Modelo animal experimental para adiestramiento en realización anastomosis extra intraracraneales e intracraneales, con técnicas microquirúrgicas / Experimental animal model for training in performing extra-intracranial and intracranial anastomosis, using microsurgical techniques

Las técnicas de anastomosis extra e intracraneales se han utilizado desde los aٌos 70 para el manejo de diferentes patologيasvasculares, que van desde la enfermedad cerebrovascular hasta la exclusiَn de aneurismas y malformaciones arteriovenosasde la circulaciَn o el manejo de condiciones como la enfermedad de Moya Moya. Si bien se ha cuestionado su aplicaciَnen algunas de estas patologيas hoy en dيa se sabe que constituyen una opciَn terapéutica. Las técnicas descritas requierende un entrenamiento especializado del Neurocirujano en el laboratorio de microcirugيa, entrenamiento que no siempre estلal alcance de todos los residentes. Existen dilemas éticos en cuanto al uso de animales y es poco probable que durante losaٌos de formaciَn el residente tenga la oportunidad de realizar anastomosis vasculares en el quirَfano dada la complejidadde estos procedimientos. En el presente artيculo se describe la técnica quirْrgica y microquirْrgica para la realizaciَn de unbypass extra e intracraneal en un modelo animal (cabeza de cerdo), donde se describe paso por paso el procedimiento ylos utensilios con los que debe contar el estudiante. Se hace una revisiَn de la literatura acerca de la patologيa vascular, lastécnicas de bypass y las particularidades de la anatomيa de estos animales.

Extracranial-intracranial bypass techniques have been used since the 70’s for the handling of different vascular diseases, fromcerebrovascular disease to the exclusion of aneurysms and arteriovenous malformations from the circulation or the managementof conditions such as Moyamoya disease. Although its application has been questioned in some of these diseases weknown now that this technic constitutes a therapeutic option. The described techniques require specialized training of the neurosurgeonin the of microsurgery laboratory, training that is not always available to all residents. There are ethical dilemmasregarding the use of animals and it is unlikely that during the formative years the resident may have the opportunity to performvascular anastomosis in the operating room because of the complexity of these procedures. In this article we describe thesurgical and microsurgical techniques for carrying extra- intracranial bypass in an animal model (pig’s head), and outline stepby step the procedure and utensils which the student must have. It is a review of the literature on vascular disease, bypasstechniques and peculiarities of the anatomy of these animals.

Comparative analysis on the MR imaging characteristics between Ischemic moya-moya ;disease and hemorrhagic moya-moya disease / 中国医学装备

Objective: To improve the accuracy of forecasting hemorrhagic moya-moya disease by analyzing the difference in MR imaging between ischemic moya-moya disease and hemorrhagic moya-moya disease. Methods: Retrospective analysis was conducted of clinical and MR imaging data of 64 patients with moya-moya disease between 2009 and 2014 years in Hospital 94 of PLA. Results: Among the 64 patients aged 26 to 49 (average age was 38.2), 21 cases (32.8%) were diagnosed with ischemic moya-moya diseases, while 16 cases (76.2%) diagnosed with hemorrhagic moya-moya diseases, ischemic lesions were distributed mainly in frontal and parietal area, while hemorrhagic lesions were mainly distributed in the dorsal thalamus (28 cases, 65.1%), in the basal ganglia (9 cases, 20.9%), in the simple intraventricular (4cases, 9.3%) and in pure subarachnoid (2 cases, 4.6%). In the ischemic-typed moyamoya disease and hemorrhagic-typed moyamoya disease, cerebral bottom dorsal smoke abnormal vascular network, anterior choroidal artery and callosal artery thickening of the posterior cerebral artery, cortical pial vascular thickening, thickening of vascular branches of ophthalmic artery and external carotid artery thickening were respectively occurred in 15 cases of 28 branch (71.4%) and 38 cases of 62 branches (88.4%), 12 cases with 24 branches (57.1%) and 35 cases with 45 branches (81.4%), 8 cases with 16 branches (38.1%) and 30 cases with 58 branches (69.8%), 5 cases with 10 branches (23.8%) and 13 cases of the 24 branch (30.2%), 7 cases with 11 side branches (33.3%) and 27 patients with 54 branch (62.8%). Conclusion:The tortuous and dilated choroid artery and abnormal hyperplasia vascular network in skull base are the main causes of bleeding in moya-moya diseases.

Enfermedad de Moya-Moya / Moya-Moya disease

Enfermedad esteno-oclusiva de la porción terminal de las arterias carótidas internas y de sus ramas principales (arteria carótida media y arteria carótida anterior), progresiva, prevalente en el este Asiático (Japón, Corea), muy rara en nuestro país como en el resto del mundo, de causa desconocida. Se manifiesta mas frecuentemente como un accidente cerebrovascular isquémico transitorio o permanente en los niños menores de 10 años y como accidente cerebrovascular hemorrágico en el adulto. El diagnóstico se realiza con la Angiografía Digital Cerebral y el tratamiento consiste en la revascularización cerebral, que mejora el cuadro neurológico y la calidad de vida.`Se presenta el caso de una niña de 3 años de edad con convulsiones, afasia de expresión, lúcida y hemiparesia izquierda, que luego de una franca mejoría vuelve a presentar una semana después, otra crisis más severa con compromiso de conciencia y hemiplejía derecha, cuyo estudio neurorradiológico reveló la imagen típica de volutas de humo de cigarrillo en la base del cerebro, característico de la enfermedad de Moya-Moya e intervenida quirúrgicamente con la revascularización cerebral por medio de la técnica: EncefaloDuroArterioSinangiosis (EDAS), con buen resultado.

Moya-Moya is a progressive steno-occlusive disease of the internal carotid arteries and its major branches (middle cerebral artery, and anterior cerebral artery) whose cause is unknown, and which is reported primarily in east Asia (Japan and Korea) but rare in Paraguay and the rest of the world. In children under age 10, it presents most commonly as a transient or permanent ischemic attack and in adults as a hemorrhagic stroke. Diagnosis is done by digital subtraction cerebral angiography, and treatment consists of cerebral revascularization to improve the neurological profile and quality of life. We present the case of a 3-year old female child with seizures and motor aphasia who was lucid, with left hemiparesis, and who after complete recovery presented again a week later with a more severe attack, with impaired consciousness and right hemiplegia. Radiological study revealed a typical image of swirls of 'cigarette smoke' at the base of the brain that are characteristic of Moya-Moya disease, and who was operated on using encephaloduroarteriosynangiosis (EDAS), with good results.

A Case of Moya-Moya Disease with Arteriovenous Malformation

A case of Moya-Moya disease with AVM is reported. It is well known that Moya-Moya disease sometimes is accompanied by cerebral aneurysm. However, only four case of Moya-Moya disease with AVM have previously been published in the world. A 36-year-old women suffered from sudden onset of mental deterioration & left hemiparesis, Brain CT scan showed intraventricular hemorrage in both lateral & 3rd ventricle. Enhanced CT scan revealed irregular enhancing area in the right posterior parietal cortex. Cerebral angiography showed an arteriovenous malformation fed by basal Moya-Moya vessels & posterior meningeal artery. Emergeny external ventricular drainge was done. 2 weeks later, the patient had operation for excision of AVM & encephalomyosynangiosis.

Two Operative Cases of Moya Moya Disease in Children

The treatment of moya moya disease, a chronic occlusive cerebrovascular disease of unknown etiology, isn't settled ut various operative methods to maximize cerebral revascularization have been reported. Two cases in children treated surgically are presented, one with cerebroarteriosynangiosis and the other with encephalo-duro-arterio-synangiosis(EDAS). The methods of cerebral revascularization are discussed in detail.