Characterization of purinergic signaling in tumor-infiltrating lymphocytes from lower- and high-grade gliomas.

Malignant gliomas are highly heterogeneous glia-derived tumors that present an aggressive and invasive nature, with a dismal prognosis. The multi-dimensional interactions between glioma cells and other tumor microenvironment (TME) non-tumoral components constitute a challenge to finding successful treatment strategies. Several molecules, such as extracellular purines, participate in signaling events and support the immunosuppressive TME of glioma patients. The purinergic signaling and the ectoenzymes network involved in the metabolism of these extracellular nucleotides are still unexplored in the glioma TME, especially in lower-grade gliomas (LGG). Also, differences between IDH-mutant (IDH-Mut) versus wild-type (IDH-WT) gliomas are still unknown in this context. For the first time, to our knowledge, this study characterizes the TME of LGG, high-grade gliomas (HGG) IDH-Mut, and HGG IDH-WT patients regarding purinergic ectoenzymes and P1 receptors, focusing on tumor-infiltrating lymphocytes. Here, we show that ectoenzymes from both canonical and non-canonical pathways are increased in the TME when compared to the peripheral blood. We hypothesize this enhancement supports extracellular adenosine generation, hence increasing TME immunosuppression.

Smart Check - COVID-19 triage system: Evaluation of the impact on the screening time and identification of clinical manifestations of SARS-CoV-2 infection in a public health service.

INTRODUCTION: Most patients with COVID-19 have mild or moderate manifestations; however, there is a wide spectrum of clinical presentations and even more severe repercussions that require high diagnostic suspicion. Vital sign acquisition and monitoring are crucial for detecting and responding to patients with COVID-19. OBJECTIVE: Thus, we conducted this study to demonstrate the impact of using a tool called Smart Check on the triage time of patients with suspected COVID-19 and to identify the main initial clinical manifestations in these patients. METHODOLOGY: We assessed triage times before and after the use of Smart Check in 11 466 patients at Hospital Nossa Senhora da Conceição in Porto Alegre, Brazil, from 1 June to 31 July 2020. In this group, we identified 220 patients for the identification of COVID-19 clinical manifestations in a case-control analysis. RESULTS: Smart Check was able to decrease the triage time by 33 seconds on average (P < .001), with 75% of the exams being performed within 5 minutes, whereas with the usual protocol these steps were performed within 6 minutes. A range of clinical presentations made up the COVID-19 initial manifestations. Those with the highest frequency were dry cough (46.4%), fever (41.3%), dyspnoea (35.8%), and headache (31.8%). Loss of appetite was the manifestation that had a statistically significant association with the SARS-CoV-2 presence (univariate analysis). When analysed together, loss of appetite associated with dyspnoea and/or ageusia and/or fever was related to the diagnosis of COVID-19. CONCLUSIONS: Smart Check, a simple clinical evaluation tool, along with the targeted use of rapid PCR testing, can optimise triage time for patients with and without COVID-19. In triage centres, a number of initial signs and symptoms should be cause for SARS-CoV-2 infection suspicion, in particular the association of respiratory, neurological, and gastrointestinal manifestations.

Early Transcranial Doppler Evaluation of Cerebral Autoregulation Independently Predicts Functional Outcome After Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Cerebral autoregulation (CA) impairment after aneurysmal subarachnoid hemorrhage (SAH) has been associated with delayed cerebral ischemia and an unfavorable outcome. We investigated whether the early transient hyperemic response test (THRT), a transcranial Doppler (TCD)-based CA evaluation method, can predict functional outcome 6 months after aneurysmal SAH. METHODS: This is a prospective observational study of all aneurysmal SAH patients consecutively admitted to a single center between January 2016 and February 2017. CA was evaluated within 72 h of hemorrhage by THRT, which describes the changes in cerebral blood flow velocity after a brief compression of the ipsilateral common carotid artery. CA was considered to be preserved when an increase ≥ 9% of baseline systolic velocity was present. According to the modified Rankin Scale (mRS: 4-6), the primary outcome was unfavorable 6 months after hemorrhage. Secondary outcomes included cerebral infarction, vasospasm on TCD, and an unfavorable outcome at hospital discharge. RESULTS: Forty patients were included (mean age = 54 ± 12 years, 70% females). CA was impaired in 19 patients (47.5%) and preserved in 21 (52.5%). Impaired CA patients were older (59 ± 13 vs. 50 ± 9, p = 0.012), showed worse neurological conditions (Hunt&Hess 4 or 5-47.4% vs. 9.5%, p = 0.012), and clinical initial condition (APACHE II physiological score-12 [5.57-13] vs. 3.5 [3-5], p = 0.001). Fourteen patients in the impaired CA group and one patient in the preserved CA group progressed to an unfavorable outcome (73.7% vs. 4.7%, p = 0.0001). The impaired CA group more frequently developed cerebral infarction than the preserved CA group (36.8% vs. 0%, p = 0.003, respectively). After multivariate analysis, impaired CA (OR 5.15 95% CI 1.43-51.99, p = 0.033) and the APACHE II physiological score (OR 1.67, 95% CI 1.01-2.76, p = 0.046) were independently associated with an unfavorable outcome. CONCLUSIONS: Early CA impairment detected by TCD and admission APACHE II physiological score independently predicted an unfavorable outcome after SAH.

Forced treadmill exercise prevents oxidative stress and memory deficits following chronic cerebral hypoperfusion in the rat.

Physical activity impacts functional recovery following stroke in humans, however its effects in experimental animals submitted to chronic cerebral hypoperfusion have not been investigated. The aim of this study was to evaluate the therapeutic potential of exercise, as assessed by cognitive activity in the Morris water maze and the brain oxidative status, through measurement of macromolecules damage, TBARS levels and total cellular thiols, as well as antioxidant enzymes in hippocampus, striatum and cerebral cortex. Adult male Wistar rats were submitted to the modified permanent bilateral occlusion of the common carotid arteries (2VO) method, with right common carotid artery being first occluded, and tested 3 months after the ischemic event. The effects of three different exercise protocols were examined: pre-ischemia, post-ischemia and pre+post-ischemia. Physical exercise consisted of sessions of 20-min, 3 times per week during 12 weeks (moderate intensity). Rats were submitted to cognitive assessment, in both reference and working spatial memory and after the last testing session were sacrificed to have oxidative stress parameters determined. Hypoperfusion caused a significant cognitive deficit in both spatial water maze tasks and this effect was reversed in rats receiving exercise protocol post and pre+post the ischemic event. Moreover, forced regular treadmill exercise regulated oxidative damage and antioxidant enzyme activity in the hippocampus. These results suggest that physical exercise protects against cognitive and biochemical impairments caused by chronic cerebral hypoperfusion.

Effects of chronic guanosine treatment on hippocampal damage and cognitive impairment of rats submitted to chronic cerebral hypoperfusion.

Chronic cerebral hypoperfusion contributes to a cognitive decline related to brain disorders. Its experimental model in rats is a permanent bilateral common carotid artery occlusion (2VO). Overstimulation of the glutamatergic system excitotoxicity due to brain energetic disturbance in 2VO animals seems to play a pivotal role as a mechanism of cerebral damage. The nucleoside guanosine (GUO) exerts extracellular effects including antagonism of glutamatergic activity. Accordingly, our group demonstrated several neuroprotective effects of GUO against glutamatergic excitotoxicity. Therefore, in this study, we evaluated a chronic GUO treatment effects in rats submitted to 2VO. We evaluated the animals performance in the Morris water maze and hippocampal damage by neurons and astrocytes immunohistochemistry. In addition, we investigated the cerebrospinal fluid (CSF) brain derived neurotrophic factor (BDNF) and serum S100B levels. Additionally, the purine CSF and plasma levels were determined. GUO treatment did not prevent the cognitive impairment promoted by 2VO. However, none of the 2VO animals treated with GUO showed differences in the hippocampal regions compared to control, while 20% of 2VO rats not treated with GUO presented loss of pyramidal neurons and increased glial labeling cells in CA1 hippocampal region. In addition, we did not observe differences in CSF BDNF nor serum S100B levels among the groups. Of note, both the 2VO surgery and GUO treatment changed the purine CSF and plasma profile. In conclusion, GUO treatment did not prevent the cognitive impairment observed in 2VO animals, but our data suggest that GUO could be neuroprotective against hippocampal damage induced by 2VO.

Quantitative computed tomography and cranial burr holes: a model to evaluate the quality of cranial reconstruction in humans.

Current methods to evaluate the biologic development of bone grafts in human beings do not quantify results accurately. Cranial burr holes are standardized critical bone defects, and the differences between bone powder and bone grafts have been determined in numerous experimental studies. This study evaluated quantitative computed tomography (QCT) as a method to objectively measure cranial bone density after cranial reconstruction with autografts. In each of 8 patients, 2 of 4 surgical burr holes were reconstructed with autogenous wet bone powder collected during skull trephination, and the other 2 holes, with a circular cortical bone fragment removed from the inner table of the cranial bone flap. After 12 months, the reconstructed areas and a sample of normal bone were studied using three-dimensional QCT; bone density was measured in Hounsfield units (HU). Mean (SD) bone density was 1535.89 (141) HU for normal bone (P < 0.0001), 964 (176) HU for bone fragments, and 453 (241) HU for bone powder (P < 0.001). As expected, the density of the bone fragment graft was consistently greater than that of bone powder. Results confirm the accuracy and reproducibility of QCT, already demonstrated for bone in other locations, and suggest that it is an adequate tool to evaluate cranial reconstructions. The combination of QCT and cranial burr holes is an excellent model to accurately measure the quality of new bone in cranial reconstructions and also seems to be an appropriate choice of experimental model to clinically test any cranial bone or bone substitute reconstruction.

Epileptic Syndrome and Cranioplasty: Implication of Reconstructions in the Electroencephalogram.

BACKGROUND: In the presence of a skull deformity after large decompressive craniectomy (DC), neurologic deterioration manifesting as epileptic syndrome (ES) may occur independently of the primary disease or spontaneous improvement may be unduly impaired, and these unfavorable outcomes have sometimes been reversed by cranioplasty. The objective of this study was to analyze the influence of cranioplasty on the presence of ES in patients who underwent DC. METHODS: A prospective study was performed from October 2016 to October 2017 involving patients who underwent DC and subsequent cranioplasty. Electroencephalographic (EEG) status before and after cranioplasty was analyzed in the presence of seizures and was compared with results after DC. RESULTS: The sample included 52 patients. Male sex (78.8%) and traumatic brain injury (82.7%) were common indications for DC. ES after DC was verified in 26.9% of patients, and 50% of patients presented with abnormal EEG status. ES after cranioplasty was noted in 21.2% and 36.3% of patients followed by abnormal EEG status. All patients with precranioplasty epileptogenic paroxysms showed better EEG tracings after the procedure. CONCLUSIONS: In routine clinical practice, altered amplitudes were observed in the region of bone defects. Although cranioplasty reduced pathologic EEG status (epileptogenic paroxysms), it was not able to produce new EEG tracings that could predict changes in seizure discharge or reduce ES.

Cerebrospinal Fluid Collected by Lumbar Puncture Has a Higher Diagnostic Accuracy than Collected by Ventriculostomy.

BACKGROUND: Patients harboring an external ventricular drain (EVD) who develop signs of infection require screening for infection in the central nervous system (CNS). The cerebrospinal fluid (CSF) can be collected by the EVD or by lumbar puncture (LP). If only one sample is analyzed, the diagnosis might be dubious or false-negative. The objective of this study was to compare the diagnosis accuracy of CNS infection of CSF samples collected from EVD and LP. METHODS: We conducted a transversal study where data were prospectively collected from 2016 to 2019. Patients harboring EVD with signs of infection were submitted to the CSF analysis collected by LP and EVD. Diagnosis sensibility and results correlation were analyzed using the kappa index. RESULTS: The 141 samples from LP and 141 samples from EVD were collected from 108 patients. Among the 282 samples, a total of 77 had infection. Seventy CSF samples from LP fulfilled infection criteria. However, only 32 EVD samples demonstrated infection. Among the 70 cases of infection based on the LP sample, 25 CSF samples collected from the EVD were also suggestive of infection; but in 45 patients only the CSF samples from LP met infection criteria. Seven patients had diagnosis of infection only in the EVD sample. The kappa correlation index of the results obtained from LP and EVD was 0.260 and the McNemar χ2 test was <0.01. CONCLUSIONS: The CSF analysis exclusive from the EVD has a low sensibility and negative predictive value. CSF collected from LP has a sensibility 2.18 times higher than EVD.

Postoperative Supine Position Increases the Risk of Infection After Spinal Surgery by Posterior Approach.

BACKGROUND: Spine surgeries performed via the posterior approach have a higher infection rate. Several theories have been proposed, including poor hygienic condition of bed sheets and traumatized muscle associated with supine position promoting circulatory impairment. We investigated the influence of supine position on the rate of deep wound infection after spine surgery by the posterior approach. METHODS: A total of 106 patients were randomly divided into 2 groups: lateral decubitus only versus dorsal and lateral decubitus. Patient follow-up after hospital discharge was performed at 30, 60, 180, and 360 days. Deep wound infection was diagnosed according to U.S. Centers for Disease Control and Prevention criteria. RESULTS: Patient sample was mainly composed of patients with neoplastic disease and patients with trauma. Postoperative wound infection developed in 12 cases (11.3%), and Streptococcus aureus was the most common pathogen. Incidence of postsurgical deep wound infection was significantly greater in the control group (P = 0.004). CONCLUSIONS: Supine position was significantly correlated with higher rates of wound infection among patients who underwent spine surgery by the posterior approach. Avoidance of supine position may represent a modifiable risk factor to diminish postoperative spine infection rates.

Impact of surgery on pain, disability, and quality of life of patients with degenerative lumbar disease: Brazilian data.

OBJECTIVE: To study the impact of surgery on pain, disability, quality of life, and patient satisfaction in a sample of patients with Degenerative Lumbar Disease (DLD). METHODS: Retrospective analysis of prospectively collected data. Comparison between pre and postoperative (6 - 12 months) ODI and SF-36, plus postoperative Patient Satisfaction Index. RESULTS: From a total of 216 patients included, improvement was observed in average scores of pain (201.2%), disability (39.7%), physical quality of life (42%), and mental quality of life (37.8%). Among these patients, 57.7% reached or surpassed the minimal clinically important difference (MCID) for ODI, 57.7% for the SF-36 pain component, 59.7% for the SF-36 physical component summary, and 50.5% achieved or surpassed the MCID for the SF-36 mental component summary. CONCLUSIONS: Surgery produced a significantly positive impact on pain, disability, and quality of life of patients. Overall, 82.5% of the patients were satisfied.

The impact of cranioplasty on the patients' quality of life.

OBJECTIVE: To evaluate the quality of life in patients with moderate or large cranial bone defects before and after late cranioplasty. METHODS: Authors performed a prospective clinical trial including all consecutive patients that filled inclusion criteria during a period of 1 year. All patients answered the quality of life SF-36 questionnaire in 5 different times. Besides authors gathered information about the primary trauma and demographic characteristics. RESULTS: A total of 70 consecutive patients were admitted to the hospital during the study period, and 62 were included in the project. Cranioplasty statistically improved patients' quality of life in all 8 domains after a 24 months follow-up. CONCLUSION: Cranioplasty has a significant impact over the quality of life in brain trauma victims who survived the primary trauma and harbor a large cranial bone defect.

Cerebellar hemorrhage as a complication of spine surgery.

BACKGROUND: The association between remote cerebellar hematoma (RCH) and spinal surgery is poorly understood and rarely reported. We present seven cases of RCH after spinal surgery. METHODS: Seven patients were diagnosed with RCH utilizing computed tomography and/or magnetic resonance, between 2012 and 2016. Their clinical presentations, imaging data, treatment modalities, and outcome were analyzed. There were five females and two males with an average age of 55.8 ± 8.4 years. The age of onset ranged from 43 to 67 years and the time to clinical presentation ranged from 3 h to 5 days. Patients presented with: diplopia/strabismus (one patient), dysphagia/urinary incontinence (one patient), respiratory arrest (one patient), meningismus (one patient), and dysarthria (two patients), along with other symptoms/signs. RESULTS: Three patients were successfully managed without surgery, two required external ventricular drainage, and two were treated with posterior fossa decompression plus ventriculostomy. Four patients recovered completely, two showed mild residual deficits at discharge, while one expired 7 days postoperatively. CONCLUSION: RCH is an uncommon and underdiagnosed complication of spine surgery. It should be suspected when intracranial symptoms occur after spinal procedures.

Cervicothoracic Lordosis Can Influence Outcome After Posterior Cervical Spine Surgery.

BACKGROUND: Previous studies on the correlation between cervical sagittal balance with improvement in quality of life showed significant results only for parameters of the anterior translation of the cervical spine (such as C2-C7 SVA). OBJECTIVE: We test whether a new parameter, cervicothoracic lordosis, can predict clinical success in this type of surgery. METHODS: The focused group involved patients who underwent surgical treatment of cervical degenerative disk disease by the posterior approach, due to myelopathy, radiculopathy or a combination of both. Neurologic deficit was measured before and after surgery with the Nurick Scale, postoperative quality of life, physical and mental components of SF-36 and NDI. Cervicothoracic lordosis and various sagittal balance parameters were also measured. Cervicothoracic lordosis was defined as the angle between: a) the line between the centroid of C2 and the centroid of C7; b) the line between the centroid of C7 and the centroid of T6. Correlations between postoperative quality of life and sagittal parameters were calculated. RESULTS: Twenty-nine patients between 27 and 78 years old were evaluated. Surgery types were simple decompression (laminectomy or laminoforaminotomy) (3 patients), laminoplasty (4 patients) and laminectomy with fusion in 22 patients. Significant correlations were found for C2-C7 SVA and cervicothoracic lordosis. C2-C7 SVA correlated negatively with MCS (r=-0.445, p=0.026) and PCS (r=-0.405, p=0.045). Cervicothoracic lordosis correlated positively with MCS (r=0.554, p= 0.004) and PCS (r=0.462, p=0.020) and negatively with NDI (r=-0.416, p=0.031). CONCLUSION: The parameter cervicothoracic lordosis correlates with improvement of quality life after surgery for cervical degenerative disk disease by the posterior approach.

Metabotropic glutamate receptors as a new therapeutic target for malignant gliomas.

Metabotropic glutamate receptors (mGluR) are predominantly involved in maintenance of cellular homeostasis of central nervous system. However, evidences have suggested other roles of mGluR in human tumors. Aberrant mGluR signaling has been shown to participate in transformation and maintenance of various cancer types, including malignant brain tumors. This review intends to summarize recent findings regarding the involvement of mGluR-mediated intracellular signaling pathways in progression, aggressiveness, and recurrence of malignant gliomas, mainly glioblastomas (GBM), highlighting the potential therapeutic applications of mGluR ligands. In addition to the growing number of studies reporting mGluR gene or protein expression in glioma samples (resections, lineages, and primary cultures), pharmacological blockade in vitro of mGluR1 and mGluR3 by selective ligands has been shown to be anti-proliferative and anti-migratory, decreasing activation of MAPK and PI3K pathways. In addition, mGluR3 antagonists promoted astroglial differentiation of GBM cells and also enabled cytotoxic action of temozolomide (TMZ). mGluR3-dependent TMZ toxicity was supported by increasing levels of MGMT transcripts through an intracellular signaling pathway that sequentially involves PI3K and NF-κB. Further, continuous pharmacological blockade of mGluR1 and mGluR3 have been shown to reduced growth of GBM tumor in two independent in vivo xenograft models. In parallel, low levels of mGluR3 mRNA in GBM resections may be a predictor for long survival rate of patients. Since several Phase I, II and III clinical trials are being performed using group I and II mGluR modulators, there is a strong scientifically-based rationale for testing mGluR antagonists as an adjuvant therapy for malignant brain tumors.

Impact of surgery on ambulatory status in patients with symptomatic neoplastic spinal cord compression in southern brazil / Impacto da cirurgia sobre a capacidade de ambulatória em pacientes com compressão neoplásica sintomática da medula espinalno sul do brasil / Impacto de la cirugía en la capacidad de ambulación en pacientes con compresión medular neoplásica sintomática en el sur de brasil

ABSTRACT Background: Spinal cord compression is a common complication of spine metastasis and multiple myeloma. About 30% of patients with cancer develop symptomatic spinal metastases during their illness. Prompt diagnosis and surgical treatment of these lesions, although palliative, are likely to reduce the morbidity and improve quality of life by improving ambulatory function. Study Design: Retrospective review of medical records. Objective: To evaluate postoperative functional recovery and the epidemiological profile of neoplastic spinal cord compression in two neurosurgical centers in southern Brazil. Methods: We retrospectively analyzed the data of all patients who underwent palliative surgery for symptomatic neoplastic spine lesion from metastatic cancer, in two neurosurgical centers, between January 2003 and July 2021. The variables age, sex, neurological status, histological type, affected segment, complications and length of hospitalization were analyzed. Results: A total of 82 patients were included. The lesions occurred in the thoracic spine in 60 cases. At admission, 95% of the patients had neurological deficits, most of which were Frankel C (37%). At histopathological analysis, breast cancer was the most common primary site. After surgery, the neurological status of 46 patients (56%) was reclassified according to the Frankel scale. Of these, 22 (47%) regained ambulatory capacity. Conclusion: Surgical treatment of metastatic spinal cord compression improved neurological status and ambulatory ability in our sample. Level of evidence II; Retrospective study.

RESUMO: Introdução: A compressão medular é uma complicação comum de metástases da coluna vertebral e de mieloma múltiplo. Cerca de 30% dos pacientes com câncer desenvolvem metástases sintomáticas na coluna no decorrer da doença. O diagnóstico imediato e o tratamento cirúrgico dessas lesões, embora paliativos, em geral reduzema morbidade e melhoram a qualidade de vidaao ampliar a capacidade de deambular. Desenho do estudo: Revisão retrospectiva de prontuários médicos. Objetivo: Avaliar a recuperação funcional pós-operatória e o perfil epidemiológico da compressão medular neoplásica em dois centros de neurocirurgia do sul do Brasil. Métodos: Analisamos retrospectivamente os dados de todos os pacientes submetidos à cirurgia paliativa de lesão neoplásica sintomática da coluna decorrente decâncer metastático, em dois centros neurocirúrgicos entre janeiro de 2003 e julho de 2021. Foram analisadas as variáveis idade, sexo, estado neurológico, tipo histológico, segmento acometido, complicações e tempo de internação. Resultados: Foram incluídos 82 pacientes no estudo. As lesões ocorreram na coluna torácica em 60 casos. À internação, 95% dos pacientes apresentavam déficits neurológicos, sendoa maioria classificada como Frankel C (37%). Na análise histopatológica, o câncer de mama foi o sítio primário mais comum. Depois da cirurgia, 46 pacientes (56%) tiveram o estado neurológico reclassificado pela escala de Frankel. Entre eles, 22 (47%) recuperaram a capacidade de deambular. Conclusões: O tratamento cirúrgico da compressão medular metastática melhorou o estado neurológico e a capacidade de deambulação em nossa amostra. Nível de evidência II; Estudo retrospectivo.

RESUMEN: Introducción: La compresión de la médula espinal es una complicación común de la metástasis de la columna vertebral y el mieloma múltiple. Aproximadamente el 30% de los pacientes con cáncer desarrollan metástasis espinales sintomáticas en el curso de la enfermedad. El diagnóstico precoz y el tratamiento quirúrgico de estas lesiones, aunque son paliativos, suelen reducir la morbilidad y mejor en lacalidad de vida al aumentar la de ambulación. Diseño del estudio: Revisión retrospectiva de registros médicos. Objetivo: Evaluarla recuperación funcional postoperatoria y el perfil epidemiológico de la compresión medular neoplásica en dos centros neuroquirúrgicos del sur de Brasil. Métodos: Analizamos retrospectivamente los datos de todos los pacientes sometidos a cirugía paliativa por lesión vertebral neoplásica sintomática por cáncer metastásico, en dos centros neuroquirúrgicos entre enero de 2003 y julio de 2021. Se analizaron las variables edad, sexo, estado neurológico, tipo histológico, segmento afectado, complicaciones y duración de la hospitalización. Resultados: Se incluyeron 82 pacientes en el estudio. Las lesiones se produjeron en la columna torácica en 60 casos. Al ingreso, el 95% de los pacientes presentaban déficits neurológicos y la mayoría de ellos eran clasificados como Frankel C (37%). En el análisis histopatológico, elcáncer de mama fue el sitio primario más común. Después de la cirugía, se reclasificó el estado neurológico de 46 pacientes (56%) por la escala de Frankel. Entre ellos, 22 (47%) recuperaron la capacidadde deambulación. Conclusiones: El tratamiento quirúrgico de la compresión medular metastásica mejoró el estado neurológico y la capacidad de deambulación en nuestra muestra. Nivel de evidencia II; Estudio retrospectivo.

Giant scalp arteriovenous malformation.

Arteriovenous malformations (AVMs) of the scalp are rare lesions. The clinical picture presents with complaints of increased scalp, scalp disfigurement, pain and neurological symptoms. Its origin can be congenital or traumatic. We present a case of giant scalp AVMs and its management, followed by a brief literature review on the subject. The diagnosis of scalp AVMs is based on physical examination and confirmed by internal and external carotid angiography or computed tomographic angiography (CTA). Surgical excision is especially effective in scalp AVMs, and is the most frequently used treatment modality.

Polymethylmethacrylate imbedded with antibiotics cranioplasty: An infection solution for moderate and large defects reconstruction?

BACKGROUND: In cases where autologous bone graft reconstruction is not possible (such as comminuted fractures, bone graft reabsorption, or infection) and the use of synthetic material is required, polymethylmethacrylate (PMMA) use is a safe and efficient solution. Studies comparing the incidence of postoperative complications between autologous and synthetic cranioplasty are heterogeneous, not allowing a conclusion of which is the best material for skull defects reconstruction. Current medical literature lacks prospective well-delineated studies with long-term follow-up that analyze the impact of antibiotic use in PMMA cranial reconstruction of moderate and large defects. METHODS: A prospective series of patients, who underwent cranioplasty reconstruction with PMMA impregnated with antibiotic, were followed for 2 years. Authors collected data regarding demographic status, clinical conditions, surgical information, and its complications. RESULTS: A total of 58 patients completed full follow-up with a mean group age of 40 years and a male predominance (77%). Major complications that required surgical management were identified in 5 patients, and 10 patients evolved with minor complications. Postoperative surgical site infection incidence was 3.2%. CONCLUSION: The infection rate in patients submitted to PMMA flap cranioplasty impregnated with antibiotic is significantly inferior comparing to the data described in medical literature. A lower infection incidence impacts secondary endpoints such as minimizing surgical morbidity, mortality, hospitalization period, and, consequently, costs.

A simple scoring system for predicting early major complications in spine surgery: the cumulative effect of age and size of surgery.

OBJECTIVE: To analyze the cumulative effect of risk factors associated with early major complications in postoperative spine surgery. METHODS: Retrospective analysis of 583 surgically-treated patients. Early "major" complications were defined as those that may lead to permanent detrimental effects or require further significant intervention. A balanced risk score was built using multiple logistic regression. RESULTS: Ninety-two early major complications occurred in 76 patients (13%). Age > 60 years and surgery of three or more levels proved to be significant independent risk factors in the multivariate analysis. The balanced scoring system was defined as: 0 points (no risk factor), 2 points (1 factor) or 4 points (2 factors). The incidence of early major complications in each category was 7% (0 points), 15% (2 points) and 29% (4 points) respectively. CONCLUSIONS: This balanced scoring system, based on two risk factors, represents an important tool for both surgical indication and for patient counseling before surgery.

Autologous cranial bone graft use for trepanation reconstruction.

BACKGROUND: Esthetic deformities in the human skull are a subject of concern among neurosurgical patients and neurosurgeons; they can be disfiguring and harm the patient's social relationships. To access inner structures, neurosurgical operations require skull trepanation, a process that frequently involves loss of bone tissue and leads to esthetic problems. Satisfactory reconstruction is a challenge, and neurosurgeons search for an implant which ideally is organic and low cost and does not cause an immunological or allergic reaction. Therefore, autologous bone tissue remains the gold standard for reconstruction. OBJECTIVES: To develop a technique that allows neurosurgeons to rebuild the trepanation hole with a better esthetic outcome. METHOD: Craniotomy orifices in 108 patients were closed with a graft obtained from the cranial bone inner layer. In order to remove the graft a specially made trephine was used. RESULTS: No grafts dislocated during follow-up. Cosmetic outcomes and results seen on image examinations were favorable for this new technique when compared with others previously described in medical literature. CONCLUSION: The authors present a new and feasible trepanation reconstruction technique that allows a better esthetic outcome without increasing the surgical risk for the patient, or making the surgical procedure longer or more expensive.