Carlos Umberto Pereira

Intraoperative assistive technologies and extent of resection in glioma surgery: a systematic review of prospective controlled studies

Several studies published to date about glioma surgery have addressed the validity of using novel technologies for intraoperative guidance and potentially improved outcomes. However, most of these reports are limited by questionable methods and/or by their retrospective nature. In this work, we performed a systematic review of the literature to address the impact of intraoperative assistive technologies on the extent of resection (EOR) in glioma surgery, compared to conventional unaided surgery. We were also interested in two secondary outcome variables: functional status and progression-free survival. We primarily used PubMed to search for relevant articles. Studies were deemed eligible for our analysis if they (1) were prospective controlled studies; (2) used EOR as their primary target outcome, assessed by MRI volumetric analysis; and (3) had a homogeneous study population with clear inclusion criteria. Out of 493 publications identified in our initial search, only six matched all selection criteria for qualitative synthesis. Currently, the evidence points to 5-ALA, DTI functional neuronavigation, neurophysiological monitoring, and intraoperative MRI as the best tools for improving EOR in glioma surgery. Our sample and conclusions were limited by the fact that studies varied in terms of population characteristics and in their use of different volumetric analyses. We were also limited by the low number of prospective controlled trials available in the literature. Additional evidence-based high-quality studies assessing cost-effectiveness should be conducted to better determine the benefits of intraoperative assistive technologies in glioma surgery.

Cerebral metastasis of cervical uterine cancer: report of three cases

Cervical uterine cancer (CUC) spreads locally (pelvis and paraortic lymphnodes) or distantly (lungs, liver and bones). Metastasis to central nervous system (CNS) are rare. There are about 80 cases reported in the literature. Outcome is poor and survival varies from 3 to 6 months. Three cases of CNS metastasis from CUC are reported, one infratentorial and two supratentorials in location. In one patient, the initial manifestation was due to the cerebral lesion, a feature reported for the first time. All cases were treated by surgery, radiotherapy and/or chemotherapy. Clinical findings and treatment options of these rare lesions are reviewed.

Infecções em dispositivos neurológicos implantáveis em crianças e adolescentes

OBJECTIVE: To determine frequency, etiology, site and clinical and laboratory findings of ventriculoperitoneal shunt (VPS) infections in children and adolescents with hydrocephalus managed in Hospital Governador Joao Alves Filho, Aracaju SE, Brazil. METHOD: A non-controlled prospective observational study comprising 50 patients that underwent VPS (58 procedures) from January/2003 to October/2004. RESULTS: Infection rate per procedure was 27.6%; surgical risk index (NNISS-CDC) 0 and 1-2 were 25.7% and 30.4% respectively; surgical site infection was the main complication with 50% of the cases. CONCLUSION: Infection rates per procedure, per patient, and per surgical risk index were high. No statistical differences were found related to the following: age, etiology of hydrocephalus, type of procedure, pre-operative length of stay, duration of procedure, antibiotic prophylaxis, previous central nervous system catheter, and surgical risk index.

Malformações do sistema nervoso central e malformações associadas diagnosticadas pela ultrassonografia obstétrica

Objetivo: Identificar a prevalencia de malformacoes congenitas do sistema nervoso central (SNC) e malformacoes asso-ciadas diagnosticadas pela ultrassonografia obstetrica. Materiais e Metodos: Estudo observacional, transversal, des-critivo, em instituicao de referencia para gestacoes de alto risco. Resultados: Malformacoes congenitas do SNC estive-ram presentes sem outras malformacoes associadas em 65,78%, com a distribuicao: hidrocefalia (37,5%), mielomenin-gocele (15%), encefalocele (12,5%), agenesia de corpo caloso (12,5%), anencefalia (12,5%), holoprosencefalia (7,5%),Dandy-Walker (7,5%), Arnold-Chiari (5,0%), hidranencefalia (5,0%), meningocele (5,0%), cisto aracnoideo (2,5%). Mal-formacoes congenitas de outros sistemas estiveram associadas as do SNC: craniofacial (73,9%), ortopedica (65,2%),cardiovascular (34,8%), geniturinaria (30,4%), gastrintestinal (30,4%), respiratoria (8,7%), sindromica (8,7), oftalmolo-gica (4,3%). A sensibilidade ultrassonografica no estudo de malformacoes fetais do SNC foi 79,4%. A taxa de falso-ne-gativos foi 20,5%. Dentre as limitacoes quantificaveis destaca-se o oligodrâmnio, presente em 25% dos falso-negativos.Conclusao: A ultrassonografia obstetrica possui boa sensibilidade no rastreio de malformacoes fetais do SNC, em espe-cial com o aperfeicoamento constante e dominio na utilizacao de metodos especializados, como o Doppler e a ultrasso-nografia volumetrica (3D/4D), contribuindo para firmar-se como modalidade de escolha nesta rotina. Complementar aometodo, a ressonância magnetica pode vir a fornecer subsidios para uma ainda melhor assistencia perinatal.Unitermos: Malformacoes congenitas; Malformacoes do sistema nervoso central; Malformacoes associadas; Ultrasso-nografia.Objective: To identify and evaluate the prevalence of congenital central nervous system (CNS) malformations andassociated defects diagnosed by obstetric ultrasonography. Materials and Methods: Observational, descriptive, cross-sectional study developed in an institution of reference for high-risk pregnancies. Results: Congenital CNS malformationswithout other associated defects were present in 65.78% of cases, as follows: hydrocephalus (37.5%), myelomeningocele(15%), encephalocele (12.5%), corpus callosum agenesis (12.5%), anencephaly (12.5%), holoprosencephaly (7.5%),Dandy-Walker (7.5%), Arnold-Chiari (5.0%), hydranencephaly (5.0%), meningocele (5.0%), arachnoid cyst (2.5%).Congenital malformations of other systems were associated with such malformations, as follows: craniofacial (73.9%),orthopedic (65.2%), cardiovascular (34.8%), genitourinary (30.4%), gastrointestinal (30.4%), respiratory (8.7%),syndromic (8.7%), ophthalmologic (4.3%). The sonographic sensitivity in the study of CNS malformations was 79.4%.The rate of false-negative results was 20.5%. Oligohydramnios, present in 25% of false-negative studies, stands outamong the quantifiable limitations. Conclusion: Obstetric ultrasonography presents good sensitivity in the screeningfor fetal CNS malformations, specially with the constant improvement and control of specialized methods such as Dopplerand volumetric ultrasonography (3D/4D), contributing to consolidate its role as a modality of choice in this routine.Magnetic resonance imaging may play a supplementary role, providing information for an even better perinatal care.Keywords: Congenital malformations; Central nervous system malformations; Associated malformations; Ultrasonog-raphy.ResumoAbstract

Immediate post-craniotomy headache.

Introduction Headache is the most common adverse event immediately following craniotomy and is due to the surgical procedure and meningeal irritation. Objectives The aim of this study was to investigate the prevalence of headache during the first week after a craniotomy, as well as headache intensity, whether pain was registered in the patients medical records, the use of analgesics and predictors of headache. Methods Ninety-one patients who underwent craniotomy were evaluated from the first to the seventh post-operative day. The variables analysed were gender, age, medical history, indication for craniotomy, surgery, occurrence of headache, pain registration in the medical records, length of hospital stay and analgesics consumption. Results On the second post-operative day, 29.2% of patients had a headache and there was under-reporting of this pain in the patients’ records. The analgesics used were non-steroidal anti-inflammatory in 75% of cases. An age of <45 years (odds ratio = 3.0, p = 0.041) and surgery duration lasting >4 hours (odds ratio = 3.7, p = 0.019) were associated with the occurrence of immediate post-craniotomy headache. Conclusion Further training should be provided to professionals caring for patients undergoing craniotomy to better manage post-operative headache.

Epidural hematoma after ventriculoperitoneal shunt surgery: report of two cases

Ventriculoperitoneal shunt operations represent the most used choice for treating hydrocephalus, although some related complications have been reported. Due to its rarity, potential dangers, and mortality rate, we present two cases of epidural hematoma following ventriculoperitoneal shunt, discussing its pathophysiology and prophylaxis.

Knowledge of doctors and nurses on pain in patients undergoing craniotomy

The study objectives were to characterize the profile of the doctors and nurses caring for patients in the craniotomy postoperative period, checking pain assessment methods and to identify the existence of analgesia protocols. Cross-sectional and analytical study. The casuistry is constituted of 30 doctors and 30 nurses. The results revealed that 83.3 % of the nurses were female, 63.3% knew pain scales, and 16.6% said that analgesia protocols exist. Regarding doctors 60% were male, 70% knew the pain scales, 3.3% had specialization in pain treatment, 13.3% they stated that there are analgesia protocols. The ignorance on the part of doctors and nurses about the assessment scales and pain assessment methods reveals the need for the creation of institutional policies on controlling pain, the use of instruments for the measurement of the pain phenomenon and analgesia protocols in the institution.The study objectives were to characterize the profile of the doctors and nurses caring for patients in the craniotomy postoperative period, checking pain assessment methods and to identify the existence of analgesia protocols. Cross-sectional and analytical study. The casuistry is constituted of 30 doctors and 30 nurses. The results revealed that 83.3 % of the nurses were female, 63.3% knew pain scales, and 16.6% said that analgesia protocols exist. Regarding doctors 60% were male, 70% knew the pain scales, 3.3% had specialization in pain treatment, 13.3% they stated that there are analgesia protocols. The ignorance on the part of doctors and nurses about the assessment scales and pain assessment methods reveals the need for the creation of institutional policies on controlling pain, the use of instruments for the measurement of the pain phenomenon and analgesia protocols in the institution.

Gross-total resection of temporal low grade gliomas is a critically important factor in achieving seizure-freedom

OBJECTIVE To present a surgical series of patients with low grade temporal gliomas causing intractable epilepsy, focusing on long-term seizure outcome. METHOD A retrospective study was conducted with patients with temporal low-grade gliomas (LGG). RESULTS Sixty five patients with were operated in our institution. Males were more affected than females and the mean age at surgery was 32.3 ± 8.4 (9-68 years). The mean age at seizure onset was 25.7 ± 9.2 (11-66 years). Seizure outcome was classified according with Engel classification. After one year of follow up, forty two patients (64.6%) were Engel I; seventeen (26.2%) Engel II; four (6.2%) Engel III and two (3.1%) Engel IV. Statistically significant difference in seizure outcome was obtained when comparing the extension of resection. Engel I was observed in 39 patients (69.6%) with total resection and in only 3 (33.3%) patients with partial resection. CONCLUSION Gross-total resection of temporal LGGs is a critically important factor in achieving seizure-freedom.

Anestésicos Locais, Como Escolher e Previnir Complicações Sistémicas

Abstract The discovery of substances that cause a loss of sensitivity was a benchmark in the history of medicine and dentistry and is considered one of the ten most important discoveries in medicine. Such substances allow performing surgical procedures without pain, which had previously been considered an unachievable ideal in academic circles. One of the most frequent errors in dentistry is systematically employing the same local anesthetic. Dentists should choose an anesthetic solution based on the patient and procedure to be carried out. Prevention is the best treatment for systemic complications stemming from local anesthesia and is achieved through an adequate anamnesis and physical exam, which allow choosing the safest anesthetic solution for each specific case. The aim of the present study was to carry out a literature review on local anesthetics, providing readers with information to guide them in the choice and amount of anesthetic solution, thereby preventing the occurrence of systemic complications.

Knowledge of caregivers of children with hydrocephalus

Pouco se discute sobre conhecimentos dos cuidadores de criancas com hidrocefalia. Este estudo buscou identificar as fontes de informacao dos cuidadores e verificar seus conhecimentos sobre hidrocefalia. Foram entrevistados 54 cuidadores com idade entre 18 a 52 anos no periodo de novembro de 2007 a agosto de 2008. O genero do cuidador foi predominantemente feminino. Vinte e nove cuidadoras (53,7%) aprenderam a cuidar sozinhas. Apenas quatro cuidadoras (16,0%) receberam orientacoes na alta hospitalar. Vinte e nove (53,7%) conhecem a definicao e 11 (20,4%) conhecem as causas da hidrocefalia. Verificou-se maior conhecimento entre cuidadoras com mais de oito anos de estudo. A escolaridade teve relacao significativa para maior conhecimento, entretanto as cuidadoras possuem pouco conhecimento sobre aspectos importantes da hidrocefalia.