Análisis multivariado de factores pronósticos en niños con traumatismo craneoencefálico grave que requirieron craneotomía descompresiva / Multivariate Analysis of Prognostic Factors in Children with Severe Cranioencephalic Trauma Requiring Decompressive Craniotomy

Introducción: El traumatismo craneoencefálico en edades pediátricas constituye un problema de salud relevante a nivel mundial y en Cuba. Objetivo: Determinar los factores pronósticos del trauma craneoencefálico grave en niños que requirieron craneotomía descompresiva. Métodos: Se realizó un estudio transversal correlacional, de tipo serie de casos, en el Servicio de Neurocirugía del Hospital Pediátrico de Camagüey durante el período comprendido desde enero de 2019 a diciembre de 2021. Fueron estudiados un total de 27 niños con traumatismo craneoencefálico grave, que cumplieron con los criterios de selección de la investigación. Las variables analizadas incluyeron: grupo etario, sexo, intensidad de la lesión, técnica quirúrgica, perfusión cerebral y resultados quirúrgicos obtenidos. Resultados: Predominó el grupo etario de 11-18 años (45,5 porciento) y el sexo masculino (72,7 porciento). El mayor puntaje en la variable intensidad de la lesión correspondió con la realización de craneotomías bilaterales (media = 78,63). Se halló disminución significativa (p = 0,024) de la perfusión cerebral en los pacientes con edad menor o igual a 8 años (media = 61,6387) y se encontró más disminuida en los pacientes que requirieron craneotomía bilateral (p = 0,001). Los peores resultados obtenidos correspondieron a los pacientes con edad biológica igual o menor a 8 años, que requirieron craneotomía bilateral. Conclusiones: La edad menor a 8 años se relacionó con mayor deterioro de la perfusión cerebral y peores resultados. La necesidad de craneotomías bilaterales se asoció con mayor intensidad de la lesión encefálica, presión intracraneal preoperatoria más elevada y deterioro de la perfusión cerebral(AU)

Introduction: Cranioencephalic trauma in pediatric ages is a relevant health problem worldwide and in Cuba. Objective: To determine the prognostic factors of severe cranioencephalic trauma in children who required decompressive craniotomy. Methods: A cross-sectional and correlational study of case series type was carried out at the neurosurgery service of Hospital Pediátrico de Camagüey during the period from January 2019 to December 2021. A total of 27 children with severe cranioencephalic trauma who met the research selection criteria were studied. The analyzed variables included age group, sex, injury intensity, surgical technique, cerebral perfusion and obtained surgical outcomes. Results: The age group 11-18 years (45.5 percent) and male sex (72.7 percent) predominated. The highest score in the variable injury intensity corresponded to the realization of bilateral craniotomies (mean = 78.63). A significant decrease (p = 0.024) in cerebral perfusion was found in patients aged 8 years or under (mean = 61.6387) and it was found to be more diminished in patients who required bilateral craniotomy (p = 0.001). The worst obtained outcomes corresponded to patients with a biological age of 8 years or under, who required bilateral craniotomy. Conclusions: Age under 8 years was associated with greater cerebral perfusion impairment and worse outcomes. The need for bilateral craniotomies was associated with greater intensity of the encephalic injury, higher preoperative intracranial pressure and cerebral perfusion impairment(AU)

Enfermedad de Rosai-Dorfman intracraneal: un infrecuente diagnóstico diferencial del meningioma. Reporte de un caso ilustrativo

La Enfermedad de Rosai-Dorfman es un trastorno infrecuente y de etiología desconocida. La presentación intracraneal es aún más rara y suele imitar la apariencia de un meningioma en las imágenes del encéfalo. Se presenta el caso de un paciente varón de 38 años que ingresa por una tumoración intracraneal, extra-axial y supratentorial asociada a déficit neurológico leve; con diagnóstico presuntivo de meningioma de la convexidad. Después de la intervención quirúrgica, el diagnóstico histológico definitivo fue de Enfermedad de Rosai-Dorfman intracraneal. Se debe considerar la Enfermedad de Rosai-Dorfman intracraneal dentro del diagnóstico diferencial de una lesión intracraneal extra-axial sugestiva de un meningioma debido a la similitud en las neuroimágenes y la presentación clínica entre ambas patologías.

Rosai-Dorfman disease is an infrequent condition with no known etiology. The intracranial presentation is even rarer, and it resembles the appearance of a meningioma in image studies. We present the case of a 38-year-old male patient who was admitted because of an extra-axial supratentorial cranial tumor, associated to mild neurological deficit. The presumptive diagnosis was convexity meningioma. After surgery, the definitive histologic diagnosis was intracranial Rosai-Dorfman disease. This condition should be considered in the differential diagnosis of an extra-axial intracranial lesion suggesting meningioma, because of similar neuroimaging results and the similar clinical picture.

Decompressive craniotomy for malignant cerebral venous sinus thrombosis / 国际脑血管病杂志

Cerebral venous sinus thrombosis (CVST) is a rare type of cerebrovascular disease, accounting for about 0.5% of all strokes. About 4% of patients with CVST have supratentorial brain parenchymal lesions and brain edema sufficient to cause brain hernia and neurological deterioration, which is called malignant CVST. Malignant CVST refers to the clinical (loss of consciousness, unilateral or bilateral pupil dilation) and imaging signs of supratentorial cortical lesions (ischemia or hemorrhage) accompanied by tentorial hiatal hernia formation at the onset or after treatment with heparin. For patients with malignant CVST, decompressive craniectomy is not only a life-saving treatment, but also can make most patients achieve good functional outcome.

Impacto pronóstico de la utilización intensiva de tecnologías complementarias intraoperatorias en gliomas cerebrales. Revisión de la literatura y presentación de 1 caso

Introducción: El manejo de los gliomas cerebrales durante las últimas cuatro décadas ha sufrido cambios relevantes en su estudio y tratamiento. Dentro de estos cambios se encuentra el desarrollo de técnicas imagenológicas, neurofisiológicas e histopatológicas. El presente trabajo intenta estimar el impacto que la utilización de dichas tecnologías ha tenido sobre el pronóstico de los pacientes. Material y método: Revisión exhaustiva de la literatura en medios digitales e impresos abarcando mayormente publicaciones y comunicaciones desde la década de 1980 hasta el presente. Se expone 1 caso sometido recientemente a cirugía por los autores en el que se utilizaron varias de estas herramientas, presentando el análisis que se llevó a cabo en la planificación quirúrgica. Resultados: La literatura muestra mejorías consistentes pero discretas en el pronóstico asociado al uso de tecnologías complementarias intraoperatorias en gliomas cerebrales, relacionadas a la ayuda que prestarían en la extensión de la resección tumoral y en la preservación funcional. Conclusiones: La utilización intensiva de las tecnologías complementarias descritas parece recomendable si la planificación quirúrgica anticipa beneficios fundados en cuanto a morbi-mortalidad para un paciente en particular. Se debe ser cauto en anticipar y generalizar el impacto pronóstico global que puedan tener, beneficio que es consistente en la literatura pero que en estos momentos parece modesto en términos generales en especial para gliomas de alto grado.

Introduction: The management of cerebral gliomas during the last four decades has undergone relevant changes in terms of its study and treatment. Among these changes is the development of imaging, neurophysiological and histopathological techniques. The present study attempts to estimate the impact that the use of these technologies has had on the prognosis of patients. Material and Method: Comprehensive review of the literature in digital and print media covering mostly publications and communications from the 1980s to the present. 1 case recently submitted to surgery by the authors in which several of these tools were used is exposed, presenting the analysis that was carried out in the surgical planning. Results: The literature shows consistent but discrete improvements in the prognosis associated with the use of intraoperative complementary technologies in cerebral gliomas, related to the help they would provide in the extension of tumor resection and functional preservation. Conclusions: The intensive use of the complementary technologies described seems advisable if surgical planning anticipates well-founded benefits in terms of morbidity and mortality for a particular patient. Caution should be exercised in anticipating and generalizing the global prognostic impact they may have, a benefit that is consistent in the literature but currently seems modest in general terms especially for high grade gliomas.

Anestesia en craneotomías con el paciente despierto. Reporte de los primeros casos en Paraguay / Anesthesia during awake craniotomy. Report of the first cases in Paraguay

Las craneotomías en pacientes conscientes (CPC) plantea desafíos para los anestesiólogos, como la necesidad de mantener al paciente sedado, consciente, tranquilo, cómodo, neurológicamente íntegro y colaborador, sin compromiso respiratorio o hemodinámico y provisto de una excelente analgesia, al tiempo de permitir su cooperación durante las pruebas neurológicas. Se presenta la serie de 6 primeros casos en nuestro medio, a través de los cuales se tiene por objetivo describir el manejo anestésico de craneotomías en pacientes conscientes. Se realizó un estudio observacional, descriptivo y de corte transverso, marco temporal retrospectivo en pacientes sometidos a CPC en el Hospital de Clínicas. El manejo anestésico discriminado por fases fue de la siguiente manera. Fase 1 (dormido: 6 pacientes): Inducción con Propofol, Lidocaína, Atracurio y Remifentanilo. Colocación de máscaras laríngeas. Bloqueo regional de escalpe. Mantenimiento con Remifentanilo. Fase 2 con sedación consciente (despierto: 6 pacientes): retiro de máscara laríngea y perfusión de dosis baja de propofol y remifentanilo para mantener un Ramsay 2. Fase 3 (despierto: 4 pacientes): se aumentó la dosis de propofol y remifentanilo para obtener un Ramsay 3. Fase 3 (dormido: 2 pacientes): se realizó inducción anestésica con mismas dosis de la fase 1 e intubación orotraqueal. Mantenimiento con propofol y remifentanilo. En conclusión, la anestesia permitió un despertar intraoperatorio rápido y adecuado para la fase consciente, la administración de dosis bajas de remifentanilo y propofol durante esta segunda fase proporcionaron a los pacientes un buen estado de confort para su colaboración con los test cognitivos y motores

Craniotomies in conscious patients (CCP) pose challenges for anesthesiologists, such as the need to keep the patient sedated, conscious, calm, comfortable, neurologically sound and cooperative, without respiratory or hemodynamic compromise and provided with excellent analgesia, while allowing their cooperation during neurological tests. The series of 6 first cases in our environment is presented, through which the objective is to describe the anesthetic management of craniotomies in conscious patients. An observational, descriptive and cross-sectional study was carried out, retrospective time frame in patients undergoing CCP at the Hospital de Clínicas. The anesthetic management discriminated by phases was as follows. Phase 1 (asleep: 6 patients): Induction with Propofol, Lidocaine, Atracurium and Remifentanil. Placement of laryngeal masks. Scalp regional lock. Remifentanil maintenance. Phase 2 with conscious sedation (awake: 6 patients): removal of the laryngeal mask and infusion of low-dose propofol and remifentanil to maintain Ramsay 2. Phase 3 (awake: 4 patients): the dose of propofol and remifentanil was increased to obtain a Ramsay 3. Phase 3 (asleep: 2 patients): anesthetic induction was performed with the same doses as phase 1 and orotracheal intubation. Maintenance with propofol and remifentanil. In conclusion, anesthesia allowed rapid and adequate intraoperative awakening for the conscious phase, the administration of low doses of remifentanil and propofol during this second phase provided the patient with a good state of comfort for collaboration with cognitive and motor tests

Abordaje perioperatorio en cirugía neurológica con el paciente despierto / Perioperative approach in neurological surgery with the patient awake

Resumen: La craneotomía con el paciente despierto se refiere a aquellos procedimientos en los que el paciente conserva su estado de consciencia durante toda la cirugía o en parte de ésta con el objetivo de explorar la integridad de sus funciones cerebrales superiores en tiempo real. Estas técnicas neuroanestésicas son útiles para ayudar al neurocirujano a preservar la integridad del tejido cerebral, o bien, no causar mayor daño del que la propia enfermedad ha causado.

Abstract: Awake craniotomy refers to those procedures in which the patient remains conscious for all or part the time, with the aim of explore in real time the integrity of their higher brain functions. This kind of neuroanesthetic techniques are useful in assisting the neurosurgeon to preserve the integrity of the brain or not to damage more than what the disease has caused.

Craneoplastía con prótesis de polimetilmetacrilato y planificación en 3D. Presentación de caso clínico y revisión de la literatura / Cranioplasty with polymethylmethacrylate prosthesis and 3D planification, case report and literature review

En este artículo se muestra que es posible realizar una prótesis digital con polimetilmetacrilato (PMMA) de forma sencilla con programas gratuitos y una impresora 3D de bajo costo y de fácil manejo. El caso clínico corresponde a un masculino de 38 años de edad quien refiere haber sido operado de urgencia por un hematoma subdural de origen traumático, secundario a una caída desde un andamio de 5 metros de altura, por parte del Servicio de Neurocirugía con una craneotomía descompresiva 10 meses atrás, actualmente presentando un defecto en región supraorbitaria y frontal bilateral y refiriendo cefaleas y mareos constantes con diagnóstico de síndrome del trefinado. Se decide diseñar digitalmente una prótesis con PMMA colocándola bajo anestesia general balanceada en quirófano mediante un acceso coronal, fijándola con tornillos de titanio y reposicionando tejidos con suturas. Se logra eliminar de forma inmediata el defecto visual, la sintomatología desapareció por completo confirmándolo en los controles desde los 7 días. Se muestra que es posible realizar una prótesis craneal personalizada de bajo costo de forma sencilla, resolviendo las molestias y eliminando las secuelas y complicaciones que afectan a los pacientes tratados por craniectomías descompresivas con presencias de defectos.

In this aticle it is showns that it is possible to make a digital prosthesis with Polymethylmethacrylate (PMMA) with free programs and a low-cost and easy-to-use 3D printer. The clinical case corresponds to a 38-year-old male who reported having undergone emergency surgery for a subdural hematoma of traumatic origin, secondary to a fall from a 5-meter-high scaffolding, procedure done by the Neurosurgery Service with a decompressive craniotomy 10 months ago, nowadays he presents a bilateral defect at the supraorbital and frontal region, referring constant headaches and dizziness with a diagnosis of a trephination syndrome. We decided to digitally design a prosthesis with PMMA, placing it under balanced general anesthesia in the operating room through a coronal approach, fixing it with titanium screws and repositioning tissues with sutures. The visual defect was immediately eliminated, the symptoms disappeared completely, confirming it at the controls since day 7. It is shown that it is possible to perform a low-cost personalized cranial prosthesis in a simple way, solving the discomfort and eliminating the sequelae and complications that affect patients treated by decompressive craniectomies with the presence of defects.

Conciencia transoperatoria en personas operadas mediante craneotomía despierto / Intraoperative awareness in awake craniotomy patients

La craneotomía con paciente despierto (CPD) demanda un manejo multidisciplinario particular debido al componente de conciencia transoperatoria que aporta beneficios en la resección tumoral y preservación neurológica, pero también implica el manejo de los riesgos asociados a la necesidad de cooperación del paciente durante el procedimiento. En este trabajo se describen los beneficios y las complicaciones en pacientes operados bajo la modalidad de CPD. Además, se abordan los retos documentados tanto para el equipo profesional a cargo, como para los pacientes, los cuales tienen un rol activo durante la cirugía. En ese sentido, se exponen los criterios para la selección, preparación psicológica y neuropsicológica tanto previo como durante la cirugía. A su vez, se proponen las consideraciones para lograr un procedimiento exitoso y evitar las posibles secuelas psicológicas a largo plazo, como insumos para la protocolización de este tipo de procedimientos con base en nuestra experiencia.

Awake craniotomy (AC) requires a multidisciplinary management due to trans operative awareness, which benefits the tumor resection and neurologic preservation, but it also implies risks for the patient cooperation during the procedure. This article describes the benefits and complications in patients operated under AC. Besides, it approaches the documented challenges for both the professional team and patients, who have an active role during surgery. In this regard, the criteria for selection and psychological and neuropsychological preparation before and during surgery are set out. It suggests considerations to achieve a successful procedure and to avoid possible long- term psychological sequelae, as a resource for the protocol of this type of procedures based on our experience.

Prognostic value of pre-operation systemic inflammation response index in decompressive craniectomy for massive cerebral infarction caused by middle cerebral artery embolization / 中国综合临床

Objective:To explore the correlation between systemic inflammatory response index (SIRI) and clinical outcome of patients with massive cerebral infarction (MCI) after craniotomy and decompression.Methods:The clinical data of 50 MCI patients who were treated in the Affiliated Hospital of Qingdao University from January 2016 to December 2020 and underwent craniotomy and decompression were retrospectively analyzed. The measurement data of normal distribution were expressed as xˉ± s, and the measurement data of non normal distribution were expressed as M( Q1, Q3). T-test or rank sum test was used for comparison between the two groups. Multivariate Logistic regression was used to analyze the relationship between SIRI and prognosis of MCI patients and establish a prediction model. The predictive value and optimal cutoff value of SIRI were analyzed by receiver operating characteristic curve (ROC). Results:Among the 50 MCI patients who underwent craniotomy and decompression, 12 (24%, 12/50) had a good prognosis; In the poor prognosis group, 38 cases (76%, 12/50), of which 9 cases (18%, 9/50) died during hospitalization. The age of patients in the good prognosis group and the poor prognosis group ((54±11) years and (63±9) years; t=2.72, P=0.015), body mass index (BMI): ((23.91±2.64) kg/m 2 and (26.72±3.28) kg/m 2, t=3.01, P=0.006)), neutrophil count (7.08 (5.12, 7.38))×10 9/L and 10.59 (8.91,14.64)×10 9/L, Z=5.72, P<0.001), white blood cell count ((9.09±2.80)×10 9/L and (13.20±3.49) ×10 9/L; t=4.16, P<0.001), SIRI (2.49(1.78, 4.75) and 8.34(5.17, 13.61); Z=3.84, P<0.001), Glasgow Coma Score (12(9,14) and 8(6,10); Z=3.36, P=0.002) and lymphocyte count (1.58(0.91, 1.91)×10 9/L and 0.77(0.59,1.02) ×10 9/L; Z=3.30, P=0.001).The difference between the two groups was statistically significant. The prognosis of patients with dominant hemisphere infarction was worse than that of patients with non-dominant hemisphere infarction (22 cases (91.67%, 22/24) vs. 16 cases (61.54%, 16/26); χ 2=6.21, P=0.013). The ICU stay in the good prognosis group was significantly shorter than that in the poor prognosis group (2 (1, 5) days vs. 8 (3, 19) days; Z=2.78, P=0.005). Multivariate Logistic regression analysis showed that SIRI and GCS were correlated with clinical prognosis: SIRI ( OR: 2.378; 95% CI: 1.131-5.003; P=0.022); GCS at admission ( OR: 0.548; 95% CI: 0.307-0.980; P=0.043). The ROC curve analysis of SIRI prediction of poor prognosis: Area under the curve (AUC): 0.871, (95% CI: 0.765-0.976, P<0.001), sensitivity was 78.9%, specificity was 88.3%, and the optimal cut-off value was 4.96. The sensitivity, specificity and AUC of GCS for predicting poor prognosis after MCI craniotomy decompression were 89.5%, 58.3% and 0.791 (95% CI: 0.638~0.943, P=0.003), and the best truncation value was 11.5. Conclusion:SIRI was an effective predictor of clinical outcome for MCI patients underwent Craniotomy for decompression, and SIRI value greater than 4.96 indicates adverse clinical outcome.

Clinical study of Xuefu Zhuyu Capsule combined with drilling and drainage in the treatment of chronic subdural hematoma / 中国医师进修杂志

Objective:To identify the effects of Xuefu Zhuyu Capsule (XZC) on the surgical treatment of patients with chronic subdural hematoma (CSDH).Methods:Retrospectively collected 96 pairs of patients who undergoing burr-hole craniotomy (BHC) for CSDH from January 2016 to December 2019 in Dalian Municipal Central Hospital. Clinical characteristics and imaging information of each patient were extracted, the follow-up period was six months. Differences in demographics and postoperative outcomes were compared between BHC+XZC group and BHC only group. Univariate analysis and multivariate analysis with Logistic regression model were performed to determine independent associations among the various probable effective factor. The relationship between related factors and effectiveness of CSDH was estimated with odds ratio ( OR) and 95% CI. Results:Effectiveness in 87 cases (90.6%) patients with surgery and received XZC postoperatively was significantly higher than 76 cases (79.2%) patients who underwent surgery alone. Multivariate Logistic regression analysis showed postoperative administration of XZC and preoperative Glasgow coma scale (GCS) score were independent protective factors for CSDH to improve therapeutic effect.Conclusions:This study suggested postoperative administration of XZC for CSDH patients can improve the therapeutic effect, a higher preoperative GCS score is contributed to the postoperative effect.

Clinical study on surgical methods of supratentorial intracerebral hemorrhage / 国际外科学杂志

Objective:To explore and analyze the selection of surgical methods for supratentorial intracerebral hemorrhage.Methods:A total of 260 patients with spontaneous intracerebral hemorrhage who underwent surgery in Department of Neurosurgery, Suzhou Hospital Affiliated to Nanjing Medical University from January 2017 to December 2021 were included in the study by retrospective case analysis. According to different surgical methods, they were divided into three groups: large bone flap group ( n=116), conventional bone flap group( n=89)and stereotactic group( n=55). The large bone flap group underwent standard supratentorial large bone flap craniotomy, the conventional bone flap group underwent conventional bone flap craniotomy, and the stereotactic group underwent stereotactic hematoma puncture suction + drainage. Clinical indicators such as operation time, intraoperative bleeding, pulmonary infection, length of hospital stay, and Glasgow outcome scale (GOS) at 6 months of postoperative follow-up, and the proportion of good prognosis (GOS 4-5) were calculated. Measurement data with normal distribution were expressed as mean±standard deviation( ± s), count data were expressed as cases and percentages (%). Results:In the large bone flap group, the operation time, intraoperative bleeding, hospital stay, pulmonary infection, postoperative rebleeding were(193±24) min, (625±65) mL, (46±11) d, 102 patients(87%), 9 patients(7.8%), and (124±17) min, (297±35) mL, (32±9) d, 29 patients(33%), 4 patients(4.4%)in the conventional bone flap group, and (73±11) min, (53±15) mL, (21±4) d, 10 patients(18%), 2 patients(3.6%)in stereotactic group. All patients were followed up for 6 months, and 165 patients (63.5%) had good prognosis (GOS 4-5), including 36 patients (31%) in the large bone flap group, 82 patients (93.2%) in the conventional bone flap group, and 47 patients (85.5%) in the stereotactic group.Conclusion:Standard large craniectomy has sufficient effect of decompression, and is suitable for serious life threatening hematoma; Conventional craniotomy has advantages in the treatment of secondary intracerebral hemorrhage. Stereotactic surgery has the characteristics of short operation time, less intraoperative bleeding, short hospital stay and low incidence of pulmonary infection, which is worthy of promotion in the treatment of primary intracerebral hemorrhage.

Outcomes of patients experiencing cardiovascular adverse events within 1 year following craniotomy for intracranial aneurysm clipping: a retrospective cohort study / 南方医科大学学报

OBJECTIVE@#To investigate the impact of postoperative serious cardiovascular adverse events (CAE) on outcomes of patients undergoing craniotomy for intracranial aneurysm clipping.@*METHODS@#This retrospective cohort study was conducted among the patients undergoing craniotomy for intracranial aneurysm clipping during the period from December, 2016 to December, 2017, who were divided into CAE group and non-CAE group according to the occurrence of Clavien-Dindo grade ≥II CAEs after the surgery. The perioperative clinical characteristics of the patients, complications and neurological functions during hospitalization, and mortality and neurological functions at 1 year postoperatively were evaluated. The primary outcome was mortality within 1 year after the surgery. The secondary outcomes were Glasgow outcome scale (GOS) score at 1 year, lengths of postoperative hospital and intensive care unit (ICU) stay, and Glasgow coma scale (GCS) score at discharge.@*RESULTS@#A total of 361 patients were enrolled in the final analysis, including 20 (5.5%) patients in CAE group and 341 in the non-CAE group. No significant differences were found in the patients' demographic characteristics, clinical history, or other postoperative adverse events between the two groups. The 1-year mortality was significantly higher in CAE group than in the non-CAE group (20.0% vs 5.6%, P=0.01). Logistics regression analysis showed that when adjusted for age, gender, emergency hospitalization, subarachnoid hemorrhage, volume of bleeding, duration of operation, aneurysm location, and preoperative history of cardiovascular disease, postoperative CAEs of Clavien-Dindo grade≥II was independently correlated with 1-year mortality rate of the patients with an adjusted odds ratio of 3.670 (95% CI: 1.037-12.992, P=0.04). The patients with CEA also had a lower GOS score at 1 year after surgery than those without CEA (P=0.002). No significant differences were found in the occurrence of other adverse events, postoperative hospital stay, ICU stay, or GCS scores at discharge between the two groups (P > 0.05).@*CONCLUSION@#Postoperative CAEs may be a risk factor for increased 1-year mortality and disability in patients undergoing craniotomy for intracranial aneurysms.

Abordaje de la vía aérea en el paciente neuroquirúrgico / Airway approach in the neurosurgical patient

Resumen: El abordaje de la vía aérea en el paciente neuroquirúrgico presenta grandes retos debido al escenario tan complejo al cual nos enfrentamos; debemos considerar las características propias del paciente, las comorbilidades presentes y la patología neurológica por la que va a ser intervenido. Conocer la patología neurológica y las implicaciones o repercusiones que ésta puede llegar a tener en el manejo de la vía aérea ayudarán a la toma de decisiones y conocer los retos y escenarios que se pudieran presentar durante el evento anestésico-quirúrgico.

Abstract: The approach to the airway in the neurosurgical patient presents great challenges due to the complex scenario we face; we must consider the patient's own characteristics, the co-morbidities present and the neurological pathology for which it is going to be intervened. Knowing the neurological pathology and the implications or repercussions that this may have over the management of the airway will help decision making and manage the challenges and scenarios that could arise during the anesthetic surgical event.

Reabilitação funcional em unidades de terapia intensiva para pacientes pós-craniotomia: protocolo de estudo / Functional rehabilitation in intensive care units for post craniotomy patients: study protocol

INTRODUÇÃO: A craniotomia torna mais fácil a compreensão e abordagem do cérebro, mas acompanha as doenças. As unidades de terapia intensiva são equipadas com fisioterapeutas profissionais treinados para lidar com esses efeitos deletérios após este programa cirúrgico, mas falta um protocolo progressivo, definido e apoiado por evidências para esses pacientes. OBJETIVO: Avaliar a viabilidade do protocolo de neuro-reabilitação elaborado para pacientes pós-craniotomia durante sua internação em Unidade de Terapia Intensiva (UTI) para melhorar seus resultados funcionais e reduzir seu tempo de internação (LOS). MATERIAIS E MÉTODOS: Será um ensaio de quase viabilidade pós-teste de pré-teste de grupo único. Quinze pacientes submetidos à craniotomia serão recrutados para o estudo e serão processados com protocolo de Neuro-reabilitação por 60 minutos do primeiro dia da cirurgia até o 15º dia da cirurgia. O resultado primário será a Escala de Habilidades Funcionais Precoces (EFA) para medição de resultados funcionais como nível de consciência, habilidades sensório-motoras, habilidades cognitivo-perceptuais e habilidades oromotoras de pacientes que serão avaliadas no primeiro dia após a craniotomia. Os resultados secundários incluirão Escala de Coma de Glasgow (GCS), Escala de Recuperação de Coma - Revisada (CRS-R), Técnica de Reabilitação de Avaliação de Modalidade Sensorial (SMART), Escala de Ashworth modificada modificada (mMAS), Pontuação de Avaliação Cognitiva de Montreal (MoCA) e Conselho de Pesquisa Médica Escala (MRC). As avaliações serão feitas no primeiro e no décimo quinto dia pós-operatório. PERSPECTIVAS: Espera-se que este protocolo melhore os resultados funcionais e reduza a incidência de ocorrência de comorbidades em pacientes após craniotomia em UTI.

INTRODUCTION: Craniotomy makes insight and approach towards the brain easier but accompanies ailments. Intensive care units are equipped with trained professional physical therapists working over these deleterious after-effects of this surgical program, but a progressive, defined, and evidence-supported protocol for such patients is lacking. OBJECTIVE: To assess the feasibility of a Neurorehabilitation protocol devised for post-craniotomy patients within their stay in the Intensive Care Unit (ICU) to improve their functional outcomes and reduce their length of stay (LOS). MATERIALS AND METHODS: It will be a single group pre-test post-test quasi feasibility trial. Fifteen patients undergoing craniotomy will be recruited for the trial and will be rendered with Neuro-rehabilitation protocol for 60 minutes from the first day of surgery up to 15 days of surgery. The primary outcome will be the Early Functional Abilities (EFA) Scale to measure functional outcomes like conscious level, sensorimotor abilities, cognitive-perceptual abilities, and oro-motor abilities of patients, which will be assessed first-day post craniotomy. Secondary outcomes will include Glasgow Coma Scale (GCS), Coma Recovery Scale-Revised (CRS-R), Sensory Modality Assessment Rehabilitation Technique (SMART), Modified Ashworth Scale (mMAS), Montreal Cognitive Assessment Score (MoCA), and Medical Research Council Scale (MRC). Assessments will be taken on the first and fifteenth days post-surgery. PERSPECTIVES: It is expected that this protocol might improve functional outcomes and may reduce the occurrence of comorbidities in patients after Craniotomy in ICUs.

Chronic postoperative orofacial pain. Case reports / Dor orofacial pós-operatória crônica. Relato de casos

ABSTRACT BACKGROUND AND OBJECTIVES: The presence of neoplasms, chronic and oral diseases may require surgical treatment for its resolution, although it may consequently cause chronic pain. Chronic postoperative orofacial pain remains even after tissue healing and its causes are not defined. Although neuropathic etiology is the most reported, it represents 30% of cases; the other 70% are still unclear and the main risk factors involved in the development of this chronic pain condition remains on discussion. The aim of the study was to report three clinical cases of different postoperative orofacial pain etiologies. CASE REPORTS: Case 1: Female patient, 39-year-old, history of osteoblastoma exeresis in the mandibular body, presenting continuous postoperative shock pain, with intra and extraoral allodynia in the area. Diagnosis: post-traumatic trigeminal neuropathic pain. Case 2: Female patient, 30-year-old, diagnosed with refractory epilepsy and neurocysticercosis, complained of orofacial pain and bitemporal headache worse after craniotomy that treated the reported diseases. Diagnosis: post-craniotomy headache and orofacial pain. Case 3: Female patient, 49-year-old, with hereditary hemorrhagic telangiectasia, complained of pulsing in the alveolar ridge after extraction of three teeth, performed at different times. Diagnosis: Perception of orofacial pain secondary to systemic vascular disease. CONCLUSION: Different surgical procedures, intra and extraoral, led to the development of orofacial postoperative pain in the reported cases, whose etiology is not only neuropathic. Prospective multidisciplinary studies are necessary in order to clarify the causes of orofacial postoperative pain.

RESUMO JUSTIFICATIVA E OBJETIVOS: A presença de neoplasias, doenças crônicas e doenças bucais pode exigir tratamento cirúrgico para sua resolução, embora possa ocasionar dor crônica. A dor orofacial pós-operatória crônica permanece mesmo após a cicatrização tecidual e suas causas não estão claramente descritas. A etiologia neuropática, embora seja a mais relatada, representa 30% dos casos; os outros 70% não estão elucidados e ainda são discutidos quais os principais fatores de risco envolvidos no desenvolvimento desta condição de dor crônica. O objetivo deste estudo foi relatar três casos clínicos de indivíduos com diferentes etiologias de dor orofacial pós-operatória crônica. RELATO DOS CASOS: Caso 1: Paciente do sexo feminino, 39 anos, com histórico de exérese de osteoblastoma em corpo mandibular, apresentou dor pós-operatória em choque, contínua, com alodínia intra e extraoral na área abordada. Diagnóstico: dor neuropática trigeminal pós-traumática. Caso 2: Paciente do sexo feminino, 30 anos, com diagnóstico de epilepsia refratária e neurocisticercose, queixou-se de dor orofacial e cefaleia bitemporal com piora após craniotomia para tratamento das doenças relatadas. Diagnóstico: cefaleia e dor orofacial pós-craniotomia. Caso 3: Paciente do sexo feminino, 49 anos, com telangiectasia hemorrágica hereditária, queixou-se de pulsar em rebordo alveolar após exodontia de três dentes, realizada em momentos distintos. Diagnóstico: percepção de dor orofacial secundária à doença vascular sistêmica. CONCLUSÃO: Diferentes procedimentos cirúrgicos, intra e extraorais, levaram ao desenvolvimento da dor orofacial pós-operatória crônica nos casos relatados, de etiologia não apenas neuropática. Estudos prospectivos multidisciplinares serão necessários para esclarecer as causas desse quadro doloroso.

Craneotomía en el paciente despierto / Awake craniotomy

Introducción: La craneotomía con el paciente despierto es útil para lograr resecciones cerebrales amplias de lesiones de áreas elocuentes. Objetivo: Presentar un caso al que se le realizó la técnica dormido- despierto. Método: Se realizó la inducción de la anestesia con propofol/fentanilo/rocuronio y se colocó una mascarilla laríngea. Después del bloqueo de escalpe se mantuvo la infusión de propofol/fentanilo y lidocaína hasta que se realizó la craneotomía. Se disminuyó la velocidad de infusión y se mantuvo de esta manera hasta finalizada la intervención. Resultados: Se logró el despertar del paciente a los 13 minutos de reducida la infusión. Se mantuvo buena estabilidad hemodinámica, sin depresión respiratoria ni otras complicaciones. El paciente se mantuvo colaborador, respondió preguntas y movilizó sus extremidades. No presentó complicaciones posoperatorias. Discusión: Dentro de las técnicas anestésicas utilizadas en el mundo la dormido- despierto-dormido es la más popular; sin embargo, constituye una alternativa no dormir nuevamente al paciente ni reinstrumentar la vía respiratoria. Los medicamentos más empleados son el propofol/remifentanilo, aunque la comparación con otros opioides no arrojan diferencias significativas; aunque sí supone un beneficio adicional la dexmedetomidina. Conclusiones: La craneotomía con el paciente despierto es posible de realizar en el entorno hospitalario siempre que exista un equipo multidisciplinario que consensue las mejores acciones médicas para el paciente(AU)

Introduction: Awake craniotomy is useful to achieve wide brain resections of lesions in eloquent areas. Objective: To present the case of a patient who was operated on with the asleep-awake-asleep technique. Method: Anesthesia was induced with propofol-fentanyl-rocuronium and a laryngeal mask was placed. After scalp block, the propofol-fentanyl and lidocaine infusion was maintained until craniotomy was performed. The infusion rate was decreased and remained this way until the end of the intervention. Results: The patient was awakened thirteen minutes after the infusion was reduced. Good hemodynamic stability was maintained, without respiratory depression or other complications. The patient remained collaborative, answered questions, and mobilized his limbs. He had no postoperative complications. Discussion: Among the anesthetic techniques used in the world, asleep-awake-asleep is the most popular. However, it is an alternative not to put the patient back to sleep or re-instrument the airway. The most commonly used drugs are propofol-remifentanil, although the comparison with other opioids does not show significant differences, except for dexmedetomidine, which does represent an additional benefit. Conclusions: Awake craniotomy is possible to be performed in the hospital setting as long as there is a multidisciplinary team that agrees on the best medical actions for the patient(AU)

Caso raro: trauma penetrante craneoencefálico por un cuchillo. Actualización del diagnóstico y tratamiento / Rare case: penetrating head trauma by a knife. Diagnosis and treatment update

El trauma penetrante craneoencefálico representa alrededor del 0.4% de los casos, pocos son los descritos en la literatura, por lo cual, no existe un manejo protocolizado del mismo.Describimos un caso de un paciente masculino de 24 años que sufre un trauma penetrante a nivel de región parietal izquierda con arma blanca "cuchillo", dejando incrustada la hoja del mismo. La Tomografía computarizada simple de cráneo con reconstrucción en 3 dimensiones más angiografía, confirma el diagnóstico y descarta el compromiso vascular. Se realiza la extirpación completa del cuerpo extraño, sin complicaciones. Evolución favorable con mejoría de la sintomatología neurológica al alta.Este tipo de trauma es una emergencia que puede poner en riesgo la vida del paciente dependiendo del área afectada. La extirpación del cuerpo extraño debe realizarse en un medio hospitalario por la afectación de grandes vasos. Se debe tener una alta sospecha diagnóstica asociada al antecedente.

Craneoencephalic penetrating trauma represents about 0.4% of cases, few are described in the literature, therefore, there is no protocolized management of them.We describe a case of a 24-year-old male patient who suffers penetrating trauma at left parietal region with a "knife", leaving the blade embedded. Simple Computed Tomography of the Skull with Reconstruction in 3 dimensions plus angiography, confirms the diagnosis without vascular compromise. The complete removal of the foreign body was performed, without complications. Evolution is favorable and was discharged with improvement neurological symptoms.This type of trauma is an emergency that can put the life at risk depending on the affected area. The removal of the foreign body must be performed in a hospital environment due to the involvement of large vessels. There must be a high diagnostic suspicion associated with the antecedent.

Comparison of pulse pressure variation, stroke volume variation, and plethysmographic variability index in pediatric patients undergoing craniotomy / 北京大学学报(医学版)

OBJECTIVE@#To compare well-known preload dynamic parameters intraoperatively including stroke volume variation (SVV), pulse pressure variation (PPV), and plethysmographic variability index (PVI) in children who underwent craniotomy for epileptogenic lesion excision.@*METHODS@#A total of 30 children aged 0 to 14 years undergoing craniotomy for intracranial epileptogenic lesion excision were enrolled. During surgery, we measured PPV, SVV (measured by the Flotrac/Vigileo device), and PVI (measured by the Masimo Radical-7 monitor) simultaneously and continuously. Preload dynamic parameter measurements were collected at predefined steps: after induction of anesthesia, during opening the skull, intraoperative electroencephalogram monitoring, excision of epileptogenic lesion, skull closure, at the end of the operation. After exclusion of outliers, agreement among SVV, PPV, and PVI was assessed using repeated measures of Bland-Altman approach. The 4-quadrant and polar plot techniques were used to assess the trending ability among the changes in the three parameters.@*RESULTS@#The mean SVV, PPV, and PVI were 8%±2%, 10%±3%, and 15%±7%, respectively during surgery. We analyzed a total of 834 paired measurements (3 to 8 data sets for each phase per patient). Repeated measures Bland-Altman analysis identified a bias of -2.3 and 95% confidence intervals between -1.9 and -2.7 (95% limits of agreement between -6.0 and 1.5) between PPV and SVV, showing significant correlation at all periods. The bias between PPV and PVI was -5.0 with 95% limits of agreement between -20.5 and 10.5, and that between SVV and PVI was -7.5 with 95% limits of agreement between -22.7 and 7.8, both not showing significant correlation. Reflected by 4-quadrant plots, the con-cordance rates showing the trending ability between the changes in PPV and SVV, PPV and PVI, SVV and PVI were 88.6%, 50.4%, and 50.1%, respectively. The concordance rate between PPV and SVV was higher (92.7%) in children aged less than 3 years compared with those aged 3 and more than 3 years. The mean angular bias, radial limits of agreement, and angular concordance rate in the polar analysis were not clinically acceptable in the changes between arterial pressure waveform-based parameters and volume-based PVI (PPV vs. PVI: angular mean bias 8.4°, angular concordance rate 29.9%; SVV vs. PVI: angular mean bias 2.4°, angular concordance rate 29.1%). There was a high concordance between the two arterial pressure waveform-based parameters reflected by the polar plot (angular mean bias -0.22°, angular concordance rate 86.6%).@*CONCLUSION@#PPV can be viewed as a surrogate for SVV, especially in children aged less than 3 years. The agreement between arterial pressure waveform-based preload parameters (PPV and SVV) and PVI is poor and these two should not be considered interchangeable. Attempt to combine PVI and PPV for improving the anesthesiologist's ability to monitor cardiac preload in major pediatric surgery is warranted.

Challenges in the performance of awake craniotomies in the Philippine General Hospital: A case series

@#Awake craniotomy is a neurosurgical technique that involves an awake neurological testing during the resection of an intracranial lesion in eloquent cerebral cortical areas representing motor, language, and speech. This technique is highlighted by an intra-operative cortical mapping that requires active participation by the patient and poses unique challenges to the anesthesiologist. The surgical and anesthetic techniques have evolved significantly over time, as the neurosurgeon and the anesthesiologist learn new steps in making this technique safe to achieve reasonable patient satisfaction. A thorough understanding of this surgical technique's rationale will guide the anesthesiologist in planning the anesthetic management depending on the surgery and neurologic testing. Constant communication between the neurosurgeon, anesthesiologist, and the patient will define this surgical technique's success. It is already a well-established procedure; however, factors that contribute to failures in awake craniotomy procedures have not been well characterized in the literature. Failure is defined as the inability to conduct awake neurologic testing during the awake craniotomy procedure because of various factors which will be described. This paper aims to review the challenges in the performance of three (3) cases of awake craniotomies performed in the Philippine General Hospital. The challenges described in these three (3) cases reveal that this can be experienced by the neurosurgeon, neuroanesthesiologist, and most especially the patient in an acute critical condition. Identification of the procedures' failure and the steps taken to manage such situations with the patient's safety in mind are discussed.

Recomendaciones para un protocolo Enhanced Recovery After Surgery (ERAS) de craneotomía electiva / Recommendations for an Enhanced Recovery After Surgery protocol (ERAS) for elective craniotomy

La implementación de un protocolo Enhanced Recovery After Surgery (ERAS), que consiste en un conjunto de medidas perioperatorias orientadas a mejorar el desenlace postoperatorio y a disminuir la estadía hospitalaria, las tasas de complicaciones y los costos económicos, ha sido costo-beneficiosa en muchas especialidades quirúrgicas. En neurocirugía, sin embargo, no existe actualmente un protocolo ERAS de amplio uso para craneotomía electiva. Experiencias iniciales, obtenidas tras la implementación de unos pocos protocolos ERAS para dicha intervención, son alentadoras, demostrando disminuir la estadía hospitalaria y el dolor postoperatorio y aumentando la satisfacción del paciente, sin aumentar las complicaciones. En el presente artículo formulamos recomendaciones que podrían utilizarse para diseñar un protocolo ERAS para una realidad particular, en base a un análisis de la evidencia actual sobre intervenciones que han demostrado disminuir las complicaciones y la estadía hospitalaria.

The implementation of an Enhanced Recovery After Surgery protocol (ERAS) consisting of a set of perioperative measures aimed at improving the post-operatory outcome, shortening hospital stay, and reducing the rate of complications and economic costs has been cost-beneficial in many surgical specialties. However, there is currently no widely used ERAS protocol for elective craniotomy in neurosurgery. Initial experience with implementation of some ERAS protocols for said intervention are encouraging, showing shortened hospital stays, less postoperative pain, and higher patient satisfaction with no increase in complications. In this article we draw up recommendations which could be used in the designing of an ERAS protocol for a specific situation, based on an analysis of current evidence on interventions which have been shown to reduce complications and hospital stay.