Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 59
Filtrar
1.
Artigo em Inglês | MEDLINE | ID: mdl-33609126

RESUMO

Cavernous malformations that have not previously bled have been reported to have an annual bleeding rate of 0.6% per year.1 Those with prior hemorrhage have been reported to have rebleeding rates of up to 4.5%.1 Additionally, infratentorial location, young age, and female gender have been associated with increased risk.1 We present the case of a 26-yr-old female who initially presented to an outside institution with left-sided weakness. She improved following her initial bleeding event and presented to us for further management. A large, cavernous malformation in the right pons was identified on imaging. The patient underwent a right expanded retrosigmoid craniotomy with splitting of the horizontal cerebellar fissure to completely remove the lesion. The expanded retrosigmoid craniotomy allows for an enhanced view of the medial pontine region and can be utilized for appropriately selected brainstem cavernous malformations. The case presentation, surgical anatomy, operative nuances, and postoperative course and outcome are reviewed. The patient gave verbal consent for participating in the procedure and surgical video. The patient also consented to the publication of her image.

3.
Clin Neurol Neurosurg ; 197: 106199, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32916397

RESUMO

The prediction of outcome after mechanical thrombectomy (MT) of basilar artery occlusion (BAO) remains an area of investigation. The objective of this study was to evaluate the prognostic role of presenting National Institute Health of Stroke Scale (NIHSS) scores in predicting favorable 90-day functional outcome. A survey of 7 electronic databases from inception to May 2020 was conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Multivariate odds ratios (ORs) for favorable 90-day function outcome (modified Rankin Score 0-2) were extracted and pooled by meta-analysis of proportions with random effects modeling. A total of 10 individual studies satisfied criteria for selection and described a total of 941 BAO patients managed by MT. Analysis revealed 590 (63%) males with a mean age of 66.6 years. The median presenting NIHSS was 19, and 316 (34%) patients were reported to have a favorable functional status 90-days after treatment. Lower presenting NIHSS scores independently and significantly predicted favorable 90-day functional outcome in BAO patients with a pooled OR of 0.89 (95% CI, 0.87-0.92; I2 = 18%; P-heterogeneity = 0.28). Meta-regression did not detect any clinical parameter that influenced this trend direction or its significance, and bias assessments were unremarkable. We confirm in this study via a consensus within the literature that the presenting NIHSS score predicts 90-day functional outcome in BAO patients treated by MT. Further, its standardized use allows more meaningful comparisons between interventions and anatomical locations.

4.
Neurocirugía (Soc. Luso-Esp. Neurocir.) ; 31(4): 173-183, jul.-ago. 2020. ilus
Artigo em Inglês | IBECS | ID: ibc-193898

RESUMO

OBJECT: The breadth and complexity of neurovascular pathologies treated with endovascular neurosurgery has expanded dramatically in recent years. Many aneurysms remain difficult to treat safely. Transcirculation (contralateral and/or retrograde) approaches through the circle of Willis are useful alternatives for treating challenging lesions endovascularly. Here, we present a series of patients treated with unconventional transcirculation techniques. METHODS: A total of six patients were treated: four patients with five aneurysms, one patient with an MCA stroke, and one patient with a meningioma requiring preoperative embolization were initially thought not to be amenable to endovascular treatment. The decision was made to treat these patients with transcirculation approaches. All patients were treated by one interventionist. One aneurysm was located in the cavernous internal carotid artery (ICA), one in the vertebral artery, two in the paraclinoid ICA, and one in a cerebellar AVM feeder vessel were treated. RESULTS: Five of six patients (83%) made a full neurologic recovery. Three aneurysms were treated to complete occlusion, one aneurysm was left with small residual neck filling, and one aneurysm was not able to be treated. One patient underwent mechanical thrombectomy of a middle cerebral artery (MCA) embolus and MCA filling was restored after treatment. One patient underwent complete embolization of the deep vascular supply of a meningioma. CONCLUSIONS: Although many neurovascular pathologies remain unsuitable for endovascular treatment, transcirculation approaches can allow for safe, successful treatment of challenging lesions in select patients


OBJETIVO: La variedad y la complejidad de las enfermedades neurovasculares tratadas con neurocirugía endovascular ha aumentado drásticamente en los últimos años. Muchos aneurismas continúan siendo difíciles de tratar de forma segura. Los enfoques de transcirculación (contralateral y/o retrógrada) a través del círculo de Willis son alternativas útiles para el tratamiento endovascular de lesiones difíciles. Presentamos una serie de casos de pacientes tratados con técnicas de transcirculación no convencionales. MÉTODOS: Se trató a un total de 6 pacientes que inicialmente se creía que no eran aptos para el tratamiento endovascular: 4 pacientes con 5 aneurismas, un paciente con un ictus de la arteria cerebral media (ACM) y un paciente con un meningioma que requería embolización preoperatoria. Se tomó la decisión de tratar a estos pacientes con métodos de transcirculación. Todos los pacientes fueron tratados por un solo especialista. Se localizaron y trataron un aneurisma en el segmento cavernoso de la arteria carótida interna (ACI), otro en la arteria vertebral, 2 en el segmento paraclinoideo de la ACI y otro en una malformación arteriovenosa cerebelosa de un vaso nutriente. RESULTADOS: Cinco de los 6 pacientes (83%) alcanzaron una recuperación neurológica completa. Se trataron 3 aneurismas hasta una oclusión completa, un aneurisma se dejó con un pequeño relleno de cuello residual y otro aneurisma no pudo ser tratado. Un paciente fue sometido a una trombectomía mecánica de un émbolo en la ACM y el relleno de la ACM se restauró después del tratamiento. Un paciente se sometió a embolización completa del riego vascular profundo de un meningioma. CONCLUSIONES: Aunque muchas enfermedades neurovasculares siguen sin ser adecuadas para el tratamiento endovascular, los enfoques de transcirculación pueden permitir el tratamiento seguro y exitoso de lesiones difíciles en pacientes seleccionados


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Procedimentos Endovasculares/instrumentação , Doenças Arteriais Intracranianas/diagnóstico por imagem , Doenças Arteriais Intracranianas/cirurgia , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Trombectomia/métodos , Embolização Terapêutica/instrumentação
5.
Neurocirugia (Astur) ; 31(4): 173-183, 2020.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-31987753

RESUMO

OBJECT: The breadth and complexity of neurovascular pathologies treated with endovascular neurosurgery has expanded dramatically in recent years. Many aneurysms remain difficult to treat safely. Transcirculation (contralateral and/or retrograde) approaches through the circle of Willis are useful alternatives for treating challenging lesions endovascularly. Here, we present a series of patients treated with unconventional transcirculation techniques. METHODS: A total of six patients were treated: four patients with five aneurysms, one patient with an MCA stroke, and one patient with a meningioma requiring preoperative embolization were initially thought not to be amenable to endovascular treatment. The decision was made to treat these patients with transcirculation approaches. All patients were treated by one interventionist. One aneurysm was located in the cavernous internal carotid artery (ICA), one in the vertebral artery, two in the paraclinoid ICA, and one in a cerebellar AVM feeder vessel were treated. RESULTS: Five of six patients (83%) made a full neurologic recovery. Three aneurysms were treated to complete occlusion, one aneurysm was left with small residual neck filling, and one aneurysm was not able to be treated. One patient underwent mechanical thrombectomy of a middle cerebral artery (MCA) embolus and MCA filling was restored after treatment. One patient underwent complete embolization of the deep vascular supply of a meningioma. CONCLUSIONS: Although many neurovascular pathologies remain unsuitable for endovascular treatment, transcirculation approaches can allow for safe, successful treatment of challenging lesions in select patients.

6.
Neurosurgery ; 87(2): 193-199, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-31586199

RESUMO

BACKGROUND: Arteriovenous malformation (AVM) rupture is highly morbid. Outcomes after AVM rupture differ from other types of brain hemorrhage. There are no specific widely used grading systems designed to predict clinical outcome after AVM rupture. OBJECTIVE: To develop an all-comers scoring system to grade patients with AVM rupture and predict clinical outcome more accurately than grading systems currently in use. METHODS: We retrospectively reviewed patients who presented to our institution with a ruptured AVM. Using change in modified Rankin Score (mRS) as our response variable, we generated an ordinal logistic regression model to test for significant predictor variables. The full model was sequentially condensed until the simplest model with the highest area under the receiver operating curve (AUROC) was achieved. RESULTS: A total of 115 patients who presented with ruptured AVMs were included in the study, with a mean follow-up time of 4 yr. The Ruptured AVM Grading Scale (RAGS) consists of the Hunt and Hess (HH) score (1-5), patient age (<35 = 0, 35-70 = 1, and >70 = 2), deep venous drainage (1), and eloquence (1). The RAGS score outperformed other neurosurgical grading scales in predicting change in mRS, with an AUROC greater than 0.80 across all follow-up periods. CONCLUSION: The RAGS score is a simple extension of the HH scale that predicts clinical outcome after AVM rupture more accurately than other grading systems.

7.
BMC Surg ; 19(1): 162, 2019 Nov 06.
Artigo em Inglês | MEDLINE | ID: mdl-31694627

RESUMO

BACKGROUND: Iatrogenic bile duct injuries (BDIs) are mostly associated with laparoscopic cholecystectomy but may also occur following gastroduodenal surgery or liver resection. Delayed diagnosis of type of injury with an ongoing biliary leak as well as the management in a non-specialized general surgical units are still the main factors affecting the outcome. CASE PRESENTATION: Herein we present three types of BDIs (Bismuth type I, IV and V) following three different types of upper abdominal surgery, ie. Billroth II gastric resection, laparoscopic cholecystectomy and left hepatectomy. All of them were complex injuries with complete bile duct transections necessitating surgical treatment. All were also very difficult to treat mainly because of a delayed diagnosis of type of injury, associated biliary leak and as a consequence severe inflammatory changes within the liver hilum. The treatment was carried out in our specialist hepatobiliary unit and first focused on infection and inflammation control with adequate biliary drainage. This was followed by a delayed surgical repair with the technique which had to be tailored to the type of injury in each case. CONCLUSION: We emphasize that staged and individualized treatment strategy is often necessary in case of a delayed diagnosis of complex BDIs presenting with a biliary leak, inflammatory intraabdominal changes and infection. Referral of such patients to expert hepatobiliary centres is crucial for the outcome.


Assuntos
Doenças dos Ductos Biliares/etiologia , Ductos Biliares/lesões , Complicações Pós-Operatórias/cirurgia , Adulto , Colecistectomia Laparoscópica/efeitos adversos , Drenagem , Feminino , Hepatectomia/efeitos adversos , Humanos , Doença Iatrogênica , Fígado/patologia , Masculino , Pessoa de Meia-Idade
8.
Front Oncol ; 9: 929, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31608232

RESUMO

Purpose: This study aimed to evaluate the efficacy and overall clinical outcome of patients over the age of 80 undergoing stereotactic radiofrequency ablation (SRFA) and to compare the results to a younger population with propensity score matching. Materials and Methods: Between 2006 and 2018 36 patients aged between 80 and 90 years underwent 46 SRFA sessions of 70 primary and secondary liver tumors. For comparison of treatment safety and efficacy 36 younger patients were selected with propensity score matching by the R package "MatchIt" in this retrospective, single-center study. Results: 68/70 tumors were successfully ablated at first ablation session (97% primary technical efficacy rate). Local tumor recurrence developed in 5 of 70 nodules (7.1%). The complication rate above Clavien-Dindo Grade III was 6.5% (3 of 46). The overall survival (OS) rates at 1-, 3-, and 5- years from the date of the first SRFA were 84.6, 50.5, and 37.9% for HCC patients and 87.5%, 52.5% at 1-, and 3-years for CRC patients. The disease-free survival (DFS) for HCC patients after SRFA was 79.1, 35.6, and 23.7%, at 1-, 3-, and 5- years, and 75%, 22.5% at 1-, and 3-years for CRC patients. There were no significant differences in terms of technical efficacy, local recurrences, major complications, OS and DFS compared to the control group. Conclusion: SRFA in octogenarians is a safe, feasible and useful option in the management of primary or metastatic liver tumors with no significant difference in outcomes compared to a younger control group.

9.
J Neurosurg Spine ; : 1-7, 2019 Sep 06.
Artigo em Inglês | MEDLINE | ID: mdl-31491759

RESUMO

OBJECTIVE: Recent advances in computer vision have revolutionized many aspects of society but have yet to find significant penetrance in neurosurgery. One proposed use for this technology is to aid in the identification of implanted spinal hardware. In revision operations, knowing the manufacturer and model of previously implanted fusion systems upfront can facilitate a faster and safer procedure, but this information is frequently unavailable or incomplete. The authors present one approach for the automated, high-accuracy classification of anterior cervical hardware fusion systems using computer vision. METHODS: Patient records were searched for those who underwent anterior-posterior (AP) cervical radiography following anterior cervical discectomy and fusion (ACDF) at the authors' institution over a 10-year period (2008-2018). These images were then cropped and windowed to include just the cervical plating system. Images were then labeled with the appropriate manufacturer and system according to the operative record. A computer vision classifier was then constructed using the bag-of-visual-words technique and KAZE feature detection. Accuracy and validity were tested using an 80%/20% training/testing pseudorandom split over 100 iterations. RESULTS: A total of 321 total images were isolated containing 9 different ACDF systems from 5 different companies. The correct system was identified as the top choice in 91.5% ± 3.8% of the cases and one of the top 2 or 3 choices in 97.1% ± 2.0% and 98.4 ± 13% of the cases, respectively. Performance persisted despite the inclusion of variable sizes of hardware (i.e., 1-level, 2-level, and 3-level plates). Stratification by the size of hardware did not improve performance. CONCLUSIONS: A computer vision algorithm was trained to classify at least 9 different types of anterior cervical fusion systems using relatively sparse data sets and was demonstrated to perform with high accuracy. This represents one of many potential clinical applications of machine learning and computer vision in neurosurgical practice.

10.
World Neurosurg ; 131: e46-e51, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31295616

RESUMO

BACKGROUND: Machine learning (ML) has been increasingly used in medicine and neurosurgery. We sought to determine whether ML models can distinguish ruptured from unruptured aneurysms and identify features associated with rupture. METHODS: We performed a retrospective review of patients with intracranial aneurysms detected on vascular imaging at our institution between 2002 and 2018. The dataset was used to train 3 ML models (random forest, linear support vector machine [SVM], and radial basis function kernel SVM). Relative contributions of individual predictors were derived from the linear SVM model. RESULTS: Complete data were available for 845 aneurysms in 615 patients. Ruptured aneurysms (n = 309, 37%) were larger (mean 6.51 mm vs. 5.73 mm; P = 0.02) and more likely to be in the posterior circulation (20% vs. 11%; P < 0.001) than unruptured aneurysms. Area under the receiver operating curve was 0.77 for the linear SVM, 0.78 for the radial basis function kernel SVM models, and 0.81 for the random forest model. Aneurysm location and size were the 2 features that contributed most significantly to the model. Posterior communicating artery, anterior communicating artery, and posterior inferior cerebellar artery locations were most highly associated with rupture, whereas paraclinoid and middle cerebral artery locations had the strongest association with unruptured status. CONCLUSIONS: ML models are capable of accurately distinguishing ruptured from unruptured aneurysms and identifying features associated with rupture. Consistent with prior studies, location and size show the strongest association with aneurysm rupture.


Assuntos
Aneurisma Roto/diagnóstico , Aneurisma Intracraniano/diagnóstico , Aprendizado de Máquina , Adulto , Idoso , Aneurisma Roto/diagnóstico por imagem , Aneurisma Roto/epidemiologia , Estudos de Casos e Controles , Comorbidade , Diabetes Mellitus/epidemiologia , Feminino , Humanos , Hiperlipidemias/epidemiologia , Hipertensão/epidemiologia , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sensibilidade e Especificidade , Fumar/epidemiologia , Máquina de Vetores de Suporte
11.
HPB (Oxford) ; 21(9): 1175-1184, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30777696

RESUMO

BACKGROUND: Microwave ablation (MWA) is a recognised treatment option for liver metastases. The size of the tumour is a well-established factor that influences the success of MWA. However, the effect of "heat sink" on the success of MWA for hepatic metastases is unclear. The aim of this study was to determine whether heat sink effect is a factor that contributes to ablation site recurrence (ASR). METHODS: A prospectively maintained database of patients who underwent percutaneous MWA for treatment of colorectal liver metastases was analysed. Imaging and demographic characteristics were compared between metastases that recurred following ablation and those that did not. Proximity to a large hepatic vein was defined as <10 mm. RESULTS: 126 ablations in 87 patients met the inclusion criteria and were studied over a median follow-up period of 28 (12-75) months. ASR was detected in 43 ablations (34%) and was associated with clinical risk score (CRS) ≥2 (OR 2.2 95% CI 1.3-3.3, p = 0.029), metastasis size (OR 0.953 95% CI (0.929-0.978), p < 0.001) and proximity to a large hepatic vein (OR 7.5 95%CI 2.4-22.8, p < 0.001). Proximity to a large hepatic vein was not associated with reduced overall survival (OS) but was associated with liver-specific recurrence (HR 4.7 95%CI 1.7-12.5, p = 0.004). CONCLUSIONS: In addition to tumour size proximity to large hepatic venous structures is an independent predictor of ASR and liver-specific recurrence following MWA. However, this was not associated with overall survival.


Assuntos
Ablação por Cateter/métodos , Neoplasias Colorretais/patologia , Neoplasias Hepáticas/cirurgia , Micro-Ondas/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/secundário , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/diagnóstico por imagem , Recidiva Local de Neoplasia/mortalidade , Estudos Retrospectivos , Taxa de Sobrevida
12.
World Neurosurg ; 122: e1014-e1019, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30414522

RESUMO

OBJECTIVE: The purpose of this study was to evaluate the association between noninfectious fever onset and radiographic vasospasm, delayed ischemic neurologic deficit (DIND), delayed cerebral infarction (DCI), and clinical outcome in patients with aneurysmal subarachnoid hemorrhage. METHODS: We evaluated 44 patients for the association between noninfectious fever (greater than 101.5°F) and the development of radiographic vasospasm by digital subtraction angiography (DSA) and transcranial Doppler (TCD), DIND, DCI, and modified Rankin scale outcome score at 6 months to 2 years. Multivariate logistic regression analyses were performed to account for patient age, sex, admission Hunt and Hess grade, and Fisher grade. TCD was additionally used for temporal analysis. RESULTS: Noninfectious fever was significantly associated with radiographic vasospasm using both DSA (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.2-4.5; P = 0.02) and TCD (OR, 2.4; 95% CI, 1.2-5.6; P = 0.02), but it was not associated with DIND, DCI, or outcome. The maximum cross correlation between TCD velocity and temperature occurred for temperatures taken 1 day prior to TCD velocity measurement. A quadratic mixed-effects model demonstrated that TCD velocity was significantly associated with temperature from 1 day prior to TCD velocity measurement (ß = 13.5; 95% CI, 0.83-8.79, P = 0.01), posthemorrhage day (ß = 20.1; 95% CI, 2.14-7.52; P < 0.001), and (posthemorrhage day)2 (ß = -0.72; 95% CI, -0.26 to -0.11; P < 0.001). CONCLUSIONS: Noninfectious fever was associated with the development of radiographic vasospasm but not with DIND, DCI, or clinical outcome. Furthermore, there is a temporal association between the onset of noninfectious fever and radiographic vasospasm by 1 day. Fever independent of patient's infectious profile may be an early marker for the development of radiographic vasospasm.


Assuntos
Febre/diagnóstico por imagem , Febre/terapia , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/terapia , Vasoespasmo Intracraniano/diagnóstico por imagem , Vasoespasmo Intracraniano/terapia , Idoso , Feminino , Febre/epidemiologia , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Hemorragia Subaracnóidea/epidemiologia , Resultado do Tratamento , Vasoespasmo Intracraniano/epidemiologia
13.
J Neurosurg ; : 1-8, 2018 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-29932380

RESUMO

OBJECTIVEParaclinoid aneurysms represent approximately 5% of intracranial aneurysms (Drake et al. [1968]). Visual impairment, which occurs in 16%-40% of patients, is among the most common presentations of these aneurysms (Day [1990], Lai and Morgan [2013], Sahlein et al. [2015], and Silva et al. [2017]). Flow-diverting stents, such as the Pipeline Embolization Device (PED), are increasingly used to treat these aneurysms, in part because of their theoretical reduction of mass effect (Fiorella et al. [2009]). Limited data on paraclinoid aneurysms treated with a PED exist, and few studies have compared outcomes of patients after PED placement with those of patients after clipping or coiling.METHODSThe authors performed a retrospective analysis of 115 patients with an aneurysm of the cavernous to ophthalmic segments of the internal carotid artery treated with clipping, coiling, or PED deployment between January 2011 and March 2017. Postoperative complications were defined as new neurological deficit, aneurysm rupture, recanalization, or other any operative complication that required reintervention.RESULTSA total of 125 paraclinoid aneurysms in 115 patients were treated, including 70 with PED placement, 23 with coiling, and 32 with clipping. Eighteen (14%) aneurysms were ruptured. The mean aneurysm size was 8.2 mm, and the mean follow-up duration was 18.4 months. Most aneurysms were discovered incidentally, but visual impairment, which occurred in 21 (18%) patients, was the most common presenting symptom. Among these patients, 15 (71%) experienced improvement in their visual symptoms after treatment, including 14 (93%) of these 15 patients who were treated with PED deployment. Complete angiographic occlusion was achieved in 89% of the patients. Complications were seen in 17 (15%) patients, including 10 (16%) after PED placement, 2 (9%) after coiling, and 5 (17%) after clipping. Patients with incomplete aneurysm occlusion had a higher rate of procedural complications than those with complete occlusion (p = 0.02). The rate of postoperative visual improvement was significantly higher among patients treated with PED deployment than in those treated with coiling (p = 0.01). The significant predictors of procedural complications were incomplete occlusion (p = 0.03), hypertension, (p = 0.04), and diabetes (p = 0.03).CONCLUSIONSIn a large series in which patient outcomes after treatment of paraclinoid aneurysms were compared, the authors found a high rate of aneurysm occlusion and a comparable rate of procedural complications among patients treated with PED placement compared with the rates among those who underwent clipping or coiling. For patients who presented with visual symptoms, those treated with PED placement had the highest rate of visual improvement. The results of this study suggest that the PED is an effective and safe modality for treating paraclinoid aneurysms, especially for patients who present with visual symptoms.

14.
World J Gastrointest Endosc ; 10(5): 93-98, 2018 May 16.
Artigo em Inglês | MEDLINE | ID: mdl-29774088

RESUMO

AIM: To investigate whether endoscopic ultrasound (EUS)-guided insertion of fully covered self-expandable metal stents in walled-off pancreatic necrosis (WOPN) is feasible without fluoroscopy. METHODS: Patients with symptomatic pancreatic WOPN undergoing EUS-guided transmural drainage using self-expandable and fully covered self expanding metal stents (FCSEMS) were included. The EUS visibility of each step involved in the transmural stent insertion was assessed by the operators as "visible" or "not visible": (1) Access to the cyst by needle or cystotome; (2) insertion of a guide wire; (3) introducing of the diathermy and delivery system; (4) opening of the distal flange; and (5) slow withdrawal of the delivery system until contact of distal flange to cavity wall. Technical success was defined as correct positioning of the FCSEMS without the need of fluoroscopy. RESULTS: In total, 27 consecutive patients with symptomatic WOPN referred for EUS-guided drainage were included. In 2 patients large traversing arteries within the cavity were detected by color Doppler, therefore the insertion of FCSEMS was not attempted. In all other patients (92.6%) EUS-guided transgastric stent insertion was technically successful without fluoroscopy. All steps of the procedure could be clearly visualized by EUS. Nine patients required endoscopic necrosectomy through the FCSEMS. Adverse events were two readmissions with fever and one self-limiting bleeding; there was no procedure-related mortality. CONCLUSION: The good endosonographic visibility of the FCSEMS delivery system throughout the procedure allows safe EUS-guided insertion without fluoroscopy making it available as bedside intervention for critically ill patients.

15.
J Neurointerv Surg ; 10(11): e27, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29627792

RESUMO

High flow extracranial-intracranial (EC-IC) bypass with a saphenous vein graft (SVG) has been used for more than 40 years in patients with giant aneurysms of the posterior circulation refractory to medical management, and has demonstrated high long term patency rates. We report the case of a patient treated with external carotid artery (ECA)-posterior cerebral artery SVG bypass in 1989 who presented 27 years later with paresthesias and confusion, and was found to have partial occlusion of her SVG bypass graft and a basilar occlusion. She was treated with mechanical thrombectomy of the basilar occlusion via the partially thrombosed graft, the first report of such a procedure through a high flow posterior circulation EC-IC SVG, resulting in improvement of the patient's neurologic examination. At 27 years, this is the longest reported delay in thrombosis of a high flow SVG bypass graft, highlighting the long term patency of these grafts and the feasibility of thrombectomy through occluded bypass grafts.


Assuntos
Revascularização Cerebral/métodos , Oclusão de Enxerto Vascular/cirurgia , Veia Safena/cirurgia , Trombectomia/métodos , Insuficiência Vertebrobasilar/cirurgia , Idoso , Feminino , Oclusão de Enxerto Vascular/diagnóstico por imagem , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/métodos , Veia Safena/diagnóstico por imagem , Fatores de Tempo , Procedimentos Cirúrgicos Vasculares/métodos , Insuficiência Vertebrobasilar/diagnóstico por imagem
16.
BMJ Case Rep ; 20182018 Mar 08.
Artigo em Inglês | MEDLINE | ID: mdl-29519858

RESUMO

High flow extracranial-intracranial (EC-IC) bypass with a saphenous vein graft (SVG) has been used for more than 40 years in patients with giant aneurysms of the posterior circulation refractory to medical management, and has demonstrated high long term patency rates. We report the case of a patient treated with external carotid artery (ECA)-posterior cerebral artery SVG bypass in 1989 who presented 27 years later with paresthesias and confusion, and was found to have partial occlusion of her SVG bypass graft and a basilar occlusion. She was treated with mechanical thrombectomy of the basilar occlusion via the partially thrombosed graft, the first report of such a procedure through a high flow posterior circulation EC-IC SVG, resulting in improvement of the patient's neurologic examination. At 27 years, this is the longest reported delay in thrombosis of a high flow SVG bypass graft, highlighting the long term patency of these grafts and the feasibility of thrombectomy through occluded bypass grafts.


Assuntos
Revascularização Cerebral/métodos , Aneurisma Intracraniano/diagnóstico por imagem , Parestesia/diagnóstico por imagem , Complicações Pós-Operatórias/fisiopatologia , Veia Safena/transplante , Enxerto Vascular/métodos , Angiografia Cerebral , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/fisiopatologia , Aneurisma Intracraniano/terapia , Pessoa de Meia-Idade , Exame Neurológico , Parestesia/etiologia , Parestesia/fisiopatologia , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/terapia , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Grau de Desobstrução Vascular
17.
Br J Cancer ; 118(3): 435-440, 2018 02 06.
Artigo em Inglês | MEDLINE | ID: mdl-29360819

RESUMO

BACKGROUND: Accumulating evidence implicates the tumour stroma as an important determinant of cancer progression but the protein constituents relevant for this effect are unknown. Here we utilised a bioinformatics approach to identify an extracellular matrix (ECM) gene signature overexpressed in multiple cancer types and strongly predictive of adverse outcome. METHODS: Gene expression levels in cancers were determined using Oncomine. Geneset enrichment analysis was performed using the Broad Institute desktop application. Survival analysis was performed using KM plotter. Survival data were generated from publically available genesets. RESULTS: We analysed ECM genes significantly upregulated across a large cohort of patients with ovarian, lung, gastric and colon cancers and defined a signature of nine commonly upregulated genes. Each of these nine genes was considerably overexpressed in all the cancers studied, and cumulatively, their expression was associated with poor prognosis across all data sets. Further, the gene signature expression was associated with enrichment of genes governing processes linked to poor prognosis, such as EMT, angiogenesis, hypoxia, and inflammation. CONCLUSIONS: Here we identify a nine-gene ECM signature, which strongly predicts outcome across multiple cancer types and can be used for prognostication after validation in prospective cancer cohorts.


Assuntos
Adenocarcinoma/genética , Matriz Extracelular/genética , Expressão Gênica , Neoplasias/genética , Neoplasias da Mama/genética , Hipóxia Celular/genética , Neoplasias do Colo/genética , Biologia Computacional , Transição Epitelial-Mesenquimal/genética , Neoplasias Esofágicas/genética , Feminino , Humanos , Inflamação/genética , Estimativa de Kaplan-Meier , Neoplasias Pulmonares/genética , Neovascularização Patológica/genética , Neoplasias Ovarianas/genética , Prognóstico , Neoplasias Gástricas/genética , Taxa de Sobrevida , Regulação para Cima
18.
Dig Surg ; 35(2): 171-176, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-28704814

RESUMO

BACKGROUND: Acute acalculous cholecystitis (AAC) accounts for 5-10% of cases of acute cholecystitis. The advantage of interval cholecystectomy for patients with AAC is unclear. Therefore, a retrospective analysis of patients diagnosed with AAC at our institution was performed over a 5-year period. METHODS: Patients were identified via hospital coding using the keywords "acalculous cholecystitis, cholecystostomy and gall bladder perforation." Follow-up data was obtained by performing a retrospective review of the patients' hospital records. RESULTS: A total of 33 patients with AAC were identified and followed for a median period of 18 months. The median age at presentation was 70 (10-96) and American Society of Anesthesiologists (ASA) grade was 3 (1-5). Twenty-three patients (70%) were treated with antibiotics alone, 7 patients (21%) with percutaneous cholecystostomy and 3 patients (9%) with laparoscopic cholecystectomy. The 90-day mortality rate was 30% with significant correlation to comorbid status, as all deaths occurred in ASA grade 3-5 individuals (p = 0.020). Two patients (6%) developed recurrent AAC and were managed non-operatively. CONCLUSION: Antibiotics and cholecystostomy were the mainstay of AAC management, and comorbid status influenced related mortality. Our results suggest that it appears safe to avoid interval cholecystectomy in patients who recover from AAC, as they are typically high-risk surgical candidates.


Assuntos
Colecistite Acalculosa/cirurgia , Antibacterianos/uso terapêutico , Colecistectomia/métodos , Procedimentos Cirúrgicos Eletivos/mortalidade , Procedimentos Cirúrgicos Eletivos/métodos , Colecistite Acalculosa/diagnóstico por imagem , Colecistite Acalculosa/tratamento farmacológico , Colecistite Acalculosa/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Colangiografia/métodos , Colecistectomia/mortalidade , Colecistite Aguda/diagnóstico por imagem , Colecistite Aguda/tratamento farmacológico , Colecistite Aguda/mortalidade , Colecistite Aguda/cirurgia , Colecistostomia/métodos , Colecistostomia/estatística & dados numéricos , Estudos de Coortes , Bases de Dados Factuais , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida , Fatores de Tempo , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Ultrassonografia Doppler , Reino Unido
19.
ANZ J Surg ; 88(6): 626-629, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28653509

RESUMO

BACKGROUND: Symptomatic pancreaticojejunal anastomotic stricture (PJS) is a rare complication following pancreaticoduodenectomy. The incidence, presentation and management of this condition are infrequently reported in the literature. Revision surgery is thought to be an effective treatment. Recent literature shows some success from endoscopic management. METHODS: The patients treated for symptomatic PJS from January 2005 to June 2014 were identified. Their clinical presentation and management was retrospectively reviewed. Patients were followed up in clinic or by telephonic interviews to assess their symptoms. RESULTS: Three patients (two females and one male) had symptomatic PJS out of 314 who underwent pancreaticoduodenectomy (0.9%). Main presentating symptom was intermittent abdominal pain. The diagnosis was confirmed by computed tomography scan and/or magnetic resonance cholangiopancreatography. One patient underwent a failed endoscopic retrograde cholangiopancreatography attempt to dilate the stricture. A redo-pancreaticojejunostomy was performed in all patients. At a mean follow-up of 8 months, two patients had complete resolution of symptoms and one patient had partial benefit. Five out of seven case series in literature support surgical management. CONCLUSION: Symptomatic PJS can be successfully treated with redo-pancreaticojejunostomy, with good medium-term outcomes. Although endoscopic intervention has been described, review of the literature shows that success rates are low and the long-term results are unknown.


Assuntos
Constrição Patológica/diagnóstico por imagem , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/efeitos adversos , Pancreaticojejunostomia/efeitos adversos , Adulto , Fatores Etários , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colangiopancreatografia por Ressonância Magnética , Estudos de Coortes , Constrição Patológica/cirurgia , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/patologia , Pancreaticoduodenectomia/métodos , Pancreaticojejunostomia/métodos , Prognóstico , Reoperação/métodos , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Centros de Atenção Terciária
20.
Neuroimage Clin ; 17: 794-803, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29270359

RESUMO

Functional magnetic resonance imaging (fMRI) is increasingly used for preoperative counseling and planning, and intraoperative guidance for tumor resection in the eloquent cortex. Although there have been improvements in image resolution and artifact correction, there are still limitations of this modality. In this review, we discuss clinical fMRI's applications, limitations and potential solutions. These limitations depend on the following parameters: foundations of fMRI, physiologic effects of the disease, distinctions between clinical and research fMRI, and the design of the fMRI study. We also compare fMRI to other brain mapping modalities which should be considered as alternatives or adjuncts when appropriate, and discuss intraoperative use and validation of fMRI. These concepts direct the clinical application of fMRI in neurosurgical patients.


Assuntos
Mapeamento Encefálico/instrumentação , Mapeamento Encefálico/métodos , Encéfalo/diagnóstico por imagem , Imagem por Ressonância Magnética , Cuidados Pré-Operatórios/métodos , Encéfalo/irrigação sanguínea , Encéfalo/cirurgia , Humanos , Processamento de Imagem Assistida por Computador , Oxigênio/sangue , Cuidados Pré-Operatórios/instrumentação
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...