Neurosurgery for Refractory Schizophrenia: A Systematic Literature Review

Schizophrenia is a chronic and disabling psychiatric disease that can be refractory to conventional treatment. The present study aims to gather information about the circuitry related to schizophrenia to describe possible surgical targets, and to establish whether psychosurgery can be a safe and effective treatment option for refractory schizophrenia. A systematic review of the literature was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. An electronic search was performed in the Pubmed and BVSalud databases using medical subject headings (MeSH) combined with Boolean operators. Out of the 724 studies retrieved, 13 were included in the review. Regarding leucotomy without a stereotactic approach, we found side effects such as irritability, nervous excitement, cases of disinhibition, and compromised normal social control. In other stereotactic procedures, there was some improvement, mainly regarding aggressiveness and positive symptoms; an anterior capsulotomy had an efficacy rate of 74% according to the Clinical Global Impression (CGI) rating scales. The only deep brain stimulation (DBS) case report found in our study described a significant improvement in the positive and negative symptoms. The use of a stereotactic approach enables psychosurgery to be a safe and effective treatment option in cases of refractory schizophrenia, improving the quality of life and the symptoms. Cognitive and negative symptoms remain a challenge in the treatment of schizophrenia, revealing that more targets in the circuitrymust be surgically explored. Furthermore,more clinical trials are needed to compare these many surgical techniques and targets, using a standard evaluation parameter. The results show that DBS has a promising future in the treatment of refractory schizophrenia.

Implantação do sistema de procedimentos de alta complexidade em neurocirurgia: resultados / Implementation of high complexity service in a city hospital of metropolitan region of Porto Alegre city, Brazil

Objetivo: Demonstrar a maneira como foi implementado o Serviço de Alta Complexidade em Neurocirurgia num município da região metropolitana de Porto Alegre e seus resultados benéficos à população, aos neurocirurgiões e à Instituição Hospitalar. Material e método: São demonstrados os argumentos que o grupo de neurocirurgiões adotou para convencer a direção do Hospital Municipal de Novo Hamburgo(HMNH) a investir na especialidade antes mesmo de ter noção real das vantagens e dos lucros que adviriam. Resultados: Foi constatado que havia uma evasão mensal de aproximadamente 30 pacientes dos municípios que compunham a região para outro centro de referência (“Hospital Referência”). Essa evasão propiciaria um rendimento em torno de R$ 57 mil. Foi demonstrado que o “Hospital Referência” havia saltado de um faturamento de pouco mais de R$ 100 mil para aproximadamente R$ 500 mil após a implantação do Sipac-Neuro, e que a média de valores das autorizações de internações hospitalares(AIH) desse hospital era de R$ 1.056,12 contra R$ 382,84 do HMNH. A seguir, descrevem-se os passos que foram necessários para o credenciamento junto ao Ministério da Saúde, a implantação do serviço e os futuros investimentos que se pretende realizar em função dos novos aportes financeiros proporcionados pela Alta Complexidade. Os resultados financeiros iniciais após o credenciamento foram significativos. Conclusão: A organização e demonstração real, com exemplos de outras instituições,são instrumentos úteis e facilitadores para o convencimento das direções de hospitais que ainda são céticos quanto às vantagens proporcionadas pelo Sipac-Neuro.Administração hospitalar.

Objective: To present how a High Complexity Neurosurgical Service (accredited by the Ministry of Health denominated Sipac – Neuro) was implemented in a public hospital of the metropolitan region of the city of Porto Alegre, Brazil. Material and method: The arguments used by the group of neurosurgeons that convinced the direction of the Hospital Municipal de Novo Hamburgo (HMNH) to invest on neurosurgery, before knowing the advantages and profit that would be generated is presented. Result: It was verified that there was an monthly evasion rate of approximately 30 patients from the regions covered by HMNH to other reference center (“Reference” hospital) during the year of 2001. This evasion would have yielded around R$ 57,000. It was demonstrated that the “Reference” hospital leaped from an income of around R$100,000 to around R$ 500,000 after the implementation of the Sipac-Neuro and that the average cost of Authorization for Hospitalization (AIH) at that hospital was R$ 1,056.12 compared to R$ 382.84at HMNH. The method of accreditation with the Ministry of Health is described here in, as well as the implementation of the Service and the future investments that are to be made as a result of the new financial resources as a result of this accreditation for high complexity. Conclusion: It is concluded that the organization and actual demonstration by means of the examples of other institutions is a useful and helpful tool to convince hospital administrations who remain skeptical as to the advantages obtained with a Sipac-Neuro.

Stereotactic surgery in India: the past, present and the future.

The achievements of Indian neurosurgeons in different fields of stereotactic surgery over the past decades have been discussed. This covers diverse areas like Parkinson's disease, abnormal movements, cerebral palsy, spasticity, pain relief, and sedative and functional neurosurgery. Recently, technological advances have made stereotactic surgery useful in many fields like deep biopsies, minimally invasive surgery and radiosurgery. Apart from these areas, there is still a big scope for revival of surgery on deep structures of the brain, as was practised earlier. This will lead to newer knowledge about brain function and also give relief to many patients. The future is bright, provided Indian neurosurgeons show a paradigm shift in their thinking and bring out new ideas. Interaction with other scientific disciplines is necessary in the future if new knowledge has to be added or new techniques have to be devised.

Neurocirugía asistida por computación / Neurosurgery assisted by computation

La cirugía asistida por computación se ha constituido como un área de reciente aparición en el campo de la neurocirugía, y representa la forma más avanzada de la técnica estereotáctica. El nacimiento de ésta subespecialidad ha sido posible gracias al acoplamiento de la técnica estereotáctica, la metodología en la adquisición y manipulación de los diferentes estudios de imagen y los sistemás computacionales. El uso de esta tecnología ha permitido la orientación del cirujano en tiempo real, es decir, durante el procedimiento quirúrgico, lo que ha traído como consecuencia una disminución dramática en la morbimortalidad asociada a los procedimientos neuroquirúrgicos. En el presente trabajo se hace una revisión de los principios básicos de dicha tecnología se presenta un sistema prototipo: el sistema de planeación neuroquirúrgica estereotáctica NSPS 4.0; desarrollado en la Universidad Estatal de Wayne State, Michigan. Asimismo se describen los diferentes abordajes estereotácticos y las principales aplicaciones clínicas y las futuras tendencias de esta novedosa y útil tecnología

Neurocirugía en internet / Neuroscience on the internet

La era de las computadoras es una realidad en el momento actual y su aplicación puede observarse en todas las áreas del conocimiento humano. La ciencia médica también ha sido beneficiada con el advenimiento de esta tecnología. Se revisa en términos generales, las diversas aplicaciones de las computadoras en medicina y en particular, una de sus funciones más populares conocida como Internet, la cual ha surgido durante la ultima década como una nueva fuente electrónica de información y un excelente medio de comunicación. Se muestra el uso de Internet en el área de las neurociencias en general y de la neurocirugía, en particular. Se subraya el hecho de que estas aplicaciones pueden ejecutarse en cualesquiera de las ramas de la ciencia médica

Neurosciences - A neurosurgeon's perspective.

The advancements in the field of science in the past fifty years have highlighted the need to integrate all fields of human endeavours and have emphasised interdependency of various disciplines. The separation of humanities, therefore, from neurosciences is a preposterous practical joke on all thinking men. With the human genome project on the anvil, biotechnology is making significant headway holding out promise for organ regeneration. Macro evolution is over, but micro-evolution continues in the brain. Neural Darwinism thus, continues to evolve as long as individual remains conscious and has memory. In the milieu of widely varying internal physiological mechanisms and external stimuli, an alternative theory to preprogrammed directionalism is proposed by three mechanisms namely developmental variation and selection, experiential selections and reentrant signalling. Reentrant signalling reorients and correlates the external inputs leading to psychic development preceding the development of consciousness. The cholinergic and aminergic neuro-modelling systems are well suited to serve as value systems. The main achievement of consciousness is to bring together the many categorizations involved in perceptions into a SCENE. Another part of evolution involved capacity of reentrant signalling to be guided by a value system where it is provided with a lot of choices. With 10(13) neurons and 10(16) connections, freedom of choice may manifest into a 'Buddha' or a 'Hitler'. As part of the evolutionary process, it was interesting how capacity to categorize the need to worship by referring to environment outside evolved into a search within our minds. As the next stage of evolution, neuroscience may, thus, serve as the next gateway to understanding the mind and soul.

Anestesia para resección de adenomas de hipófisis mediante doble abordaje quirúrgico: transcraneal y transesfenoidal (A propósito de un caso)

Con la introducción del microscopio quirúrgico, el abordaje trasesfenoidal se ha implementado para los tumores pituitarios sin extensión supraselar, que ofrece algunas ventajas como son: bajas tasas de morbilidad y mortalidad y menos tiempo de hospitalización, con la desventaja inherente a la incapacidad de visualizar las estructuras adyacentes a un tumor grande y la falta de acceso al tumor con extensión a la fosa media y posterior. La vía transcraneal permite una visualización directa de las estructuras supraselares, pero constituye potencial daño a otras áreas con índices altos de mortalidad. Por los pro y contras de cada aproximación, nuestros neurocirujanos recomiendan "la vía doble transcraneal y trasesfenoidal". El curso anestésico para pacientes con tumor pituitario requiere conocimiento de las implicaciones sistémicas y entrenamiento para neuroanestesia. Aquí presentamos un caso con microadenoma pituitario y acromegalia en el cual la doble aproximación fue realizada. Se discuten los considerandos anestésicos

Resección neuroendoscópica de neurocisticercosis intraventricular: reporte de un caso / Neuroendoscopic resection of intraventricular neurocysticercosis: case report

La neurocistecercosis es una enfermedad frecuente en los países en desarrollo. En Honduras, la prevalencia de la infección es desconocida. Se reporta el caso de un paciente con neurocisticercosis intraventricular a quien se le practicó una exploración ventricular neuroendoscópica. Los hallazgos operatorios fueron la presencia de una membrana que obstruía el foramen de Monro y la existencia de dos quistes de cisticerco adheridos al plexo coroideo en la cercanias del foramen de Monro. Con la cirugía se logró la destrucción de la membrana, con lo cual se obtuvo una recanalización del foramen de Monro y se logró la extracción de los quistes. No hubo complicaciones operatorias. Ante la evidencia operatoria de cambios inflamatorios propios de una ependimitis por cisticercosis, se colocó un sistema de derivación ventriculoperitoneal. A tres meses de seguimiento el paciente ha permanecido asintomático. Se describe el procedimiento quirúrgico y se analizan los resultados obtenidos