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1.
J Clin Neurosci ; 79: 224-230, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33070901

RESUMO

Intraoperative cortical mapping provides functional information that permits the safe and maximal resection of supratentorial lesions infiltrating the so-called eloquent cortex or subcortical white matter tracts. Primary and secondary brain tumours located in eloquent cortex can render surgical treatment ineffective if it results in new or worsening neurology. A cohort of forty-six consecutive patients with supratentorial tumours of variable pathology involving eloquent cortical regions and aided with intraoperative neurophysiology were included for retrospective analysis at a single-centre tertiary institution. Intraoperative neurophysiological data has been related to immediate post-operative neurologic status as well as 3-month follow-up in patients that underwent awake or asleep surgical resection. Patients that experienced new or worsening neurologic symptoms post-operatively demonstrated a high incidence of recovery at 3-months. Those without new neurologic symptoms post-operatively demonstrated little to no worsening at 3-months. Our study explored the extent to which cortical mapping permitted safe surgical resection whilst preserving neurologic function. To the authors' knowledge this is the first documented case series in Singapore that has incorporated a systematic and individually tailored multimodal workflow to cortico-subcortical mapping and monitoring for the safe resection of infiltrative lesions of the supratentorial region.


Assuntos
Mapeamento Encefálico/métodos , Craniotomia/métodos , Eletroencefalografia/métodos , Monitorização Neurofisiológica Intraoperatória/métodos , Neoplasias Supratentoriais/cirurgia , Adulto , Craniotomia/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Vigília
2.
Anesth Analg ; 131(5): 1520-1528, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33079875

RESUMO

BACKGROUND: Cerebral blood flow (CBF) is maintained over a range of blood pressures through cerebral autoregulation (CA). Blood pressure outside the range of CA, or impaired autoregulation, is associated with adverse patient outcomes. Regional oxygen saturation (rSO2) derived from near-infrared spectroscopy (NIRS) can be used as a surrogate CBF for determining CA, but existing methods require a long period of time to calculate CA metrics. We have developed a novel method to determine CA using cotrending of mean arterial pressure (MAP) with rSO2that aims to provide an indication of CA state within 1 minute. We sought to determine the performance of the cotrending method by comparing its CA metrics to data derived from transcranial Doppler (TCD) methods. METHODS: Retrospective data collected from 69 patients undergoing cardiac surgery with cardiopulmonary bypass were used to develop a reference lower limit of CA. TCD-MAP data were plotted to determine the reference lower limit of CA. The investigated method to evaluate CA state is based on the assessment of the instantaneous cotrending relationship between MAP and rSO2 signals. The lower limit of autoregulation (LLA) from the cotrending method was compared to the manual reference derived from TCD. Reliability of the cotrending method was assessed as uptime (defined as the percentage of time that the state of autoregulation could be measured) and time to first post. RESULTS: The proposed method demonstrated minimal mean bias (0.22 mmHg) when compared to the TCD reference. The corresponding limits of agreement were found to be 10.79 mmHg (95% confidence interval [CI], 10.09-11.49) and -10.35 mmHg (95% CI, -9.65 to -11.05). Mean uptime was 99.40% (95% CI, 99.34-99.46) and the mean time to first post was 63 seconds (95% CI, 58-71). CONCLUSIONS: The reported cotrending method rapidly provides metrics associated with CA state for patients undergoing cardiac surgery. A major strength of the proposed method is its near real-time feedback on patient CA state, thus allowing for prompt corrective action to be taken by the clinician.


Assuntos
Circulação Cerebrovascular , Homeostase , Monitorização Neurofisiológica Intraoperatória/métodos , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Pressão Arterial , Pressão Sanguínea , Ponte Cardiopulmonar , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Estudos Retrospectivos , Ultrassonografia Doppler Transcraniana
4.
Anesth Analg ; 131(4): 1043-1056, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925322

RESUMO

For this child, at this particular moment, how much anesthesia should I give? Determining the drug requirements of a specific patient is a fundamental problem in medicine. Our current approach uses population-based pharmacological models to establish dosing. However, individual patients, and children in particular, may respond to drugs differently. In anesthesiology, we have the advantage that we can monitor our patients in real time and titrate drugs to the desired effect. Examples include blood pressure management or muscle relaxation. Although the brain is the primary site of action for sedative-hypnotic drugs, the brain is not routinely monitored during general anesthesia or sedation, a fact that would surprise many patients. One reason for this is that, until recently, physiologically principled approaches for anesthetic brain monitoring have not been articulated. In the past few years, our knowledge of anesthetic brain mechanisms has developed rapidly. We now know that anesthetic drug effects are clearly visible in the electroencephalogram (EEG) of adults and reflect underlying anesthetic pharmacology and brain mechanisms. Most recently, similar effects have been characterized in children. In this article, we describe how EEG monitoring could be used to guide anesthetic management in pediatric patients. We review previous evidence and present multiple case studies showing how drug-specific and dose-dependent EEG signatures seen in adults are visible in children and infants, including those with neurological disorders. We propose that the EEG can be used in the anesthetic care of children to enable anesthesiologists to better assess the drug requirements of individual patients in real time and improve patient safety and experience.


Assuntos
Anestesia , Eletroencefalografia/métodos , Monitorização Neurofisiológica Intraoperatória/métodos , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Segurança do Paciente , Pediatria
5.
Anesth Analg ; 131(4): 1184-1192, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925339

RESUMO

BACKGROUND: Clinicians can optimize propofol titration by using 2 sources of pharmacodynamic (PD) information: the predicted effect-site concentration for propofol (Ceprop) and the electroencephalographically (EEG) measured drug effect. Relation between these sources should be time independent, that is, perfectly synchronized. In reality, various issues corrupt time independency, leading to asynchrony or, in other words, hysteresis. This asynchrony can lead to conflicting information, making effective drug dosing challenging. In this study, we tried to quantify and minimize the hysteresis between the Ceprop (calculated using the Schnider model for propofol) and EEG measured drug effect, using nonlinear mixed-effects modeling (NONMEM). Further, we measured the influence of EEG-based monitor choice, namely Bispectral index (BIS) versus qCON index (qCON) monitor, on propofol PD hysteresis. METHODS: We analyzed the PD data from 165 patients undergoing propofol-remifentanil anesthesia for outpatient surgery. Drugs were administered using target-controlled infusion (TCI) pumps. Pumps were programmed with Schnider model for propofol and Minto model for remifentanil. We constructed 2 PD models (direct models) relating the Schnider Ceprop to the measured BIS and qCON monitor values. We quantified the models' misspecification due to hysteresis, on an individual level, using the root mean squared errors (RMSEs). Subsequently, we optimized the PD models' predictions by adding a lag term to both models (lag-time PD models) and quantified the optimization using the RMSE. RESULTS: There is a counterclockwise hysteresis between Ceprop and BIS/qCON values. Not accounting for this hysteresis results in a direct PD model with an effect-site concentration which produces 50% of the maximal drug effect (Ce50) of 6.24 and 8.62 µg/mL and RMSE (median and interquartile range [IQR]) of 9.38 (7.92-11.23) and 8.41(7.04-10.2) for BIS and qCON, respectively. Adding a modeled lag factor of 49 seconds to the BIS model and 53 seconds to the qCON model improved both models' prediction, resulting in similar Ce50 (3.66 and 3.62 µg/mL for BIS and qCON) and lower RMSE (median (IQR) of 7.87 (6.49-9.90) and 6.56 (5.28-8.57) for BIS and qCON. CONCLUSIONS: There is a significant "Ceprop versus EEG measured drug effect" hysteresis. Not accounting for it leads to conflicting PD information and false high Ce50 for propofol in both monitors. Adding a lag term improved the PD model performance, improved the "pump-monitor" synchrony, and made the estimates of Ce50 for propofol more realistic and less monitor dependent.


Assuntos
Anestésicos Intravenosos , Eletroencefalografia , Monitorização Neurofisiológica Intraoperatória/métodos , Propofol , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Anestesia Intravenosa , Monitores de Consciência , Feminino , Humanos , Bombas de Infusão , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Valor Preditivo dos Testes , Estudos Prospectivos , Remifentanil , Adulto Jovem
6.
Anesth Analg ; 131(4): 1228-1236, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925344

RESUMO

BACKGROUND: Recent limited evidence suggests that the use of a processed electroencephalographic (EEG) monitor to guide anesthetic management may influence postoperative cognitive outcomes; however, the mechanism is unclear. METHODS: This exploratory, single-center, randomized clinical trial included patients who were ≥65 years of age undergoing elective noncardiac surgery. The study aimed to determine whether monitoring the brain using a processed EEG monitor reduced EEG suppression and subsequent postoperative delirium. The interventional group received processed EEG-guided anesthetic management to keep the Patient State Index (PSI) above 35 computed by the SEDline Brain Function Monitor (Masimo, Inc, Irvine, CA), while the standard care group was also monitored, but the EEG data were blinded from the clinicians. The primary outcome was intraoperative EEG suppression. A secondary outcome was incident postoperative delirium during the first 3 days after surgery. RESULTS: All outcomes were analyzed using the intention-to-treat paradigm. Two hundred and four patients with a mean age of 72 ± 5 years were studied. Minutes of EEG suppression adjusted by the length of surgery was found to be less for the interventional group than the standard care group (median [interquartile range], 1.4% [5.0%] and 2.5% [10.4%]; Hodges-Lehmann estimated median difference [95% confidence interval {CI}] of -0.8% [-2.1 to -0.000009]). The effect of the intervention on EEG suppression differed for those with and without preoperative cognitive impairment (interaction P = .01), with the estimated incidence rate ratio (95% CI) of 0.39 (0.33-0.44) for those with preoperative cognitive impairment and 0.48 (0.44-0.51) for those without preoperative cognitive impairment. The incidence of delirium was not found to be different between the interventional (17%) and the standard care groups (20%), risk ratio = 0.85 (95% CI, 0.47-1.5). CONCLUSIONS: The use of processed EEG to maintain the PSI >35 was associated with less time spent in intraoperative EEG suppression. Preoperative cognitive impairment was associated with a greater percent of surgical time spent in EEG suppression. A larger prospective cohort study to include more cognitively vulnerable patients is necessary to show whether an intervention to reduce EEG suppression is efficacious in reducing postoperative delirium.


Assuntos
Monitores de Consciência , Eletroencefalografia , Monitorização Neurofisiológica Intraoperatória/métodos , Procedimentos Cirúrgicos Operatórios/métodos , Idoso , Idoso de 80 Anos ou mais , Anestesia , Anestésicos/administração & dosagem , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/etiologia , Delírio/epidemiologia , Delírio/etiologia , Delírio do Despertar/epidemiologia , Feminino , Humanos , Incidência , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/psicologia , Estudos Prospectivos
7.
Medicine (Baltimore) ; 99(36): e22029, 2020 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-32899058

RESUMO

This study aims to describe the role of open surgical treatment for focal brainstem gliomas (FBSGs) with the assistance of multimodal neuronavigation and intraoperative neurophysiological monitoring (IOM) in children to investigate the efficacy of microsurgical treatment in pediatric FBSGs. Also the prognostic factors related to the overall survival (OS) of FBSGs to describe the patient and tumor characteristics relevant to prognosis/outcome were focused on. Clinical data of 63 pediatric patients below 16 years of age with FBSGs admitted to the Neurosurgical Unit of Beijing Tiantan Hospital from January 2012 to December 2018 were retrospectively analyzed. All patients underwent initial surgical treatment, followed by magnetic resonance diffusion tensor imaging (DTI), neuronavigation and IOM. Gross or near total resection (GTR or NTR) was achieved in 57/63 (90.5%) cases, and subtotal resection (STR) was achieved in 6/63 (9.5%) cases. Postoperative adjuvant therapy was received by 27/63 (42.9%) cases. Postoperative pathological examination revealed that 36/63 (57.1%) cases had grade I gliomas, 22/63 (34.9%) had grade II, and 5/63 (8.0%) had grade III-IV gliomas according to the WHO classification. The mean Karnofsky score preoperatively was 60, and at the time of follow-up was 90. Consecutively, 6 cases demonstrated disease progression, and 5 of these were deceased. The OS in all patients was 81.2% at 5 years. Histological grade (P < .001) and age at diagnosis (P = .023) showed significant association with prolonged OS. Multimodal neuronavigation and IOM allow very precise intracranial surgery, contributing to a maximally safe resection that might decrease the postoperative disability and mortality rate. This study also showed that pediatric FBSGs were mostly low-grade tumors with excellent surgical outcomes. Consequently, it is suggested that microsurgery can be used to treat FBSGs in children in order to provide better prognosis and survival outcomes.


Assuntos
Neoplasias do Tronco Encefálico/patologia , Glioma/cirurgia , Monitorização Neurofisiológica Intraoperatória/métodos , Neuronavegação/métodos , Adolescente , Quimioterapia Adjuvante , Criança , Pré-Escolar , China/epidemiologia , Imagem de Tensor de Difusão/métodos , Progressão da Doença , Feminino , Glioma/diagnóstico por imagem , Humanos , Lactente , Avaliação de Estado de Karnofsky , Masculino , Microcirurgia/métodos , Gradação de Tumores , Cuidados Pós-Operatórios , Prognóstico , Estudos Retrospectivos , Análise de Sobrevida
8.
World Neurosurg ; 141: 210-214, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32553601

RESUMO

BACKGROUND: The robotic surgery is an advanced modern minimally invasive technology, widely used in urologic oncology, and it has become useful in particular conditions. Over time, different surgical specialties made use of the robotic properties to minimize complications for high-risk procedures. A combined 1-staged robot-assisted multidisciplinary surgery with intraoperative neurophysiological monitoring can be a safe procedure to remove a sacral chordoma with low morbidity rates. CASE DESCRIPTION: A 64-year-old woman complained of a few months of drug-resistant low back and abdominal pain. The subsequent development of constipation brought the patient to undergo an abdominal computed tomography scan and magnetic resonance imaging. Radiologic investigations revealed a large size sacral mass associated with a partial destruction of the sacrum and posterior compression of the rectum. The tumor was en bloc removed by a combined 1-staged anterior laparoscopic robot-assisted and posterior open lumbosacral approach with continue intraoperative neurophysiological monitoring of sacral and pudendal plexuses. The histological diagnosis was of chordoma. After surgery, the patient reported pain relief and the total recovery of bowel dysfunction with good 11-month follow-up outcome. CONCLUSIONS: This combined technique represents a promising treatment option in selected cases. The robotic technology combined with the experience of highly qualified staff can improve the surgical result by minimizing complications. However, longer follow-up is necessary to confirm the long-term effects in terms of recurrence and survival.


Assuntos
Neoplasias Ósseas/cirurgia , Cordoma/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Sacro/patologia , Sacro/cirurgia , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Laparoscopia/métodos , Pessoa de Meia-Idade
9.
World Neurosurg ; 142: 68-74, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32592961

RESUMO

OBJECTIVE: Carotid revascularization surgery is known to carry a risk of postoperative visual deterioration associated with retinal ischemia. We checked intraoperative visual evoked potential (VEP) monitoring in carotid endarterectomy (CEA). METHODS: Ten consecutive patients who underwent CEA in Shinshu University Hospital under total intravenous anesthesia were checked by intraoperative VEP and electroretinogram (ERG) recording in addition to somatosensory evoked potential monitoring. RESULTS: Two of 10 patients presented decreased amplitude of VEP and ERG on the ipsilateral affected side by clamping the common carotid artery and persistent attenuation of VEP and ERG during external carotid artery occlusion, using an internal carotid shunt. These findings disappeared immediately after releasing the cervical carotid artery clamping. In the other 8 patients, VEP and ERG did not change throughout the surgery. CONCLUSIONS: Transient retinal ischemia during even brief carotid artery occlusion in the CEA procedure could be estimated by intraoperative VEP and ERG monitoring.


Assuntos
Endarterectomia das Carótidas/métodos , Potenciais Evocados Visuais/fisiologia , Complicações Intraoperatórias/diagnóstico por imagem , Monitorização Neurofisiológica Intraoperatória/métodos , Isquemia/diagnóstico por imagem , Vasos Retinianos/diagnóstico por imagem , Idoso , Eletrorretinografia/métodos , Endarterectomia das Carótidas/efeitos adversos , Humanos , Complicações Intraoperatórias/etiologia , Isquemia/etiologia , Masculino
10.
Acta Orthop Belg ; 86(1): 22-27, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32490769

RESUMO

Developmental dysplasia of the hip with a high dislocation may lead to severe hip pain and a marked shortening. Nerve palsy rates following THA in dysplastic hips have been reported as being higher by ten times or more compared to the general population. We report a new technique to perform THA in high congenital dislocations. Between 2013 and 2015, 3 consecutive patients (4 hips) with severe hip pain and Crowe III hip dysplasia were treated. Surgeries were performed on a standard table using the DAA and intraoperative neurophysiological monitoring. At final follow-up (mean 24 months, range 15-43), all 3 patients reported excellent pain relief and significant improvement in activities of daily living. Radiographs showed the components to be solidly fixed in satisfactory position. Average postoperative leg lengthening was 24 mm (range 20-36). None of the patients experienced an acute or delayed neurologic deficit. Total hip arthroplasty for high congenital dislocations can be safely performed using the direct anterior approach and neuromonitoring. Significant lengthening could be obtained without neurological complications.


Assuntos
Artroplastia de Quadril/métodos , Luxação Congênita de Quadril/cirurgia , Monitorização Neurofisiológica Intraoperatória/métodos , Humanos
11.
BMC Neurol ; 20(1): 221, 2020 May 30.
Artigo em Inglês | MEDLINE | ID: mdl-32473653

RESUMO

BACKGROUND: Surgery is usually the treatment of choice for patients with cervical compressive myelopathy (CCM). Motor evoked potential (MEP) has proved to be helpful tool in evaluating intraoperative cervical spinal cord function change of those patients. This study aims to describe and evaluate different MEP baseline phenotypes for predicting MEP changes during CCM surgery. METHODS: A total of 105 consecutive CCM patients underwent posterior cervical spine decompression were prospectively collected between December 2012 and November 2016. All intraoperative MEP baselines recorded before spinal cord decompression were classified into 5 types (I to V) that were carefully designed according to the different MEP parameters. The postoperative neurologic status of each patient was assessed immediately after surgery. RESULTS: The mean intraoperative MEP changes range were 10.2% ± 5.8, 14.7% ± 9.2, 54.8% ± 31.9, 74.1% ± 24.3, and 110% ± 40 in Type I, II, III, IV, and V, respectively. There was a significant correlation of the intraoperative MEP change rate with different MEP baseline phenotypes (r = 0.84, P < 0.01). Postoperative transient new spinal deficits were found 0/31 case in Type I, 0/21 in Type II, 1/14 in Type III, 2/24 in Type IV, and 4/15 in Type V. No permanent neurological injury was found in our cases series. CONCLUSIONS: The MEP baselines categories for predicting intraoperative cervical cord function change is proposed through this work. The more serious the MEP baseline abnormality, the higher the probability of intraoperative MEP changes, which is beneficial to early warning for the cervical cord injury.


Assuntos
Medula Cervical/fisiopatologia , Medula Cervical/cirurgia , Monitorização Neurofisiológica Intraoperatória/métodos , Compressão da Medula Espinal/fisiopatologia , Compressão da Medula Espinal/cirurgia , Adulto , Idoso , Vértebras Cervicais , Descompressão Cirúrgica/métodos , Potencial Evocado Motor/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/métodos
12.
World Neurosurg ; 141: e736-e742, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32535054

RESUMO

OBJECTIVE: Intraoperative imaging is critical in cerebrovascular surgery to assess the technical success of the operation. This case series aimed to evaluate the safety and efficacy of 3-dimensional rotational angiogram (3D-RA) in addition to 2-dimensional intraoperative angiography (2D-IOA) during cerebrovascular surgery in the hybrid operating room. METHODS: All consecutive patients who underwent open cerebrovascular surgery and intraoperative 2D-IOA with 3D-RA in a hybrid operating room at 2 academic centers between August 2018 and December 2019 were identified from a prospectively maintained institutional database. Medical charts and operative videos including intraoperative angiography were reviewed, and clinical and angiographic outcomes assessed. RESULTS: A total of 40 cerebrovascular surgeries in 39 patients (mean age, 53 ± 13 years; 51% female) were carried out with the addition of 3D-RA to 2D-IOA in the hybrid operating room. After 3D-RA in addition to 2D-IOA, 1 (2.5%) surgical alteration occurred in an aneurysm clipping. Other procedures were not altered with the addition of 3D-RA to 2D-IOA. There were no complications from the addition of 3D-RA to 2D-IOA. CONCLUSIONS: Using a combination of 3D-RA and 2D-IOA in the hybrid operating room may enhance the likelihood of achieving an optimal result when employing microsurgical cerebrovascular surgery and avoid unanticipated incomplete outcomes, complications, and returns to the operating room. Whereas the addition of 3D-RA elucidated residual aneurysm not otherwise visualized on the 2D-IOA, in other cerebrovascular procedures studied, there was no additional value of the 3D-RA over the 2D-IOA.


Assuntos
Angiografia Cerebral/métodos , Transtornos Cerebrovasculares/diagnóstico por imagem , Transtornos Cerebrovasculares/cirurgia , Imageamento Tridimensional/métodos , Monitorização Neurofisiológica Intraoperatória/métodos , Procedimentos Neurocirúrgicos/métodos , Adulto , Idoso , Angiografia Digital/métodos , Feminino , Humanos , Masculino , Microcirurgia/métodos , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos
13.
Spine Deform ; 8(5): 1131-1134, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32451977

RESUMO

STUDY DESIGN: Case report and review of literature. OBJECTIVE: To illustrate the importance of "dynamic spinal cord mapping" (DSCM) in locating the site of neurophysiologic data loss during severe spinal deformity correction. During marked correction of severe spinal deformities, intra-operative neuromonitoring remains of paramount importance. This case illustrates the importance of a unique type of monitoring, particularly useful when obtaining correction at multiple sites. METHODS: A patient with symptomatic, progressive, severe kyphoscoliosis underwent multiple periapical posterior column osteotomies, partial T8 and complete T9 vertebral column resections and T2 to L3 posterior segmental instrumented fusion. During correction maneuvers, complete loss of spinous process descending neurogenic evoked potentials occurred. A flexible epidural catheter was placed at different spinal levels to dynamically stimulate the spinal cord and map out the site of data loss corresponding to the area of neural compromise. RESULTS: Using DSCM, the site of data loss was identified to the apex of the proximal thoracic region cephalad to the VCR site. This was rectified by releasing correction at the proximal end of the construct, and neurophysiologic data promptly returned to baseline. Postoperatively the patient was neurologically intact. CONCLUSION: Dynamic spinal cord mapping helps map areas of neurophysiologic data loss permitting focused attention to the site of compromise to reverse the offending agent. This improves the chance for return of baseline data, avoiding the potential for permanent neurologic catastrophe for the patient. LOE: IV.


Assuntos
Monitorização Neurofisiológica Intraoperatória/métodos , Cifose/cirurgia , Vértebras Lombares/cirurgia , Escoliose/cirurgia , Medula Espinal/fisiologia , Fusão Vertebral/instrumentação , Vértebras Torácicas/cirurgia , Adolescente , Cateteres , Espaço Epidural , Potenciais Evocados , Feminino , Humanos , Doenças do Sistema Nervoso/etiologia , Doenças do Sistema Nervoso/prevenção & controle , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Índice de Gravidade de Doença , Fusão Vertebral/efeitos adversos , Fusão Vertebral/métodos , Resultado do Tratamento
14.
Spine Deform ; 8(4): 591-596, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32451978

RESUMO

The Scoliosis Research Society has developed an updated information statement on intraoperative neurophysiological monitoring of spinal cord function during spinal deformity surgery. The statement reviews the risks of spinal cord compromise associated with spinal deformity surgery; the statement then discusses the various modalities that are available to monitor the spinal cord, including somatosensory-evoked potentials, motor-evoked potentials, and electromyographic (EMG) options. Anesthesia considerations, the importance of a thoughtful team approach to successful monitoring, and the utility of checklists are also discussed. Finally, the statement expresses the opinion that utilization of intraoperative neurophysiological spinal cord monitoring in spinal deformity surgery is the standard of care when the spinal cord is at risk.


Assuntos
Monitorização Neurofisiológica Intraoperatória/métodos , Monitorização Neurofisiológica Intraoperatória/normas , Medula Espinal/fisiologia , Curvaturas da Coluna Vertebral/cirurgia , Anestesia , Eletromiografia , Potencial Evocado Motor , Potenciais Somatossensoriais Evocados , Humanos , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/prevenção & controle , Equipe de Assistência ao Paciente , Risco , Doenças da Medula Espinal/diagnóstico , Doenças da Medula Espinal/etiologia , Doenças da Medula Espinal/prevenção & controle
15.
Epilepsia ; 61(6): e60-e65, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32385935

RESUMO

Because oral pharmacological treatment of neocortical focal epilepsy is limited due to common systemic side effects and relatively low drug concentrations reached at the epileptic foci locally, application of antiepileptic agents directly onto the neocortical focus may enhance treatment tolerability and efficacy. We describe the effects of cortically applied sodium valproate (VPA) in two patients with pharmacoresistant neocortical focal epilepsy who were selected for epilepsy surgery after a circumscribed epileptic focus had been determined by invasive presurgical evaluation using subdural electrodes. Local VPA modified epileptic activity as electrocorticographically recorded from the chronic focus in both patients. In addition, VPA induced local increase of the inhibitory neurotransmitter γ-aminobutyric acid (GABA) in cortical tissue samples, whereas the excitatory glutamate was possibly decreased. In this clinical pilot study, we could show antiepileptic effects of cortically applied VPA in humans by electrocorticographic and neurochemical parameters.


Assuntos
Anticonvulsivantes/administração & dosagem , Epilepsia Resistente a Medicamentos/fisiopatologia , Eletrocorticografia/métodos , Epilepsias Parciais/fisiopatologia , Neocórtex/fisiopatologia , Ácido Valproico/administração & dosagem , Epilepsia Resistente a Medicamentos/tratamento farmacológico , Eletrocorticografia/efeitos dos fármacos , Epilepsias Parciais/tratamento farmacológico , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Masculino , Pessoa de Meia-Idade , Neocórtex/química , Neocórtex/efeitos dos fármacos , Ácido Valproico/uso terapêutico
16.
World Neurosurg ; 139: 395-400, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32376380

RESUMO

BACKGROUND: Complete aneurysm obliteration is the goal of aneurysm treatment. In selected cases, a neck remnant may be left to preserve a critical branch. Literature on ophthalmic artery sacrifice in the treatment of cerebral aneurysms and subsequent risk of vision loss is limited. CASE DESCRIPTION: Herein, we describe 2 cases where the ophthalmic artery originated from the aneurysm dome, resulting in a situation where we either incompletely obliterate the aneurysm or sacrifice the ophthalmic artery in order to completely clip the lesion, risking visual function. CONCLUSIONS: We report for the first time the use of visual evoked potential monitoring and intraoperative awakening to test visual function following intentional ophthalmic artery sacrifice to demonstrate gross vision preservation.


Assuntos
Potenciais Evocados Visuais/fisiologia , Aneurisma Intracraniano/cirurgia , Monitorização Neurofisiológica Intraoperatória/métodos , Procedimentos Neurocirúrgicos/métodos , Artéria Oftálmica/cirurgia , Feminino , Humanos , Pessoa de Meia-Idade , Instrumentos Cirúrgicos
17.
World Neurosurg ; 139: e737-e747, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32360919

RESUMO

BACKGROUND AND OBJECTIVE: The goal of this study is to show using 5 illustrative cases that the transcortical route for resection of mediobasal temporal region (MBTR) lesions is safe and effective when performed with awake functional mapping and knowledge of the relevant subcortical anatomy. Although several have been proposed, there is a paucity of reports on transcorticosubcortical approaches to these lesions, particularly in patients with posterior-superior extension. We present a case series of 5 patients with left posterior MBTR gliomas and summarize the relevant subcortical anatomy knowledge of what is a prerequisite for safe resection. METHODS: Five patients with left posterior MBTR gliomas underwent awake resection with functional corticosubcortical electric mapping. Details of the approach are presented with a review of relevant anatomy. RESULTS: Gross total resection was achieved in 4 patients. One patient who had previously undergone radiation therapy had a subtotal resection. There were 4 cases of World Health Organization grade II glioma and 1 case of World Health Organization grade IV glioma. All patients underwent preoperative and postoperative neurologic and neuropsychological assessment and there were no new or worsening sensorimotor, visual, language, or cognitive deficits. CONCLUSIONS: The transcorticosubcortical approach is a safe and effective approach to lesions of the posterior MBTR. The approach is safe and effective even in patients with superior extension, if the surgical approach is predicated on knowledge of individual functional anatomy. Awake resection with cortical and axonal mapping with well-selected paradigms is invaluable in maximizing extent of resection and ensuring patient safety.


Assuntos
Mapeamento Encefálico/métodos , Neoplasias Encefálicas/cirurgia , Glioma/cirurgia , Procedimentos Neurocirúrgicos/métodos , Lobo Temporal/cirurgia , Adulto , Estimulação Elétrica/métodos , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Masculino , Pessoa de Meia-Idade , Cirurgia Assistida por Computador/métodos , Vigília , Substância Branca/anatomia & histologia , Adulto Jovem
18.
World Neurosurg ; 139: e827-e835, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32437985

RESUMO

OBJECTIVE: Surgical skills are generally acquired by watching the "hand movements" of experts. "Eye movements" are now attracting attention in skill-learning fields. Eye-tracking technology was introduced preliminarily to develop a better skill-learning system for neuroendovascular treatments. METHODS: During a task to place a detachable coil into a silastic cerebral aneurysm model under biplane X-ray fluoroscopy, gaze points were recorded using a head-mount eye-tracking device. RESULTS: During the task, 91% of fixations were allocated to the monitor displaying fluoroscopic images, and the others to the hands of operators or unspecified visual targets. More than 80% of fixations were located in frontal or lateral fluoroscopic images. Fixations were placed more frequently around the aneurysm than the microcatheter. One operator failed to recognize the timing when the proximal marker of the coil overlapped that of the microcatheter. The subject allocated most fixations to the frontal fluoroscopic image, whereas other subjects placed most fixations to the lateral fluoroscopic image. Furthermore, that operator put no fixations to the proximal marker of the microcatheter. CONCLUSIONS: The results of this preliminary study imply the feasibility of the eye tracking-based learning system for neuroendovascular treatments. The eye-tracking analysis has potential in investigating or preventing procedural failures in neuroendovascular treatments.


Assuntos
Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Movimentos Oculares , Aneurisma Intracraniano/cirurgia , Monitorização Neurofisiológica Intraoperatória/métodos , Modelos Anatômicos , Humanos
19.
J Clin Neurosci ; 77: 207-210, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32409213

RESUMO

The prevalence of malignant lymphoma is increasing. With the advent of novel therapeutic approaches, the distinct pathology of each type of malignant lymphoma is used to tailor its treatment for the most effective outcome. Therefore, analysis of the malignant cell pathophysiology within the cauda equina is important to devising a treatment strategy. In some cases, the tumor only invades the cauda equina. Composed of an uninterrupted bundle of nerve fibers, the cauda equina is more complex than the brain parenchyma; hence, the method for performing a biopsy of the cauda equina is relatively more challenging and requires improvement. The appropriate surgical procedure to confirm the posterior ramus, which consists of sensory roots, is mandatory. In the lumbar region, the denticulate ligaments that distinguish between the motor and sensory nerve roots do not exist. Microsurgical techniques and neurophysiological monitoring can aid with removal of posterior roots and allow for the reliable performance of a cauda equina biopsy. First, we determined where the spinal root pierces the dura mater, and then we performed electromyography. We performed cauda equina biopsy with this method for patients with malignant lymphoma and reviewed the efficacy of this procedure. This strategy prevented postoperative neurological impairments and provided detailed information to ensure optimal adjuvant therapy. Based on advances in personalized therapies for malignant tumors, opportunities for cauda equina biopsy are increasing. Our method using both morphological feature observation and neurophysiological monitoring may contribute to successful biopsy of the cauda equina.


Assuntos
Biópsia/métodos , Cauda Equina/cirurgia , Linfoma/diagnóstico , Idoso , Cauda Equina/patologia , Eletromiografia/métodos , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Masculino
20.
Acta Neurochir (Wien) ; 162(8): 1983-1993, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32424567

RESUMO

BACKGROUND: Facial nerve (FN) outcome has been improved by deciding upon the degree of vestibular schwannoma (VS) resection guided by intraoperative facial nerve monitoring (IOFM). This study aimed to evaluate hearing and FN outcomes following IOFM-guided VS removal through a retrosigmoid approach (RS). METHODS: Between January 2015 and August 2017, 77 patients undergoing VS resection through RS, regardless of their preoperative hearing or tumor size, were included in this monocentric retrospective study. Total or near-/subtotal resection was decided intraoperatively according to IOFM. Partial resection was planned preoperatively. Pre- and postoperative FN function (House-Brackmann) and hearing level (AAO-HNS and Gardner-Robertson (GR) scales) were reported. Predictive factors for hearing preservation were analyzed according to a score developed to take into account pre-/postoperative hearing evolution. RESULTS: The mean extrameatal diameter was 17 ± 8.5 mm. VS resection was total, near-/subtotal, and partial in 71%, 21%, and 8% of cases, respectively. Postoperative grade I and II FN function was achieved in 91% of patients. Serviceable (A+B or GR I+II) hearing and hearing with intelligibility (A+B+C or GR I-III) were preserved in 30% and 43% of cases, respectively. In multivariate analysis, preoperative synchronized auditory brainstem responses (ABR) were the only predictive factor (p = 0.006) imparting a five times greater chance of hearing preservation. CONCLUSION: IOFM-guided VS excision through RS, whatever the VS size and hearing level, achieved a high rate of good postoperative FN function together with significant hearing preservation, and it should be used if hearing with some intelligibility is still present preoperatively, even in large VS.


Assuntos
Denervação/métodos , Nervo Facial/cirurgia , Audição , Neuroma Acústico/cirurgia , Adulto , Idoso , Denervação/efeitos adversos , Eletromiografia/métodos , Potenciais Evocados Auditivos do Tronco Encefálico , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia
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