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2.
J Neurointerv Surg ; 12(2): 132-135, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31273073

RESUMO

OBJECTIVE: The rate of progression of the ischemic lesion is variable in patients with stroke. We tested the hypothesis that the tissue saving effect of mechanical thrombectomy (MT) is greater in fast progressors. METHODS: A single-center cohort of consecutive patients (n=242) with occlusions of the terminal internal carotid or M1 segment of the middle cerebral artery treated with MT (n=195) or best medical treatment (n=47), known time from onset, and full imaging (baseline CT perfusion and follow-up MRI) available was studied. The estimated infarct progression rate (eIPR) was calculated at baseline and patients were categorized as fast/slow progressors according to the median eIPR of 4.8 mL/hour. The primary outcome measure was the interaction between eIPR category and MT on infarct growth. The secondary outcomes assessed the effect of MT on final infarct volume and functional status in relation to the eIPR category. The safety outcomes were mortality and symptomatic intracranial hemorrhage. RESULTS: The eIPR category had a modifying effect (Pi=0.017) of MT on infarct growth that was significantly reduced with MT only in fast progressors (median (IQR) 3.8 mL (-11-55) vs 41 mL (11-107) with medical treatment; p=0.009, adjusted p=0.045). There was also a significant interaction on final infarct volume (Pi=0.005), with a greater reduction after MT in fast progressors. The functional status improved with MT both in fast and slow progressors, with no significant modifying effect of eIPR category (Pi=0.201). There were also no significant interactions on safety outcomes. CONCLUSION: MT in stroke patients with large vessel occlusion limits infarct growth more significantly in fast progressors.

3.
World Neurosurg ; 2019 Dec 05.
Artigo em Inglês | MEDLINE | ID: mdl-31811967

RESUMO

OBJECTIVES: Since the introduction of endovascular treatment for cerebral aneurysms, hospitals in which subarachnoid hemorrhage is treated show different availability and/or preferences towards both treatment modalities. The main aim is to evaluate the clinical and angiographic results according to the hospital's treatment preferences applied. METHODS: This study was conducted based on use of the subarachnoid hemorrhage database of the Vascular Pathology Group of the Spanish Neurosurgery Society. Centers were classified into 3 subtypes according to an index in the relationship between endovascular and surgical treatment as: endovascular preference, high endovascular preference, and elevated surgical preference. The clinical results and angiographic results were evaluated among the 3 treatment strategies. RESULTS: From November 2004 to December 2017, 4282 subarachnoid hemorrhage patients were selected for the study: 630 (14.7%) patients from centers with surgical preference, 2766 (64.6%) from centers with endovascular preference, and 886 (20.7%) from centers with high endovascular preference. The surgical preference group obtained the best angiographic results associated with a greater complete exclusion (odds ratio: 1.359; 95% confidence interval: 1.025-1.801; P = 0.033). The surgical preference subgroup obtained the best outcome at discharge (65.45%), followed by the high endovascular preference group (61.5%) and the endovascular preference group (57.8%) (odds ratio: 1.359; 95% confidence interval: 1.025-1.801; P = 0.033). CONCLUSIONS: In Spain, there is significant variability in aneurysm exclusion treatment in aneurysmal subarachnoid hemorrhage. Surgical centers offer better results for both surgical and endovascular patients. A multidisciplinary approach and the maintenance of an elevated quality of surgical competence could be responsible for these results.

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.
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
9.
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
10.
PLoS One ; 12(2): e0172637, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28235044

RESUMO

BACKGROUND AND PURPOSE: Interspecies variability and poor clinical translation from rodent studies indicate that large gyrencephalic animal stroke models are urgently needed. We present a proof-of-principle study describing an alternative animal model of malignant infarction of the middle cerebral artery (MCA) in the common pig and illustrate some of its potential applications. We report on metabolic patterns, ionic profile, brain partial pressure of oxygen (PtiO2), expression of sulfonylurea receptor 1 (SUR1), and the transient receptor potential melastatin 4 (TRPM4). METHODS: A 5-hour ischemic infarct of the MCA territory was performed in 5 2.5-to-3-month-old female hybrid pigs (Large White x Landrace) using a frontotemporal approach. The core and penumbra areas were intraoperatively monitored to determine the metabolic and ionic profiles. To determine the infarct volume, 2,3,5-triphenyltetrazolium chloride staining and immunohistochemistry analysis was performed to determine SUR1 and TRPM4 expression. RESULTS: PtiO2 monitoring showed an abrupt reduction in values close to 0 mmHg after MCA occlusion in the core area. Hourly cerebral microdialysis showed that the infarcted tissue was characterized by reduced concentrations of glucose (0.03 mM) and pyruvate (0.003 mM) and increases in lactate levels (8.87mM), lactate-pyruvate ratio (4202), glycerol levels (588 µM), and potassium concentration (27.9 mmol/L). Immunohistochemical analysis showed increased expression of SUR1-TRPM4 channels. CONCLUSIONS: The aim of the present proof-of-principle study was to document the feasibility of a large animal model of malignant MCA infarction by performing transcranial occlusion of the MCA in the common pig, as an alternative to lisencephalic animals. This model may be useful for detailed studies of cerebral ischemia mechanisms and the development of neuroprotective strategies.


Assuntos
Encéfalo/patologia , Modelos Animais de Doenças , Infarto da Artéria Cerebral Média/patologia , Artéria Cerebral Média/patologia , Animais , Encéfalo/irrigação sanguínea , Encéfalo/metabolismo , Feminino , Expressão Gênica , Glucose/metabolismo , Glicerol/metabolismo , Imuno-Histoquímica , Infarto da Artéria Cerebral Média/diagnóstico , Infarto da Artéria Cerebral Média/genética , Infarto da Artéria Cerebral Média/metabolismo , Ácido Láctico/metabolismo , Artéria Cerebral Média/metabolismo , Oximetria , Oxigênio/metabolismo , Pressão Parcial , Potássio/metabolismo , Ácido Pirúvico/metabolismo , Receptores Sulfonilureia/genética , Receptores Sulfonilureia/metabolismo , Canais de Cátion TRPM/genética , Canais de Cátion TRPM/metabolismo
11.
J Neurotrauma ; 34(1): 74-85, 2017 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-27220951

RESUMO

Traumatic brain injury (TBI) and ischemic stroke cause a variable disruption of ionic homeostasis and massive ionic fluxes with subsequent osmotic water movement across the cells that causes edema, brain swelling, and deformation of the damaged tissue. Although cerebral microdialysis (CMD) has been used to study the brain neurochemistry, the ionic profiles of brain interstitial space fluid have rarely been reported in humans. We studied the ionic profile in injured areas of the brain by using CMD. As a control group, we included seven patients who had undergone surgical treatment of posterior fossa lesions, without abnormalities in the supratentorial compartment. Inductively coupled plasma mass spectrometry (ICP-MS) was used for ion determination. No significant differences were found in the [Na+]o, [K+]o, and [Cl-]o between normal injured brains and controls. The ionic profile of the ischemic core was characterized by very high [K+]o and an increase in [Na+]o, whereas [Cl-]o was linearly related to [Na+]o. In the traumatic core (TC), significantly higher levels of [Na+]o, [Cl-]o, and [K+]o were found. The main finding in the penumbra was a completely normal ionic profile for [Na+]o and [K+]o in 60% of the samples. ICP-MS coupled to ionic assays creates a powerful tool for a better understanding of the complex ionic disturbances that occur after severe TBI and ischemic stroke.


Assuntos
Lesões Encefálicas/diagnóstico por imagem , Lesões Encefálicas/metabolismo , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/metabolismo , Espaço Extracelular/metabolismo , Canais Iônicos/metabolismo , Adolescente , Adulto , Cloretos/metabolismo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Potássio/metabolismo , Estudos Prospectivos , Sódio/metabolismo , Adulto Jovem
12.
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
13.
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.

15.
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
16.
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
17.
Neurosurgery ; 76(3): 302-12; discussion 312, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25584958

RESUMO

BACKGROUND: In moyamoya disease (MMD), cerebral revascularization is recommended in patients with recurrent or progressive ischemic events and associated reduced cerebral perfusion reserve. Low-flow bypass with or without indirect revascularization is generally the standard surgical treatment. Intraoperative monitoring of cerebral partial pressure of oxygen (PtiO2) with polarographic Clark-type probes in cerebral artery bypass surgery for MMD-induced chronic cerebral ischemia has not yet been described. OBJECTIVE: To describe basal brain tissue oxygenation in MMD patients before revascularization as well as the immediate changes produced by the surgical procedure using intraoperative PtiO2 monitoring. METHODS: Between October 2011 and January 2013, all patients with a diagnosis of MMD were intraoperatively monitored. Cerebral oxygenation status was analyzed based on the Ptio2/PaO2 ratio. Reference thresholds of PtiO2/PaO2 had been previously defined as below 0.1 for the lower reference threshold (hypoxia) and above 0.35 for the upper reference threshold (hyperoxia). RESULTS: Before STA-MCA bypass, all patients presented a situation of severe tissue hypoxia confirmed by a PtiO2/PaO2 ratio <0.1. After bypass, all patients showed a rapid and sustained increase in PtiO2, which reached normal values (PtiO2/PaO2 ratio between 0.1 and 0.35). One patient showed an initial PtiO2 improvement followed by a decrease due to bypass occlusion. After repeat anastomosis, the patient's PtiO2 increased again and stabilized. CONCLUSION: Direct anastomosis quickly improves cerebral oxygenation, immediately reducing the risk of ischemic stroke in both pediatric and adult patients. Intraoperative PtiO2 monitoring is a very reliable tool to verify the effectiveness of this revascularization procedure.


Assuntos
Encéfalo/irrigação sanguínea , Revascularização Cerebral/métodos , Monitorização Neurofisiológica Intraoperatória/métodos , Doença de Moyamoya/fisiopatologia , Doença de Moyamoya/cirurgia , Adolescente , Adulto , Encéfalo/cirurgia , Criança , Pré-Escolar , Feminino , Humanos , Hipóxia , Masculino , Pessoa de Meia-Idade , Oxigênio/análise , Pressão Parcial , Adulto Jovem
18.
Clin Neurol Neurosurg ; 128: 17-24, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25462090

RESUMO

OBJECTIVE: Systemic lupus erythematosus (SLE) is an autoimmune disorder of multifactorial etiology with a broad range of clinical manifestations. Cerebral disorders such as psychosis, seizures and cerebrovascular accidents are commonly described in SLE patients. Subarachnoid hemorrhage (SAH) presents a higher incidence than in the general population. Saccular aneurysms are the most frequent cause, but uncommon forms of SAH had been repeatedly reported in SLE patients. Through three case examples we outline these uncommon patterns, which we hypothesized, might be responsible for the higher incidence of SAH in SLE patients. METHODS: We present three patients previously diagnosed with SLE, who suffered a SAH and we perform a systematic literature review. RESULTS: All three cases presented with a Fisher grade IV bleeding. One harbored a distal middle cerebral artery aneurysm, another had multiple aneurysms, and the youngest patient had no findings on the cerebral angiography. A focal vasculitic process seemed most likely responsible for the two aneurismal cases. The angiography negative case was attributed to severe SLE systemic complications and had an unexpected bad outcome. Literature review yielded 39 previously reported cases. CONCLUSIONS: The uncommon SAH patterns make etiological diagnosis challenging. Management can also be daunting due to both local and systemic consequences of SLE. Awareness of these uncommon patterns, management challenges, and higher likelihood of bad outcomes may help physicians dealing with this disease. Further research to unveil the mechanisms behind it is granted to fully understand SAH in SLE patients.


Assuntos
Lúpus Eritematoso Sistêmico/complicações , Hemorragia Subaracnóidea/etiologia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Hemorragia Subaracnóidea/diagnóstico , Hemorragia Subaracnóidea/terapia , Adulto Jovem
19.
Neurocir. - Soc. Luso-Esp. Neurocir ; 25(6): 275-285, nov.-dic. 2014. ilus
Artigo em Espanhol | IBECS | ID: ibc-130365

RESUMO

Las lesiones isquémicas relacionadas con los procedimientos quirúrgicos son una de las principales causas de morbilidad en el postoperatorio de la cirugía de los pacientes con patología vascular cerebral. Con el objetivo de detectar intraoperatoriamente los fenómenos isquémicos se han implementado diferentes sistemas de neuromonitorización, entre los que se encuentra la monitorización de la presión tisular de oxígeno (PtiO2). En este trabajo se pretende describir la utilidad de la monitorización intraoperatoria de la PtiO2 en la neurocirugía vascular a partir de la discusión de 4 casos ejemplo. A partir de la presentación de estos casos se discute cómo este tipo de monitorización permite detectar de una forma precoz y fiable las situaciones relacionadas con el procedimiento quirúrgico que ocasionan una hipoxia cerebral isquémica. La monitorización continua de la PtiO2 en el área de riesgo permite además resolver la causa que ha originado los episodios isquémicos y su evolución a un infarto establecido


Ischemic lesions related to surgical procedures are a major cause of postoperative morbidity in patients with cerebral vascular disease. There are different systems of neuromonitoring to detect intraoperative ischemic events, including intraoperative monitoring of oxygen tissue pressure (PtiO2). The aim of this article was to describe, through the discussion of 4 cases, the usefulness of intraoperative PtiO2 monitoring during vascular neurosurgery. In presenting these cases, we demonstrate that monitoring PtiO2 is a reliable way to detect early ischemic events during surgical procedures. Continuous monitoring of PtiO2 in an area at risk allows the surgeon to resolve the cause of the ischemic event before it evolves to an established cerebral infarction


Assuntos
Humanos , Masculino , Feminino , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Hipóxia-Isquemia Encefálica/prevenção & controle , Consumo de Oxigênio , Procedimentos Cirúrgicos Vasculares/métodos , Procedimentos Neurocirúrgicos/métodos , Complicações Intraoperatórias/prevenção & controle
20.
Neurosurg Focus ; 37(3): E12, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25175431

RESUMO

OBJECT: Intraoperative rupture can transform an arteriovenous malformation (AVM) resection. Blood suffuses the field and visualization is lost; suction must clear the field and the hand holding the suction device is immobilized; the resection stalls while hemostasis is being reestablished; the cause and site of the bleeding may be unclear; bleeding may force technical errors and morbidity from chasing the source into eloquent white matter; and AVM bleeding can be so brisk that it overwhelms the neurosurgeon. The authors reviewed their experience with this dangerous complication to examine its causes, management, and outcomes. METHODS: From a cohort of 591 patients with AVMs treated surgically during a 15-year period, 32 patients (5%) experienced intraoperative AVM rupture. Their prospective data and medical records were reviewed. RESULTS: Intraoperative AVM rupture was not correlated with presenting hemorrhage, but had a slightly higher incidence infratentorially (7%) than supratentorially (5%). Rupture was due to arterial bleeding in 18 patients (56%), premature occlusion of a major draining vein in 10 (31%), and nidal penetration in 4 (13%). In 14 cases (44%), bleeding control was abandoned and the AVM was removed immediately ("commando resection"). The incidence of intraoperative rupture was highest during the initial 5-year period (9%) and dropped to 3% and 4% in the second and third 5-year periods, respectively. Ruptures due to premature venous occlusion and nidal penetration diminished with experience, whereas those due to arterial bleeding remained steady. Despite intraoperative rupture, 90% of AVMs were completely resected initially and all of them ultimately. Intraoperative rupture negatively impacted outcome, with significantly higher final modified Rankin Scale scores (mean 2.8) than in the overall cohort (mean 1.5; p < 0.001). CONCLUSIONS: Intraoperative AVM rupture is an uncommon complication caused by pathological arterial anatomy and by technical mistakes in judging the dissection distance from the AVM margin and in mishandling or misinterpreting the draining veins. The decrease in intraoperative rupture rate over time suggests the existence of a learning curve. In contrast, intraoperative rupture due to arterial bleeding reflects the difficulty with dysplastic feeding vessels and deep perforator anatomy rather than neurosurgeon experience. The results demonstrate that intraoperative AVM rupture negatively impacts patient outcome, and that skills in managing this catastrophe are critical.


Assuntos
Malformações Arteriovenosas/cirurgia , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/terapia , Procedimentos Neurocirúrgicos/efeitos adversos , Ruptura/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Hemorragia Cerebral/etiologia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Adulto Jovem
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