Bernardo Assumpção de Monaco

Surgical treatment of a transorbital penetrating brain injury.

Penetrating injury of the skull and brain are relatively uncommon events, representing about 0.4% of all head injuries. Transorbital penetrating brain injury is an unusual occurrence in emergency practice and presents with controversial management. We report the case of a 10-year-old boy who fell forward on a bamboo stick while playing with other children, causing a penetrating transorbital injury, resulting in meningitis. We performed a combined surgical approach with neurosurgeons and ophthalmogic surgeons. Upon discharge, the patient had a Glasgow Coma Scale score of 15, no motor deficit and no visual loss. We discuss the management of this case and review current literature.

Frame-based stereotactic neurosurgery in children under the age of seven: Freiburg University's experience from 99 consecutive cases

INTRODUCTION Stereotactic frame-based procedures proved to be precise, safe and are of widespread use among adult patients. Regarding pediatric patients few data is available, therefore the use of the stereotactic frame remains controversial in this population. This motivated us to report our experience in stereotactic procedures in the youngest patients and review the literature concerning this subject. METHODS All frame-based procedures performed in patients younger than seven years in the University of Freiburg during the last 10 years were retrospectively analyzed and discussed under the light of the current literature. RESULTS The studied population was composed of 72 patients under the age of seven (mean 3.4±2.1 years-old), in whom 99 stereotactic procedures were performed. Brain tumor was present in 60 patients, hydrocephalus in five, cystic lesions in three, intracranial abscess in three and epilepsy in one patient. Stereotactic surgery was performed in 36 cases for brachytherapy, in 29 for biopsy, in 20 cases for cyst puncture, in eight for stereotactically guided endoscopic ventriculostomy, in five for catheter placement and in one case for depth electrode insertion. The overall complication rate was 5%. There were three cases of pin penetration through the skull, one case of frame dislocation after extensive cyst drainage and two skull fractures. Neurologic deficit related to frame fixation was observed in none of the cases. In disagreement with other authors, no case of pin related infection, air embolism, hematoma or CSF leak was observed. CONCLUSION Frame-based stereotactic neurosurgery is a safe technique also in the youngest patients. Rather than the simple use of torque-limiting devices training and experience in the manual adjustment of the stereotactic frame in children have been proven to be crucial factors that contribute to reducing pin related complications.

The clip-wrap technique in the treatment of intracranial unclippable aneurysms

UNLABELLED Fusiform and dolichoectatic aneurysms are challenging lesions to treat with direct clipping. Treatment of these aneurysms often requires alternative surgical strategies, including extracranial-intracranial bypass, wrapping, or clip-wrap techniques. Nonetheless, these alternatives methods of treatment have been underused and frequently overlooked. OBJECTIVE To report a series of nine cases of otherwise untreatable aneurysms managed using the clip-wrap technique and discuss its surgical nuances. METHOD In the last four years, 9 cases of ruptured aneurysms treated by the clip-wrap techniques were identified in the Division of Neurological Surgery, University of São Paulo, School of Medicine. RESULTS The aneurysms were located at middle cerebral artery (2), anterior choroidal artery (1), anterior communicating artery (1), carotid ophthalmic (3), posterior cerebral artery (1) and posterior-inferior cerebellar artery (1). Three were dolichoectatic, 4 were unsuitable to complete surgical clipping because parent or efferent vessels arises from the aneurysm sac (1 MCA, 1 AcomA, 1 CO, 1 PICA aneurysms) and two, although ruptured aneurysms, were too small (<2mm) to be directly clipped. No early or late rebleeding was observed after 2 years mean follow-up. One patient deceased due to pulmonary tromboembolism. CONCLUSION Clip-wrap techniques for the treatment of fusiform and otherwise unclippable aneurysms seem to be safe and it can be associated with a low rate of acute or delayed postoperative complications. It can prevent rebleeding and represents an improvement when compared with the natural history.

Ischemic preconditioning and spinal cord function monitoring in the descending thoracic aorta approach

OBJECTIVES To evaluate the effectiveness of acute ischemic preconditioning (IP), based on somatosensory evoked potentials (SSEP) monitoring, as a method of spinal cord protection and to asses SSEP importance in spinal cord neuromonitoring. METHODS Twenty-eight dogs were submitted to spinal cord ischemic injury attained by descending thoracic aorta cross-clamping. In the C45 group, the aortic cross-clamping time was 45 min (n=7); in the IP45 group, the dogs were submitted to IP before the aortic cross-clamping for 45 min (n=7). In the C60 group, the dogs were submitted to 60 min of aortic cross-clamping (n=7), as in the IP60 group that was previously submitted to IP. The IP cycles were determined based on SSEP changes. RESULTS Tarlov scores of the IP groups were significantly better than those of the controls (p = 0.005). Paraplegia was observed in 3 dogs from C45 and in 6 from C60 group, although all dogs from IP45 group were neurologically normal, as 4 dogs from IP60. There was a significant correlation between SSEP recovery time until one hour of aortic reperfusion and the neurological status (p = 0.011), showing sensitivity of 75% and specificity of 83%. CONCLUSION Repetitive acute IP based on SSEP is a protection factor during spinal cord ischemia, decreasing paraplegia incidence. SSEP monitoring seems to be a good neurological injury assessment method during surgical procedures that involve spinal cord ischemia.

Estudo comparativo entre o pré-condicionamento isquêmico e a drenagem liquórica como métodos de proteção medular em cães

OBJECTIVE: This study compares the effects of immediate ischemic preconditioning based on somatosensory evoked potential (SSEP) monitoring with those of cerebrospinal fluid drainage in a model of descending thoracic aorta occlusion in dogs. METHOD: Eighteen dogs were submitted to spinal cord ischemia induced by descending thoracic aortic cross-clamping for 60 minutes. The Control Group underwent only aortic cross-clamping (n=6). The Ischemic Preconditioning Group (IPC) underwent ischemic preconditioning (n=6) and the Drainage Group underwent cerebrospinal fluid drainage (n=6), immediately before aortic cross-clamping. An independent observer assessed neurological status according to the Tarlov score. The animals were sacrificed and spinal cord harvested for histopathologic study. RESULTS: Aortic pressure before and after the occluded segment was similar in the three groups. Seven days after the procedure, Tarlov scores were significantly higher only in the Drainage Group when compared to the Control Group (p<0.05). Lower SSEP recovery times were also observed with cerebrospinal fluid drainage during the final reperfusion period (p<0.01). In the histopathologic study, stain showed less significant neuronal necrosis in the thoracic and lumbar gray matter in animals submitted to both methods of spinal cord protection, with it being more pronounced in the Ischemic Preconditioning Group (p<0.001). CONCLUSION: Cerebrospinal fluid drainage and immediate ischemic preconditioning seems to protect the spinal cord during descending thoracic aorta cross-clamping. Nevertheless, the obtained level of spinal cord protection seems to be more significant with cerebrospinal fluid drainage.

Celiac plexus neurolysis for the treatment of upper abdominal cancer pain

Optimal treatment of oncologic pain is a challenge to all professionals who deal with cancer and its complications. The management of upper abdominal pain is usually difficult and it is often refractory to conservative therapies. In this context, celiac plexus neurolysis (CPN) appears to be an important and indispensable tool because it alleviates pain, gives comfort to patients and is a safe procedure. In this study, the importance of CPN is reviewed by a retrospective study of 74 patients with pain due to upper abdominal cancer. Almost all cases evaluated (94.6%) had an excellent result after CPN and the majority of side effects were transitory.

Early resorption of an artificial bone graft made of calcium phosphate for cranioplasty: case report

The treatment of uncomplicated osteoma consists of an en bloc resection, or curettage, of the tumor, followed by cranioplasty. Here, we present a case report of a patient treated for a parietal osteoma, followed by a calcium phosphate cranioplasty, with early resorption after 3 months, which was presented by a sinking flap above the resection area. This case suggests that synthetic cranioplasty should be preferred, even in small skull-gap areas.

Does the use of DuraSeal in head and spinal surgeries reduce the risk of cerebrospinal fluid leaks and complications when compared to conventional methods of dura mater closure

INTRODUCTION Cerebrospinal fluid (CSF) fistula is a common neurosurgical complication, occurring in 1% to 27% of cases. The main clinical manifestations are postural headache, nausea, dizziness, photophobia, and tinnitus. This condition may be associated with inadequate wound healing and infection, meningitis, and pseudomeningocele, factors that increase patient morbidity and mortality. Despite the limitations, hermetic closure of the dura mater has been recommended for the prevention and treatment of CSF fistula. In recent years, techniques have been developed to reinforce the site of the dura mater closure, such as additional suture, autologous tissue grafts, fibrin sealants, and collagen sponges. DuraSeal is a dura mater sealant consisting of polyethylene glycol hydrogel (PEG hydrogel), to be applied at the site of suture, and has been indicated for head and spinal surgery with opening of the dura mater.

Caudal Zona Incerta/VOP Radiofrequency Lesioning Guided by Combined Stereotactic MRI and Microelectrode Recording for Posttraumatic Midbrain Resting-Kinetic Tremor.

OBJECTIVE Reporting the outcome of two patients who underwent unilateral ablative stereotactic surgery to treat pharmacologic resistant posttraumatic tremor (PTT). METHODS We present two patients (31 and 47 years old) with refractory PTT severely affecting their quality of life. Under stereotactic guidance, refined by T2-weighted magnetic resonance imaging and double-channel multiunit microelectrode recording (MER), three sequential radiofrequency lesions were performed in the caudal zona incerta (cZi) up to the base of thalamus (VOP). Effects of cZi/VOP lesion were prospectively rated with a tremor rating scale. RESULTS Both patients demonstrated intraoperative tremor suppression with sustained results up to 18 months follow-up, with improvement of 92% and 84%, respectively, on the tremor rating scale. Tremor improvement was associated with enhancement functionality and quality of life for the patients. The patients returned to their work after the procedure. No adverse effects were observed up to the last follow-up. CONCLUSION Radiofrequency lesion of the cZi/VOP target was effective for posttraumatic tremor in both cases. The use of T2-weighted images and MER was found helpful in increasing the precision and safety of the procedure, because it leads the RF probe by relying on neighbor structures based on thalamus and subthalamic nucleus.

Intrathecal Morphine Therapy for Chronic Non-malignant Pain Using a Constant Flow Infusion System

Background: Implantable pumps for intrathecal opioid therapy in the last decades emerged as one of the most effective treatment for chronic non-malignant pain (CNMP) in selected patients. This study analyses reliability of intrathecal infusion morphine therapy for chronic and refractory pain not related to malignancy using an implantable constant flow pump. Methods: we studied eleven patients (9 women and 2 men; age range 26-67 years), with medically unresponsive CNMP. Pain was classified as neuropathic or non-neuropathic based on clinical features. Patients were evaluated before and after pump implantation, measuring pain intensity and relief after intrathecal opioid treatment based on Visual Analogic Scale (VAS) scores. Results: Pain significantly reduced in almost all patients (91%); mean pain scores improved from 8.9 ± 1.49 before implant to 66% improvement one month after infusion therapy (3.1 ± 1.60) and 41% after 18 months (5.2 ± 2.45). Conclusion: The present data show that intrathecal morphine infusion at a constant flow proved to be a safe and suitable alternative for the treatment of CNMP.