RESUMO
The recommendation for the great majority of high-grade brain arteriovenous malformations (bAVMs) is observation, except for those patients with recurrent hemorrhages, progressive neurological deficits, steal-related symptoms, or AVM-related aneurysms, for whom intervention should be considered. These are general recommendations, and the decision should be made on an individual basis. Surgical resection of an AVM in the central lobe may cause postoperative sensorimotor deficits since this anatomical region includes the pre- and postcentral gyri on the lateral surface and the paracentral lobule on the medial surface. The authors present a patient with a ruptured high-grade bAVM in the central lobe who underwent previous surgery for hematoma evacuation and previous radiosurgery, and whose indication for reoperation was proposed based on progressive hemiparesis. Microsurgical resection was possible after a wide frontoparietal craniotomy, which made all the nidus borders accessible. This case illustrates the anatomy and surgical technique for large nidus AVMs in eloquent areas, showing that complete microsurgical resection is possible with good clinical outcome. The video can be found here: https://youtu.be/Cpd1PK6BLIM .
Assuntos
Córtex Cerebral/cirurgia , Malformações Arteriovenosas Intracranianas/cirurgia , Microcirurgia/métodos , Reoperação/métodos , Adulto , Angiografia Cerebral , Feminino , Humanos , Malformações Arteriovenosas Intracranianas/complicações , Procedimentos Neurocirúrgicos/métodos , Radiocirurgia/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND AND OBJECTIVE: Chronic low back pain is a worldwide public health issue with high socioeconomic impact. The aim of this study was to determine the efficacy of laser irradiation of the dorsal root ganglion of the second lumbar spinal nerve for chronic axial low back pain compared to lidocaine injection and radiofrequency treatment. STUDY DESIGN/MATERIALS AND METHODS: Twenty-eight patients were randomly divided into three treatment groups: lidocaine injection, radiofrequency, or laser. The second intervertebral foramen between the second and third lumbar vertebrae was accessed by percutaneous needle puncture bilaterally, guided by fluoroscopy. In the local anesthetic group, injection of 1 ml lidocaine without epinephrine was applied through a 20-gauge (G20) Quincke tip spinal needle inserted in the second lumbar intervertebral foramen. In the radiofrequency group, the probe (150 mm long with a 5 mm active tip) was directed through a G20 needle placed in the second lumbar intervertebral foramen and neuromodulation was done with a radiofrequency of Cosman G4® in pulses of 20 ms with wash-out period of 480 ms, for 300 seconds at 42°C. A single treatment was used. In the laser treatment group, a continuous wave, 808 nm wavelength diode laser (Photon Lase III® DCM, Brazil), with an output power of 100 mW was used for a single treatment. An 18 gauge needle was placed in the second lumbar intervertebral foramen guided by fluoroscopy. Light was delivered through a 600 µm optical fiber placed in the G18 needle. The tip of the fiber extended 5 mm beyond the tip of the needle in the second lumbar intervertebral foramen. The beam spot size was 0.003 cm(2) , irradiance = 35W/cm(2) , exposure time = 84 seconds, energy density = 2800J/cm(2) , total energy was 8.4 J. The low back pain score was assessed by the visual analog scale (VAS) and Pain Relief Scale (PRS) pre, post procedure and in 1 month follow up. Temperature was measured using a digital thermometer. RESULTS: All patients in the local anesthetic and laser treatment groups reported a pain reduction of at least 50% immediately post-procedure and 10 out of 11 patients in the radiofrequency group reported a pain reduction of at least 50%. At 1 month post-treatment, the laser treatment group had the greatest number of patients who reported more than 50% pain relief based on PRS (7 out of 10 patients) while only 2 out of 7 patients and 3 out of 11 patients in the lidocaine and radiofrequency treatment groups respectively reported more than a 50% pain relief. CONCLUSION: Laser irradiation caused an immediate decrease in low back pain post-procedure similar to pain reduction caused by lidocaine injection. Both lidocaine injection and laser irradiation were more effective than radiofrequency treatment for immediate and longer term (1 month post-treatment) chronic back pain. Lasers Surg. Med. 48:653-659, 2016. © 2016 Wiley Periodicals, Inc.
Assuntos
Dor Crônica/radioterapia , Lasers Semicondutores/uso terapêutico , Dor Lombar/radioterapia , Terapia com Luz de Baixa Intensidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestésicos Locais/uso terapêutico , Dor Crônica/diagnóstico , Dor Crônica/tratamento farmacológico , Feminino , Seguimentos , Gânglios Espinais , Humanos , Injeções Espinhais , Lidocaína/uso terapêutico , Dor Lombar/diagnóstico , Dor Lombar/tratamento farmacológico , Vértebras Lombares , Masculino , Pessoa de Meia-Idade , Medição da Dor , Projetos Piloto , Estudos Prospectivos , Terapia por Radiofrequência , Resultado do TratamentoRESUMO
OBJECTIVE: The objective of this study is to present a case series of nonmissile penetrating (NMP) injuries and to establish a workflow for an uncommon mechanism of traumatic head injury through the analysis of each case, classification of the type of lesion, management, and outcome score at follow-up. METHODS: From January 1991 to December 2008, 36,000 patients presenting with traumatic brain injury (TBI) were admitted in the Department of Neurosurgery, Hospital Antônio Targino, Campina Grande-PB, Brazil. From these patients, 11 presenting with lesions caused by NMP objects were selected. RESULTS: Among the 11 patients, 9 were men and 2 were women. Their ages ranged from 7 to 74 years old (mean age ± SD, 29.1 ± 22.99 years). All patients underwent neuroradiologic evaluation. The entry point was classified as natural (orbit) or artificial (skull transfixation), and we also divided the patients presenting with secondary parenchymal or vascular damage from those presenting with only lesions caused by the primary penetration into the cranium and meninges. All patients were neurosurgically treated with removal of the foreign body through craniotomy, except the patient whose object (pen) was removed without craniotomy with local anesthesia. Glasgow Coma Scale (GCS) score on admission was a statistically significant factor on prognosis, and any patient who presented with a GCS score of 15 evolved satisfactorily, and there were no deaths in this group of patients (P = 0.04). CONCLUSIONS: TBIs caused by NMP objects are unusual and caused by aggression, self-inflicted harm (in the case of psychiatric patients), and accident. The foreign body may enter into the skull through a natural hole (orbit, nose, mouth, or ear) or crosses the skull, causing a fracture and creating an artificial hole. Preoperative neuroradiologic assessment is paramount for the correct neurosurgical approach. The main prognostic factor for these patients is the GCS score at admission.
Assuntos
Traumatismos Cranianos Penetrantes/cirurgia , Acidentes , Adolescente , Adulto , Idoso , Criança , Feminino , Corpos Estranhos/diagnóstico por imagem , Corpos Estranhos/patologia , Corpos Estranhos/cirurgia , Escala de Coma de Glasgow , Traumatismos Cranianos Penetrantes/diagnóstico por imagem , Traumatismos Cranianos Penetrantes/etiologia , Traumatismos Cranianos Penetrantes/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos , Prognóstico , Comportamento Autodestrutivo/diagnóstico por imagem , Comportamento Autodestrutivo/patologia , Comportamento Autodestrutivo/cirurgia , Violência , Adulto JovemRESUMO
OBJECT: Intracranial aneurysms may grow closer to anterior optic pathways, causing mass effect over these anatomical structures, including visual deficit. The authors retrospectively reviewed a series of aneurysms in patients presenting with visual field deficit caused by mass effect, to analyze the aneurysm's characteristics, the neurosurgical management of these aneurysms, as well as their clinical, visual, and radiological outcomes. METHODS: The authors reviewed the medical charts, neuroimaging examination results, and surgical videos of 15 patients presenting with visual symptoms caused by an aneurysm's mass effect over the anterior optic pathways. These patients were treated at the Department of Neurosurgery, Center of Neurology and Neurosurgery Associates, Hospital Beneficência Portuguesa de São Paulo, Brazil. Statistical analysis was performed to identify the variables related to partial or total recovery of the visual symptoms. RESULTS: All patients underwent microsurgical clip placement and emptying of their aneurysms. After a mean follow-up of 38.5 months, the mean postoperative Glasgow Outcome Scale score was 4.33, and the visual outcomes were as follows: 1 patient (6.6%) unchanged, 7 (46.6%) improved, and 7 (46.6%) experienced complete recovery from visual deficits. The variables that influenced the visual outcomes were the size of the aneurysm (p = 0.039), duration of the visual symptoms (p = 0.002), aneurysm wall calcification (p = 0.010), and intraluminal thrombosis (p = 0.007). Postoperative examination using digital subtraction angiography showed complete aneurysm occlusion in 14 (93.3%) of the 15 patients. CONCLUSIONS: Intracranial aneurysms causing mass effect over the anterior optic pathways usually present with complex features. The best treatment option must include not only the aneurysm occlusion but also relief of the mass effect. Microsurgical clip placement with reduction of aneurysmal mass effect achieved improvement in visual ability or recovery from visual impairment, as well as total aneurysm occlusion, in 93.3% of the study group. Therefore, this option is well supported as the first choice of treatment for intracranial aneurysms presenting with mass effect over the anterior visual pathways.
Assuntos
Aneurisma Intracraniano/complicações , Aneurisma Intracraniano/cirurgia , Baixa Visão/etiologia , Baixa Visão/patologia , Vias Visuais/patologia , Adulto , Idoso , Calcinose/diagnóstico por imagem , Calcinose/patologia , Calcinose/cirurgia , Dissecação da Artéria Carótida Interna/complicações , Dissecação da Artéria Carótida Interna/diagnóstico , Dissecação da Artéria Carótida Interna/cirurgia , Angiografia Cerebral , Descompressão Cirúrgica , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Aneurisma Intracraniano/diagnóstico , Trombose Intracraniana/diagnóstico por imagem , Trombose Intracraniana/patologia , Trombose Intracraniana/cirurgia , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos , Avaliação de Resultados em Cuidados de Saúde , Estudos Prospectivos , Estudos Retrospectivos , Instrumentos Cirúrgicos , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares , Baixa Visão/fisiopatologia , Vias Visuais/diagnóstico por imagem , Vias Visuais/fisiopatologiaRESUMO
BACKGROUND: Hereditary multiple exostosis is a benign disorder characterized by multiple osteochondromas affecting long and flat bones, although occasionally vertebral column involvement can be seen. Cervical spinal cord compression in HME is a rare condition. The objective of this manuscript is to describe a rare case of cervical myelopathy due to an exostosis arising from C7 in a patient with HME and a comprehensive review of the current literature. CASE DESCRIPTION: We describe a case of HME in an 18-year-old girl with myelopathy characterized by quadriparesis due to an osteochondroma arising from the lamina of C7. The patient underwent surgery, and a laminectomy was performed with a complete removal of the exostosis and spinal cord decompression. One month after surgery, patient presented an excellent recovery without neurologic deficits. CONCLUSIONS: Cervical spinal cord compression resulting from osteochondroma is an extremely serious complication of HME. Neurosurgical approach should be recommended in order to achieve a spinal cord decompression, which usually results in excellent functional recovery.