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1.
Hosp Pract (1995) ; 47(3): 163-169, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31340694

RESUMO

Background: Aneurysmal subarachnoid hemorrhage (ASAH) and unruptured aneurysm (URA) are particularly important because of the high mortality rates, and physical and cognitive impairment, which affect the economically active population. The present work aims at describing the scenario regarding in-hospital indicators related to the following therapeutic approaches: vascular microsurgery (VMS) and endovascular therapy (EVT) in the state of Minas Gerais, Brazil, in order to gather information to construct hypotheses and plan actions. Methods: The study has an ecological design and it is also analytical for the time trends of 2008-2014. Trends for VMS and EVT therapies and mortality are estimated using linear regression, followed by the Prais-Winsten procedure. Data were obtained through Hospital Information System (Sistema de Informações Hospitalares - SIH) of Brazilian Public Health System (Sistema Único de Saúde - SUS). Results: In 2014, 601 procedures were performed, and out of these, 373 (62%) were triggered by SAH and 228 (38%) by URA. The frequency of procedures performed in males and in females results in a ratio of 1:2 for SAH procedures and 1:3 for URA procedures. A heterogeneous distribution of therapeutic approaches was seen among the hospital studied, suggesting a technological preference, which determines the therapeutic approach. Conclusion: Technological bias was observed for aneurysm treatment in Minas Gerais's hospitals. EVT is seen to have a growing trend to detriment of VMS (ß1 = 0.024; p = 0.025), with a stable mortality for both therapeutics in both pathologies (SAH and URA). EVT has been associated with a shorter hospital stay, with higher expenses for both ASAH and URA treatment. EVT showed an inverse correlation with in-hospital fatality for ASAH treatment.


Assuntos
Tomada de Decisão Clínica , Procedimentos Endovasculares , Aneurisma Intracraniano/cirurgia , Procedimentos Neurocirúrgicos , Adulto , Idoso , Brasil , Comportamento de Escolha , Bases de Dados Factuais , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/estatística & dados numéricos , Feminino , Sistemas de Informação Hospitalar , Humanos , Pacientes Internados , Aneurisma Intracraniano/fisiopatologia , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/métodos , Procedimentos Neurocirúrgicos/estatística & dados numéricos , Resultado do Tratamento
2.
Khirurgiia (Mosk) ; (5): 57-63, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31169820

RESUMO

AIM: To study the effectiveness of intraoperative administration of Cytoflavine for the prevention of ischemic brain injury during cerebral aneurysm (CA) clipping with temporary occlusion of the leading artery under general anesthesia. MATERIAL AND METHODS: The prospective cohort single-center study included 40 patients with CA ( the main group - 27 patients with intraoperative administration of cytoflavine; the comparison group -13 patients without use of cytoflavine), who underwent aneurism clipping with temporary occlusion of the afferent artery. We assesed the intraoperative state of the brain, the time of awakening and extubation of patients after surgery, neurological deficit and local ischemic changes in the area of surgery according to the CT of the brain in the early postoperative period, resuscitation bed-day and the relationship of these indicators with the duration of temporary occlusion of the afferent artery in the selected groups of patients. RESULTS: In intergroup comparison, patients of the main group treated with intraoperative cytoflavin showed a reduction in the time of awakening (p=0.013) and the time of extubation (p=0.01) both with temporary occlusion of the afferent artery and in patients without temporary occlusion (p<0.05). The duration of resuscitation bed-day decreased in the main group of patients receiving intraoperatively cytoflavine (p=0.01), as well as in patients in the comparison group without temporary occlusion (p<0.05). CONCLUSION: Temporary occlusion of the afferent artery with short intervals of vessel occlusion in combination with intraoperative intravenous administration of cytoflavine expands the tolerability to artery occlusion in patients operated in the 'cold' period, reduces the possibility of neurological deficit, reduces the recovery period and resuscitation bed-day after surgical clipping CA.


Assuntos
Lesões Encefálicas/prevenção & controle , Isquemia Encefálica/fisiopatologia , Encéfalo/irrigação sanguínea , Mononucleotídeo de Flavina/administração & dosagem , Inosina Difosfato/administração & dosagem , Aneurisma Intracraniano/fisiopatologia , Fármacos Neuroprotetores/administração & dosagem , Procedimentos Neurocirúrgicos/efeitos adversos , Niacinamida/administração & dosagem , Succinatos/administração & dosagem , Encéfalo/efeitos dos fármacos , Encéfalo/fisiopatologia , Encéfalo/cirurgia , Lesões Encefálicas/etiologia , Lesões Encefálicas/fisiopatologia , Lesões Encefálicas/cirurgia , Isquemia Encefálica/etiologia , Isquemia Encefálica/cirurgia , Combinação de Medicamentos , Mononucleotídeo de Flavina/farmacologia , Humanos , Inosina Difosfato/farmacologia , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/cirurgia , Cuidados Intraoperatórios , Fármacos Neuroprotetores/farmacologia , Procedimentos Neurocirúrgicos/métodos , Niacinamida/farmacologia , Estudos Prospectivos , Succinatos/farmacologia , Técnicas de Sutura
3.
J Clin Neurosci ; 67: 185-190, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31253387

RESUMO

Aneurysm wall thickness is an important determinant of aneurysm progression and intra-procedural rupture. Several previous studies have evaluated the association between hemodynamic stress and aneurysm wall thickness, but conflicting results were obtained and no consensus has been achieved. According to the intraoperative findings, twenty-eight unruptured middle cerebral artery (MCA) aneurysms presented with thin-walled regions were enrolled in our study. Patient-specific 3D aneurysm models were constructed from preoperative computed tomography angiography (CTA) data and computational fluid dynamics (CFD) analyses were performed under pulsatile-flow conditions. Thin-walled regions of aneurysm dome were recognized by two experienced reviewers based on the intraoperative microscopy findings. Hemodynamic parameters derived from CFD analysis, including normalized wall shear stress (NWSS), normalized pressure (NP), the oscillatory shear index (OSI) and relative residence time (RRT), were compared between thin-walled regions and surrounding normal-thickness areas. Of the included aneurysms, twenty-eight pairs of thin-walled and normal surrounding regions were determined. Compared with surrounding tissues, thin-walled regions of aneurysm wall tended to present with higher pressure (1.232 vs 1.043, p < 0.05) and lower wall shear stress (0.693 vs 0.868, p < 0.05). Multivariate analysis revealed that elevated NP was significantly associated with thinning of the local aneurysm wall. Higher pressure and lower WSS were characteristic hemodynamic features associated with thinner regions of the aneurysm wall, elevated NP was an independent risk factor for local aneurysm wall thinning. CFD seems to be a useful method to estimate the location of thin-walled region, which will be helpful in reducing the risk of intraoperative rupture.


Assuntos
Simulação por Computador , Hemodinâmica/fisiologia , Hidrodinâmica , Aneurisma Intracraniano/patologia , Aneurisma Intracraniano/fisiopatologia , Adulto , Aneurisma Roto/patologia , Aneurisma Roto/fisiopatologia , Angiografia por Tomografia Computadorizada , Humanos , Pessoa de Meia-Idade , Modelos Biológicos , Análise Multivariada , Estresse Mecânico
4.
J Stroke Cerebrovasc Dis ; 28(7): e81-e82, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31101401

RESUMO

This is the first reported case in which a mycotic aneurysm refractory to the first medical treatment was treated with a Pipeline embolization device (PED), and the first case of a mycotic aneurysm from Brucella treated by endovascular therapy. A 35-year-old man presented with left eye pain and ptosis, and fever for 2 weeks. Before symptom onset, he visited Vietnam where he developed a flu-like illness; however, antibiotics were ineffective. We suspected Brucella as the most likely infectious etiology for the patient's intracavernous aneurysm. Since the aneurysm did not reduce in size following 2 weeks of antibiotic therapy, we placed a PED in the left internal carotid artery. Follow-up angiogram 4 months later showed no residual aneurysm, and cranial nerve palsies had completely resolved. From the results of this case, it appears that flow diverter stenting may be a safe and effective treatment of mycotic aneurysms of the cavernous segment of ICA.


Assuntos
Aneurisma Infectado/cirurgia , Brucelose/cirurgia , Doenças das Artérias Carótidas/cirurgia , Procedimentos Endovasculares/instrumentação , Aneurisma Intracraniano/cirurgia , Stents , Adulto , Aneurisma Infectado/diagnóstico por imagem , Aneurisma Infectado/microbiologia , Aneurisma Infectado/fisiopatologia , Angiografia Digital , Antibacterianos/uso terapêutico , Brucelose/diagnóstico por imagem , Brucelose/microbiologia , Brucelose/fisiopatologia , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/microbiologia , Doenças das Artérias Carótidas/fisiopatologia , Angiografia Cerebral/métodos , Circulação Cerebrovascular , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/microbiologia , Aneurisma Intracraniano/fisiopatologia , Imagem por Ressonância Magnética , Masculino , Desenho de Prótese , Resultado do Tratamento
5.
Comput Methods Biomech Biomed Engin ; 22(11): 961-971, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31045444

RESUMO

Conventional approaches of implementing computational fluid dynamics to study aneurysmal hemodynamics after treatment with a flow diverter stent are computationally expensive. Cumbersome meshing and lengthy simulation runtimes are common. To address these issues, we present a novel volume penalization method that considers flow diverters as heterogeneous porous media. The proposed model requires a considerably smaller number of mesh elements, leading to faster simulation runtimes. Three patient-specific aneurysms were virtually treated with flow diverters and aneurysmal hemodynamics were simulated. The results of the virtual deployments including aneurysmal hemodynamics were compared to corresponding results from conventional approaches. The comparisons showed that the proposed approach led to 9.12 times increase in the speed of simulations on average. Further, aneurysmal kinetic energy and inflow rate metrics for the proposed approach were consistent with those from conventional approaches, differing on average by 3.52% and 3.78%, respectively.


Assuntos
Hemodinâmica , Aneurisma Intracraniano/fisiopatologia , Análise Numérica Assistida por Computador , Stents , Algoritmos , Simulação por Computador , Humanos , Hidrodinâmica , Porosidade
6.
World Neurosurg ; 122: e577-e583, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-31108073

RESUMO

BACKGROUND: Flow diverter stents have become a useful tool for treatment of complex intracranial aneurysms. A serious complication is incomplete wall apposition after flow diverter placement. The aim of this study was to present a comprehensive investigation of hemodynamic changes induced by incomplete expansion of a flow diverter. METHODS: A case of a patient treated for an internal carotid artery aneurysm by flow diversion with incomplete wall apposition was virtually investigated. The effect of incomplete flow diverter expansion was studied using image-based blood flow simulations under physiologically relevant flow conditions based on patient-specific clinical data. RESULTS: The numerical results revealed that incomplete expansion at the proximal end of the stent had minimal impact on the intra-aneurysmal blood flow alteration. A region of nonphysiologically high wall shear stress was observed near the contact area between the incompletely expanded proximal end of the flow diverter and the parent artery, which caused an intimal hyperplasia in this region. These simulation results were consistent with the real-life clinical course and outcome. CONCLUSIONS: The results of this study can be considered during treatment planning of complex cases where the risk of incomplete flow diverter expansion exists. Further studies are required before results can also be used to support the decision process about antiplatelet therapy and additional interventions to improve wall apposition.


Assuntos
Doenças das Artérias Carótidas/terapia , Embolização Terapêutica/efeitos adversos , Aneurisma Intracraniano/terapia , Túnica Íntima/patologia , Velocidade do Fluxo Sanguíneo/fisiologia , Prótese Vascular/efeitos adversos , Doenças das Artérias Carótidas/fisiopatologia , Artéria Carótida Interna , Embolização Terapêutica/instrumentação , Hemodinâmica/fisiologia , Humanos , Hiperplasia/etiologia , Hiperplasia/fisiopatologia , Aneurisma Intracraniano/fisiopatologia , Pessoa de Meia-Idade , Modelos Biológicos , Stents/efeitos adversos , Telas Cirúrgicas
8.
J Neurointerv Surg ; 11(9): 908-911, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30814328

RESUMO

INTRODUCTION: Modern coil-adjunctive intracranial stent designs have increased metal surface coverage to construct putative 'flow diverter lights.' This is rooted in the assumption that flow diversion is linearly correlated with metal surface coverage rather than being a threshold to be reached by device porosity and design. OBJECTIVE: To evaluate this assumption, by performing computational flow analysis on three aneurysm models treated with low metal surface coverage stents (ATLAS and Enterprise), a Pipeline flow diverter, and the LVIS Blue stent. METHODS: Computational flow analysis was performed on virtual deployment models entailing deployment of an ATLAS, Enterprise, LVIS Blue, or Pipeline. The impact of device deployment on velocity vectors at the neck, maximum wall shear stress, inflow rate into the aneurysm, and turnover time was determined. RESULTS: Velocity vector plots demonstrated low magnitude, localized inflow jets for Pipeline only; asymmetric, selectively high inflow jets were seen for LVIS Blue, and broader velocity vector clusters were seen for Atlas and Enterprise. Reduction in wall shear stress as compared with baseline was significant for all devices and greatest for the Pipeline. Mean peak wall shear stress was significantly lower for LVIS Blue in comparison with ATLAS or Enterprise but significantly lower for Pipeline than for LVIS Blue. Reduction of inflow rate into the aneurysm was significant for LVIS Blue and Pipeline but significantly lower for Pipeline than for LVIS Blue. Turnover time was statistically similar for ATLAS, Enterprise, and LVIS Blue, but significantly increased for Pipeline. CONCLUSION: Considerable differences in peak wall shear stress, inflow rates, and turnover time between flow diverters, moderate- and low-porosity stents reinforce the assumption that effective flow diversion represents a threshold in device design, encompassing metal surface coverage only in part.


Assuntos
Simulação por Computador , Desenho de Equipamento , Hemodinâmica/fisiologia , Stents Metálicos Autoexpansíveis , Velocidade do Fluxo Sanguíneo/fisiologia , Simulação por Computador/normas , Desenho de Equipamento/métodos , Humanos , Aneurisma Intracraniano/fisiopatologia , Aneurisma Intracraniano/cirurgia , Stents Metálicos Autoexpansíveis/normas , Estresse Mecânico
9.
J Neurointerv Surg ; 11(8): 853-858, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30718383

RESUMO

OBJECTIVE: This study aimed to compare the hemodynamic differences among no sac (NOS), porous media (POM) and finite element analysis (FEA) models to investigate the recurrence-related risks for coiled intracranial aneurysms (IAs). METHODS: The study enrolled 10 patients with 11 IAs who received simple coiling treatment and hemodynamic simulations were performed for all IAs using the above three models. Velocity, wall shear stress (WSS) and residual flow volume (RFV) were calculated and compared in order to assess the model differences for both aneurysm sac and parent vessel regions. RESULTS: For parent artery regions, all three models produced similar flow patterns and quantification analysis did not indicate differences in velocity and WSS (p>0.05). For aneurysm sac regions, the FEA model resulted in higher sac-maximized (0.18 m/s vs 0.06 m/s) and sac-averaged velocity (0.013 m/s vs 0.007 m/s), and higher sac-averaged (0.55 Pa vs 0.36 Pa, p=0.006) and sac-maximized WSS (12.1 Pa vs 6.6 Pa) than the POM model. The differences in RFV between the POM and FEA models under 11 different isovelocity thresholds (0.0001 m/s, 0.001 m/s, 0.002 m/s, 0.005 m/s, 0.01 m/s, 0.02 m/s, 0.05 m/s, 0.1 m/s, 0.2 m/s, 0.5 m/s, and 1 m/s) showed that the POM RFV was generally larger than those of the FEA model. CONCLUSIONS: Compared with the FEA model, the POM model provides a lower velocity and WSS and higher RFV for the aneurysm sac, which could lead to incorrect estimates of the recurrent risk of coiled IAs under high packing density.


Assuntos
Análise de Elementos Finitos , Hemodinâmica/fisiologia , Hidrodinâmica , Aneurisma Intracraniano/fisiopatologia , Modelos Cardiovasculares , Realidade Virtual , Adulto , Idoso , Feminino , Análise de Elementos Finitos/normas , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/terapia , Masculino , Pessoa de Meia-Idade , Porosidade , Estresse Mecânico
10.
Expert Rev Med Devices ; 16(3): 229-236, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30775934

RESUMO

INTRODUCTION: Intrasaccular flow disruption is an innovative technique for the endovascular treatment of intracranial aneurysms. Among flow disrupting devices, the Woven EndoBridge (WEB) is currently the only flow disrupter on the market and has seen an extensive scientific evaluation. It was shown that the device provides a safe and effective treatment particularly for wide-neck aneurysms of proximal bifurcations. AREAS COVERED: We describe the principal concept and the technical evolution of intrasaccular flow disruption and discuss all devices that have to date been presented, with a special focus on the WEB. Key results of the literature are summarized, and we review possible future indications for this innovative treatment concept. EXPERT COMMENTARY: The tools for the endovascular management of intracranial aneurysms continue to evolve rapidly with intrasaccular flow disruption being the most recent innovation in the field. The WEB is currently the only device on the market. Compared to competing techniques, intrasaccular flow disruption offers several advantages and it is likely that given the technically straightforward nature of the procedure and the high-quality scientific evidence of its safety and efficacy, the device will see a progressive expansion of its indications and will replace standard coiling in an increasing number of cases.


Assuntos
Prótese Vascular , Circulação Cerebrovascular , Aneurisma Intracraniano/fisiopatologia , Aneurisma Intracraniano/terapia , Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/instrumentação , Seguimentos , Humanos , Resultado do Tratamento
11.
J Int Med Res ; 47(4): 1565-1572, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30727794

RESUMO

OBJECTIVE: This study was performed to compare the clinical value of the second-generation Shikani optical stylet with that of the Macintosh laryngoscope for tracheal intubation of patients undergoing cerebral aneurysm embolization. METHODS: Thirty-six patients who underwent cerebral aneurysm embolization were included. The intubation time, intubation success rate, blood oxygen saturation, heart rate, systolic blood pressure (SBP), and diastolic blood pressure (DBP) were measured. Adverse reactions during tracheal intubation and the local tissue injury rate were recorded. Comparisons between the groups were performed with one-way analysis of variance. RESULTS: The heart rate, SBP, and DBP upon tracheal intubation and at 1 and 3 minutes were significantly higher in the Macintosh laryngoscope group than in the Shikani optical stylet group. The time to completion of tracheal intubation was significantly shorter and the tissue injury rate was significantly lower in the Shikani optimal stylet group than in the Macintosh laryngoscope group. CONCLUSIONS: The second-generation Shikani optical stylet is a simple, safe, and reliable tool for tracheal intubation in critically ill patients undergoing cerebral aneurysm embolization.


Assuntos
Embolização Terapêutica , Aneurisma Intracraniano/fisiopatologia , Aneurisma Intracraniano/terapia , Intubação Intratraqueal/métodos , Laringoscopia/instrumentação , Idoso , Pressão Sanguínea , Estado Terminal , Feminino , Seguimentos , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico
12.
Stroke ; 50(2): 504-506, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30602357

RESUMO

Background and Purpose- Intracranial aneurysm (IA) size and location are important determinants of aneurysm rupture risk. In familial IAs there is concordance of location; however, if such concordance exists for size is unknown. We analyzed the concordance of aneurysm size at time of rupture in familial IAs. Methods- In pairs of affected relatives with aneurysmal subarachnoid hemorrhage, the ratio between the largest and the smallest aneurysm size at time of rupture was calculated. We also compared the proportion of families in which both IAs ruptured at a size < or ≥7 mm with the proportion of families in which one IA ruptured at <7 mm and another ≥7 mm. We calculated the repeatability with corresponding 95% CI for aneurysm size at time of rupture. Results- About 130 patients from 64 families were included. Of the 68 affected pairs 18 (26%) had a ratio ≤1.2, 38 (57%) had a ratio >1.2, and 12 (17%) had a ratio ≥3. We found no difference between the proportion of families (n=31; 49%) who both had IA at time of rupture <7 mm (n=20; 31%) or both ≥7 mm (n=11; 18%) and the proportion of those families with one patient with an IA <7 mm and another with an IA ≥7 mm (n=33; 51%; P=0.86). Overall, the repeatability in aneurysm size at rupture within familial IAs was 0.10 (95% CI, 0-0.35). Conclusions- There is no good concordance in aneurysm size at rupture within familial IAs. These data suggest that size of a ruptured IA in a family member should not significantly impact on the management of a familial unruptured IA in a relative.


Assuntos
Aneurisma Roto/epidemiologia , Aneurisma Roto/fisiopatologia , Aneurisma Intracraniano/epidemiologia , Aneurisma Intracraniano/fisiopatologia , Adulto , Família , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
13.
J Stroke Cerebrovasc Dis ; 28(4): 1099-1106, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30660485

RESUMO

OBJECTIVE: Our objective was to review 15 consecutive patients with anterior circulation aneurysms managed through a contralateral approach. Individualized surgical simulation using three-dimensional (3D) imaging was adopted to enable safe performance of clipping surgery. METHODS: Five patients had multiple intracranial aneurysms, and 10 patients had a single aneurysm on the contralateral side of the craniotomy. Preoperatively, the unique architecture of aneurysms was fully understood in their 3-dimensionality reconstructed by Mimics software. The location of the cranial bone window and the patient's head position was individually optimized using a preoperative simulation system. RESULTS: In this cohort, 17 contralateral aneurysms showed no wall calcifications. Projections of the aneurysms were superomedial (3/17, 17.6%), medial (8/17, 47.1%), posterior (3/17, 17.6%), and superior (3/17, 17.6%). The visual similarity between the simulating scene and the operative view was excellent in 100% of the cases. Four patients were treated with a contralateral pterional approach, and the remaining 11 patients were treated with a contralateral supraorbital keyhole approach. All of them were well-clipped, except 1 blister-like aneurysm being wrapped. All 15 patients had good outcomes (mRS ≤ 3) after a mean 13 months follow-up. There were no recurrences after surgical treatment. CONCLUSIONS: The contralateral approach for the selected anterior circulation aneurysms is feasible in experienced hands with acceptable morbidity. This approach should be the choice only under judicious case-to-case planning based on a preoperative 3D virtual osteotomy technique.


Assuntos
Angiografia Cerebral/métodos , Angiografia por Tomografia Computadorizada/métodos , Craniotomia/métodos , Imagem Tridimensional/métodos , Aneurisma Intracraniano/cirurgia , Osteotomia/métodos , Cirurgia Assistida por Computador/métodos , Adulto , Idoso , Pontos de Referência Anatômicos , Craniotomia/efeitos adversos , Bases de Dados Factuais , Avaliação da Deficiência , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/fisiopatologia , Masculino , Pessoa de Meia-Idade , Osteotomia/efeitos adversos , Modelagem Computacional Específica para o Paciente , Valor Preditivo dos Testes , Cuidados Pré-Operatórios , Interpretação de Imagem Radiográfica Assistida por Computador , Recuperação de Função Fisiológica , Cirurgia Assistida por Computador/efeitos adversos , Resultado do Tratamento
14.
J Neurointerv Surg ; 11(6): 614-617, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30670624

RESUMO

BACKGROUND: Complex and unstable flow patterns are reported to be associated with the rupture status of cerebral aneurysms, while their evaluation depends on qualitative analysis of streamlines of bloodflow. Oscillatory velocity index (OVI) is a hemodynamic parameter to quantify flow patterns. The aim of this study is to elucidate the associations between OVI and the rupture status of cerebral aneurysms. METHODS: One hundred and twenty-nine ruptured and unruptured cerebral aneurysms were analyzed with computational fluid dynamics under pulsatile flow conditions. With the use of median value of OVI, all aneurysms were divided into high and low OVI groups. Statistical analysis was performed to compare rupture status, and morphological and hemodynamic parameters between the two groups. RESULTS: The median value of OVI was 0.006. High OVI was more likely observed in ruptured aneurysms (P=0.028) and associated with irregular shape, complex flow patterns, and unstable flow patterns (P<0.001, respectively). In morphological parameters, maximum size, aspect, projection, size, and volume-to-ostium area ratios were significantly higher in the high OVI group (P<0.001, respectively). In hemodynamic parameters, wall shear stress and wall shear stress gradient were significantly lower, and oscillatory shear index and gradient oscillatory number were significantly higher in the high OVI group (P<0.001, respectively). CONCLUSION: High OVI was associated with rupture status, and morphological and hemodynamic characteristics of ruptured aneurysms. These results indicate that OVI may serve as a valuable hemodynamic parameter for diagnosing rupture status and risks of aneurysms.


Assuntos
Aneurisma Roto/fisiopatologia , Velocidade do Fluxo Sanguíneo/fisiologia , Hemodinâmica/fisiologia , Hidrodinâmica , Aneurisma Intracraniano/fisiopatologia , Fluxo Pulsátil/fisiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma Roto/diagnóstico por imagem , Aneurisma Roto/cirurgia , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Masculino , Microcirurgia/métodos , Pessoa de Meia-Idade , Estresse Mecânico , Adulto Jovem
15.
J Neurol Surg A Cent Eur Neurosurg ; 80(2): 102-108, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30583304

RESUMO

BACKGROUND: Although intraoperative motor-evoked potential (MEP) monitoring is widely performed during neurosurgical operations, evaluating its results is controversial. STUDY AIMS: The cutoff point of MEP monitoring should be determined not only to predict but also to prevent postoperative neurologic deficits. MATERIAL AND METHODS: MEP monitoring was performed during 484 neurosurgical operations for patients without definitive preoperative motor palsy including 325 spinal operations, 102 cerebral aneurysmal operations, and 57 brain tumor operations, all monitored by transcranial stimulation, and 34 brain tumor operations monitored under direct cortical stimulation. To exclude the effects of muscle relaxants on MEP, the compound muscle action potential (CMAP), measured immediately after transcranial stimulation or direct cortical stimulation at supramaximal stimulation of the peripheral nerve, was used for normalization. The cutoff points, sensitivity, and specificity of MEP recorded during neurosurgery were examined by receiver operating characteristic (ROC) analyses and categorized according to the type of operation and stimulation. RESULTS: In spinal operations under transcranial stimulation, amplitude reduction of 77.9% and 80.6% as cutoff points for motor palsy with and without CMAP normalization, respectively, provided a sensitivity of 100% and specificity of 96.8% and 96.5%. In aneurysmal operations under transcranial stimulation, cutoff points of 70.7% and 69.6% offered specificities of 95.2% and 95.7% with and without CMAP normalization, respectively. The sensitivities for both were 100%. In brain tumor operations under direct stimulation, cutoff points were 83.5% and 86.3% with or without CMAP normalization, respectively, and the sensitivity and specificity for both were 100%. CONCLUSION: An amplitude decrease of 80% in brain tumor operations, 75% in spinal operations, and 70% in aneurysmal operations should be used as the cutoff points.


Assuntos
Neoplasias Encefálicas/cirurgia , Potencial Evocado Motor/fisiologia , Aneurisma Intracraniano/cirurgia , Monitorização Neurofisiológica Intraoperatória , Doenças da Medula Espinal/cirurgia , Adulto , Neoplasias Encefálicas/fisiopatologia , Feminino , Humanos , Aneurisma Intracraniano/fisiopatologia , Masculino , Pessoa de Meia-Idade , Nervos Periféricos/fisiopatologia , Valor Preditivo dos Testes , Curva ROC , Doenças da Medula Espinal/fisiopatologia
16.
Neurol Med Chir (Tokyo) ; 59(1): 19-26, 2019 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-30555120

RESUMO

Subarachnoid hemorrhage due to rupture of a pre-existing intracranial aneurysm has quite a poor outcome in spite of intensive medical care. Hemodynamic stress loaded on intracranial arterial walls is considered as a trigger and a regulator of formation and progression of the disease, but how intracranial arterial walls or intracranial aneurysm walls behave under hemodynamic stress loading remains unclear. The purpose of this study was to visualize and analyze the wall motion of intracranial aneurysms to detect a pathological flow condition. We subjected a transgenic rat line, in which endothelial cells are specifically visualized by expression of a green fluorescent protein, to an intracranial aneurysm model and observed a real-time motion of intracranial arterial walls or intracranial aneurysm walls by a multiphoton laser confocal microscopy. The anterior cerebral artery-olfactory artery bifurcation was surgically exposed for the monitoring. First, we observed the proper flow-dependent physiological dilatation of a contralateral intracranial artery in response to increase of blood flow by one side of carotid ligation. Next, we observed intracranial aneurysm lesions induced in a rat model and confirmed that a wall motion of the dome was static, whereas that of the neck was more dynamic in response to pulsation of blood flow. We successfully monitored a real-time motion of intracranial aneurysm walls. Findings obtained from such a real-time imaging will provide us many insights especially about the correlation of mechanical force and the pathogenesis of the disease and greatly promote our understanding of the disease.


Assuntos
Aneurisma Intracraniano/diagnóstico por imagem , Animais , Modelos Animais de Doenças , Aneurisma Intracraniano/patologia , Aneurisma Intracraniano/fisiopatologia , Microscopia Confocal , Ratos , Ratos Wistar , Vasodilatação/fisiologia
17.
J Stroke Cerebrovasc Dis ; 28(3): 845-849, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30579731

RESUMO

INTRODUCTION: Patients with ventriculoperitoneal/pleural (VP) shunts occasionally must undergo subsequent craniotomy, craniectomy, or cranioplasty. Due to changes in pressure dynamics following shunt placement, we hypothesized that such patients may have an increased risk of developing symptomatic collections of extra-axial blood, fluid, and/or air postoperatively, leading to longer stays and worse outcomes compared to those undergoing cranial operations without a VP shunt. METHODS: From a retrospective cohort of patients who underwent cranial operations for management of cerebral aneurysms in 2005-2014, we identified patients who previously had a VP shunt placed, determined the temporal relationship between shunt placement and cranial operation, and investigated outcomes in those with and without a shunt. RESULTS: Of 818 patients who underwent cranial operations, 28 (3.4%) had a VP shunt. Four of these 28 (14.3%, 95% confidence interval [CI] 4.0%-32.7%) developed postoperative complications, compared to 42 of 790 (5.3%, 95% CI 4.0%-7.1%) without a history of VP shunt (P = .07). In addition, patients with a shunt were more likely to have longer cranial procedures (P = .04), longer hospital stays (P = .05), and more computed tomography scans during their craniotomy-associated admission (P = .002). Multivariate analysis, though not significant, demonstrated that the presence of a shunt contributed to the development of complications (odds ratio [OR] 2.24, 95% CI .70-7.13, P = .17). Length of surgery (OR 1.17, 95% CI 1.04-1.31, P = .01) and length of stay (OR 1.04, 95% CI 1.01-1.07, P = .01) were significantly longer in those with a postoperative complication. CONCLUSION: We found a nonsignificant trend toward increased postoperative complications in patients with a VP shunt who underwent a subsequent cranial operation.


Assuntos
Aneurisma Intracraniano/cirurgia , Microcirurgia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Derivação Ventriculoperitoneal/efeitos adversos , Adulto , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/fisiopatologia , Tempo de Internação , Ligadura , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento
18.
Stroke ; 49(12): 2883-2889, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30571422

RESUMO

Background and Purpose- Whether maximal treatment should be offered to elderly patients suffering from poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is controversial. The survival of patients in this subgroup beyond the usual outcome measurements 6 to 12 months after aSAH is unclear. The purpose of this study is to provide survival and outcome data to support clinicians making decisions on treatment for this subgroup of patients. Methods- We performed a retrospective analysis of the Bernese SAH database for poor-grade (World Federation of Neurosurgical Societies grade IV and V) elderly patients (age ≥60 years) suffering from aSAH admitted to our institution from 2005 to 2017. Patients were divided into 3 age groups (60-69, 70-79, and 80-90 years). Survival analysis was performed to estimate mean survival and hazard ratios for death. Binary logarithmic regression was used to estimate the odds ratio for favorable (modified Rankin Scale score of 0-3) and unfavorable (modified Rankin Scale score of 4-6) outcome. Results- Increasing age was associated with an increasing risk of death after aSAH. The hazard ratio increased by 6% per year of age ( P<0.001; hazard ratio, 1.06; 95% CI, 1.03-1.09) and 76% per decade ( P<0.001; hazard ratio, 1.76; 95% CI, 1.35-2.29). Mean survival was 56.3±8 months (patients aged 60-69 years), 31.6±7.6 months (70-79 years), and 7.6±5.8 months (80-90 years). Unfavorable outcomes 6 to 12 months after aSAH were strongly related to older age. The odds ratio increased by 11% per year of age ( P<0.001; odds ratio, 1.11; 95% CI, 1.05-1.18) and 192% per decade ( P<0.001; odds ratio, 2.92; 95% CI, 1.63-5.26). Conclusions- Risk for death and unfavorable outcome increases markedly with older age in elderly patients with poor-grade aSAH. Despite a high initial mortality, treatment resulted in a reasonable proportion of favorable outcomes up to 79 years of age and only a small number of patients who were moderately or severely disabled 6 to 12 months after aSAH. Mean survival and proportion of favorable outcomes decreased markedly in patients older than 80 years.


Assuntos
Aneurisma Roto/mortalidade , Aneurisma Intracraniano/mortalidade , Hemorragia Subaracnóidea/mortalidade , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Aneurisma Roto/fisiopatologia , Feminino , Humanos , Aneurisma Intracraniano/fisiopatologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Ruptura Espontânea , Hemorragia Subaracnóidea/fisiopatologia , Análise de Sobrevida , Taxa de Sobrevida , Suíça
19.
World Neurosurg ; 118: e601-e609, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29990603

RESUMO

BACKGROUND: Orbital compartment syndrome (OCS) is a rare but devastating complication following pterional craniotomy. Although the causes of OCS are unclear, external compression of the orbit by a myocutaneous flap is commonly mentioned as a major factor. We evaluated the ocular influence of external compression using an extraocular pressure monitor. METHODS: We measured extraocular pressure in 86 patients who underwent surgery for cerebral aneurysm via a pterional approach. Clinical information and radiologic parameters, including the area of the medial rectus muscle (MRM) and the craniotomy height from the bottom of the anterior skull base, were collected. As a control group, 117 patients who underwent surgery without pressure monitoring were also evaluated. RESULTS: Extraocular pressure reached a maximum during craniotomy (mean, 22.0 mm Hg; range, 18.4-51.0 mm Hg) and decreased after myocutaneous flap adjustment (mean, 7.9 mm Hg; range, 5.4-17.5 mm Hg). Pressure before myocutaneous flap manipulation differed between patients with anterior communicating artery (Acomm) aneurysms and other patients (mean, 16.5 mm Hg vs. 9.4 mm Hg; P = 0.003). Among Acomm aneurysm cases, the monitored group showed a significantly lower MRM swelling ratio (postoperative MRM area/preoperative MRM area) compared with the control group (1.03 ± 0.10 vs. 1.17 ± 0.15; P = 0.036). CONCLUSIONS: Myocutaneous flaps can produce unnoticed overpressure on the orbit, resulting in OCS-related blindness during aneurysm clipping surgery, especially in cases involving mandatory lower craniotomy. The continuous extraocular compressive pressure monitoring technique is a simple and effective approach to prevent such a serious complication.


Assuntos
Síndromes Compartimentais/prevenção & controle , Craniotomia/métodos , Aneurisma Intracraniano/cirurgia , Órbita/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Retalhos Cirúrgicos , Adulto , Idoso , Idoso de 80 Anos ou mais , Síndromes Compartimentais/diagnóstico por imagem , Síndromes Compartimentais/fisiopatologia , Craniotomia/efeitos adversos , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/fisiopatologia , Pessoa de Meia-Idade , Fenômenos Fisiológicos Oculares , Órbita/diagnóstico por imagem , Órbita/fisiopatologia , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/fisiopatologia , Retalhos Cirúrgicos/efeitos adversos
20.
J Stroke Cerebrovasc Dis ; 27(10): 2691-2695, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30033099

RESUMO

BACKGROUND AND PURPOSE: Spontaneous intracranial arterial dissections are characterized by the sudden disruption of the internal elastic lamina in the intracranial arteries. The purpose of our retrospective study was to investigate whether patients with nontraumatic intracranial arterial dissections had normal endothelial function. METHODS: The study included symptomatic patients with nontraumatic intracranial arterial dissections who underwent an endothelial function test. Controls were selected from headache patients matched for sex and age. Endothelial function was assessed using flow-mediated dilatation. We investigated patients' ankle brachial index and pulse wave velocity to determine the degree of atherosclerosis. Patient characteristics, brachial flow-mediated dilatation, ankle brachial index, and pulse wave velocity were compared between the 2 groups. RESULTS: During the study period, there were 22 patients with nontraumatic intracranial arterial dissections matched with 22 controls. Clinical characteristics were compared between the groups. Although there were no significant differences in ankle brachial index or pulse wave velocity between the 2 groups, patients with intracranial arterial dissections had lower flow-mediated dilatation values than controls (median flow-mediated dilatation, 3.95% in dissection patients versus 7.3% in controls, P = .0035). Brachial flow-mediated dilatation was impaired in symptomatic patients with nontraumatic intracranial arterial dissections despite the normal ankle brachial index and pulse wave velocity. CONCLUSIONS: Impaired brachial flow-mediated dilatation is a probable predictor of intracranial arterial dissections.


Assuntos
Aneurisma Dissecante/fisiopatologia , Artéria Braquial/fisiopatologia , Aneurisma Intracraniano/fisiopatologia , Vasodilatação , Adulto , Aneurisma Dissecante/complicações , Aneurisma Dissecante/diagnóstico , Índice Tornozelo-Braço , Artéria Braquial/diagnóstico por imagem , Angiografia Cerebral , Feminino , Humanos , Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/diagnóstico , Masculino , Pessoa de Meia-Idade , Prognóstico , Análise de Onda de Pulso , Fluxo Sanguíneo Regional , Estudos Retrospectivos , Fatores de Risco , Ultrassonografia Doppler de Pulso
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