Helder Tedeschi

Comprehensive management of arteriovenous malformations

The treatment of arteriovenous malformations depends on the efforts of a multidisciplinary team whose ultimate goal is to achieve better results when compared to the natural history of the pathology. The role of adjuvant treatment modalities such as radiosurgery and endovascular embolization is discussed. Treatment strategies and surgical results from a personal series of 344 patients operated in a ten-year period are reviewed. The Spetzler and Martin classification was modified to include subgroups IIIA (large size grade III AVMs) and IIIB (small grade III AVMs in eloquent areas) to assist the surgical resection criteria. The treatment strategy followed was surgery for grades I and II, embolization plus surgery for grades IIIA, radiosurgery for grades IIIB, and conservative for grades IV and V. According to the new proposed classification 45 (13%) patients were grade I, 96 (28%) were grade II, 44 (13%) grade IIIA, 97 (28%) grade IIIB, 45 (13%) grade IV, and 17 (5%) were grade V. As for surgical results 85.8% of the patients had a good outcome (no additional neurological deficit), 12.5% had a fair outcome (minor neurological deficit), 0.6% had a bad outcome (major neurological deficit), and 1.2% died. These figures indicate that the treatment of arteriovenous malformations can achieve better results compared to the natural history if managed by a well trained group of specialists led by an experienced neurosurgeon.

Does Resection of the Medial Temporal Lobe Improve the Outcome of Temporal Lobe Epilepsy Surgery

Summary:  Purpose: Surgical removal of the hippocampus is the standard of care of patients with drug‐resistant medial temporal lobe epilepsy (MTLE). The procedure carries a success rate of ∼75%, but the reasons that some patients fail to achieve seizure control after surgery remain inexplicable. The question of whether the resection of medial temporal lobe structures in addition to the hippocampus would influence the surgical outcome in patients with MTLE was examined.

Dynamic changes in white and gray matter volume are associated with outcome of surgical treatment in temporal lobe epilepsy

BACKGROUND The reasons for surgical failure in 30% of patients with unilateral mesial temporal lobe epilepsy (MTLE) are still unclear. We investigated if different outcomes could be associated to different patterns of subtle gray matter atrophy (GMA) and white matter atrophy (WMA), and searched for postoperative magnetic resonance imaging (MRI) changes. METHODS We studied 69 controls and 67 operated patients with refractory unilateral MTLE. Patients were grouped as seizure-free (SF) group (34 patients Engels IA), worthwhile improvement group (23 patients, Engels IB-IIA) and failure group (10 patients Engels IIB-IV). We created a voxel-based morphometry/MATLAB code to mask the surgical lacuna, and performed t-test and paired t-test to evaluate preoperative and postoperative MRI scans. RESULTS Failure group showed a widespread pattern of preoperative GMA. On SF and improvement groups we identified a more restricted pattern of GMA. The three groups presented a widespread, bilateral pattern of WMA. In contrast, postoperative analyses showed bilateral hemispheric recovery (a relative increase of WM concentration) on SF and improvement groups, but few changes on failure group. We also identified areas with relative postoperative increase of GM on both SF and improvement groups, more widespread on SF group. CONCLUSION Areas of subtle GMA may be related to poorer surgical outcome. In addition, we demonstrated a postoperative relative increase of WM and GM concentration associated with seizure control. These changes may represent neuroplasticity related to improvement of brain function after seizure control. Further studies with a multimodal approach may help to predict surgical outcome and improve selection of patients for surgical treatment of MTLE.

Hippocampal gene expression dysregulation of Klotho, nuclear factor kappa B and tumor necrosis factor in temporal lobe epilepsy patients

BackgroundPrevious research in animal seizure models indicates that the pleiotropic cytokine TNF is an important effector/mediator of neuroinflammation and cell death. Recently, it has been demonstrated that TNF downregulates Klotho (KL) through the nuclear factor kappa B (NFkB) system in animal models of chronic kidney disease and colitis. KL function in the brain is unclear, although Klotho knockout (Kl−/−) mice exhibit neural degeneration and a reduction of hippocampal synapses. Our aim was to verify if the triad KL-NFKB1-TNF is also dysregulated in temporal lobe epilepsy associated with hippocampal sclerosis (TLE(HS)) patients.FindingsWe evaluated TNF, NFKB1 and KL relative mRNA expression levels by reverse transcription quantitative PCR (RT-qPCR) in resected hippocampal tissue samples from 14 TLE(HS) patients and compared them to five post mortem controls. Four reference genes were used: GAPDH, HPRT1, ENO2 and TBP. We found that TNF expression was dramatically upregulated in TLE(HS) patients (P <0.005). NFKB1 expression was also increased (P <0.03) while KL was significantly downregulated (P <0.03) in TLE(HS) patients. Hippocampal KL expression had an inverse correlation with NFKB1 and TNF.ConclusionsOur data suggest that, similar to other inflammatory diseases, TNF downregulates KL through NFkB in TLE(HS) patients. The remarkable TNF upregulation in patients is a strong indication of hippocampal chronic inflammation. Our finding of hippocampal KL downregulation has wide implications not only for TLE(HS) but also for other neuronal disorders related to neurodegeneration associated with inflammation.

Comparison of short-term outcome between surgical and clinical treatment in temporal lobe epilepsy: A prospective study

OBJECTIVE To compare the efficacy of medical and surgical treatment for refractory mesial temporal lobe epilepsy associated with hippocampal sclerosis (MTLE). METHODS A prospective controlled non-randomized study of 26 patients with MTLE who underwent surgical treatment and 75 patients with MTLE who underwent medical treatment between August 2002 and October 2004. All patients failed to achieve seizure control with at least two first line antiepileptic drugs (AED) for partial seizures before entering the study. We used Kaplan-Meier survival analyses as a function of time of seizure recurrence to obtain estimates of 95% confident interval of seizure freedom and log-rank test to compare the status of seizure control between the two groups. RESULTS The cumulative proportion of patients free of all seizures (Engels class IA) was higher in the surgical group (73%) compared to the clinical group (12%) (p<0.0001). In the surgical group, 2 of 26 patients (7.7%) had transient adverse effects and 2 of 26 patients (7.7%) had a permanent deficit related to the surgical procedure. In the clinical group 7 patients (9.3%) major adverse events during follow-up, including burns and status epilepticus. CONCLUSIONS Surgical treatment for patients with MTLE who failed to achieve seizure control with two previous AED regimens was more efficient than medical treatment with further trials of AED.

Retrospective evaluation of the validity of the Thoracolumbar Injury Classification System in 458 consecutively treated patients

BACKGROUND CONTEXT The Thoracolumbar Injury Classification System (TLICS) system has been developed to improve injury classification and guide surgical decision-making, yet validation of this new system remains sparse. PURPOSE This study evaluates the use of the TLICS in a large, consecutive series of patients. STUDY DESIGN/SETTING This is a retrospective case series. PATIENT SAMPLE A total of 458 patients treated for thoracic or lumbar spine trauma between 2000 and 2010 at a single, tertiary medical center were included in this study. OUTCOME MEASURES American Spinal Injury Association (ASIA) status and crossover from conservative to surgical treatment were measured. METHODS Clinical and radiological data were evaluated, classifying the injuries by ASIA status, the Magerl/AO classification, and the TLICS system. RESULTS A total of 310 patients (67.6%) was treated conservatively (group 1) and 148 patients (32.3%) were surgically (group 2) treated. All patients in group 1 were ASIA E, except one (ASIA C). In this group, 305 patients (98%) had an AO type A fracture. The TLICS score ranged from 1 to 7 (mean 1.53, median 1). A total of 307/310 (99%) patients matched TLICS treatment recommendation (TLICS≤4), except three with distractive injuries (TLICS 7) initially misdiagnosed. Nine patients (2.9%) were converted to surgical management. In group 2, 105 (70.9%) were ASIA E, whereas 43 (29%) had neurological deficits (ASIA A-D). One hundred and three patients (69.5%) were classified as AO type A, 36 (24.3%) as type B, and 9 (6%) as type C. The TLICS score ranged from 2 to 10 (mean 4.29, median of 2). Sixty-nine patients (46.6%) matched the TLICS recommendation; all discordant patients (53.4%) were treated for stable burst fractures (TLICS=2). No neurological complications occurred in either group. CONCLUSIONS The TLICS recommendation matched treatment in 307/310 patients (99%) in the conservative group. However, in the surgical group, 53.4% of patients did not match TLICS recommendations, all were burst fractures without neurological injury (TLICS=2). The TLICS system can be used to effectively classify thoracolumbar injuries and guide conservative treatment. Inconsistencies, however, remain in the treatment thoracolumbar burst fractures.

Radiocirurgia estereotáxica para metástases de coluna vertebral: revisão de literatura

ABSTRACT Objective: The spine is the most common location for bone metastases. Since cure is not possible, local control and relief of symptoms is the basis for treatment, which is grounded on the use of conventional radiotherapy. Recently, spinal radiosurgery has been proposed for the local control of spinal metastases, whether as primary or salvage treatment. Consequently, we carried out a literature review in order to analyze the indications, efficacy, and safety of radiosurgery in the treatment of spinal metastases. Methods: We have reviewed the literature using the PubMed gateway with data from the MEDLINE library on studies related to the use of radiosurgery in treatment of bone metastases in spine. The studies were reviewed by all the authors and classified as to level of evidence, using the criterion defined by Wright. Results: The indications found for radiosurgery were primary control of epidural metastases (evidence level II), myeloma (level III), and metastases known to be poor responders to conventional radiotherapy – melanoma and renal cell carcinoma (level III). Spinal radiosurgery was also proposed for salvage treatment after conventional radiotherapy (level II). There is also some evidence as to the safety and efficacy of radiosurgery in cases of extramedullar and intramedullar intradural metastatic tumors (level III) and after spinal decompression and stabilization surgery. Conclusion: Radiosurgery can be used in primary or salvage treatment of spinal metastases, improving local disease control and patient symptoms. It should also be considered as initial treatment for radioresistant tumors, such as melanoma and renal cell carcinoma.

Radiological evaluation of cervical spine involvement in rheumatoid arthritis

Cervical spine involvement commonly occurs in patients with rheumatoid arthritis (RA), especially those with inadequate treatment or severe disease forms. The most common site affected by RA is the atlantoaxial joint, potentially resulting in atlantoaxial instability, with cervical pain and neurological deficits. The second most common site of involvement is the subaxial cervical spine, often with subluxation, resulting in nerve root or spinal cord compression. In this paper, the authors review the most commonly used plain radiographic criteria to diagnose cervical instabilities seen with RA. Finally, we discuss the advantages and disadvantages of cervical CT and MRI in the setting of cervical involvement in RA.

Upper cervical injuries – A rational approach to guide surgical management

Abstract Context The complex anatomy and the importance of ligaments in providing stability at the upper cervical spine region (O–C1–C2) require the use of many imaging modalities to evaluate upper cervical injuries (UCI). While separate classifications have been developed for distinct injuries, a more practical treatment algorithm can be derived from the injury pattern in UCI. Objective To propose a practical treatment algorithm to guide treatment based on injuries characteristic of UCI. Methods A literature review was performed on the Pubmed database using the following keywords: (1) “occipital condyle injury”; (2) “craniocervical dislocation or atlanto-occipital dislocation or craniocervical dislocation”; (3) “atlas fractures”; and (4) “axis fractures”. Just articles containing the diagnosis, classification, and treatment of specific UCI were included. The data obtained were analyzed by the authors, dividing the UCI into two groups: Group 1 – patients with clear ligamentous injury and Group 2 – patients with fractures without ligament disruption. Results Injuries with ligamentous disruption, suggesting surgical treatment, include: atlanto-occipital dislocation, mid-substance transverse ligament injury, and C1–2 and C2–3 ligamentous injuries. In contrast, condyle, atlas, and axis fractures without significant displacement/misalignment can be initially treated using external orthoses. Odontoid fractures with risk factors for non-union are an exception in Group 2 once they are better treated surgically. Patients with neurological deficits may have more unstable injuries. Conclusions Ascertaining the status of relevant ligamentous structures, fracture patterns and alignment are important in determining surgical compared with non-surgical treatment for patients with UCI.

Measuring the impact of the Thoracolumbar Injury Classification and Severity Score among 458 consecutively treated patients.

Abstract Context The Thoracolumbar Injury Classification and Severity Score (TLICS) was proposed to improve injury classification and guide surgical decision-making of thoracolumbar spinal trauma (TLST), but its impact on the care of patients has not been quantified. Study design Retrospective study. Patient sample Analysis of 458 patients treated for TLST trauma from 2000 through 2010 at a single center. Outcome measures Neurological status – ASIA Impairment Scale (AIS), failure of conservative treatment, and surgical complications. Methods Clinical and radiological data were evaluated. Patients were grouped according to the period before (2000–2006) and after (2007–2010) utilization of the TLICS. Results From 2000 to 2006, 148 patients were initially treated conservatively (C) and 66 were surgically (S) treated. In the C group, the TLICS ranged from 1 to 7 (median 1; mean 1.57). In the S group, the TLICS ranged from 2 to 10 (median 2; mean 4.14). The TLICS matched treatment in 97.9% of conservatively treated patients. From 2007 to 2010, 162 patients were initially treated C and 82 were treated S. In the C group, the TLICS ranged from 1 to 4 (median 1; mean 1.48). In the S group, the TLICS ranged from 2–10 (median 4; mean 4.4). The TLICS matched treatment in 98.8% of C-treated patients. Overall, failure of C treatment occurred in nine patients; most failures (7/9) and all three missed distractive injuries occurred prior to use of the TLICS. Conclusions After introduction of the TLICS, there was a trend towards more successful conservative treatment with fewer conversions to surgical treatment.