Prenatal Repair of Spina Bifida: A 2-Center Experience with Open Intrauterine Neurosurgery in Chile.

OBJECTIVE: To report the experience with prenatal repair of open spina bifida (OSB) from 2 centers in Chile. METHODS: Women with a second-trimester fetus with OSB were offered intrauterine neurosurgical repair following the protocol from the Management of Myelomeningocele Study (MOMS) trial. Pediatric follow-up with infants reaching 12 and 30 months of life was also reviewed. RESULTS: Fifty-eight fetuses with OSB underwent intrauterine repair at an average (±SD) gestational age of 24.8 ± 0.9 weeks. There were 3 (5.1%) intrauterine deaths. The average gestational age at delivery of the remaining 55 cases was 33.3 ± 3.6 weeks, and the average birth weight was 2,172 ± 751 g. Delivery before 30 weeks occurred in 11 cases (20.0%). Two (3.6%) neonatal deaths (<28 days) occurred. At 12 months, a ventriculoperitoneal shunt or an endoscopic third ventriculostomy was required in 25% of the cases. At 30 months, 72.4% of the infants were able to walk. DISCUSSION: Prenatal neurosurgical repair of OSB is a complex and challenging intervention. Major complications include perinatal death and severe prematurity. No major maternal complications occurred in our series. A reduction in the need for cerebrospinal fluid diversion and an improved ability to walk seem to be the greatest long-term advantages of this procedure.

Inverse Association between Omega-3 Index and Severity of COVID-19: A Case-Control Study.

Background: Omega-3 fatty acids enhance immune response and modulate inflammation. This study aimed to determine the relationship between omega-3 fatty acid status and the severity of SARS-CoV-2 infection. Methods: Using a case−control design, we compared hospitalized patients with severe SARS-CoV-2 infection (cases, n = 73) with a group of ambulatory patients with mild SARS-CoV-2 infection (controls, n = 71). No patients were vaccinated against SARS-CoV-2. Results: The cases were older (p = 0.003), less educated (p = 0.001), had larger neck and smaller waist circumferences (p = 0.035 and p = 0.003, respectively), more frequently had diabetes (p < 0.001), consumed less fish (p < 0.001), consumed higher proportions of fried fish (p = 0.001), and had lower Omega-3 Index (O3I) values (p = 0.001) than controls. Cases had significantly lower rates of upper airway symptoms than controls. Lower O3I was associated with an increased likelihood of developing severe COVID-19 after adjusting for potential confounders (OR: 0.52; CI 0.32−0.86). Diabetes (OR: 4.41; CI 1.60−12.12), neck circumference (OR: 1.12; CI 1.03−1.21), and older age (OR: 1.03; CI 1.002−1.062) were also linked to COVID-19 severity. Fried fish consumption and low educational level were independent risk factors for severe COVID-19. Conclusions: This study suggests incorporating nutritional interventions to improve omega-3 status within nonpharmacological measures may help to reduce the severity of COVID-19.

Omega-3 Index and Clinical Outcomes of Severe COVID-19: Preliminary Results of a Cross-Sectional Study.

The potentially detrimental effects of the worldwide deficiency of Omega-3 fatty acids on the COVID-19 pandemic have been underestimated. The Omega-3 Index (O3I), clinical variables, biometric indices, and nutritional information were directly determined for 74 patients with severe COVID-19 and 10 healthy quality-control subjects. The relationships between the OI3 and mechanical ventilation (MV) and death were analyzed. Results: Patients with COVID-19 exhibited low O3I (mean: 4.15%; range: 3.06-6.14%)-consistent with insufficient fish and Omega-3 supplement consumption, and markedly lower than the healthy control subjects (mean: 7.84%; range: 4.65-10.71%). Inverse associations were observed between O3I and MV (OR = 0.459; C.I.: 0.211-0.997) and death (OR = 0.28; C.I.: 0.08-0.985) in severe COVID-19, even after adjusting for sex, age, and well-known risk factors. Conclusion: We present preliminary evidence to support the hypothesis that the risk of severe COVID-19 can be stratified by the O3I quartile. Further investigations are needed to assess the value of the O3I as a blood marker for COVID-19.

Use of plastic wound retractor at hysterotomy site in prenatal repair of myelomeningocele: a new technique.

Objective: To describe the use of a self-retaining thermoplastic polyurethane wound retractor for the management of hysterotomy during prenatal repair of myelomeningocele.Methods: The preliminary experience with 16 consecutive cases of open surgery for prenatal repair of myelomeningocele using a new technique is presented. Under general anesthesia, the gravid uterus was partially exteriorized through a low transverse abdominal incision and a high 3-4-cm midline vertical mini-hysterotomy was performed. After chorioamniotic membranes were opened with scissors, the internal ring of the retractor was placed into the amniotic cavity to compress the chorioamniotic membranes against the internal uterine wall and permit full retraction of the hysterotomy. Once the neurosurgical intervention was completed, the retractor was removed manually and uterine and abdominal incisions were closed using conventional techniques. Intra- and post-operative complications, as well as short-term pregnancy outcomes, were evaluated.Results: Intrauterine surgery was performed at a mean gestational age of 25.3 weeks and all except two of the interventions were completed within 3.0 h. When compared with the technique described in the Management of Myelomeningocele study (MOMS) trial, the use of the retractor was associated with a lower, although statistically nonsignificant, rate of chorioamniotic membrane separation (20/78 (26%) versus 2/16 (13%), respectively), preterm rupture of membranes (36/78 (46%) versus 4/16 (25%), respectively), and persistent oligohydramnios (16/78 (21%) versus 1/16 (6%), respectively) as well as higher gestational age at delivery (34.1 weeks ± 3.1 versus 36.0 weeks ± 1.93, respectively) and birthweight (2383 g ± 688 versus 2790 g ± 529, respectively). There were no intra- or post-operative complications associated with the use of the device. Only one (6%) of the hysterotomy scars was noted to be thin at the time of the cesarean delivery and no cases of dehiscence occurred.Conclusions: The use of a plastic wound retractor at the hysterotomy site provides a less traumatic approach than the conventional technique for the management of the uterine incision during open intrauterine surgery. Our experience with this technique was associated with short-term pregnancy outcomes that are similar and perhaps even superior to the technique reported in the MOMS trial. Because the device is inexpensive, easy to use, and widely available, its use during open intrauterine surgery should be considered. However, further clinical experience is required to reach a definitive conclusion regarding whether this technique should be incorporated into the protocol of prenatal repair of myelomeningocele.

Long-chain omega-3 fatty acids in aneurysmal subarachnoid hemorrhage: A randomized pilot trial of pharmaconutrition.

BACKGROUND: Functional recovery after aneurysmal subarachnoid hemorrhage (SAH) remains a significant problem. We tested a novel therapeutic approach with long-chain omega-3 polyunsaturated fatty acids (n-3 PUFAs) to assess the safety and feasibility of an effectiveness trial. METHODS: We conducted a multicentre, parallel, randomized, open-label pilot trial. Patients admitted within 72 hours after SAH with modified Fisher scale scores of 3 or 4 who were selected for scheduled aneurysm clipping were allocated to receive either n-3 PUFA treatment (parenteral perioperative: 5 days; oral: 8 weeks) plus usual care or usual care alone. Exploratory outcome measures included major postoperative intracranial bleeding complications (PIBCs), cerebral infarction caused by delayed cerebral ischemia, shunt-dependent hydrocephalus, and consent rate. The computed tomography evaluator was blinded to the group assignment. RESULTS: Forty-one patients were randomized, but one patient had to be excluded after allocation. Twenty patients remained for intention to treat analysis in each trial arm. No PIBs (95% confidence interval [CI]: 0.00 to 0.16) or other unexpected harm were observed in the intervention group (IG). No patient suspended the intervention due to side effects. There was a trend towards improvements in all benefit-related outcomes in the IG. The overall consent rate was 0.91 (95% CI: 0.78 to 0.96), and there was no consent withdrawal. CONCLUSIONS: Although the balance between the benefit and harm of the intervention appears highly favourable, further testing on SAH patients is required. We recommend proceeding with amendments in a dose-finding trial to determine the optimal duration of parenteral treatment.

A1­A2 Fenestration Tube Technique for Clipping a Ruptured Anterior Communicating Artery Aneurysm

A fenestration tube is a clipping reconstruction technique that allows the preservation of critical vessels in aneurysm surgery. A patient with a ruptured anterior communicating artery (ACoA) aneurysm with a posterior projection was admitted to our neurosurgery unit. A right dominant A1 with rotation of the A2 fork was observed on preoperative computed tomography angiography (CTA). During surgery, we observed that the recurrent artery of Heubner branched off the A2 just distal to the neck of the aneurysm. Successful clipping was achieved by building an "A1­A2 fenestration tube," with preservation of the recurrent artery and of the ACoA perforators. Surgical nuances and the advantages of fenestration tubes are discussed.

Surgery of a Posterior Communicating Artery Aneurysm with Fetal-Type Circulation

Inadvertent occlusion of a fetal-type posterior communicating artery in aneurysm surgery could result in posterior circulation infarction and neurological morbidity. The case of a patient with an unruptured posterior communicating artery aneurysm with lateral projection and a fetal-type posterior communicating artery is presented. The utility of the carotid-oculomotor window as a surgical corridor to safely find the fetaltype posterior communicating artery is discussed.

A oclusão da artéria comunicante posterior do tipo fetal em cirurgia de aneurisma pode resultar em infarto da circulação posterior e morbidade neurológica. Apresentamos o caso de um paciente com aneurisma não roto da artéria comunicante posterior com projeção lateral e uma artéria comunicante posterior do tipo fetal. Discutimos a utilidade da janela carótida-oculomotora como um corredor cirúrgico para encontrar com segurança a artéria comunicante posterior do tipo fetal.

Microanatomía de la arteria cerebral posterior / Microanatomy of the posterior cerebral artery

La arteria cerebral posterior pertenece a la circulación posterior del encéfalo e irriga las regiones inferiores de los lóbulos temporal y occipital, además del tálamo, hipocampo y mesencéfalo. Se origina de la bifurcación de la arteria basilar y sigue su trayecto rodeando el mesencéfalo hasta la cisterna cuadrigeminal, donde continúa hacia posterior hasta introducirse en el parénquima cerebral y dividirse en sus ramas terminales, la arteria calcarina y parietoccipital. El objetivo de este estudio es describir los distintos segmentos de la arteria cerebral posterior (ACP) en individuos chilenos y analizar las diferencias anatómicas en relación a lo descrito en la literatura internacional. Se estudiaron veinte hemisferios, los que fueron fijados con formalina, y posteriormente sus arterias fueron inyectadas con acrílico coloreado para disecarse con aumentos de 6x a 40x mediante técnicas microanatómicas. Se analizaron los resultados estadísticamente. La ACP y cada una de sus ramas en su recorrido y morfología son similares a lo descrito por otros autores. Se encontró diferencias significativas en la distribución por segmento de grupos arteriales entre hemisferios derecho e izquierdo. Con respecto a la comparación con el trabajo de Zeal y Rhoton (1) sólo existen diferencias en los largos de ACP por segmento, en el porcentaje de presencia de 3 grupos arteriales y en la distribución de grupos arteriales por segmento de origen. Se observó, en el 20 por ciento de los hemisferios analizados, la emergencia de las ramas terminales de la ACP en el interior de la cisura calcarina