Short-term survival in extensive craniofacial resections

OBJECTIVES: Craniofacial resection (CFR) procedures for craniofacial tumors with cranial extension are often extensive. Although CFRs may yield good oncological results, there are concerns about high perioperative morbidity and mortality. This study aimed to determine risk factors for perioperative mortality after open CFR in terms of deaths occurring during index hospitalizations. METHODS: We conducted a retrospective analysis of CFRs conducted at a tertiary oncology hospital from May 2009 through December 2018. RESULTS: Our analysis included data from the medical records of 102 patients, the majority of whom were male (n=74, 72.5%). The mean age was 61 years (±18.3 years). Skin malignancies (n=64, 63.4%) accounted for nearly two-thirds of the treated tumors, and most of these were squamous cell carcinoma. Postoperative medical complications occurred in 33 patients (33%), and surgical complications occurred in 48 (47%). Multivariate analysis revealed the only independent risk factors for perioperative deaths to be the presence of intracranial tumor extension on preoperative imaging (hazard ratio [HR]=4.56; 95% confidence interval [CI]: 1.74-11.97; p=0.002) and the unexpected emergence of postoperative neurological dysfunction (HR=10.9; 95% CI: 2.21-54.3; p=0.003). CONCLUSIONS: In our study, factors related to tumor extension were associated with a higher risk of perioperative death.

Good sensory recovery of the hand in brachial plexus surgery using the intercostobrachial nerve as the donor / Boa recuperação da sensibilidade da mão usando o nervo intercostobraquial como doador em cirurgia do plexo braquial

ABSTRACT Objective: Restoration of the sensitivity to sensory stimuli in complete brachial plexus injury is very important. The objective of our study was to evaluate sensory recovery in brachial plexus surgery using the intercostobrachial nerve (ICBN) as the donor. Methods: Eleven patients underwent sensory reconstruction using the ICBN as a donor to the lateral cord contribution to the median nerve, with a mean follow-up period of 41 months. A protocol evaluation was performed. Results: Four patients perceived the 1-green filament. The 2-blue, 3-purple and 4-red filaments were perceptible in one, two and three patients, respectively. According to Highet's scale, sensation recovered to S3 in two patients, to S2+ in two patients, to S2 in six patients, and S0 in one patient. Conclusion: The procedure using the ICBN as a sensory donor restores good intensity of sensation and shows good results in location of perception in patients with complete brachial plexus avulsion.

RESUMO Objetivo: A restauração da sensibilidade em pacientes com lesão completa do plexo braquial é muito importante. O objetivo desse estudo foi avaliar a recuperação sensitiva em cirurgia do plexo braquial utilizando o nervo intercostobraquial (NICB) como doador. Métodos: Onze pacientes foram submetidos a reconstrução sensitiva usando o NICB como doador para a contribuição lateral do nervo mediano, com tempo de acompanhamento pós-operatório médio de 41 meses. Um protocolo de avaliação foi realizado. Resultados: Quatro pacientes perceberam o filamento 1-verde. Os filamentos 2-azul, 3-roxo e 4-vermelho foram percebidos por um, dois e três pacientes, respectivamente. Um paciente não apresentou recuperação sensitiva. Dois pacientes obtiveram recuperação S3, dois S2+, seis S2 e um S0, pela escala de Highet. Conclusão: O procedimento usando o NICB como doador promove boa intensidade de recuperação sensitiva e bons resultados são obtidos quanto ao local de percepção em pacientes com avulsão completa do plexo braquial.

Computed Tomographic Angiography for Cerebral Aneurysms in Spontaneous Subarachnoid Hemorrhage

Computed tomographic angiography (CTA) has recently gained popularity as an initial imaging test for spontaneous subarachnoid hemorrhage (SAH). This study evaluated 59 patients presenting aneurysmal SAH who underwent microsurgical clipping based on CTA findings alone and digital subtraction angiography (DSA) at postoperative follow-up. Multiple aneurysms were identified by CTA in 27% of patients and in 10% of patients, DSA identified aneurysms in addition to those diagnosed with CTA. The time between CTA and surgical treatment ranged from 0­4 days. Postoperative DSA revealed that 24% of patients had residual neck. The use of CTA alonemay not be enough to detect small unruptured aneurysms in patients with multiple lesions or aneurysm remnants adjacent to an aneurysm clip. However, the advantages of CTA compared with DSA include its rapidity, reduced invasiveness, and lower cost, which allow us to proceed to ruptured aneurysm repair entirely on the basis of good-quality CTA studies.

Angiotomografia computadorizada (ATC) ganhou popularidade como exame de imagem inicial na hemorragia subaracnoide (HSA). Este estudo retrospectivo, descritivo e observacional, avaliou 59 pacientes com HSA aneurismática. Todos foram submetidos à clipagem microcirúrgica apenas com base na ATC e no seguimento realizou-se avaliação com angiografia digital (AD). Em 27% dos pacientes encontramos múltiplos aneurismas na ATC e 10% tinham outros diferentes aneurismas diagnosticados pela AD. O intervalo entre ATC e tratamento cirúrgico variou de 0­4 dias. AD pós-operatória mostrou 24% dos pacientes com colo residual. A detecção de pequenos aneurismas não rotos em pacientes com múltiplos aneurismas e colo residual pós clipagem cirúrgica continuam a ser um problema quando a ATC é realizada isoladamente. No entanto, as vantagens da ATC incluem sua rapidez, menor invasão e custo, o que nos permite realizar o tratamento cirúrgico de aneurismas rotos apenas com os achados da ATC de boa qualidade.

Compressão do nervo ulnar na região do cotovelo ­ síndrome do túnel cubital: revisão da literatura / Compression of the Ulnar Nerve in the Elbow Region - Cubital Tunnel Syndrome: Review of the Literature

A síndrome do túnel cubital é responsável pela neuropatia do nervo ulnar, sendo superada em frequência apenas pela síndrome do túnel do carpo. O nervo ulnar apresenta anatomia complexa podendo sofrer compressão em distintos pontos ao longo de seu trajeto, por isso o entendimento das nuances clínicas e da anatomia pormenorizada assim como da técnica cirúrgica meticulosa torna-se essencial no tratamento desta patologia.

The cubital tunnel syndrome is responsible for the ulnar nerve neuropathy, this condition is surpassed in frequency only by carpal tunnel syndrome. The ulnar nerve has complex anatomy andmay suffer compression at different points along its path, so understanding the clinical nuances and detailed anatomy as well asmeticulous surgical technique becomes essential in the treatment of this pathology.

The clip-wrap technique in the treatment of intracranial unclippable aneurysms / Técnica de "clip-wrap" no tratamento de aneurismas rotos não clipáveis

Fusiform and dolichoectatic aneurysms are challenging lesions to treat with direct clipping. Treatment of these aneurysms often requires alternative surgical strategies, including extracranial-intracranial bypass, wrapping, or clip-wrap techniques. Nonetheless, these alternatives methods of treatment have been underused and frequently overlooked. Objective: To report a series of nine cases of otherwise untreatable aneurysms managed using the clip-wrap technique and discuss its surgical nuances. Method: In the last four years, 9 cases of ruptured aneurysms treated by the clip-wrap techniques were identified in the Division of Neurological Surgery, University of São Paulo, School of Medicine. Results: The aneurysms were located at middle cerebral artery (2), anterior choroidal artery (1), anterior communicating artery (1), carotid ophthalmic (3), posterior cerebral artery (1) and posterior-inferior cerebellar artery (1). Three were dolichoectatic, 4 were unsuitable to complete surgical clipping because parent or efferent vessels arises from the aneurysm sac (1 MCA, 1 AcomA, 1 CO, 1 PICA aneurysms) and two, although ruptured aneurysms, were too small (<2mm) to be directly clipped. No early or late rebleeding was observed after 2 years mean follow-up. One patient deceased due to pulmonary tromboembolism. Conclusion: Clip-wrap techniques for the treatment of fusiform and otherwise unclippable aneurysms seem to be safe and it can be associated with a low rate of acute or delayed postoperative complications. It can prevent rebleeding and represents an improvement when compared with the natural history.

Aneurismas fusiformes são lesões de difícil tratamento e frequentemente necessitam de técnicas alternativas de tratamento, incluindo anastomose extra-intracranial ou técnicas de "clip-wrap". Contudo o uso destas técnicas é frequentemente esquecido e negligenciado. Objetivo: Descrever retrospectivamente casuística de nove casos de aneurismas não clipáveis tratados com a técnicas de "clip-wrap" e discutir as nuances cirúrgicas. Resultados: Revisão dos últimos quatro anos da casuística da Divisão de Clínica Neurocirúrgica do HCFMUSP mostrou que 384 casos eram de aneurismas rotos. Destes, 9 eram de aneurismas não clipáveis tratados com a técnica de "clip-wrap". Destes, 2 aneurismas eram de artéria cerebral media, 1 de artéria coroidéia anterior, 1 de artéria comunicante anterior, 3 de artéria oftálmica, 1 de artéria cerebral posterior e 1 de PICA. Três eram lesões ectásicas, 4 não puderam ser completamente clipados devido a relação de aneurismas com vasos eferentes, aferentes ou perfurantes, e dois, apesar de rotos eram pequenos demais para serem clipados (<2,0 mm). Sangramento precoce ou tardio não foram observados, em um seguimento médio de 2 anos. Conclusão: A técnica descrita é segura e está associada com baixa incidência de complicações agudas ou tardias. Ela previne ressangramanto e representa um avanço em relação à história natural destas lesões.