J Neurosurg ; : 1-12, 2019 04 05.
Artigo em Inglês | MEDLINE | ID: mdl-30952121

RESUMO

Objective: Anterior communicating artery (ACoA) aneurysms are common intracranial aneurysms. Despite advances in endovascular therapy, microsurgical clipping remains an important treatment for aneurysms with broad necks, large size, intraluminal thrombus, complex branches, or previous coiling. Anatomical triangles identify safe corridors for aneurysm access. The authors introduce the A1-A2 junctional triangle and the A1-A1 precommunicating triangle and examine relationships between dome projection, triangular corridors of access, and surgical outcomes. Methods: Preoperative catheter and CT angiograms were evaluated to characterize aneurysm dome projection. Aneurysm projection was categorized into quadrants and octants. Preoperative, intraoperative, and postoperative factors were correlated to aneurysm dome projection and patient outcomes using univariate and multivariate analyses. Results: A total of 513 patients with microsurgically treated ACoA aneurysms were identified over a 13-year period, and 400 had adequate imaging and follow-up data for inclusion. Surgical clipping was performed on 271 ruptured and 129 unruptured aneurysms. Good outcomes were observed in 91% of patients with unruptured aneurysms and 86% of those with ruptured aneurysms, with a mortality rate < 1% among patients with unruptured aneurysms. Increasing age (p < 0.01), larger aneurysm size (p = 0.03), and worse preoperative modified Rankin Scale score (p < 0.01) affected outcomes adversely. Aneurysms projecting superiorly and posteriorly required dissection in the junctional triangle, and multivariate analysis demonstrated worse clinical outcomes in these patients (p < 0.01). Conclusions: Anteriorly and inferiorly projecting aneurysms involve only the precommunicating triangle, are simpler to treat microsurgically, and have more favorable outcomes. Superior and posterior dome projections make ACoA aneurysms more difficult to visualize and require opening the junctional triangle. Added visualization through the junctional triangle is recommended for these aneurysms in order to facilitate dissection of efferent branch arteries, careful clip application, and perforator preservation. Dome projection can be determined preoperatively from images and can help anticipate dissection routes through the junctional triangle. Abbreviations: ACA = anterior cerebral artery; ACoA = anterior communicating artery; FpA = frontopolar artery; ICG = indocyanine green; mRS = modified Rankin Scale; OfA = orbitofrontal artery; RAH = recurrent artery of Heubner; SAH = subarachnoid hemorrhage.

4.
World Neurosurg ; 127: e1159-e1165, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30995551

RESUMO

OBJECTIVE: To describe the technique and initial experience of using a rotational 3-dimensional (3D) fluoroscopy system (O-arm; Medtronic) as intraoperative angiography (IA) in the surgery of cerebral aneurysms. METHODS: The 3D IA with O-arm (IAWOA) was performed in a consecutive cohort of patients with unruptured intracranial aneurysms. Conventional microsurgical clipping was performed with the assistance of indocyanine green videoangiography. Then the O-arm chassis was brought in, the ipsilateral internal carotid artery was catheterized, and contrasted images were acquired. Resulting datasets were exported in Digital Imaging and Communications in Medicine and processed using the Osirix software in an accessory computer. The 3D image reconstruction was evaluated intraoperatively to confirm aneurysm occlusion and parent vessel patency. Afterward, agreement among IAWOA, indocyanine green videoangiography, and standard postoperative angiography was analyzed. RESULTS: The initial pilot study was performed in 6 patients with 7 unruptured aneurysms. The aneurysm occlusion rate was 100%. The concordance of the IAWOA and the standard postoperative angiography was complete, both in terms of occlusion and parent vessel patency. No complications derived from the IAWOA were observed except in 1 patient, who presented a retroperitoneal hematoma without clinical consequences. CONCLUSIONS: The 3D rotational fluoroscopy (O-arm) device could be safely and effectively used as an IA system in selected patients. To the best of our knowledge, this is the first study reporting its use as an IA device. This technique seems to offer excellent image quality that could be compared with that of the gold standard 3D digital subtraction angiography but with a lower cost and versatility of use for other subspecialties.


Assuntos
Angiografia Cerebral/métodos , Imagem Tridimensional/métodos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Monitorização Intraoperatória/métodos , Cirurgia Assistida por Computador/métodos , Idoso , Estudos de Viabilidade , Feminino , Fluoroscopia/métodos , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto
5.
Neurocirugía (Soc. Luso-Esp. Neurocir.) ; 30(2): 87-93, mar.-abr. 2019. ilus, tab
Artigo em Inglês | IBECS | ID: ibc-182007

RESUMO

Microsurgical clipping is still regarded as the gold-standard treatment for broad-neck intracranial aneurysms. New endovascular techniques like balloon or stent assisted coiling are quickly rising to the challenge and showing promising outcomes. As a result, broad-neck aneurysms are increasingly addressed by these techniques despite they have not been tested against clipping in a randomized controlled trial and long-term complications might be unknown yet. Intraprocedural coil migration has been well documented in the literature, but the same complication in a delayed fashion is scarcely reported. We present a case of delayed coil migration occurring after a balloon-assisted embolization of a wide-necked intracranial aneurysm and we perform a literature review for similar cases. We discuss how, despite seeming an extremely rare complication, with new endovascular techniques increasingly perceived as the safer option in any aneurysm, potential adverse events may become more frequent. Strategies proposed to address this developing scenario are also reviewed


El clipaje microquirúrgico todavía se considera el tratamiento de elección para los aneurismas intracraneales de cuello ancho. Técnicas de embolización asistida por balón o stent se han desarrollado para estas lesiones y muestran resultados prometedores. Como consecuencia, los aneurismas de cuello ancho se abordan cada vez más mediante estas técnicas, a pesar de que no existen ensayos controlados aleatorizados al respecto, y las complicaciones a largo plazo podrían ser desconocidas. La migración intraprocedimiento de un coil está bien documentada, pero la misma complicación de forma tardía apenas está descrita. Presentamos un caso de migración tardía de un coil tras embolización asistida con balón de un aneurisma intracraneal de cuello ancho y revisamos la literatura para casos similares. Argumentamos que, a pesar de parecer una complicación extremadamente rara, con la creciente percepción de que las nuevas técnicas endovasculares son la opción más segura en cualquier aneurisma, los potenciales eventos adversos pueden aumentar. También revisamos las estrategias propuestas para abordar este nuevo escenario


Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Embolização Terapêutica/efeitos adversos , Aneurisma Intracraniano/diagnóstico por imagem , Oclusão com Balão/efeitos adversos , Migração de Corpo Estranho/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Stents , Migração de Corpo Estranho/etiologia , Migração de Corpo Estranho/cirurgia
6.
Neurocirugia (Astur) ; 30(2): 87-93, 2019.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-29625853

RESUMO

Microsurgical clipping is still regarded as the gold-standard treatment for broad-neck intracranial aneurysms. New endovascular techniques like balloon or stent assisted coiling are quickly rising to the challenge and showing promising outcomes. As a result, broad-neck aneurysms are increasingly addressed by these techniques despite they have not been tested against clipping in a randomized controlled trial and long-term complications might be unknown yet. Intraprocedural coil migration has been well documented in the literature, but the same complication in a delayed fashion is scarcely reported. We present a case of delayed coil migration occurring after a balloon-assisted embolization of a wide-necked intracranial aneurysm and we perform a literature review for similar cases. We discuss how, despite seeming an extremely rare complication, with new endovascular techniques increasingly perceived as the safer option in any aneurysm, potential adverse events may become more frequent. Strategies proposed to address this developing scenario are also reviewed.


Assuntos
Artérias Cerebrais/diagnóstico por imagem , Embolização Terapêutica/efeitos adversos , Embolização Terapêutica/instrumentação , Migração de Corpo Estranho/diagnóstico por imagem , Aneurisma Intracraniano/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
7.
J Neurosurg ; 131(6): 1743-1750, 2018 Dec 21.
Artigo em Inglês | MEDLINE | ID: mdl-30579275

RESUMO

OBJECTIVE: Reliable tools are lacking to predict shunt-dependent hydrocephalus (SDHC) development after aneurysmal subarachnoid hemorrhage (aSAH). Quantitative volumetric measurement of hemorrhagic blood is a good predictor of SDHC but might be impractical in the clinical setting. Qualitative assessment performed using scales such as the modified Fisher scale (mFisher) and the original Graeb scale (oGraeb) is easier to conduct but provides limited predictive power. In between, the modified Graeb scale (mGraeb) keeps the simplicity of the qualitative scales yet adds assessment of acute hydrocephalus, which might improve SDHC-predicting capabilities. In this study the authors investigated the likely capabilities of the mGraeb and compared them with previously validated methods. This research also aimed to define a tailored mGraeb cutoff point for SDHC prediction. METHODS: The authors performed retrospective analysis of patients admitted to their institution with the diagnosis of aSAH between May 2013 and April 2016. Out of 168 patients, 78 were included for analysis after the application of predefined exclusion criteria. Univariate and multivariate analyses were conducted to evaluate the use of all 4 methods (quantitative volumetric assessment and the mFisher, oGraeb, and mGraeb scales) to predict the likelihood of SDHC development based on clinical data and blood amount assessment on initial CT scans. RESULTS: The mGraeb scale was demonstrated to be the most robust predictor of SDHC, with an area under the curve (AUC) of 0.848 (95% CI 0.763-0.933). According to the AUC results, the performance of the mGraeb scale was significantly better than that of the oGraeb scale (χ2 = 4.49; p = 0.034) and mFisher scale (χ2 = 7.21; p = 0.007). No statistical difference was found between the AUCs of the mGraeb and the quantitative volumetric measurement models (χ2 = 12.76; p = 0.23), but mGraeb proved to be the simplest model since it showed the lowest Akaike information criterion (66.4), the lowest Bayesian information criterion (71.2), and the highest R2Nagelkerke coefficient (39.7%). The initial mGraeb showed more than 85% specificity for predicting the development of SDHC in patients presenting with a score of 12 or more points. CONCLUSIONS: According to the authors' data, the mGraeb scale is the simplest model that correlates well with SDHC development. Due to limited scientific evidence of treatments aimed at SDHC prevention, we propose an mGraeb score higher than 12 to identify patients at risk with high specificity. This mGraeb cutoff point might also serve as a useful prognostic tool since patients with SDHC after aSAH have worse functional outcomes.


Assuntos
Derivações do Líquido Cefalorraquidiano/métodos , Hidrocefalia/diagnóstico por imagem , Hidrocefalia/cirurgia , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/cirurgia , Tomografia Computadorizada por Raios X/métodos , Adulto , Idoso , Determinação do Volume Sanguíneo/métodos , Feminino , Humanos , Hidrocefalia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Hemorragia Subaracnóidea/fisiopatologia
8.
Neurocirugía (Soc. Luso-Esp. Neurocir.) ; 29(4): 170-186, jul.-ago. 2018. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-180308

RESUMO

Introducción: Las técnicas de revascularización cerebral constituyen una herramienta indispensable en el arsenal actual del neurocirujano vascular. Presentamos la experiencia adquirida y los resultados de la cirugía de revascularización tanto en la enfermedad de moyamoya como en la isquemia cerebral oclusiva. Pacientes y métodos: Se analizan los pacientes con enfermedad isquémica oclusiva y enfermedad de moyamoya revascularizados microquirúrgicamente en el periodo comprendido entre octubre de 2014 y septiembre de 2017. Resultados: En el periodo de estudio, 23 pacientes con enfermedad isquémica oclusiva han sido revascularizados microquirúrgicamente. Tres pacientes presentaron complicaciones postoperatorias graves (2 hemorragias intraparenquimatosas en el postoperatorio inmediato y una trombosis de la arteria femoral). En todos los pacientes, excepto en uno, el SPECT muestra una normalización de la reserva hemodinámica cerebral (RHC). Veinte pacientes presentaron un buen resultado neurológico, sin recurrencias isquémicas del territorio revascularizado. De la serie de pacientes con moyamoya, 20 presentaban una enfermedad de moyamoya y 5 un síndrome de moyamoya con afectación unilateral. Cinco pacientes fueron tratados en edad pediátrica. Hubo un comienzo hemorrágico en 2 pacientes. El estudio de la RHC mostró un compromiso hemodinámico en todos los pacientes. El SPECT cerebral al año ha mostrado una resolución del fracaso hemodinámico en todos los pacientes. Ha habido 4 complicaciones postoperatorias (hematoma subdural agudo, 2 colecciones subdurales y una dehiscencia de la herida quirúrgica). Ningún paciente ha presentado un empeoramiento neurológico en los controles a los 6 y 12meses. Conclusión: La revascularización cerebral mediante la realización de una anastomosis termino-lateral entre la arteria temporal superficial y una rama cortical de la arteria cerebral media constituye una técnica indiscutible en el tratamiento de la enfermedad de moyamoya y posiblemente pueda serlo en un subgrupo de pacientes con patología oclusiva isquémica cerebral sintomática


Introduction: Cerebral revascularization techniques are an indispensable tool in the current armamentarium of vascular neurosurgeons. We present revascularization surgery experience and results in both moyamoya disease and occlusive cerebral ischaemia. Patients and methods: Patients with ischaemic occlusive disease and moyamoya disease who underwent microsurgical revascularization between October 2014 and September 2017 were analysed. Results: In the study period, 23 patients with occlusive ischaemic disease underwent microsurgical revascularization. Three patients presented with serious postoperative complications (2 intraparenchymal haemorrhages in the immediate postoperative period and one thrombosis of the femoral artery). All patients, except one, achieved normalization of the cerebral hemodynamic reserve (CHR) in the SPECT study. Twenty patients had a good neurological result, with no ischaemic recurrence of the revascularized territory. Among patients with moyamoya, 20 had moyamoya disease and 5 had moyamoya syndrome with unilateral involvement. Five patients were treated at paediatric age. Haemorrhagic onset occurred in 2 patients. The CHR study showed hemodynamic compromise in all patients. Cerebral SPECT at one year showed resolution of the hemodynamic failure in all patients. There have been 4 postoperative complications (acute subdural hematoma, two subdural collections and one dehiscence of the surgical wound). No patient presented with neurological worsening at 6 and 12months of follow-up. Conclusions: Cerebral revascularization through end-to-side anastomosis between the superficial temporal artery and a cortical branch of the middle cerebral artery is an indisputable technique in the treatment of moyamoya disease and possibly in a subgroup of patients with symptomatic occlusive ischaemic cerebrovascular disease


Assuntos
Humanos , Masculino , Feminino , Idoso , Arteriopatias Oclusivas/cirurgia , Isquemia Encefálica/cirurgia , Artérias Carótidas , Revascularização Cerebral , Doença de Moyamoya/cirurgia , Resultado do Tratamento , Arteriopatias Oclusivas/complicações , Isquemia Encefálica/complicações , Doença de Moyamoya/complicações
9.
Front Plant Sci ; 9: 625, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29868081

RESUMO

In eukaryotes, the formation of a 5'-cap and 3'-poly(A) dependent protein-protein bridge is required for translation of its mRNAs. In contrast, several plant virus RNA genomes lack both of these mRNA features, but instead have a 3'-CITE (for cap-independent translation enhancer), a RNA element present in their 3'-untranslated region that recruits translation initiation factors and is able to control its cap-independent translation. For several 3'-CITEs, direct RNA-RNA long-distance interactions based on sequence complementarity between the 5'- and 3'-ends are required for efficient translation, as they bring the translation initiation factors bound to the 3'-CITE to the 5'-end. For the carmovirus melon necrotic spot virus (MNSV), a 3'-CITE has been identified, and the presence of its 5'-end in cis has been shown to be required for its activity. Here, we analyze the secondary structure of the 5'-end of the MNSV RNA genome and identify two highly conserved nucleotide sequence stretches that are complementary to the apical loop of its 3'-CITE. In in vivo cap-independent translation assays with mutant constructs, by disrupting and restoring sequence complementarity, we show that the interaction between the 3'-CITE and at least one complementary sequence in the 5'-end is essential for virus RNA translation, although efficient virus translation and multiplication requires both connections. The complementary sequence stretches are invariant in all MNSV isolates, suggesting that the dual 5'-3' RNA:RNA interactions are required for optimal MNSV cap-independent translation and multiplication.

10.
Neurocirugia (Astur) ; 29(4): 170-186, 2018.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-29550248

RESUMO

INTRODUCTION: Cerebral revascularization techniques are an indispensable tool in the current armamentarium of vascular neurosurgeons. We present revascularization surgery experience and results in both moyamoya disease and occlusive cerebral ischaemia. PATIENTS AND METHODS: Patients with ischaemic occlusive disease and moyamoya disease who underwent microsurgical revascularization between October 2014 and September 2017 were analysed. RESULTS: In the study period, 23 patients with occlusive ischaemic disease underwent microsurgical revascularization. Three patients presented with serious postoperative complications (2 intraparenchymal haemorrhages in the immediate postoperative period and one thrombosis of the femoral artery). All patients, except one, achieved normalization of the cerebral hemodynamic reserve (CHR) in the SPECT study. Twenty patients had a good neurological result, with no ischaemic recurrence of the revascularized territory. Among patients with moyamoya, 20 had moyamoya disease and 5 had moyamoya syndrome with unilateral involvement. Five patients were treated at paediatric age. Haemorrhagic onset occurred in 2 patients. The CHR study showed hemodynamic compromise in all patients. Cerebral SPECT at one year showed resolution of the hemodynamic failure in all patients. There have been 4 postoperative complications (acute subdural hematoma, two subdural collections and one dehiscence of the surgical wound). No patient presented with neurological worsening at 6 and 12months of follow-up. CONCLUSIONS: Cerebral revascularization through end-to-side anastomosis between the superficial temporal artery and a cortical branch of the middle cerebral artery is an indisputable technique in the treatment of moyamoya disease and possibly in a subgroup of patients with symptomatic occlusive ischaemic cerebrovascular disease.


Assuntos
Arteriopatias Oclusivas/cirurgia , Isquemia Encefálica/cirurgia , Artérias Carótidas , Revascularização Cerebral , Doença de Moyamoya/cirurgia , Idoso , Arteriopatias Oclusivas/complicações , Isquemia Encefálica/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença de Moyamoya/complicações , Resultado do Tratamento
11.
J Nanobiotechnology ; 16(1): 17, 2018 Feb 20.
Artigo em Inglês | MEDLINE | ID: mdl-29463260

RESUMO

BACKGROUND: Tamoxifen is the standard endocrine therapy for breast cancers, which require metabolic activation by cytochrome P450 enzymes (CYP). However, the lower and variable concentrations of CYP activity at the tumor remain major bottlenecks for the efficient treatment, causing severe side-effects. Combination nanotherapy has gained much recent attention for cancer treatment as it reduces the drug-associated toxicity without affecting the therapeutic response. RESULTS: Here we show the modular design of P22 bacteriophage virus-like particles for nanoscale integration of virus-driven enzyme prodrug therapy and photodynamic therapy. These virus capsids carrying CYP activity at the core are decorated with photosensitizer and targeting moiety at the surface for effective combinatory treatment. The estradiol-functionalized nanoparticles are recognized and internalized into ER+ breast tumor cells increasing the intracellular CYP activity and showing the ability to produce reactive oxygen species (ROS) upon UV365 nm irradiation. The generated ROS in synergy with enzymatic activity drastically enhanced the tamoxifen sensitivity in vitro, strongly inhibiting tumor cells. CONCLUSIONS: This work clearly demonstrated that the targeted combinatory treatment using multifunctional biocatalytic P22 represents the effective nanotherapeutics for ER+ breast cancer.


Assuntos
Antineoplásicos Hormonais/administração & dosagem , Bacteriófago P22/enzimologia , Neoplasias da Mama/tratamento farmacológico , Sistema Enzimático do Citocromo P-450/administração & dosagem , Fármacos Fotossensibilizantes/administração & dosagem , Tamoxifeno/administração & dosagem , Antineoplásicos Hormonais/farmacologia , Bacteriófago P22/química , Biocatálise , Neoplasias da Mama/metabolismo , Sobrevivência Celular/efeitos dos fármacos , Sistema Enzimático do Citocromo P-450/farmacologia , Portadores de Fármacos/química , Sistemas de Liberação de Medicamentos , Terapia Enzimática , Feminino , Humanos , Células MCF-7 , Modelos Moleculares , Fotoquimioterapia , Fármacos Fotossensibilizantes/farmacologia , Espécies Reativas de Oxigênio/metabolismo , Receptores Estrogênicos/metabolismo , Tamoxifeno/farmacologia
12.
World Neurosurg ; 113: e465-e470, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29462735

RESUMO

OBJECTIVE: Acquired anomalies of the dural venous sinuses (DVS) have been correlated extensively with the development of dural arteriovenous fistulas (DAVFs). Despite the known similarities of DAVFs' pathogenesis with that of arteriovenous malformations (AVMs), the relationship of venous sinuses anomalies with AVMs scarcely has been studied. We aimed to investigate whether patients with AVM show a greater prevalence of congenital DVS anomalies. We hypothesized that these congenital anomalies trigger AVM development during early childhood just as acquired DVS anomalies trigger DAVFs formation during adulthood. METHODS: Angiographic anomalies of the brain venous sinuses were studied in a cohort of 45 consecutive patients with AVM and compared with the angiographic; venous sinus anomalies of a control group formed by a second consecutive; series of 45 patients with subarachnoid hemorrhage. RESULTS: Congenital anomalies of any DVS were more frequent in patients with AVM than in the control group (49.8% vs. 22.2%; P = 0.015). Congenital abnormalities of the superior sagittal sinus not only were more frequent in patients with AVM (27% vs. 6.7%; P = 0.021) but seemed also related to the AVM location: in 5 of the 6 AVM cases with unilateral superior sagittal sinus aplasia, the AVM was ipsilateral to the venous anomaly. CONCLUSIONS: Patients with AVM have a greater likelihood of congenital anomalies of any DVS. These anomalies seem to be related also to the AVM location. These findings suggest that congenital anomalies of DVS may be related to the development of AVMs.


Assuntos
Cavidades Cranianas/anormalidades , Malformações Arteriovenosas Intracranianas/patologia , Adulto , Angiografia Digital , Causalidade , Angiografia Cerebral , Cavidades Cranianas/diagnóstico por imagem , Progressão da Doença , Feminino , Humanos , Achados Incidentais , Malformações Arteriovenosas Intracranianas/complicações , Malformações Arteriovenosas Intracranianas/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Modelos Biológicos , Prevalência , Hemorragia Subaracnóidea/etiologia
14.
Rev. neurol. (Ed. impr.) ; 64(12): 538-542, 16 jun., 2017. ilus
Artigo em Espanhol | IBECS | ID: ibc-164006

RESUMO

Objetivo. Conocer las causas de la mortalidad en la hemorragia cerebral de los pacientes con malformaciones arteriovenosas (MAV) tratadas en un hospital terciario. Pacientes y métodos. De un registro prospectivo de malformaciones vasculares se han seleccionado los pacientes que fallecieron con MAV en el período 1990-2014. Se han revisado aspectos demográficos, localización de la MAV, aneurismas asociados y tratamientos previos. Se han establecido tres causas principales de muerte: sangrado inicial/resangrado, relacionadas con el tratamiento de la MAV y otras causas no relacionadas con la MAV. Resultados. Se trató a 400 pacientes de MAV, 216 (54%) con MAV rotas, de los que fallecieron 26 (12,1%) por hemorragia cerebral. La media de edad del grupo de pacientes fallecidos fue de 48,8 años (rango: 8-78 años). Veinte (76,9%) ingresaron en coma (escala de coma de Glasgow < 9). En cinco casos (19,2%), el sangrado se debió a un aneurisma asociado. Un porcentaje muy elevado (38,5%) tenía la MAV en la fosa posterior. Tres pacientes habían recibido previamente en otros centros tratamientos no curativos de la MAV. Del total, seis (23,1%) recibieron tratamiento endovascular/quirúrgico en nuestro hospital, y hemos asumido que, por la indicación o por el momento en que se realizó, la causa de la muerte se relacionaba con el tratamiento, aunque dos pacientes jóvenes se operaron con midriasis bilateral. Un paciente falleció por un glioblastoma asociado, y el resto, 19 (76%), por el resangrado o el daño cerebral inicial. Conclusión. El conocimiento de las causas de mortalidad puede contribuir a mejorar el resultado clínico, sobre todo en los casos en que podría estar indicado un tratamiento precoz (AU)


Aim: To determine the causes of mortality in cases of brain haemorrhage among patients with arteriovenous malformations (AVM) treated in a tertiary hospital. Patients and Methds: The patients with AVM who died over the period 1990-2014 were selected from a prospective register of vascular malformations. Demographic aspects, localisation of the AVM, associated aneurysms and previous treatments were reviewed. Three main causes of death were established: initial bleeding/rebleeding, those related with the treatment of the AVM and other causes not related with AVM. Results: A total of 400 patients were treated for AVM, 216 (54%) with a ruptured AVM, of whom 26 (12.1%) died as a result of a brain haemorrhage. The mean age of the group of patients who died was 48.8 years (range: 8-78 years). Twenty (76.9%) were admitted in coma (Glasgow Coma Scale < 9). In five cases (19.2%), bleeding was due to an associated aneurysm. A very high percentage (38.5%) had the AVM in the posterior fossa. Three patients had previously received non-curative treatments for the AVM in other medical centres. Of the total number, six (23.1%) received endovascular/surgical treatment in our hospital, and we have assumed that, due to the indication or owing to the time in which it was carried out, the cause of death was treatment-related, although two young patients underwent surgery with bilateral mydriasis. One patient died due to an associated glioblastoma, and the others, 19 (76%), due to rebleeding or to the initial brain damage. CONCLUSION. Knowing the causes of mortality can help improve the clinical outcome, above all in cases in which an early treatment could be indicated (AU)


Assuntos
Humanos , Malformações Arteriovenosas Intracranianas/epidemiologia , Hemorragia Cerebral/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Aneurisma Roto/epidemiologia , Malformações Arteriovenosas Intracranianas/complicações , Hemorragia Cerebral/etiologia , Mortalidade Hospitalar , Estudos Prospectivos , Procedimentos Endovasculares
15.
Neurosurgery ; 80(6): 908-916, 2017 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-28327921

RESUMO

BACKGROUND: Superior cerebellar artery (SCA) aneurysms are usually grouped with aneurysms that arise from the upper basilar artery or more broadly, the posterior circulation. However, the SCA aneurysm has distinctive anatomy that facilitates safe surgical management, notably few associated perforating arteries, and excellent exposure in the carotid-oculomotor triangle. OBJECTIVE: To demonstrate the outcomes of patients treated with microsurgery in a continuous surgical series. METHODS: Sixty-two patients harboring 63 SCA aneurysms were retrospectively reviewed from a prospectively maintained database, focusing on clinical characteristics, surgical techniques, and clinical outcomes. RESULTS: Of 31 patients (49%) presenting with subarachnoid hemorrhage, the SCA aneurysm was the source in 16 (25%). Thirty-three aneurysms were complex (52%) and 43 patients (59%) had multiple aneurysms. Fifty-seven SCA aneurysms (90.5%) were clipped and 5 were bypassed/trapped or wrapped. Complete angiographic occlusion was achieved in 91.7%. Permanent neurological morbidity occurred in 3 patients and 3 patients that presented in coma after subarachnoid hemorrhage died. All patients with "simple" aneurysms and without subarachnoid hemorrhage had improved or unchanged modified Rankin scale scores. Overall, outcomes were stable or improved in 82.5% of patients. CONCLUSION: SCA aneurysms are favorable for microsurgical clipping with low rates of permanent morbidity and mortality. Microsurgery should be considered alongside endovascular techniques as a treatment option in many patients.


Assuntos
Aneurisma Intracraniano/patologia , Aneurisma Intracraniano/cirurgia , Procedimentos Neurocirúrgicos/métodos , Adulto , Idoso , Artéria Basilar/cirurgia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Feminino , Humanos , Aneurisma Intracraniano/complicações , Masculino , Microcirurgia/métodos , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/efeitos adversos , Procedimentos Neurocirúrgicos/instrumentação , Estudos Retrospectivos , Hemorragia Subaracnóidea/etiologia , Hemorragia Subaracnóidea/cirurgia , Instrumentos Cirúrgicos , Resultado do Tratamento
16.
World Neurosurg ; 98: 867.e5-867.e7, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27923760

RESUMO

This report portrays our pitfall in the initial diagnosis of an intracranial arterial dissection that we misinterpreted as a saccular aneurysm. Intracranial arterial dissections presenting with convexity subarachnoid hemorrhage are rare, thus being easily mistaken with mild traumatic head injuries and therefore preventing transfer to a tertiary hospital. Even in those cases where the dissection is suspected and the patient is transferred to the appropriate facility for a diagnostic angiogram, misdiagnosis is not infrequent. The typical radiographic signs such as the double lumen or "pearl and string" are scarcely present in the diagnostic angiogram. Thrombus within the dissected segment can be mistaken by vasospasm and may even reveal fake images of saccular aneurysms, thus prompting inadequate endovascular or surgical treatment. The case reported here illustrates all these likely pitfalls in the diagnosis and management of intracranial arterial dissections.


Assuntos
Aneurisma Dissecante/patologia , Aneurisma Intracraniano/patologia , Adulto , Aneurisma Dissecante/diagnóstico por imagem , Doenças Arteriais Cerebrais/diagnóstico por imagem , Doenças Arteriais Cerebrais/patologia , Diagnóstico Diferencial , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Masculino , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/patologia , Tomografia Computadorizada por Raios X
17.
J Neurosurg Sci ; 2016 Jun 07.
Artigo em Inglês | MEDLINE | ID: mdl-27273219

RESUMO

Multiple cerebral arteriovenous malformations (AVMs) are a rare occurrence usually associated with defined genetic disorders or a family history of cerebrovascular disease. The remaining cases cannot be associated to a genetic pathogenesis and are considered idiopathic. We report an extremely unusual case nor genetic neither idiopathic, but linked to an anatomical intracranial venous variation. The patient presented two independent frontal AVMs associated with rostral hypoplasia of the superior sagittal sinus. This anatomical variation may have induced frontal venous hypertension (VHT) triggering the development of the two AVMs. Throughout this intriguing case, we discuss the role of VHT in AVM development.

19.
J Clin Neurosci ; 26: 126-9, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26755452

RESUMO

Acute subdural hematomas (aSDH) secondary to intracranial aneurysm rupture are rare. Most patients present with coma and their functional prognosis has been classically considered to be very poor. Previous studies mixed good-grade and poor-grade patients and reported variable outcomes. We reviewed our experience by focusing on patients in coma only and hypothesized that aSDH might worsen initial mortality but not long-term functional outcome. Between 2005 and 2013, 440 subarachnoid hemorrhage (SAH) patients were admitted to our center. Nineteen (4.3%) were found to have an associated aSDH and 13 (2.9%) of these presented with coma. Their prospectively collected clinical and outcome data were reviewed and compared with that of 104 SAH patients without aSDH who presented with coma during the same period. Median aSDH thickness was 10mm. Four patients presented with an associated aneurysmal cortical laceration and only one had good recovery. Overall, we observed good long-term outcomes in both SAH patients in coma with aSDH and those without aSDH (38.5% versus 26.4%). Associated aSDH does not appear to indicate a poorer long-term functional prognosis in SAH patients presenting with coma. Anisocoria and brain herniation are observed in patients with aSDH thicknesses that are smaller than those observed in trauma patients. Despite a high initial mortality, early surgery to remove the aSDH results in a good outcome in over 60% of survivors. Aneurysmal cortical laceration appears to be an independent entity which shows a poorer prognosis than other types of aneurysmal aSDH.


Assuntos
Aneurisma Roto/diagnóstico , Coma/diagnóstico , Hematoma Subdural Agudo/diagnóstico , Aneurisma Intracraniano/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma Roto/epidemiologia , Aneurisma Roto/cirurgia , Coma/epidemiologia , Coma/cirurgia , Feminino , Seguimentos , Hematoma Subdural Agudo/epidemiologia , Hematoma Subdural Agudo/cirurgia , Humanos , Aneurisma Intracraniano/epidemiologia , Aneurisma Intracraniano/cirurgia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Resultado do Tratamento
20.
Clin Neurol Neurosurg ; 134: 37-43, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25938563

RESUMO

OBJECTIVE: Hydrocephalus associated with different types of intracranial arteriovenous malformations (AVMs) has been scarcely studied. In the present report we investigate this association with posterior fossa AVMs (pfAVMs). We hypothesized that there is an increased risk of hydrocephalus and required permanent cerebrospinal fluid (CSF) shunt in patients with pfAVMs that may be linked to the increased risk of bleeding of these lesions. We also review the factors associated with this increased risk of hemorrhagic presentation and we assess how it affects management strategies and functional outcomes in these patients. METHODS: Out of a prospective registry of 374 patients with brain AVMs diagnosed in our center from 1993 to 2013, 60 (16%) had a pfAVM. We described these patients' demographics, their AVM characteristics, clinical presentation, and hydrocephalus incidence and compared the results with those of the supratentorial AVM (spAVM) patients recorded during the same period. RESULTS: Out of the 60 patients with pfAVMs, 10 (16.7%) presented AVMs located in the brainstem. Hemorrhagic presentation (49/60; 82%) was significantly higher in pfAVMs than in spAVMs (122/314; 38.8%; p<0.05). Hydrocephalus was a common complication in pfAVM patients who had a statistically significant higher need for both temporary external ventricular drain (EVD) (6.7 vs. 20%; p<0.05) and permanent CSF shunts (3.5 vs. 20%; p<0.05). The initial mortality was high (12/60; 20.3%) and half of these patients died before any treatment option could be offered. However, out of those who survived, 70% (42/60) had already shown good clinical outcome at the 6-month follow-up. CONCLUSIONS: Hemorrhagic presentation and hydrocephalus have a higher incidence in pfAVM patients, which initially results in more neurological deficits and an elevated mortality even before receiving any treatment. However, a large number of survivors present good functional outcomes at early follow-up, justifying an aggressive management strategy with microsurgery as the first treatment option in most cases, and radiosurgery as an alternative, especially in brainstem AVMs.


Assuntos
Tronco Encefálico/cirurgia , Cerebelo/cirurgia , Hidrocefalia/etiologia , Malformações Arteriovenosas Intracranianas/cirurgia , Hemorragias Intracranianas/cirurgia , Sistema de Registros , Hemorragia Subaracnóidea/cirurgia , Adolescente , Adulto , Idoso , Tronco Encefálico/diagnóstico por imagem , Cerebelo/diagnóstico por imagem , Derivações do Líquido Cefalorraquidiano , Criança , Pré-Escolar , Embolização Terapêutica , Feminino , Humanos , Lactente , Malformações Arteriovenosas Intracranianas/complicações , Malformações Arteriovenosas Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/etiologia , Masculino , Microcirurgia , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Radiocirurgia , Ruptura Espontânea , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/etiologia , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Adulto Jovem
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