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1.
Br J Anaesth ; 124(1): 63-72, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31607388

RESUMO

BACKGROUND: The prospective observational European multicentre cohort study (POPULAR) of postoperative pulmonary complications (NCT01865513) did not demonstrate that adherence to the recommended train-of-four ratio (TOFR) of 0.9 before extubation was associated with better pulmonary outcomes from the first postoperative day up to hospital discharge. We re-analysed the POPULAR data as to whether there existed a better threshold for TOFR recovery before extubation to reduce postoperative pulmonary complications in patients who had quantitative neuromuscular monitoring (87% acceleromyography). METHODS: To identify the optimal TOFR, the complete case cohort of patients with quantitative neuromuscular monitoring (n=3150) was split into several pairs of sub-cohorts related to TOFR values from 0.86 to 0.96; values of 0.97 and higher could not be used as the sub-cohorts were too small. The optimal TOFR was considered to have the lowest P-value from multivariate logistic regression calculated for each of the TOFR values. Data are presented as adjusted absolute risk reduction or median difference with 95% confidence interval. RESULTS: Extubating patients with TOFR >0.95 rather than >0.9 reduced the adjusted risk of postoperative pulmonary complications by 3.5% (0.7-6.0%) from that reported in POPULAR (11.3%). Increasing the recommended TOFR from 0.9 to 0.95 reduced the adjusted risk by 4.9% (1.2-8.5%). Sub-cohorts resulting from 1:1 propensity score matching revealed that sugammadex had been given in higher doses by 0.30 (0.13-0.48) mg kg-1 in the sub-cohort with TOFR > 0.95. CONCLUSIONS: A post hoc analysis of patients receiving quantitative monitoring of neuromuscular function suggests that postoperative pulmonary complications are reduced for TOFR > 0.95 before tracheal extubation compared with TOFR > 0.9. TRIAL REGISTRATION NUMBER: NCT01865513.


Assuntos
Extubação/métodos , Monitorização Neurofisiológica Intraoperatória/métodos , Monitoração Neuromuscular/métodos , Complicações Pós-Operatórias/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestesia , Estudos de Coortes , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio Neuromuscular/métodos , Bloqueadores Neuromusculares , Complicações Pós-Operatórias/epidemiologia , Pontuação de Propensão , Estudos Prospectivos , Comportamento de Redução do Risco , Sugammadex , Adulto Jovem
2.
World Neurosurg ; 132: e28-e33, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31521756

RESUMO

OBJECTIVE: To evaluate whether use of partial nondepolarizing neuromuscular blocking agents, at a train-of-four level 1, compromise facial nerve monitoring during vestibular schwannoma (VS) resection. METHODS: Sixty consecutive patients undergoing VS resection were enrolled into a partial peripheral neuromuscular blockade group or free of neuromuscular blockade group. Stimulation threshold to elicit an electromyographic response amplitude of at least 100 µV was recorded at the proximal and distal facial nerve after VS removal. The proximal-to-distal ratio of amplitude of the orbicularis oculi and oris muscles was calculated. RESULTS: All patients successfully passed the electromyography monitoring test. Mean electrical stimulation thresholds were higher in the peripheral neuromuscular blockade group than in the free of neuromuscular blockade group (0.12 mA vs. 0.06 mA at proximal site, P = 0.001; 0.08 mA vs. 0.03 mA at distal site, P = 0.0002). The differences in median proximal-to-distal amplitude ratios were not statistically significant in both groups. There was a trend toward more patients needing phenylephrine. Recovery profiles were comparable in the 2 groups. CONCLUSIONS: Although mean stimulation threshold to elicit a response amplitude was higher in the peripheral neuromuscular blockade group than in the free of neuromuscular blockade group at the proximal site, the stimulation thresholds in both groups were sufficient for facial nerve monitoring in VS surgery, indicating no clinical difference in both groups.


Assuntos
Eletromiografia , Nervo Facial , Monitorização Neurofisiológica Intraoperatória/métodos , Neuroma Acústico/cirurgia , Bloqueio Neuromuscular , Adulto , Período de Recuperação da Anestesia , Estimulação Elétrica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Músculos Oculomotores/efeitos dos fármacos , Músculos Oculomotores/cirurgia , Fenilefrina/farmacologia , Simpatomiméticos/farmacologia
3.
World Neurosurg ; 131: 191-193, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31394364

RESUMO

BACKGROUND: Vagus nerve stimulation is a palliative treatment for patients with refractory epilepsy; however, the misplacement of electrodes may cause complications and thus needs to be avoided. METHODS: We herein report an intraoperative monitoring technique to prevent the misplacement of electrodes. Endotracheal tube electrodes were inserted to record electromyographic activity from the vocal cords and identify the vagus nerve. Electromyography electrodes were placed on the sternomastoid muscle, sternohyoid muscle, geniohyoid muscle, and trapezius muscle to record muscle activities innervated by the ansa cervicalis. The vagus nerve and ansa cervicalis were electrically stimulated during surgery, and electromyography of the vocal cords and muscles innervated by the ansa cervicalis was recorded. The threshold of vagus nerve activation ranged between 0.05 and 0.75 mA. RESULTS: The vagus nerve was successfully identified and differentiated from the nerve root of the ansa cervicalis using this technique. CONCLUSIONS: Intraoperative monitoring of the vagus nerve and ansa cervicalis is useful for safe and effective vagus nerve stimulation.


Assuntos
Monitorização Neurofisiológica Intraoperatória , Estimulação do Nervo Vago , Adolescente , Adulto , Idoso , Criança , Epilepsia Resistente a Medicamentos/fisiopatologia , Epilepsia Resistente a Medicamentos/cirurgia , Estimulação Elétrica , Eletromiografia , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Masculino , Pessoa de Meia-Idade , Músculo Esquelético/fisiopatologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Nervo Vago/fisiopatologia , Nervo Vago/cirurgia , Estimulação do Nervo Vago/métodos , Prega Vocal/fisiopatologia , Adulto Jovem
4.
J Clin Neurosci ; 69: 104-108, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31416732

RESUMO

This retrospective study aims to explore the clinical utility of microelectrode recording (MER) during subthalamic deep brain stimulation (DBS) surgery in patients with Parkinson's disease (PD). We analyzed the data from 103 PD patients, who consecutively received bilateral subthalamic nucleus (STN) DBS at an experienced academic medical center. We collected demographic, clinical, and DBS related data, including intraoperative microelectrode recording data, electrode positioning, and clinical effects provided by intraoperative microstimulation. The 2 brain sides were independently analyzed and are described as first and second side (to be operated on); the first side is contralateral to motor symptoms onset. Patients were mostly men (64.1%). In both sides of the brain, percentage of agreement with the electrode final position was higher with clinical results than with intraoperative microelectrode recordings (98% vs 57% on the first implantation side, and 97% vs 58% on the second implantation side, respectively). Regarding electrode final implantation depth, 86% of electrodes were implanted between 0 mm and +2 mm in relation to anatomical target, and 95% of electrodes were implanted from -2 mm to +2 mm. Our study suggests that MER might not be necessary to achieve good clinical outcomes in PD patients undergoing STN DBS. These results support and inform the design of future prospective controlled research studies.


Assuntos
Estimulação Encefálica Profunda/métodos , Monitorização Neurofisiológica Intraoperatória/métodos , Doença de Parkinson/terapia , Eletrodos Implantados , Feminino , Humanos , Masculino , Microeletrodos , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Núcleo Subtalâmico/fisiologia
5.
World Neurosurg ; 132: e487-e495, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31449992

RESUMO

OBJECTIVE: During deep brain stimulation (DBS) surgery, microelectrode recording (MER) leads to target refinement from the initial plan in 30% to 47% of hemispheres; however, it is unclear whether the DBS lead ultimately resides within the MER-optimized target in relation to initial radiographic target coordinates in these hemispheres. This study aimed to determine the frequency of discordance between radiographic and neurophysiologic nucleus and whether target optimization with MER leads to a significant change in DBS lead location away from initial target. METHODS: Consecutive cases of DBS surgery with MER using intraoperative computed tomography were included. Coordinates of initial anatomic target (AT), MER-optimized target (MER-O) and DBS lead were obtained. Hemispheres were categorized as "discordant" (D) if there was a suboptimal neurophysiologic signal despite accurate targeting of AT. Hemispheres where the first MER pass was satisfactory were deemed "concordant" (C). Coordinates and radial distances between 1) AT/MER-O; 2) MER-O/DBS; and 3) AT/DBS were calculated and compared. RESULTS: Of the 273 hemispheres analyzed, 143 (52%) were D, and 130 (48%) were C. In C hemispheres, DBS lead placement error (mean ± standard error of the mean) was 0.88 ± 0.07 mm. In D hemispheres, MER resulted in significant migration of DBS lead (mean AT-DBS error 2.11 ± 0.07 mm), and this distance was significantly greater than the distance between MER-O and DBS (2.11 vs. 1.09 mm, P < 0.05). Directional assessment revealed that the DBS lead migrated in the intended direction as determined by MER-O in D hemispheres, except when the intended direction was anterolateral. CONCLUSIONS: Discordance between radiographic and neurophysiologic target was seen in 52% of hemispheres, and MER resulted in appropriate deviation of the DBS lead toward the appropriate target. The actual value of the deviation, when compared with DBS lead placement error in C hemispheres, was, on average, small.


Assuntos
Estimulação Encefálica Profunda/métodos , Monitorização Neurofisiológica Intraoperatória/métodos , Transtornos dos Movimentos/terapia , Neuronavegação/métodos , Idoso , Eletrodos Implantados , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Microeletrodos , Pessoa de Meia-Idade , Neuroimagem/métodos , Tomografia Computadorizada por Raios X
6.
World Neurosurg ; 132: e563-e576, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31442644

RESUMO

BACKGROUND: Recent data suggest a favorable benefit/risk ratio for insular glioma surgery. However, it remains unknown if this is also applicable in the learning period of this expertise. Moreover, little is known about the neuropsychological outcomes after resection of insular glioma. OBJECTIVE: To report an initial experience of isocitrate dehydrogenase (IDH)-mutated insular glioma resection and to contribute to our knowledge of neuropsychological outcomes after insular glioma resection. METHODS: A consecutive series of 12 patients operated on for an IDH-mutated insular glioma was retrospectively reviewed. Surgery was performed through a transopercular approach. In 10 of the 12 patients, brain mapping with electric stimulation in an awake patient guided the resection. The extent of resection was assessed by volumetric measures of postoperative fluid-attenuated inversion recovery magnetic resonance imaging. Areas of postoperative ischemia were detected by diffusion imaging. Neurologic, neuropsychological, and professional outcomes were retrieved from medical files. RESULTS: The median extent of resection was 94% (range, 80%-100%). None of the patients had permanent speech or motor deficits. Areas of ischemia were observed in 75% of patients. Neuropsychological evaluations showed slight deterioration regarding lexical abilities and verbal memory in patients with left-sided tumors. Patients' performances in cognitive flexibility also commonly declined, regardless of the tumor side. Eight of the 9 patients working at the time of the surgery were able to resume their professional activity. CONCLUSIONS: Resecting insular glioma under brain mapping techniques is a safe option, even during the learning period. Patients should be informed about the risk of mild deterioration of lexical abilities and cognitive flexibility.


Assuntos
Neoplasias Encefálicas/cirurgia , Córtex Cerebral/cirurgia , Glioma/cirurgia , Monitorização Neurofisiológica Intraoperatória/métodos , Procedimentos Neurocirúrgicos/métodos , Adulto , Idoso , Mapeamento Encefálico/métodos , Neoplasias Encefálicas/genética , Feminino , Glioma/genética , Humanos , Isocitrato Desidrogenase/genética , Masculino , Pessoa de Meia-Idade , Mutação , Estudos Retrospectivos , Adulto Jovem
7.
Braz J Cardiovasc Surg ; 34(4): 484-487, 2019 08 27.
Artigo em Inglês | MEDLINE | ID: mdl-31454204

RESUMO

Placement of a mediastinal drain is a routine procedure following heart surgery. Postoperative bed rest is often imposed due to the fear of potential risk of drain displacement and cardiac injury. We developed an encapsulating stitch as a feasible, effective and low-cost technique, which does not require advanced surgical skills for placement. This simple, novel approach compartmentalizes the drain allowing for safe early mobilization following cardiac surgery.


Assuntos
Ponte de Artéria Coronária , Drenagem/instrumentação , Monitorização Neurofisiológica Intraoperatória/métodos , Mediastino/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Drenagem/métodos , Estudos de Viabilidade , Ventrículos do Coração/lesões , Humanos , Derrame Pericárdico/prevenção & controle
8.
World Neurosurg ; 130: e880-e887, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31301441

RESUMO

BACKGROUND: The basal ganglia and thalamus are uncommon locations for infiltrating gliomas. Tumors here are usually managed with biopsy and adjuvant therapy, with relatively poor results. Rarely do patients undergo extensive surgical intervention. It seems reasonable to suggest that successful cytoreduction may help these patients. However, this hypothesis has not been studied because of the general view that it is not possible to remove deep-seated brain tumors with acceptable outcomes. METHODS: Through retrospective data collection, we describe a small case series of patients undergoing awake contralateral, transcallosal surgery for deep-seated brain tumors affecting the basal ganglia. We describe our patient cohort, report on patient outcomes, and describe our surgical technique. RESULTS: Four patients underwent awake contralateral, transcallosal surgery for glioblastoma invading the basal ganglia. All 4 patients demonstrated hemibody weakness contralateral to the side of their tumors, with 3 patients confined to wheelchairs at presentation. Their ages ranged from 25 to 64 years. Tumor volumes ranged from 14 to 93 cm3. More than 50% resection of each tumor was achieved during surgery. In 2 cases, approximately 90% resection was achieved. Motor strength improved in 1 patient who presented with hemiplegia. Two patients required ventriculoperitoneal shunting for complications related to hydrocephalus. At the writing of this article, 2 of our patients were still alive, functional, and free of tumor progression. CONCLUSIONS: We present the results of our attempts to resect large gliomas infiltrating the basal ganglia in 4 patients. Our technique combined a contralateral, transcallosal approach with awake neuromonitoring. Our results suggest it is possible to remove these tumors with reasonable outcomes.


Assuntos
Gânglios da Base/cirurgia , Neoplasias Encefálicas/cirurgia , Corpo Caloso/cirurgia , Glioma/cirurgia , Procedimentos Neurocirúrgicos/métodos , Vigília , Adulto , Gânglios da Base/diagnóstico por imagem , Neoplasias Encefálicas/diagnóstico por imagem , Estudos de Coortes , Corpo Caloso/diagnóstico por imagem , Feminino , Seguimentos , Glioma/diagnóstico por imagem , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
9.
Handb Clin Neurol ; 161: 327-342, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31307611

RESUMO

Electrophysiologic techniques are available to measure many of the cranial nerves. The procedures can be done using equipment available in standard clinical neurophysiology laboratories. These studies can aid in localization of cranial nerve lesions as well help identify the underlying pathology and possibly aid in prognosis. The trigeminal pathways can be measured using the blink and masseter responses. The facial nerve is measured by the blink response and by direct facial stimulation; techniques such as lateral spread can identify specific abnormalities. The spinal accessory nerve is measured using nerve conduction techniques. Needle examination can be routinely performed on muscles innervated by cranial nerves V, VII, X, XI and XII. These studies reliably measure the functional integrity of cranial nerves and their central pathways. Intraoperative monitoring of the cranial nerves is useful in certain surgeries. This chapter reviews current techniques used to evaluate cranial nerves, emphasizing the methods available in most clinical neurophysiology laboratories.


Assuntos
Doenças dos Nervos Cranianos/diagnóstico , Doenças dos Nervos Cranianos/fisiopatologia , Eletrodiagnóstico/métodos , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos
10.
J Clin Neurosci ; 67: 221-225, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31279700

RESUMO

Most current awake craniotomy techniques utilize unnecessarily complicated airway management, and cause discomfort to the patients during the awake phase of the surgery. Our manuscript is written to discuss the neurosurgical and anesthetic techniques that we have developed to optimize awake craniotomy techniques at Stony Brook University Medical Center. We used the frameless Brainlab™ skull-mounted array for stereotactic navigation. Rigid fixation of the skull was avoided. General anesthesia with established airway was used during the "asleep" phase of the surgery. Following the removal of the bone flap and the opening of the dura, the patients were woken up, and the established airway was removed. Cortical mapping was performed to establish a safe entry zone for tumor removal. While the tumors were being removed, we continued motor examination and casual conversation with the patients to ensure safety. Patients were sedated during the remaining phase of the surgery until skin closure. No patient exhibited any neurological deficits or adverse anesthesia outcomes during the postoperative period. The protocol we developed avoids rigid skull fixation and emphasizes flexible intraoperative planning, thereby maximizing patient and physician comfort while allowing for successful tumor resection.


Assuntos
Anestesia Geral/métodos , Mapeamento Encefálico/métodos , Craniotomia/métodos , Monitorização Neurofisiológica Intraoperatória/métodos , Técnicas Estereotáxicas , Adulto , Neoplasias Encefálicas/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Vigília
11.
J Neurol ; 266(9): 2244-2251, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31155683

RESUMO

The pedunculopontine nucleus (PPN) is engaged in posture and gait control, and neuronal degeneration in the PPN has been associated with Parkinsonian disorders. Clinical outcomes of deep brain stimulation of the PPN in idiopathic Parkinson's disease (IPD) and progressive supranuclear palsy (PSP) differ, and we investigated whether the PPN is differentially affected in these conditions. We had the rare opportunity to record continuous electrophysiological data intraoperatively in 30 s blocks from single microelectrode contacts implanted in the PPN in six PSP patients and three IPD patients during rest, passive movement, and active movement. Neuronal spikes were sorted according to shape using a wavelet-based clustering approach to enable comparisons between individual neuronal firing rates in the two disease states. The action potential widths showed a bimodal distribution consistent with previous findings, suggesting spikes from noncholinergic (likely glutamatergic) and cholinergic neurons. A higher PPN spiking rate of narrow action potentials was observed in the PSP than in the IPD patients when pooled across all three conditions (Wilcoxon rank sum test: p = 0.0141). No correlation was found between firing rate and disease severity or duration. The firing rates were higher during passive movement than rest and active movement in both groups, but the differences between conditions were not significant. PSP and IPD are believed to represent distinct disease processes, and our findings that the neuronal firing rates differ according to disease state support the proposal that pathological processes directly involving the PPN may be more pronounced in PSP than IPD.


Assuntos
Potenciais de Ação/fisiologia , Monitorização Neurofisiológica Intraoperatória/métodos , Neurônios/fisiologia , Doença de Parkinson/fisiopatologia , Núcleo Tegmental Pedunculopontino/fisiologia , Paralisia Supranuclear Progressiva/fisiopatologia , Idoso , Estudos de Coortes , Eletrodos Implantados , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/instrumentação , Masculino , Pessoa de Meia-Idade , Doença de Parkinson/diagnóstico , Doença de Parkinson/cirurgia , Paralisia Supranuclear Progressiva/diagnóstico , Paralisia Supranuclear Progressiva/cirurgia
12.
Anticancer Res ; 39(6): 3203-3205, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31177168

RESUMO

We report a case of esophageal cancer with a non-recurrent inferior laryngeal nerve associated with aberrant right subclavian artery that was treated by neck dissection using intraoperative neurological monitoring followed by thoracoscopic esophagectomy. A 76-year-old man had dysphagia. Endoscopy revealed thoracic esophageal cancer, and computed tomography revealed the presence of an aberrant right subclavian artery between the esophagus and vertebrae. We performed neck dissection followed by thoracoscopic esophagectomy. During the neck dissection, we confirmed a non-recurrent inferior laryngeal nerve through intraoperative neurological monitoring. No postoperative complications were observed, and the patient was discharged 19 days after surgery. We recommend using intraoperative neurological monitoring to avoid injury to the non-recurrent inferior laryngeal nerve associated with the aberrant right subclavian artery.


Assuntos
Anormalidades Cardiovasculares/complicações , Neoplasias Esofágicas/cirurgia , Carcinoma de Células Escamosas do Esôfago/cirurgia , Esofagectomia/métodos , Monitorização Neurofisiológica Intraoperatória/métodos , Esvaziamento Cervical/métodos , Nervo Laríngeo Recorrente/anormalidades , Artéria Subclávia/anormalidades , Toracoscopia , Idoso , Anormalidades Cardiovasculares/diagnóstico por imagem , Neoplasias Esofágicas/complicações , Neoplasias Esofágicas/diagnóstico por imagem , Carcinoma de Células Escamosas do Esôfago/complicações , Carcinoma de Células Escamosas do Esôfago/diagnóstico , Humanos , Traumatismos do Nervo Laríngeo/etiologia , Traumatismos do Nervo Laríngeo/prevenção & controle , Masculino , Esvaziamento Cervical/efeitos adversos , Fatores de Risco , Artéria Subclávia/diagnóstico por imagem , Resultado do Tratamento
13.
World Neurosurg ; 122: 43-47, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-31108065

RESUMO

BACKGROUND: The intraoperative use of neurophysiological monitoring (IONM) and indocyanine green video angiography (ICGVA) for aneurysm clipping have evolved during the last years. Both modalities are useful and safe by allowing greater rates of complete aneurysm occlusion with less intraoperative complications and postoperative neurologic deficits. We report a case of attempted aneurysm clipping in which the combined use of ICGVA and IONM was crucial for intraoperative decision-making. CASE DESCRIPTION: A 62-year-old woman was operated for an incidental 6-mm aneurysm at the origin of the right fronto-opercular branch. During aneurysm clipping, IONM amplitudes dropped drastically, despite patency of the parent artery and perforators in ICGVA. Several attempts for clipping were made with recurring drops in IONM amplitudes, which forced us to leave the aneurysm untreated. The patient had a postoperative left-sided hemiparesis that improved on follow-up. Thereafter, the aneurysm was treated with stent-assisted coiling. CONCLUSIONS: The combination of IONM and ICGVA during aneurysm surgery allows for a better assessment of vascular integrity and patient's postoperative outcome than ICGVA alone. Simultaneous evaluation of vessel patency and integrity of the somatosensory and motor pathways illustrates the complementarity of testing different modalities for intraoperative decision-making and for maximizing safeness in aneurysm clipping.


Assuntos
Aneurisma Intracraniano/cirurgia , Angiografia Cerebral/métodos , Corantes , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Humanos , Verde de Indocianina , Aneurisma Intracraniano/diagnóstico por imagem , Monitorização Neurofisiológica Intraoperatória/métodos , Pessoa de Meia-Idade , Stents , Resultado do Tratamento , Cirurgia Vídeoassistida/métodos
14.
Surg Radiol Anat ; 41(8): 889-900, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31028450

RESUMO

PURPOSE: The arcuate fasciculus (AF) is a white matter fibers tract that links the lateral temporal with the frontal cortex. The AF can be divided into three components: two superficial indirect short tracts (anterior and posterior) and one deep direct long tract. Both DTI and white matter dissections studies find differences regarding the anatomy of the AF, especially its cortical connections. This paper aims at providing a comprehensive anatomical classification of the AF, using the terminologia anatomica. METHODS: Articles (n = 478) were obtained from a systematical PRISMA review. Studies which focused on primates, unhealthy subjects, as well as studies without cortical termination description and review articles were excluded from the analysis. One hundred and ten articles were retained for full-text examination, of which 19 finally fulfilled our criteria to be included in this review. RESULTS: We classified main descriptions and variations of each segment of the AF according to fiber orientation and cortical connections. Three types of connections were depicted for each segment of the AF. Concerning the anterior segment, most of the frontal fibers (59.35%) ran from the ventral portion of the precentral gyrus and the posterior part of the pars opercularis, to the supramarginal gyrus (85.0%). Main fibers of the posterior segment of the AF ran from the posterior portion of the middle temporal gyrus (100%) to the angular gyrus (92.0%). In main descriptions of the long segment of the AF, fibers ran from both the ventral portion of the precentral gyrus and posterior part of the pars opercularis (63.9%) to the middle and inferior temporal gyrus (60.3%). Minor subtypes were described in detail in the article. CONCLUSION: We provide a comprehensive classification of the anatomy of the AF, regarding the orientation and cortical connections of its fibers. Although fiber orientation is very consistent, cortical endings of the AF may be different from one study to another, or from one individual to another which is a key element to understand the anatomical basis of current models of language or to guide intraoperative stimulation during awake surgery.


Assuntos
Variação Anatômica , Lobo Frontal/anatomia & histologia , Vias Neurais/anatomia & histologia , Lobo Temporal/anatomia & histologia , Substância Branca/anatomia & histologia , Imagem de Tensor de Difusão , Lobo Frontal/diagnóstico por imagem , Lobo Frontal/fisiologia , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Vias Neurais/diagnóstico por imagem , Vias Neurais/fisiologia , Procedimentos Neurocirúrgicos/métodos , Fala/fisiologia , Lobo Temporal/diagnóstico por imagem , Lobo Temporal/fisiologia , Vigília , Substância Branca/diagnóstico por imagem , Substância Branca/fisiologia
15.
J Clin Neurosci ; 64: 77-82, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31014908

RESUMO

Re-appearance of trigeminal neuralgia (TN) pain following microvascular decompression (MVD) is a challenging issue. A selective ablation with MVD provides the best response in such recurrences. The absence of intra-operative indicator for immediate correction of sub-optimal decompression is the primary factor for failure. We analysed the effectiveness and safety of awake MVD in minimizing failure, by tailoring the procedure according to intra-operative response with re-exploration or additional procedure like internal neurolysis in the same setting, especially in patients without vascular compression and those unfit for General Anesthesia (GA). The prospective study from June 2016 to June 2017 includes one glossopharyngeal neuralgia (GPN) and 6 trigeminal neuralgia (TN). Five cases responded with immediate complete pain relief but in 2 cases, incomplete pain relief resulted in alteration of intraoperative decision. In one case, a partial pain relief, mandated an additional internal neurolysis in the same setting, resulting in complete pain relief while in the other, re-exploration revealed a hidden venous conflict, not identified on MRI following which an additional IN was performed. All cases were followed up with BNI PIS for a minimum of one year without recurrence. Awake MVD is safe and reliable intraoperative neurophysiological prognostic marker of immediate pain relief and provides a window for an immediate correction of sub-optimal decompression with Internal Neurolysis when needed, in the same setting, especially in neuroimaging negative and elderly cases unfit for GA. It has the potential to reduce the rate of re-intervention and increase the overall effectiveness of MVD by specifically ameliorating the pain burden and quality of life.


Assuntos
Monitorização Neurofisiológica Intraoperatória/métodos , Cirurgia de Descompressão Microvascular/métodos , Neuralgia do Trigêmeo/cirurgia , Idoso , Nervos Cranianos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Politetrafluoretileno , Estudos Prospectivos , Recidiva , Reoperação/métodos , Resultado do Tratamento , Vigília
16.
Eur J Orthop Surg Traumatol ; 29(6): 1177-1185, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31016452

RESUMO

BACKGROUND: A prospective clinical study of amplitudes of intraoperative transcranial motor-evoked potentials (TcMEPs) was performed in patients undergoing surgery for the posterior longitudinal ligament of thoracic spine (T-OPLL). OBJECTIVE: To investigate intraoperative TcMEPs during posterior decompression and dekyphotic corrective fusion with instrumentation for T-OPLL. METHODS: The subjects were 33 patients with an average age of 48 years at surgery who underwent posterior decompression and fusion with instrumentation under intraoperative TcMEP monitoring. Age, gender, BMI, modified McCormick scale, prone and supine position test (PST), operative time, estimated blood loss, and Japanese Orthopaedic Association (JOA) score were recorded. Rates of successful appearance of TcMEPs, factors related to successful appearance, intraoperative amplitude changes, procedures related to amplitude deterioration, recovery of amplitude, procedures related to recovery, and postoperative paralysis were also investigated. RESULTS: The rate of appearance was highest from the abductor hallucis (AH) (83.3%) compared with other muscles. There were 24 cases with amplitude deterioration: during exposure in 6, screwing in 2, and decompression in 16. No deterioration occurred during rod placement. There were 13 (39%) with postoperative motor deficits. Significantly lower rates of amplitude appearance occurred in cases with BMI, positive PST, modified McCormick scale IV, and preoperative JOA score. CONCLUSIONS: AH muscles were particularly useful for functional assessment of corticospinal conduction. High BMI, positive PST, modified McCormick scale IV, and low preoperative JOA score were associated with low rates of amplitude appearance. Amplitude deteriorations occurred throughout surgery, except during rod placement, and speedy rigid rod placement is important.


Assuntos
Descompressão Cirúrgica , Potencial Evocado Motor , Monitorização Neurofisiológica Intraoperatória/métodos , Ossificação do Ligamento Longitudinal Posterior/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Fusão Vertebral , Descompressão Cirúrgica/efeitos adversos , Descompressão Cirúrgica/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Fusão Vertebral/efeitos adversos , Fusão Vertebral/métodos , Vértebras Torácicas/cirurgia , Estimulação Transcraniana por Corrente Contínua/métodos , Resultado do Tratamento
17.
World Neurosurg ; 127: e1044-e1050, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30980975

RESUMO

OBJECTIVE: Corkscrew (CS) electrodes are usually used for transcranial electrical stimulation (TES) in the intraoperative monitoring of motor evoked potentials (MEP). Direct cranial stimulation with peg-screw (PS) electrodes can elicit MEP. The present study investigated the difference in the initial threshold between PS and CS electrodes for intraoperative MEP monitoring. METHODS: We retrospectively analyzed TES-MEP monitoring for supratentorial surgery in 72 patients. Of these 72 patients, 44 were monitored with PS and CS electrodes (PS/CS group) and 28 were monitored with CS and CS electrodes (CS/CS group). TES was used to deliver electrical stimulation by a train of 4-pulse anodal constant current stimulation. The initial threshold in each electrode was checked and analyzed. RESULTS: In the PS/CS group, the initial threshold with the PS electrode was 38.3 ± 15.1 mA (mean ± standard deviation) on the affected side, and the initial threshold with the CS electrode was 51.4 ± 13.9 mA on the unaffected side. The initial threshold with the PS electrode was significantly lower than that with the CS electrode (P = 0.0001). In the CS/CS group, the initial threshold was 56.2 ± 16.5 mA on the affected side and 62.1 ± 18.6 mA on the unaffected side, with no statistically significant difference (P = 0.23). CONCLUSION: The initial threshold to elicit MEP was significantly lower with the PS electrode than with the CS electrode. A PS electrode can be used as a feasible stimulation electrode for TES-MEP.


Assuntos
Parafusos Ósseos , Eletrodos Implantados , Potencial Evocado Motor/fisiologia , Monitorização Neurofisiológica Intraoperatória/métodos , Crânio/cirurgia , Estimulação Transcraniana por Corrente Contínua/métodos , Adolescente , Adulto , Idoso , Parafusos Ósseos/normas , Encéfalo/fisiologia , Encéfalo/cirurgia , Criança , Eletrodos Implantados/normas , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/instrumentação , Monitorização Neurofisiológica Intraoperatória/normas , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estimulação Transcraniana por Corrente Contínua/instrumentação , Estimulação Transcraniana por Corrente Contínua/normas , Adulto Jovem
18.
Acta Cytol ; 63(3): 224-232, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30982032

RESUMO

OBJECTIVE: Intraoperative examination is a highly valuable tool for the evaluation of central nervous system (CNS) lesions, helping the neurosurgeon to determine the best surgical management. This study aimed to evaluate the accuracy and to analyze the diagnostic disagreements and pitfalls of the intraoperative examinations through correlation with the final histopathological diagnosis in CNS lesions. STUDY DESIGN: Retrospective analysis of intraoperative examination of CNS lesions and their final diagnosis obtained during 16 consecutive years. All diagnoses were reviewed and classified according to World Health Organization (WHO) grading for CNS tumors. Squash was performed in 119 cases, while frozen section and both methods were done in 7 cases each. RESULTS: Among the 133 intraoperative examinations considered, 114 (85.7%) presented concordance and 19 (14.3%) diagnostic disagreement when compared with subsequent histopathological examinations. The sensitivity and specificity for the detection of neoplasia in intraoperative examination was 98 and 94%, respectively. The positive and negative predictive values were 99 and 88%, respectively. The accuracy for neoplastic and nonneoplastic disease was 85.7%. Disagreements were more frequent among low-grade (WHO grades I and II) neoplasms and nonmalignant cases. CONCLUSIONS: Our results showed good accuracy of the intraoperative assessments for diagnosis of CNS lesions, particularly in high-grade (grades III and IV) lesions and metastatic neoplasms.


Assuntos
Doenças do Sistema Nervoso Central/diagnóstico , Neoplasias do Sistema Nervoso Central/diagnóstico , Sistema Nervoso Central/patologia , Monitorização Neurofisiológica Intraoperatória/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Sistema Nervoso Central/fisiopatologia , Sistema Nervoso Central/cirurgia , Doenças do Sistema Nervoso Central/fisiopatologia , Doenças do Sistema Nervoso Central/cirurgia , Neoplasias do Sistema Nervoso Central/fisiopatologia , Neoplasias do Sistema Nervoso Central/cirurgia , Criança , Pré-Escolar , Citodiagnóstico/métodos , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sensibilidade e Especificidade , Adulto Jovem
19.
Eur Arch Otorhinolaryngol ; 276(7): 1915-1920, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30955064

RESUMO

OBJECTIVES: To assess the diagnostic capacity of intraoperative neurophysiological monitoring with respect to "gold standard" microscopic findings of facial canal dehiscence in middle ear cholesteatoma surgery. STUDY DESIGN, PATIENTS AND SETTING: We carried out a retrospective cohort study of 57 surgical interventions for cholesteatoma between 2008 and 2013 at Hospital Universitario de Canarias, Spain. DIAGNOSTIC INTERVENTIONS: Each patient underwent preoperative computed tomography (CT), intraoperative neurophysiological monitoring and intraoperative inspection of the facial nerve during microsurgery. Diagnostic concordance on the presence/absence of facial canal dehiscence was assessed in 54 surgical interventions. MAIN OUTCOME: Presence of facial canal dehiscence. RESULTS: Of 57 interventions, 39 were primary surgeries; 11 (28.2%) showed facial canal dehiscence. and 18 were revision surgeries; 6 (33.3%) showed facial canal dehiscence. The facial nerve was not damaged in any patient. Facial canal dehiscence was observed in 17 (29.82%) interventions. We used intraoperative microscopic findings as the gold standard. Neurophysiological study showed a sensitivity of 94.1, specificity 97.3, positive predictive value (PPV) 57.8 and negative predictive value of 97.2. CT showed a sensitivity of 64.7, specificity 78.4, PPV 57.8 and negative predictive value of 82. CONCLUSIONS: Our neurophysiological study showed greater sensitivity and higher PPV than CT for the detection of facial canal dehiscence. We found no relationship between disease progression time and the presence of facial canal dehiscence.


Assuntos
Colesteatoma da Orelha Média , Traumatismos do Nervo Facial , Complicações Intraoperatórias/prevenção & controle , Monitorização Neurofisiológica Intraoperatória/métodos , Procedimentos Cirúrgicos Otológicos , Adulto , Colesteatoma da Orelha Média/diagnóstico , Colesteatoma da Orelha Média/fisiopatologia , Colesteatoma da Orelha Média/cirurgia , Traumatismos do Nervo Facial/etiologia , Traumatismos do Nervo Facial/prevenção & controle , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Otológicos/efeitos adversos , Procedimentos Cirúrgicos Otológicos/métodos , Estudos Retrospectivos , Sensibilidade e Especificidade , Espanha , Tomografia Computadorizada por Raios X/métodos
20.
World Neurosurg ; 127: e644-e648, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30947011

RESUMO

BACKGROUND: The outcome of neurophysiologic motor evoked potential (MEP) monitoring during surgery for Chiari formation by atlantoaxial fixation and without any bone or dural foramen magnum decompression is analyzed. METHODS: During the period August 2017 to October 2018, 20 patients having Chiari formation with or without syringomyelia were surgically treated by atlantoaxial fixation. Apart from other forms of monitoring, MEP monitoring formed the basis of study. MEP monitoring was done during various phases of surgery that included monitoring immediately after screw tightening for atlantoaxial fixation. RESULTS: It was observed that there was positive improvement in MEP in 100% of the patients when measured in the surgical stage immediately after the procedure of screw tightening for atlantoaxial fixation. The improvement in MEP correlated with parallel improvement in neurologic function. CONCLUSIONS: Improvement in MEP adds credence to the hypothesis that atlantoaxial instability forms the nodal point of pathogenesis of Chiari formation.


Assuntos
Malformação de Arnold-Chiari/cirurgia , Articulação Atlantoaxial/cirurgia , Potencial Evocado Motor/fisiologia , Monitorização Neurofisiológica Intraoperatória/métodos , Instabilidade Articular/cirurgia , Adolescente , Adulto , Malformação de Arnold-Chiari/diagnóstico por imagem , Malformação de Arnold-Chiari/epidemiologia , Articulação Atlantoaxial/diagnóstico por imagem , Criança , Eletromiografia/métodos , Feminino , Humanos , Instabilidade Articular/diagnóstico por imagem , Instabilidade Articular/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
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