José Augusto Malheiros

Human Placenta Aneurysm Model for Training Neurosurgeons in Vascular Microsurgery

BACKGROUND: Neurosurgery, a demanding specialty, involves many microsurgical procedures that require complex skills, including open surgical treatment of intracranial aneurysms. Simulation or practice models may be useful for acquiring these skills before trainees perform surgery on human patients. OBJECTIVE: To describe a human placenta model for the creation and clipping of aneurysms. METHODS: Placental vessels from 40 human placentas that were dimensionally comparable to the sizes of appropriate cerebral vessels were isolated to create aneurysms of different shapes. The placentas were then prepared for vascular microsurgery exercises. Sylvian fissure--like dissection technique and clipping of large- and small-necked aneurysms were practiced on human placentas with and without pulsatile flow. A surgical field designed to resemble a real craniotomy was reproduced in the model. RESULTS: The human placenta has a plethora of vessels that are of the proper dimensions to allow the creation of aneurysms with dome and neck dimensions similar to those of human saccular and fusiform cerebral aneurysms. These anatomic scenarios allowed aneurysm inspection, manipulation, and clipping practice. Technical microsurgical procedures include simulation of sylvian fissure dissection, unruptured aneurysm clipping, ruptured aneurysm clipping, and wrapping; all were reproduced with high fidelity to the haptics of live human surgery. Skill-training exercises realistically reproduced aneurysm clipping. CONCLUSION: Human placenta provides an inexpensive, widely available, convenient biological tissue that can be used to create models of cerebral aneurysms of different morphologies. Neurosurgical trainees may benefit from the preoperative use of a realistic model to gain familiarity and practice with critical surgical techniques for treating aneurysms.

Endoscopic choroid plexus cauterization versus ventriculoperitoneal shunt for hydranencephaly and near hydranencephaly: a prospective study.

OBJECTIVETo prospectively evaluate the results of endoscopic choroid plexus cauterization (ECPC) and ventriculoperitoneal shunts (VPSs) in infants with hydranencephaly or near hydranencephaly. METHODSWe prospectively collected clinical data from all untreated hydranencephalic and near hydranencephalic children from October 2006 to March 2008. All patients treated were randomly divided into 2 groups, ECPC or VPS, and submitted to either endoscopic choroid plexus cauterization or ventriculoperitoneal shunt placement. RESULTSSeventeen patients were entered into the study. ECPC was completed in 9 patients; the procedure successfully controlled excessive head circumference and signs of increased intracranial pressure in 8 of these patients (88.8%). One endoscopic procedure in a hydranencephalic child failed after 7 months, resulting in VPS placement. Thus, of the 10 patients randomized to ECPC, 8 were treated successfully by ECPC (80%), and 2 went on to have a VPS. There were no complications related to this method of treatment. Seven children were randomized to the VPS group; and of these, 2 patients (28.5%) required shunt revisions during follow-up. There were no complications related to shunt placement. There was no difference in the success rate between patients randomized to ECPC and VPS, but the ECPC was more economical. CONCLUSIONECPC is an acceptable alternative to VPS for treatment of hydranencephaly and near hydranencephaly. It is a single, definitive, safe, effective, and economical treatment that may avoid the complications of shunting.

A Brazilian family with Brown-Vialetto-van Laere syndrome with autosomal recessive inheritance

We report the first Brazilian family with Brown-Vialetto-van Laere syndrome. The presence of consanguineous marriages and illness affecting three sisters and one niece support an autosomal recessive transmission. The age at onset of the illness ranged from 12 to 20 years old. The time interval between hearing loss and involvement of other cranial nerves varied from 3 to 12 years. MRI demonstrated bulbar atrophy and also high intensity signal at T2 weighted and fluid attenuated inversion recovery (FLAIR) sequences.

Fourth ventriculostomy: an alternative treatment for hydrocephalus due to atresia of the Magendie and Luschka foramina

Atresia of the foramina of Magendie and Luschka is a rare cause of obstructive hydrocephalus. Although this condition has been classically treated by CSF shunting, recent treatments have also included endoscopic third ventriculostomy. In the present study, the authors present the case of a patient with hydrocephalus in whom an alternative method was used following a CSF shunt malfunction. A young female patient in whom a shunt was placed during the patients 1st year of life was faring well until she was 8 years old. She was admitted to the emergency department 5 times with signs of CSF shunt malfunction. Each time, the CT scan showed a slight dilation of the lateral and third ventricles and a large increase in the size of the fourth ventricle. In comparison, ventricles were smaller in a previous imaging study obtained when the patient was asymptomatic. Magnetic resonance imaging showed the same slight dilation of all the ventricles and a significant increase in the fourth ventricle. There was no aqueductal stenosis. An important enlargement of both lateral recesses of the fourth ventricle suggested the possibility of an atresia of the foramina. The foramen of Monro and the width of the third ventricle would not allow the passage of an endoscope. The decision was made to open those foramina endoscopically through the fourth ventricle. After induction of general anesthesia, with the patient in the prone position, a bur hole was made in the left paramedian and suboccipital region. The endoscope was introduced underneath the cerebellar hemisphere. The authors were then able to distinguish the floor of the fourth ventricle and other anatomical landmarks. Navigation through the lateral recesses allowed them to see the fine membranes closing the foramina. These membranes were opened with a monopolar cautery as a blunt instrument. The orifice was then enlarged with a 3 Fr Fogarty catheter. The authors also opened a bulging thin membrane located at the foramen of Magendie. During the postoperative period, the authors observed a marked improvement in the state of the patients alertness as well as a disappearance of her headaches and cessation of vomiting. In addition, the patients gait ataxia improved slowly. Six-month postoperative MR imaging demonstrated an unequivocal reduction in the size of the fourth ventricle. The patient was still doing well 36 months after the surgery. Endoscopic fourth ventriculostomy, the opening of the 3 foramina of the fourth ventricle, may be an alternative treatment in cases in which these structures are congenitally closed.

Spontaneous acute subdural hematoma contralateral to an arachnoid cyst

Arachnoid cysts (AC) are extra-cerebral cerebrospinal fluid collections of unknown origin. They correspond to 1% of all intracranial nontraumatic space-occupying lesions and appear more frequently in the middle fossa (50%). More than 25% of these cysts are incidental findings and the majority of patients are asymptomatic. Seizures, intracranial hypertension signs, neurological deficits, macrocrania, developmental delay and bulging of the skull are the main signs and symptoms of the lesion. AC rupture and bleeding are rare, usually occurring in young adults and associated with trauma. The risk of hemorrhage does not exceed 0.04% / year. We describe the case of a ten-year-old boy who presented with acute signs of intracranial hypertension secondary to a spontaneous acute subdural hematoma, contralateral to an AC of the middle fossa. Three factors were significant in this case: signs and symptoms occurred spontaneously; the presence of an acute subdural hematoma exclusively contralateral to the AC; successful outcome of the conservative treatment.

A new expansive two-open-doors laminoplasty for multilevel cervical spondylotic myelopathy: technical report and follow-up results

UNLABELLED The laminoplasty technique was devised by Hirabayashi in 1978 for patients diagnosed with multilevel cervical spondylotic myelopathy. OBJECTIVE To describe an easy modification of Hirabayashis method and present the clinical and radiological results from a five-year follow-up study. METHOD AND RESULTS Eighty patients had 5 levels of decompression (C3-C7), 3 patients had 6 levels of decompression (C2-T1) and 3 patients had 4 levels of decompression (C3-C6). Foraminotomies were performed in 23 cases (27%). Following Nurick`s scale, 76 patients (88%) improved, 9 (11%) had the same Nurick grade, and one patient worsened and was advised to undergo another surgical procedure. No deaths were observed. The mean surgery time was 122 min. Radiographic evaluation showed an increase in the mean sagittal diameter from 11.2 mm at pretreatment to 17.3 mm post surgery. There was no significant difference between pretreatment and post-surgery C2-C7 angles. CONCLUSIONS This two-open-doors laminoplasty technique is safe, easy and effective and can be used as an alternative treatment for cases of multilevel cervical spondylotic myelopathy without instability.

Civilian Gunshot Wound to the Spine: 87 Cases

Introduction Penetrating spinal cord injury (SCI) by gunshot is relatively common in Brazil, and the literature available is scarce. This study aims to report the experience of a level I trauma center, exploring epidemiological data, clinical features, treatment, and outcomes of victims of gunshot wound to the spine. Material and Methods A retrospective study was performed and included all victims of gunshot wound to the spine at João XXIII Hospital from April 2011 to March 2014 (36-month period). The epidemiological profile, topography of the injury, neurological status, treatment, and in-hospital morbidity and mortality are reported. Statistical analysis was performed on Epi Info 7.0 with Fisher exact test. Correlation with the current literature was conducted. Results A total of 1,088 patients were admitted with blunt and penetrating spinal injury in the 36 months evaluated. A total of 87 cases were gunshot wounds (8% of the 1,088 cases). A majority of the patients were men (93.1%) and young (76.1% are under 30 years). Topographically, 48% affected the cervical spine, followed by 32% in the thoracic spine. The motor status had a dichotomous presentation, with complete neurological deficit (ASIA A, 58.6%) and no neurological deficit (ASIA E, 27.6%). Incomplete neurological deficits represented a small number of cases. The vertebral instability, defined as the presence of acute or delayed deformity, was unusual (three cases, 3.4%). Almost 50% (n = 44) of the patients had isolated spinal trauma and the remaining presented with associated traumas. Thoracic trauma was the most prevalent, followed by abdominal and facial injury. Only 10 patients (11.5%) required surgical treatment: laminectomy with bullet removal in 7 cases and instrumented fixation in the remaining 3. Infection was present in five cases: four postoperative infections and one in a patient with nonoperative management. Surgical treatment was associated with a 50-fold increase risk of infection (p = 0.0004). CSF fistula was observed in only one case after surgical treatment and because of the rarity of the event, a statistical analysis could not be performed. Overall mortality was 14.9% (13 patients) and was more common in patients with cervical lesions (10 patients). Associated trauma was present in 70% of the patients who died, but did not acquire statistical significance (p = 0.1) with mortality risk. Conclusion Gunshot wound to the spine is common in our population, affecting especially young men, associated with neurological deficit in two-thirds of the patients. Instability is a rare event in these patients (3.4%) and surgical treatment was associated with a significant risk of infection.

Powdered Vancomycin versus Povidone Iodine in Spinal Fusion Deep Infection Prophylaxis: A Comparative Study in Trauma Patients

Introduction Incidence of deep surgical site infection (SSI) in spinal fusion varies from 0.3 to 20% according to the international literature. Instrumentation is a well-established risk factor for this complication. Higher morbidity and mortality rates and increased cost of treatment up to fourfold are associated with this complication. Prophylaxis with intravenous antibiotic is consensual, but few studies have evaluated the efficacy of topical agents in the surgical site with prophylactic intent. Irrigation with 3.5% povidone iodine and application of lyophilized vancomycin powder in surgical site have shown benefit, but there are no studies comparing these two methods. A comparative study using topic povidone iodine and vancomycin powder was conducted to reduce this knowledge gap. Patients and Methods The medical records of 439 patients who underwent spinal fusion with instrumentation for traumatic spinal lesion treatment were analyzed. Procedures were consecutively performed at Joao XXIII Hospital (level 1 trauma center). Patients were combined in the following two groups, according to the prophylactic agent used: Povidone iodine (PVPI) historical series (n = 181), performed from January 2009 to April 2012 and vancomycin (VANCO) cohort study (n = 239) conducted from May 2012 to December 2013. The surgical site in PVPI group was irrigated with 5% topic iodine solution during 3 minutes, before deep lumbar fascia closure. One gram of vancomycin powder was applied directly to the hardware in VANCO group. Both the groups received 2 g of intravenous cefazolin 30 minutes before surgery and had surgical site exhaustively washed with saline 0.9%, before closure in PVPI group and prior to apply vancomycin powder in VANCO group. Results No difference according to mean age, sex, and lesion level distribution (cervical × thoracolumbar) was observed between the two groups. Number of levels instrumented, coexisting infection, and surgical access were not compared because of a lack of information in medical records, especially those from PVPI series. SSI rate was lower in VANCO group (1.67%) compared with PVPI group (6.62%), this difference was statistically significant (chi-square test with Yates correction = 5.618; p = 0.018; IC 0.069–0.824). Conclusion The application of 1 g vancomycin powder in surgical site was superior to irrigation with 5% povidone iodine in the prophylaxis of deep surgical site infection. These results are valid for patients with spinal trauma who underwent instrumented fusion. Variability in surgical team, difference in the interval admission surgery (patients recently are being operated earlier), and number of levels instrumented are possible bias to this study. The low cost and easy applicability of topic prophylactic measures justify new studies with better statistical power (multicenter and randomized).

Project BHTRM: new strategy of monitoring and acting in spinal cord injuries in the city of Belo Horizonte

Objetivo: O Projeto BHTRM tem como objetivo estudar a epidemiologia do trauma raquimedular (TRM) na cidade de Belo Horizonte e fornecer meios de monitoramento desses pacientes. Método: Para avaliação da eficácia e resolubilidade do projeto, comparamos dois grupos de pacientes atendidos no Hospital João XXIII, em dois períodos distintos. Grupo 1: de 1o de maio de 2011 a 31 de julho de 2011, meses de início do projeto e Grupo 2: de 1º de dezembro de 2012 a 28 de fevereiro de 2013. Resultados: Apesar do aumento de 34% no número de pacientes atendidos, observa-se uma queda de 30% na média de dias de internação, assim como a diminuição na média de dias de espera para cirurgia dos pacientes que necessitavam tratamento cirúrgico, de 10,9 para 4,84, uma queda de 56%. Conclusão: O Projeto BHTRM é uma ferramenta útil em gestão de saúde pública. Otimiza o tratamento do paciente com trauma raquimedular, diminuindo o tempo entre internação e cirurgia. Oferece acompanhamento ativo do paciente assegurando melhor atendimento e inserção dos cuidados de reabilitação.

Proyecto BHTRM: nueva estrategia de monitoreo y actuación en las lesiones de la médula espinal en la ciudad de Belo Horizonte

Objetivo: O Projeto BHTRM tem como objetivo estudar a epidemiologia do trauma raquimedular (TRM) na cidade de Belo Horizonte e fornecer meios de monitoramento desses pacientes. Método: Para avaliação da eficácia e resolubilidade do projeto, comparamos dois grupos de pacientes atendidos no Hospital João XXIII, em dois períodos distintos. Grupo 1: de 1o de maio de 2011 a 31 de julho de 2011, meses de início do projeto e Grupo 2: de 1º de dezembro de 2012 a 28 de fevereiro de 2013. Resultados: Apesar do aumento de 34% no número de pacientes atendidos, observa-se uma queda de 30% na média de dias de internação, assim como a diminuição na média de dias de espera para cirurgia dos pacientes que necessitavam tratamento cirúrgico, de 10,9 para 4,84, uma queda de 56%. Conclusão: O Projeto BHTRM é uma ferramenta útil em gestão de saúde pública. Otimiza o tratamento do paciente com trauma raquimedular, diminuindo o tempo entre internação e cirurgia. Oferece acompanhamento ativo do paciente assegurando melhor atendimento e inserção dos cuidados de reabilitação.