Advances in diffuse glial tumors diagnosis.

In recent decades, there have been significant advances in the diagnosis of diffuse gliomas, driven by the integration of novel technologies. These advancements have deepened our understanding of tumor oncogenesis, enabling a more refined stratification of the biological behavior of these neoplasms. This progress culminated in the fifth edition of the WHO classification of central nervous system (CNS) tumors in 2021. This comprehensive review article aims to elucidate these advances within a multidisciplinary framework, contextualized within the backdrop of the new classification. This article will explore morphologic pathology and molecular/genetics techniques (immunohistochemistry, genetic sequencing, and methylation profiling), which are pivotal in diagnosis, besides the correlation of structural neuroimaging radiophenotypes to pathology and genetics. It briefly reviews the usefulness of tractography and functional neuroimaging in surgical planning. Additionally, the article addresses the value of other functional imaging techniques such as perfusion MRI, spectroscopy, and nuclear medicine in distinguishing tumor progression from treatment-related changes. Furthermore, it discusses the advantages of evolving diagnostic techniques in classifying these tumors, as well as their limitations in terms of availability and utilization. Moreover, the expanding domains of data processing, artificial intelligence, radiomics, and radiogenomics hold great promise and may soon exert a substantial influence on glioma diagnosis. These innovative technologies have the potential to revolutionize our approach to these tumors. Ultimately, this review underscores the fundamental importance of multidisciplinary collaboration in employing recent diagnostic advancements, thereby hoping to translate them into improved quality of life and extended survival for glioma patients.

Nas últimas décadas, houve avanços significativos no diagnóstico de gliomas difusos, impulsionados pela integração de novas tecnologias. Esses avanços aprofundaram nossa compreensão da oncogênese tumoral, permitindo uma estratificação mais refinada do comportamento biológico dessas neoplasias. Esse progresso culminou na quinta edição da classificação da OMS de tumores do sistema nervoso central (SNC) em 2021. Esta revisão abrangente tem como objetivo elucidar esses avanços de forma multidisciplinar, no contexto da nova classificação. Este artigo irá explorar a patologia morfológica e as técnicas moleculares/genéticas (imuno-histoquímica, sequenciamento genético e perfil de metilação), que são fundamentais no diagnóstico, além da correlação dos radiofenótipos da neuroimagem estrutural com a patologia e a genética. Aborda sucintamente a utilidade da tractografia e da neuroimagem funcional no planejamento cirúrgico. Destacaremos o valor de outras técnicas de imagem funcional, como ressonância magnética de perfusão, espectroscopia e medicina nuclear, na distinção entre a progressão do tumor e as alterações relacionadas ao tratamento. Discutiremos as vantagens das diferentes técnicas de diagnóstico na classificação desses tumores, bem como suas limitações em termos de disponibilidade e utilização. Além disso, os crescentes avanços no processamento de dados, inteligência artificial, radiômica e radiogenômica têm grande potencial e podem em breve exercer uma influência substancial no diagnóstico de gliomas. Essas tecnologias inovadoras têm o potencial de revolucionar nossa abordagem a esses tumores. Em última análise, esta revisão destaca a importância fundamental da colaboração multidisciplinar na utilização dos recentes avanços diagnósticos, com a esperança de traduzi-los em uma melhor qualidade de vida e uma maior sobrevida.

Stroke Due to Orthognathic Surgery: Case Report of a Rare Complication.

Le Fort I osteotomy is a frequent surgical procedure used in orthognathic surgeries to treat severe malocclusions and is associated with relatively rare surgical complications. Here, the authors report a case of thrombotic ischemic stroke as a result of this procedure, a complication still not described in the literature. A 19-year-old man with class II malocclusion and retrognathia underwent orthognathic surgery for aesthetic purposes. The surgery included a Le Fort I maxillary osteotomy with vertical impaction, bilateral sagittal split ramus osteotomy for mandibular advancement, and genioplasty. Postoperatively, the patient developed left eye blindness, headache, somnolence, aphasia, and right hemiplegia. Medical imaging showed the Le Fort I line of fracture extending from the maxillary osteotomy to the left optic canal and to the left carotid canal, with osseous fragments impinging the petrous segment of the internal carotid artery, left carotid artery occlusion and associated to an ischemic stroke at the left middle cerebral artery territory. Treatment required decompressive craniectomy and later focused on clinical stabilization, infection management, orthognathic care, neurorehabilitation, and cranioplasty. The hemiplegia and aphasia partially recovered during 12 months, and final dental occlusion was appropriate. Our report demonstrates that an unfavorable Le Fort I fracture trajectory can lead to ischemic stroke and severe neurological deficits.

Gamma ventral capsulotomy for treatment of resistant obsessive-compulsive disorder: a structural MRI pilot prospective study.

OBJECTIVE: The purpose of this study was to investigate regional structural abnormalities in the brains of five patients with refractory obsessive-compulsive disorder (OCD) submitted to gamma ventral capsulotomy. METHODS: We acquired morphometric magnetic resonance imaging (MRI) data before and after 1 year of radiosurgery using a 1.5-T MRI scanner. Images were spatially normalized and segmented using optimized voxel-based morphometry (VBM) methods. Voxelwise statistical comparisons between pre- and post-surgery MRI scans were performed using a general linear model. Findings in regions predicted a priori to show volumetric changes (orbitofrontal cortex, anterior cingulate gyrus, basal ganglia and thalamus) were reported as significant if surpassing a statistical threshold of p<0.001 (uncorrected for multiple comparisons). RESULTS: We detected a significant regional postoperative increase in gray matter volume in the right inferior frontal gyri (Brodmann area 47, BA47) when comparing all patients pre and postoperatively. CONCLUSIONS: Our results support the current theory of frontal-striatal-thalamic-cortical (FSTC) circuitry involvement in OCD pathogenesis. Gamma ventral capsulotomy is associated with neurobiological changes in the inferior orbitofrontal cortex in refractory OCD patients.

Interspinous process devices for treatment of degenerative lumbar spine stenosis: A systematic review and meta-analysis.

BACKGROUND: Degenerative lumbar spinal stenosis is a condition related to aging in which structural changes cause narrowing of the central canal and intervertebral foramen. It is currently the leading cause for spinal surgery in patients over 65 years. Interspinous process devices (IPDs) were introduced as a less invasive surgical alternative, but questions regarding safety, efficacy, and cost-effectiveness are still unanswered. OBJECTIVES: The aim of this study was to provide complete and reliable information regarding benefits and harms of IPDs when compared to conservative treatment or decompression surgery and suggest directions for forthcoming RCTs. METHODS: We searched MEDLINE, EMBASE, Cochrane Library, Scopus, and LILACS for randomized and quasi-randomized trials, without language or period restrictions, comparing IPDs to conservative treatment or decompressive surgery in adults with symptomatic degenerative lumbar spine stenosis. Data extraction and analysis were conducted following the Cochrane Handbook. Primary outcomes were pain assessment, functional impairment, Zurich Claudication Questionnaire, and reoperation rates. Secondary outcomes were quality of life, complications, and cost-effectiveness. This systematic review was registered at Prospero (International prospective register of systematic reviews) under number 42015023604. RESULTS: The search strategy resulted in 17 potentially eligible reports. At the end, nine reports were included and eight were excluded. Overall quality of evidence was low. One trial compared IPDs to conservative treatment: IPDs presented better pain, functional status, quality of life outcomes, and higher complication risk. Five trials compared IPDs to decompressive surgery: pain, functional status, and quality of life had similar outcomes. IPD implant presented a significantly higher risk of reoperation. We found low-quality evidence that IPDs resulted in similar outcomes when compared to standard decompression surgery. Primary and secondary outcomes were not measured in all studies and were often published in incomplete form. Subgroup analysis was not feasible. Difficulty in contacting authors may have prevented us of including data in quantitative analysis. CONCLUSIONS: Patients submitted to IPD implants had significantly higher rates of reoperation, with lower cost-effectiveness. Future trials should improve in design quality and data reporting, with longer follow-up periods.

Advances in diffuse glial tumors diagnosis / Avanços no diagnóstico dos gliomas difusos

Abstract In recent decades, there have been significant advances in the diagnosis of diffuse gliomas, driven by the integration of novel technologies. These advancements have deepened our understanding of tumor oncogenesis, enabling a more refined stratification of the biological behavior of these neoplasms. This progress culminated in the fifth edition of the WHO classification of central nervous system (CNS) tumors in 2021. This comprehensive review article aims to elucidate these advances within a multidisciplinary framework, contextualized within the backdrop of the new classification. This article will explore morphologic pathology and molecular/genetics techniques (immunohistochemistry, genetic sequencing, and methylation profiling), which are pivotal in diagnosis, besides the correlation of structural neuroimaging radiophenotypes to pathology and genetics. It briefly reviews the usefulness of tractography and functional neuroimaging in surgical planning. Additionally, the article addresses the value of other functional imaging techniques such as perfusion MRI, spectroscopy, and nuclear medicine in distinguishing tumor progression from treatment-related changes. Furthermore, it discusses the advantages of evolving diagnostic techniques in classifying these tumors, as well as their limitations in terms of availability and utilization. Moreover, the expanding domains of data processing, artificial intelligence, radiomics, and radiogenomics hold great promise and may soon exert a substantial influence on glioma diagnosis. These innovative technologies have the potential to revolutionize our approach to these tumors. Ultimately, this review underscores the fundamental importance of multidisciplinary collaboration in employing recent diagnostic advancements, thereby hoping to translate them into improved quality of life and extended survival for glioma patients.

Resumo Nas últimas décadas, houve avanços significativos no diagnóstico de gliomas difusos, impulsionados pela integração de novas tecnologias. Esses avanços aprofundaram nossa compreensão da oncogênese tumoral, permitindo uma estratificação mais refinada do comportamento biológico dessas neoplasias. Esse progresso culminou na quinta edição da classificação da OMS de tumores do sistema nervoso central (SNC) em 2021. Esta revisão abrangente tem como objetivo elucidar esses avanços de forma multidisciplinar, no contexto da nova classificação. Este artigo irá explorar a patologia morfológica e as técnicas moleculares/genéticas (imuno-histoquímica, sequenciamento genético e perfil de metilação), que são fundamentais no diagnóstico, além da correlação dos radiofenótipos da neuroimagem estrutural com a patologia e a genética. Aborda sucintamente a utilidade da tractografia e da neuroimagem funcional no planejamento cirúrgico. Destacaremos o valor de outras técnicas de imagem funcional, como ressonância magnética de perfusão, espectroscopia e medicina nuclear, na distinção entre a progressão do tumor e as alterações relacionadas ao tratamento. Discutiremos as vantagens das diferentes técnicas de diagnóstico na classificação desses tumores, bem como suas limitações em termos de disponibilidade e utilização. Além disso, os crescentes avanços no processamento de dados, inteligência artificial, radiômica e radiogenômica têm grande potencial e podem em breve exercer uma influência substancial no diagnóstico de gliomas. Essas tecnologias inovadoras têm o potencial de revolucionar nossa abordagem a esses tumores. Em última análise, esta revisão destaca a importância fundamental da colaboração multidisciplinar na utilização dos recentes avanços diagnósticos, com a esperança de traduzi-los em uma melhor qualidade de vida e uma maior sobrevida.

Endoscopic endonasal management of cerebrospinal fluid rhinorrhea after anterior clinoidectomy for aneurysm surgery: changing the paradigm of complication management.

Resection of the anterior clinoid process results in the creation of the clinoid space, an important surgical step in the exposure and clipping of clinoidal and supraclinoidal internal carotid artery aneurysms. Cerebrospinal fluid rhinorrhea is an undesired and potentially serious complication. Conservative measures may be unsuccesful, and there is no consensus on the most appropriate surgical treatment. Two patients with persistent transclinoidal CSF rhinorrhea after aneurysm surgery were successfully treated with a combined endoscopic transnasal/transeptal binostril approach using a fat graft and ipsilateral mucosal nasal septal flap. Anatomical considerations and details of the surgical technique employed are discussed, and a management plan is proposed.

Radiofrequency denervation for facet joint low back pain: a systematic review.

STUDY DESIGN: A systematic review and meta-analysis of randomized controlled trials. OBJECTIVE: To assess treatment effects (benefits and harms) of radiofrequency denervation for patients with facet joint-related chronic low back pain. SUMMARY OF BACKGROUND DATA: There is no consensus regarding the treatment efficacy of facet joint radiofrequency denervation (FJRD) and how it compares with nerve blockades and joint infiltration with anesthetics and/or corticosteroids. METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and LILACS for randomized controlled trials that compared FJRD with blockades, infiltrations, or placebo. Primary outcomes were pain, functional status, and quality of life. Secondary outcomes were cost-effectiveness and complications. RESULTS: Fifteen studies were selected and 9 were eligible. Overall quality of evidence was rated low to moderate. The evidence favored FJRD regarding pain control. There was no sufficient evidence for cost-effectiveness and complications. CONCLUSION: The available evidence reviewed in this study should be interpreted with caution. The data indicate that FJRD is more effective than placebo in pain control and functional improvement and is also possibly more effective than steroid injections in pain control. Complications and adverse effects were not sufficiently reported to allow comparisons, and there was no evidence for cost-effectiveness. High-quality randomized controlled trials addressing pain, function, quality of life, complications, and cost-effectiveness are urgently needed. LEVEL OF EVIDENCE: 1.

Endoscopic endonasal management of cerebrospinal fluid rhinorrhea after anterior clinoidectomy for aneurysm surgery: changing the paradigm of complication management / Endoscopia endonasal no tratamento da fístula liquórica após clinoidectomia anterior na cirurgia de aneurisma: mudando o paradigma no manejo desta complicação

ABSTRACT Resection of the anterior clinoid process results in the creation of the clinoid space, an important surgical step in the exposure and clipping of clinoidal and supraclinoidal internal carotid artery aneurysms. Cerebrospinal fluid rhinorrhea is an undesired and potentially serious complication. Conservative measures may be unsuccesful, and there is no consensus on the most appropriate surgical treatment. Two patients with persistent transclinoidal CSF rhinorrhea after aneurysm surgery were successfully treated with a combined endoscopic transnasal/transeptal binostril approach using a fat graft and ipsilateral mucosal nasal septal flap. Anatomical considerations and details of the surgical technique employed are discussed, and a management plan is proposed.

RESUMO A ressecção da clinóide anterior resulta na criação do espaço clinoideo, um passo cirúrgico importante na exposição e clipagem de aneurismas dos segmentos clinoideo e supraclinoideo da artéria carótida interna. Fístula liquórica é uma das complicaçoes mais indesejadas e é potencialmente grave. O manejo com medidas conservadoras pode ser bem sucedido, e não há consenso sobre o tratamento cirúrgico mais adequado. Dois pacientes com rinorréia persistente secundária a fistula liquórica transclinoidal após cirurgia de aneurisma foram tratados com sucesso por uma abordagem endoscópica combinada transnasal/transseptal binostril usando um enxerto de gordura e retalho de mucosa naso-septal ipsilateral. Considerações anatômicas e detalhes da técnica cirúrgica empregada são discutidos, e um plano de manejo destes tipo de fistula líquorica é proposto.

Physiological responses to brain stimulation during limbic surgery: further evidence of anterior cingulate modulation of autonomic arousal.

BACKGROUND: In view of conflicting neuroimaging results regarding autonomic-specific activity within the anterior cingulate cortex (ACC), we investigated autonomic responses to direct brain stimulation during stereotactic limbic surgery. METHODS: Skin conductance activity and accelerative heart rate responses to multi-voltage stimulation of the ACC (n = 7) and paralimbic subcaudate (n = 5) regions were recorded during bilateral anterior cingulotomy and bilateral subcaudate tractotomy (in patients that had previously received an adequate lesion in the ACC), respectively. RESULTS: Stimulations in both groups were accompanied by increased autonomic arousal. Skin conductance activity was significantly increased during ACC stimulations compared with paralimbic targets at 2 V (2.34 +/- .68 [score in microSiemens +/- SE] vs. .34 +/- .09, p = .013) and 3 V (3.52 +/- .86 vs. 1.12 +/- .37, p = .036), exhibiting a strong "voltage-response" relationship between stimulus magnitude and response amplitude (difference from 1 to 3 V = 1.15 +/- .90 vs. 3.52 +/- .86, p = .041). Heart rate response was less indicative of between-group differences. CONCLUSIONS: This is the first study of its kind aiming at seeking novel insights into the mechanisms responsible for central autonomic modulation. It supports a concept that interregional interactions account for the coordination of autonomic arousal.

Influência do pré-condicionamento isquêmico na proteçäo miocárdica em revascularizaçäo do miocárdio com pinçamento intermitente da aorta. Análise de íons e gasometria / Influence of ischemic preconditioning in myocardial protection in patients undergoing myocardial revascularization with intermittent crossclamping of the aorta. Analysis of ions and blood gases

OBJECTIVE: To test the hypothesis that short periods of ischemia may increase the myocardial protection obtained with intermittent crossclamping of the aorta. METHODS: In the control group (18 patients), surgery was performed with systemic hypothermia at 32ºC and intermittent crossclamping of the aorta. Extracorporeal circulation was used. In the preconditioning group (17 patients), 2 crossclampings of the aorta lasting 3min each were added prior to the intermittent crossclamping of the conventional technique with an interval of 2min of reperfusion between them. Blood samples for analyses of pH, pCO2, pO2, sodium, potassium, calcium, and magnesium were obtained from the coronary sinus at the beginning of extracorporeal circulation (time 1), at the end of the first anastomosis (time 2), and at the end of extracorporeal circulation (time 3). RESULTS: No difference was observed in the results of the 2 groups, except for a variation in the ionic values in the different times of blood withdrawal; sodium values, however, remained stable. All patients had a good clinical outcome. CONCLUSION: The results of intermittent crossclamping of the aorta with moderate hypothermia were not altered by the use of ischemic preconditioning

Evoluçäo hemodinâmica da revascularizaçäo do miocárdio com dois métodos de proteçäo miocárdica / Hemodynamic evolution of myocardial revascularization through two methods of myocardial protection

OBJETIVO: Avaliar a evoluçäo hemodinâmica imediata na revascularizaçäo do miocárdio com pinçamento intermitente da aorta, acrescido ou näo de um protocolo de pré-condicionamento. CASUISTICA E METODOS: Trinta e cinco pacientes submetidos à revascularizaçäo do miocárdio foram randomizados em 2 grupos. No grupo controle (18), o procedimento foi realizado com pinçamento intermitente da aorta; no segundo grupo (17), denominado pré-condicionamento, foram acrescidos 2 pinçamentos curtos da aorta, previamente ao pinçamento intermitente convencional. Foram obtidos a pressäo arterial média (PAm), a pressço capilar pulmonar (PCP), o índice cardíaco (IC) e o índice de trabalho sistólico do VE (ITSVE) antes da circulaçäo extracorpórea (1); antes da sutura esternal (2); com 6h (3); 12h (4); 18h (5) e 24h de pós-operatório (6), além da fraçäo de ejeçäo (FEVE) por ecocardiograma nos momentos 1 e 2. RESULTADOS: Näo houve diferença estatística entre os grupos, havendo um aumento do IC e FEVE após a revascularizaçäo. Todos os pacientes tiveram boa evoluçäo clínica. CONCLUSÃO: O comportamento hemodinâmico foi semelhante nos dois grupos de pacientes

Influência do pré-condicionamento isquêmico na proteçäo miocárdica em revascularizaçäo do miocárdio com pinçamento intermitente da aorta / Influence of the ischemic preconditioning in the myocardial protection in myocardial revascularization with intermittent aortic cross-clamping

Objetivo: Este estudo testa a hipótese de que curtos períodos de isquemia podem aumentar a proteçäo obtida pelo pinçamento intermitente da aorta. Métodos: No grupo controle (18), a operaçäo foi realizada com hipotermia sistêmica a 32 ºC com pinçamento intermitente da aorta e uso de circulaçäo extracorpórea (CEC). No segundo grupo, denominado de pré-condicionamento (17), foram acrescidos dois pinçamentos de 3 minutos da aorta com intervalo de 2 minutos de reperfusäo entre eles, previamente ao pinçamento intermitente da forma convencional. CK-MB, troponina I, adenosina e lactato foram obtidos do seio ocoronário no início da circulaçäo extracorpórea (1), ao final da segunda anastomose (2) e ao final da CEC (3). Resultados: Os níveis de CK-MB e troponina I apresentaram uma leve tendência a aumentar ao final da CEC no grupo controle, enquanto os de adenosina e lactato näo apresentaram diferença. (Ver tabela). Conclusäo: Concluímos que o pré-condicionamento isquêmico näo promoveu melhora significante na proteçäo miocárdica

Revascularizacao transmiocardica com o uso de laser / Transmyocardial laser revascularization

A miocardiopatia isquemica e uma patologia extremamente frequente em todo o mundo, sendo uma das principais causas de internacao e morbi-mortalidade. As tecnicas convencionais para o tratamento da doenca coronariana incluem terapia medicamentosa, angioplastia e cirurgias de bypass da arteria coronariana ou transplante. Porem, alguns pacientes que apresentam angina severa nao respondem bem ou nao se enquadram como candidatos a tais procedimentos. A revascularizacao transmiocardica com o uso de laser (transmyocardial laser revascularization - TMLR) surgiu como uma alternativa para esses pacientes. Ela consiste na perfuracao de pequenos canais no musculo cardiaco utilizando-se um feixe de laser, via toracotomia lateral. Espera-se que atraves desses canais o sangue contido nas cavidades ventriculares penetre no miocardio e atinja uma rede de microcirculacao, irrigando o musculo antes isquemico...