Accuracy of acute hyperglycemia as a biomarker of severe brain damage in children with traumatic brain injury.

PURPOSE: Biomarkers are substances measured at the systemic level to evaluate organic responses in certain situations, establishing diagnoses, disease staging, and prognosis. Blood glucose is a biomarker recognized as a predictor of prognosis in children victims of traumatic brain injury (TBI). The scope of this study was to identify the accuracy of blood glucose as a biomarker of severe brain injury. METHODS: A retrospective analytical study was conducted through the consecutive review of medical records of children and teenage victims of TBI who underwent neurological surgery between 2016 and 2023 in a level 1 trauma center. Two groups were compared: children with Glasgow Coma Scale (GCS) score ≤ 8 and children with GCS > 8. We calculated the predictive values to define the accuracy of blood glucose as a biomarker of brain injury. RESULTS: Ninety-two medical records were included for analysis. Hyperglycemia predominated in cases with GCS ≤ 8 (48% vs 3%; p < 0.0001; OR, 30; 95% CI, 5.9902-150.2448). The glycemic measurement considering the cutoff point of 200 mg/dL or 11.1 mmol/L showed a specificity of 97%, a positive predictive value of 86%, an accuracy of 84%, and a likelihood ratio for a positive test of 16. CONCLUSION: Victims with GCS ≤ 8 are 16 times more likely to develop acute hyperglycemia after TBI when compared to those with GCS > 8. Blood glucose is a biomarker with an accuracy of 84% to predict severe brain injury, considering the cutoff point of 200 mg/dL or 11.1 mmol/L.

Spontaneous Bone Flap Resorption Following Cranioplasty Using Autologous Bone.

ABSTRACT: Cranioplasty is a common neurosurgical procedure. The main reasons for performing cranioplasty are, in addition to aesthetic correction and protection of the brain, the reestablishment of the adequate flow of cerebrospinal fluid and the prevention of complications inherent to the perpetuation of bone failure. In our institution the patient's autologous bone remains the best method for performing cranioplasty, despite the existence of other heterologous grafts and bone substitutes. Despite representing for us, the best material for cranioplasty, the use of autologous grafting is subject to complications. In this paper, the authors present the case of a patient who underwent cranioplasty with autologous bone that progressed with spontaneous resorption of the bone flap. The authors herein briefly discuss the case and review the literature on the subject, with an emphasis on the factors that can lead to such an outcome.

Opposing roles of PGD2 in GBM.

BACKGROUND: The World Health Organization classifies glioblastoma (GBM) as a grade IV astrocytoma. Despite the advances in chemotherapy, surgery, and radiation treatments that improve a patient's length of survival, the overall trajectory of the disease remains unchanged. GBM cells produce significant levels of various types of bioactive lipids. Prostaglandin D2 (PGD2) influences both pro- and anti-tumorigenic activities in the cell; however, its role in GBM is unclear. Therefore, this study aimed to identify the impact of PGD2 on GBM cell activities in vitro. METHODS: First we looked to identify the presence of the PGD2 synthesis pathway through RT-PCR, immunohistochemistry, and HPLC-MS/MS in three GBM cell lines. Then, to observe PGD2's effects on cell count and apoptosis/mitosis (Hoechst 33342 stain), and migration (Transwell Assay), the cells were treated in vitro with physiological (<1µM) and/or supraphysiological (>1µM) concentrations of PGD2 over 72h. HPLC-MS/MS was used to identify the lipid composition of patients with either Grade II/III gliomas or GBM. RESULTS: We identified the presence of endogenous PGD2 with its corresponding enzymes and receptors. Exogenous PGD2 both increased cell count (<1µM) and decreased cell count (10µM) in a concentration-dependent manner. There were no significant effects on apoptosis. A significant decrease in mitotic activity was seen only in U251MG, and a significant increase was seen in migration with 5µM PGD2 treatments. A very significant increase of PGD2 was seen from Grade II/III gliomas to GBM. CONCLUSIONS: Our study demonstrates that prostaglandin D2 possesses a dynamic, concentration-dependent effect in GBM cell activities. The increase of PGD2 production in GBM patients suggests a pro-tumorigenic role of PGD2 in glioma growth and invasion. Therefore, prostaglandin signaling in GBM requires further investigation to identify new targets for more effective therapies.

The prostanoid pathway contains potential prognostic markers for glioblastoma.

Prostanoids derived from the activity of cyclooxygenases and their respective synthases contribute to both active inflammation and immune response in the tumor microenvironment. Their synthesis, deactivation and role in glioma biology have not yet been fully explored and require further study. Using quantitative real time PCR, gas chromatography/ electron impact mass spectrometry and liquid chromatography/ electrospray ionization tandem mass spectrometry, we have further characterized the prostanoid pathway in grade IV glioblastoma (GBM). We observed significant correlations between high mRNA expression levels and poor patient survival for microsomal PGE synthase 1 (mPGES1) and prostaglandin reductase 1 (PTGR1). Conversely, high mRNA expression levels for 15-hydroxyprostaglandin dehydrogenase (15-HPGD) were correlated with better patient survival. GBMs had a higher quantity of the prostanoid precursor, arachidonic acid, versus grade II/III tumors and in GBMs a significant positive correlation was found between arachidonic acid and PGE2 content. GBMs also had higher concentrations of TXB2, PGD2, PGE2 and PGF2α versus grade II/III tumors. A significant decrease in survival was detected for high versus low PGE2, PGE2 + PGE2 deactivation products (PGEMs) and PGF2α in GBM patients. Our data show the potential importance of prostanoid metabolism in the progression towards GBM and provide evidence that higher PGE2 and PGF2α concentrations in the tumor are correlated with poorer patient survival. Our findings highlight the potential importance of the enzymes 15-HPGD and PTGR1 as prognostic biomarkers which could be used to predict survival outcome of patients with GBM.

Retroclival Pneumocephalus Associated with Bilateral Abducens Palsy in a Child.

Traumatic brain injury (TBI) is less common in children than in adults. Posterior fossa lesions are even more uncommon, but, when present, are usually epidural hematomas. These lesions, even when small, may have a bad outcome because of the possibility of compression of the important structures that the infratentorial compartment contains, such as the brainstem and cranial nerves, and the constriction of the fourth ventricle, causing acute hydrocephalus. Although unusual, posterior fossa lesions are increasingly being diagnosed because of the better quality of and easier access to cranial tomography. In this paper, we report a case of a 12-year-old male patient who had suffered a TBI and presented with several pneumocephali, one of them in the retroclival region, causing a mass effect and then compression of the sixth cranial nerve which is the most susceptible to these injuries. We discuss these traumatic posterior fossa lesions, with an emphasis on retroclival pneumocephalus, not yet described in the literature in association with bilateral abducens palsy. In addition, we discuss associated lesions and the trauma mechanism.

Congenital giant craniopharyngioma.

PURPOSE: Congenital intracranial tumors are extremely rare and the most common is teratoma. Craniopharyngioma is a rare neonatal tumor with only eight cases reported. The management of this tumor in the neonatal period is still controversial, with the best results obtained when radical resection is performed. We present the case of a patient who received the diagnosis of a suprasellar tumor during the prenatal period and reviewed literature regarding the management. METHODS: We report a case of neonatal craniopharyngioma treated surgically. RESULTS: The routine ultrasound at 29 weeks of gestation showed a suprasellar echogenic image measuring 44 mm in diameter with polyhydramnios and macrocephaly. The patient was born at 38 weeks of gestation and underwent a surgical treatment on its 32nd day of life and the excision of almost 80 % of the lesion was achieved. He developed a subdural hygroma and on the 51st day of life, a subduroperitoneal shunt was installed to treat it. This patient died at 8 months of life due to complications of a shunt infection. CONCLUSION: The present case is the ninth diagnosed during the prenatal period and the literature is controversial on the management of this rare tumor. The complete excision of the lesion using the microsurgical technique is the gold standard treatment for these patients; however, there are many factors that limit this approach in neonates. Usually, the resected tumors were smaller than 6 cm. Tumors larger than 8 cm have a worse prognosis, with a short survival time.

Evaluation of konjac noodle as a microsurgery training model: learning curve analysis.

BACKGROUND: classical models of microsurgical anastomosis training are expensive and have ethical implications. Some alternatives join low cost and easiness to store. However, the translation of knowledge acquired by training in these methods into the traditional ones is not clear. This project aims to assess the feasibility of konjac noodles as a reliable microsurgery-training model. METHODS: 10 neurosurgery residents performed an end-to-end anastomosis in a 2-3mm placenta artery. The anastomoses were evaluated quantitatively, recording time; and qualitatively, applying a validated score (Anastomosis Lapse Index - ALI) by three experienced neurosurgeons and verifying the presence of gross leakage through the infusion of fluorescein. Subsequently, they performed 10 non-consecutive sessions of anastomosis training in the konjac noodle. Eventually, a final anastomosis in the placenta model was performed and the same parameters were scored. RESULTS: we observed a 17min reduction in the mean time to perform the anastomosis in the placenta model after the training in the konjac (p<0.05). There was a non-significant 20% reduction in gross leakage, but the training sessions were not able to consistently improve the ALI score. CONCLUSIONS: we demonstrate a reduction in anastomosis performing time in placental arteries after training sessions in the konjac noodle model, which can be regarded as a feasible low-cost method, particularly useful in centers with surgical microscopes only in the operation room.

Malignant chondroid syringoma with central nervous system involvement.

Malignant chondroid syringoma is a mixed cutaneous tumor, with epithelial and mesenchymal components, which compromises principally the trunk and extremities. This lesion is quite rare, with few cases related in the literature and no publications demonstrating its involvement of the central nervous system. Histologically, owing to its mixed origin, it represents a lesion that is difficult to recognize, often being confused with basocellular carcinoma. We report the case of a female patient, carrier of malignant chondroid syringoma in the occipital region, with invasion of the central nervous system, who was submitted to surgical excision of the lesion at our service. We also made a brief revision of the literature on the theme.

An economic study of neuro-oncological patients in a large developing country: a cost analysis.

BACKGROUND: Neuro-oncological patients require specialized medical care. However, the data on the costs incurred for such specialized care in developing countries are currently lacking. These data are relevant for international cooperation. OBJECTIVE: The present study aimed to estimate the direct cost of specialized care for an adult neuro-oncological patient with meningioma or glioma during hospitalization in the largest philanthropic hospital in Latin America. METHODS: The present observational economic analysis describes the direct cost of care of neuro-oncological patients in Santa Casa de São Paulo, Brazil. Only adult patients with a common primary brain tumor were included. RESULTS: Due to differences in the system records, the period analyzed for cost estimation was between December 2016 and December 2019. A group of patients with meningiomas and gliomas was analyzed. The estimated mean cost of neurosurgical hospitalization was US$4,166. The cost of the operating room and intensive care unit represented the largest proportion of the total cost. A total of 17.5% of patients had some type of infection, and 66.67% of these occurred in nonelective procedures. The mortality rate was 12.7% and 92.3% of all deaths occurred in emergency procedures. CONCLUSIONS: Emergency surgeries were associated with an increased rate of infections and mortality. The findings of the present study could be used by policymakers for resource allocation and to perform economic analyses to establish the value of neurosurgery in achieving global health goals.

ANTECEDENTES: Pacientes neuro-oncológicos demandam tratamento médico especializado. Em países em desenvolvimento, há falta de dados sobre custos em neurocirurgia. Estes dados são relevantes para ajudar na cooperação internacional. OBJETIVO: O presente estudo objetiva estimar o custo direto de um paciente neuro-oncológico adulto com meningioma ou glioma durante sua internação no maior hospital filantrópico da América Latina. MéTODOS: A presente análise econômica observacional descreve os custos diretos de um paciente neuro-oncológico da Santa Casa de São Paulo. Apenas pacientes adultos e com os dois tumores cerebrais primários mais comuns foram considerados. RESULTADOS: Devido a uma mudança no sistema de prontuários, para análise de custos o período analisado foi de dezembro de 2016 a dezembro de 2019. Uma amostra significativa de pacientes com gliomas e meningiomas foi analisada. O custo médio da hospitalização foi de U$ 4.166. O tempo de sala cirúrgica e os cuidados em terapia intensiva representaram a maior proporção dentro do custo total. Um total de 17.5% dos pacientes teve algum tipo de infecção e 66.67% delas ocorreram em procedimentos não eletivos. A taxa de mortalidade foi de 12.5% e 92.3% dos óbitos ocorreram em procedimentos de urgência. CONCLUSõES: Cirurgias de urgência foram mais associadas a taxas de infecção e mortalidade. Os achados do presente estudo podem ser usados por planejadores em política pública de saúde para alocação de recursos e para análise econômica para estabelecer o valor dos procedimentos neurocirúrgicos para atingir metas mundiais.

Clinical assessment of head injuries in motorcyclists involved in traffic accidents: A prospective, observational study.

OBJECTIVE: to review the clinical assessment of head injuries in motorcyclists involved in traffic accidents. METHOD: prospective observational study, including adult motorcyclists involved in traffic accidents in a period of 12 months. Patients sustaining signs of intoxication were excluded. A modification of the Canadian Head CT Rules was used to indicate computed tomography (CT). Patients not undergoing CT were followed by phone calls for three months. Collected variables were compared between the group sustaining head injuries and the others. We used chi-square, Fisher, and Student's t for statistical analysis, considering p<0.05 as significant. RESULTS: we included 208 patients, 99.0% were wearing helmets. Seventeen sustained signs of intoxication and were excluded. Ninety (47.1%) underwent CT and 12 (6.3%) sustained head injuries. Head injuries were significantly associated with Glasgow Coma Scale<15 (52.3% vs. 2.8% - p<0,001) and a positive physical exam (17.1% vs. zero - p<0,05). Four (2.1%) patients with intracranial mass lesions needed surgical interventions. None helmet-wearing patients admitted with GCS=15 and normal physical examination sustained head injuries. CONCLUSION: Head CT is not necessary for helmet-wearing motorcyclists admitted with GCS=15 and normal physical examination.

Periodontoid pseudotumoral lesions.

BACKGROUND: Periodontoid pseudotumoral lesions (PPL) are an uncommon cause of cervical pain and myelopathy. In addition, they may be associated with atlantoaxial instability (AAI). CASE DESCRIPTION: Two patients over 60 years of age presented with neck pain alone. Their MR scans showed expansive lesions involving the odontoid process. One patient with AAI required an occipitocervical arthrodesis, while the other patient without instability was managed with an external orthosis (Philadelphia collar). Both of them experienced full resolution of pain and remained neurologically intact an average 36 months later (range 24-48). CONCLUSION: Here, we discussed the clinical, MR, and non-surgical (without AAI) versus surgical management (with AAI) for different types of PPL.

Awake craniotomy for eloquent pial arteriovenous fistula - Anesthetic and surgical consideration of a rare case.

Intracranial pial Arteriovenous Fistulas (AVFs) are rare cerebral vascular lesions composed of one or more arterial connections to a single venous channel. We report a 50-year-old patient with a ruptured pial AVF located in an eloquent area. Microsurgery for pial AVF occlusion was proposed with awake craniotomy for motor function and neurological evaluation. Awake craniotomy is a technique that is especially useful for cerebral vascular lesions in eloquent areas, where an occlusion often compromises or suppresses the blood supply, culminating in ischemia with consequent transient or definitive deficits in neurological function.

Awake craniotomy in brain tumors - Technique systematization and the state of the art.

The anesthesia for awake craniotomy (AC) is a consecrated anesthetic technique that has been perfected over the years. Initially used to map epileptic foci, it later became the standard technique for the removal of glial neoplasms in eloquent brain areas. We present an AC anesthesia technique consisting of three primordial times, called awake-asleep-awake, and their respective particularities, as well as delve into the anesthetic medications used. Its use in patients with low and high-grade gliomas was favorable for the resection of tumors within the functional boundaries of patients, with shorter hospital stay and lower direct costs. The present study aims to systematize the technique based on the experience of the largest philanthropic hospital in Latin America and discusses the most relevant aspects that have consolidated this technique as the most appropriate in the surgery of gliomas in eloquent areas.

Observational study of patients with occipital condyle fracture at a brazilian referral trauma center.

OBJECTIVE: to evaluate the clinical-epidemiological characteristics, treatment, and evolution of patients with occipital condyle fracture (OCF) at one of the largest referral trauma centers in Latin America. METHODS: this was a retrospective observational study of OCF identified from trauma cases admitted between December 2011 and December 2019 by the neurosurgery team at a Type 3 trauma center. RESULTS: a total of twenty-eight occipital condyle fractures were identified in twenty-six patients. The incidence was less than 0.2% per year and more common in male patients (4:1 ratio) involved in traffic accidents. The mean age was 42.08 years. Anderson and Montesano type II and Tuli type 1 were the most frequent (67.9% and 89.3%, respectively) and no case presented C0-C1-C2 instability. All patients were treated with a cervical collar for 3 to 6 months. About 65% of the patients exhibited good progression (Glasgow Outcome Scale equal to 4), and the severity of traumatic brain injury was the main determinant for negative outcomes. CONCLUSION: the findings of this study are in accordance with available literature data. The use of external stabilization with a cervical collar is reinforced for the treatment of stable lesions, even when these are bilateral. Assessment of the patients' follow-up results in the studied sample may contribute with useful information for the treatment of occipital condyle fractures.

Slip Clip after successful microsurgery of a blister aneurysm: Should bypass always be the first option?

Blood Blister-like aneurysms are intracranial non-saccular aneurysms with higher rupture risk due to its fragile wall. Diagnosis is performed in the acute phase of a subarachnoid hemorrhage. There are several treatment options based on reconstructive or deconstructive techniques. This paper aims to discuss the limitations of microsurgery clipping for a ruptured blister aneurysm. We report on a case of a female patient presented with a Fisher III subarachnoid hemorrhage. Cerebral angiography revealed an internal carotid artery blister aneurysm. Initially microsurgery clipping was successfully performed. However, after a few days the patient presented new subarachnoid hemorrhage. The new cerebral angiography showed growth of the previously clipped aneurysm, with displacement of the clip from the position adjacent to the artery. High-flow bypass was performed obtaining definitive treatment. This is a definitive approach for blister aneurysms. If microsurgery clipping is chosen, a strict follow-up is required due to the dynamic nature of this lesion and the chance of re-bleeding even after successfully clipping.

Report of intradural aneurysm in the cavernous segment of the internal carotid artery presented with subarachnoid hemorrhage and oculomotor palsy.

BACKGROUND: Aneurysms of the cavernous segment of the internal carotid artery (ICA) do not usually cause subarachnoid hemorrhage (SAH). We report a patient who presented with this condition due to a ruptured aneurysm located on the posterior genu of the cavernous segment, raising the question of what factors could have led to such evolution. CASE DESCRIPTION: A 55-year-old male patient presented with sudden, intense thunderstorm headache, associated with complete palsy of the left oculomotor nerve and neck stiffness. Cranial computed tomography (CT) showed no SAH, but showed an expansive process in the sella turcica, consistent with a pituitary macroadenoma. After that, SAH was confirmed by lumbar puncture (Fisher I). Cranial angio-CT revealed an intradural saccular aneurysm in the cavernous segment of the left ICA. The patient underwent cranial microsurgery for cerebral aneurysm clipping. Unlike the normal anatomic pattern, the cavernous segment of the carotid artery in this patient was located in the intradural compartment. CONCLUSION: Intradural rupture of proximal cavernous segment carotid aneurysms is rare. We review the literate for such cases and discuss the possible causes.

Residual lesions in patients who underwent microsurgical clipping of cerebral aneurysms.

Microsurgical clipping is currently the main method of treating cerebral aneurysms, even with the improvement of endovascular therapy techniques in recent years. Treatment aims at complete occlusion of the lesion, which is not always feasible. Although appearing superior to endovascular treatment, microsurgical clipping may present varying percentages of incomplete occlusion. Such incidence may be reduced with the use of intraoperative vascular study. Some classifications were elaborated in an attempt to standardize the characteristics of residual lesions, but the classification criteria and terminology used in the studies remain vague and poorly documented, and there is no consensus for a uniform classification. Thus, there is also no agrément on which residual aneurysms should be treated. The aim of this study is to review the literature on residual lesions after microsurgery to treat cerebral aneurysms and how to proceed with them.

"Whiplash" cervical trauma with fracture and migration of carotid stent fragments.

BACKGROUND: Angioplasty using a carotid stent is a treatment modality for carotid stenosis, with results similar to those obtained with endarterectomy, as demonstrated by important studies. The increasing use of this procedure has also led to a larger number of reports of complications, stent fractures among those. Stent fracture is a rare manifestation and hence needs further studying so that its actual prevalence can be determined, as well as its associated risk factors and proper clinical management. The current study reports the case of a patient who had previously undergone angioplasty with a carotid stent and, after an automobile accident, presented with a stent fracture and distal embolization of fragments thereof with neurological manifestation. CASE DESCRIPTION: A male patient, 40 years old, presented with a history of previously stent carotid angioplasty. He had been involved in an automobile accident and suffered a stent fracture with distal fragment migration. As he was an asymptomatic patient (NIHSS 0, Rankin zero), we opted for a conservative treatment with oral anticoagulant. CONCLUSION: Angioplasty is an effective treatment for extracranial atherosclerosis and, albeit rare, stent fractures can result in the migration of fragments thereof. This occurrence should be suspected in patients who have sustained severe neck injuries due to sudden deceleration and may be associated with thromboembolism.

Retro-odontoid pseudotumor: a poorly recognized alteration of the craniocervical junction.

INTRODUCTION: Retro-odontoid pseudotumor (ROP) is a rare disease that affects the atlantoaxial joint and, in general, is associated with local biomechanical alterations that may or may not cause instability. METHODS: Descriptive study of the literature available in databases MEDLINE/PubMed, LILACS, and Scopus. The research was conducted in April 2019. DISCUSSION: ROP is, possibly, a syndromic designation that encompasses a significant variety of diseases of the atlantoaxial joint. There are different pathophysiological mechanisms implicated in its genesis. The patients, almost in their entirety, present with severe myelopathy, and most of them are treated surgically, with the posterior decompression being the most commonly used method, with or without arthrodesis. Evolution is usually favorable. CONCLUSION: The ROP is still poorly recognized as a differential diagnosis between the diseases of the cranial-cervical junction. The information available in the literature analyzed was based mainly on the study of reports or case series; therefore, it is insufficient to define conducts with a high level of scientific evidence.

Residual lesions in patients undergoing microsurgical clipping of cerebral aneurysms in a reference university hospital.

OBJECTIVES: This study aimed to analyze the incidence and epidemiological, angiographic, and surgical aspects associated with incomplete clipping of brain aneurysms in a cohort of patients undergoing microsurgical treatment. METHODS: The medical record data of patients who underwent microsurgery for cerebral aneurysm treatment and postoperative digital subtraction angiography, treated at the same teaching hospital between 2014 and 2019, were retrospectively analyzed. The studied variables involved epidemiological and clinical data, as well as neurological status and findings on neuroimaging. The time elapsed between hemorrhage and microsurgical treatment, data on the neurosurgical procedure employed for aneurysm occlusion, and factors associated with the treated aneurysm, specifically location and size, were also evaluated. RESULTS: One hundred and seventeen patients were submitted to 139 neurosurgical procedures, in which 167 aneurysms were clipped. The overall rate of residual injury was 23%. Smoking (odds ratio [OR]: 3.38, 95% confidence interval [CI95%]: 1.372-8.300, p=0.008), lesion size >10 mm (OR: 5.136, CI95%: 2.240-11.779, p<0.001) and surgery duration >6 h (OR: 8.667, CI95%: 2.713-27.681, p<0.001) were found to significantly impact incomplete aneurysm occlusion in the univariate analyses. CONCLUSION: Incomplete microsurgical aneurysm occlusion is associated with aneurysm size, complexity, and current smoking status. Currently, there is no consensus on postoperative assessment of clipped aneurysms, hindering the correct assessment of treatment outcomes.