Evaluation of safety, effectiveness and reproducibility of telemedicine for neurosurgical screening / Avaliação da segurança, da efetividade e da reprodutibilidade na utilização de telemedicina para triagem neurocirúrgica

ABSTRACT Objective: To ascertain the safety, effectiveness and reproducibility of screening potential neurosurgical patients by means of smartphones. Methods: This is a retrospective and multicentric study. Data were collected from the medical records of patients subjected to real emergency neurosurgical evaluations and compared with assessments by neurosurgeons using smartphones to determine the feasibility of identifying changes in cranial computed tomography scans, potentially serious conditions of patients, and the need for transfer to reference centers. Results: We analyzed 232 cases. The main diagnosis was traumatic brain injury, with 119 cases (51.3%). Of this, 105 (45.3%) patients were discharged immediately after the assessment. The telemedicine evaluators presented 95.69% accuracy in the identification of changes in computed tomography scans, with 0.858 concordance. Accuracy in the identification of severity was 95.26%, with 0.858 concordance. As for procedure, the concordance among evaluators was 0.672, increasing to 100% in cases that required surgical treatment. Conclusion: Our study indicated that the use of telemedicine for screening patients with acute neurological disorders was safe, effective and reproducible. Implementation of the method shows a promising potential to improve the patient's outcome by reducing unnecessary transfers and decreasing the time elapsed until a specialist can be consulted.

RESUMO Objetivo: Verificar a segurança, a efetividade e a reprodutibilidade da triagem de pacientes potencialmente neurocirúrgicos feita por smartphones. Métodos: Estudo retrospectivo e multicêntrico. Dados de prontuários dos pacientes submetidos à avaliação neurocirúrgica de urgência foram coletados e comparados com a avaliação realizada por neurocirurgiões por meio de smartphones, determinando a capacidade de identificar alterações na tomografia computadorizada de crânio, pacientes potencialmente graves e necessidade de transferência. Resultados: Foram analisados 232 casos. O principal diagnóstico foi traumatismo crânio encefálico, com 119 casos (51,3%). Destes, 105 (45,3%) tiveram alta após a avaliação. Os avaliadores por telemedicina apresentaram acurácia de 95,69% para identificação de alteração na tomografia computadorizada, com concordância de 0,858. Com relação à identificação de gravidade, a acurácia foi de 95,26%, com concordância de 0,858. Com relação à conduta, os avaliadores apresentaram concordância de 0,672, aumentando para 100% nos casos de tratamento cirúrgico. Conclusão: O uso da telemedicina em nosso estudo foi seguro, efetivo e reprodutível para triagem dos pacientes com afecções neurológicas agudas. A implementação do método tem potencial de impacto na melhora do resultado para o paciente devido à redução das transferências desnecessárias e do tempo até o atendimento.

Incidence, indication and complications of postoperative reintubation after elective intracranial surgery / Incidencia, indicacao e complicacoes da reintubacao no pos-operatorio de cirurgia eletiva intracraniana

CONTEXT AND OBJECTIVE There are no reports on reintubation incidence and its causes and consequences during the postoperative period following elective intracranial surgery. The objective here was to evaluate the incidence of reintubation and its causes and complications in this situation. DESIGN AND SETTING Prospective cohort study, using data obtained at a tertiary university hospital between 2003 and 2006. METHODS 169 patients who underwent elective intracranial surgery were studied. Preoperative assessment was performed and the patients were followed up until hospital discharge or death. The rate of reintubation with its causes and complications was ascertained. RESULTS The incidence of reintubation was 12.4%, and the principal cause was lowered level of consciousness (71.5%). There was greater incidence of reintubation among females (P = 0.028), and greater occurrence of altered level of consciousness at the time of extubation (P < 0.0001). Reintubated patients presented longer duration of mechanical ventilation (P < 0.0001), longer stays in the intensive care unit (ICU) and in the hospital (P < 0.0001), greater incidence of pulmonary complications (P < 0.0001), greater need for reoperation and tracheostomy, and higher mortality (P < 0.0001). CONCLUSION The incidence of reintubation in these patients was 12.4%. The main cause was lowering of the level of consciousness. Female gender and altered level of consciousness at the time of extubation correlated with higher incidence of reintubation. Reintubation was associated with pulmonary complications, longer durations of mechanical ventilation, hospitalization and stay in the ICU, greater incidence of tracheostomy and mortality. .

CONTEXTO E OBJETIVO Não há relatos sobre incidência de reintubação, suas causas e consequências no pós-operatório de cirurgia intracraniana eletiva. O objetivo foi avaliar a incidência de reintubação, suas causas e complicações em pós-operatório de cirurgia intracraniana eletiva. TIPO DE ESTUDO E LOCAL Estudo de coorte prospectivo, com dados que foram obtidos de 2003 a 2006 em um hospital universitário terciário. MÉTODO 169 pacientes submetidos a cirurgia intracraniana eletiva foram estudados. Foi realizada avaliação pré-operatória e os pacientes foram acompanhados até a alta hospitalar ou óbito, verificando a taxa de reintubação, suas causas e complicações. RESULTADOS A incidência de reintubação foi de 12,4% sendo a principal causa o rebaixamento do nível de consciência (71,5%). Houve maior incidência de reintubação no sexo feminino (P = 0,028), bem como do nível de consciência alterado no momento da extubação (P < 0,0001). Pacientes reintubados apresentaram maior tempo de ventilação mecânica (P < 0,0001) e de internação em unidade de terapia intensiva (UTI) e hospitalar (P < 0,0001), maior incidência de complicações pulmonares (P < 0,0001), maior necessidade de reoperação e traqueostomia, além de aumento de mortalidade (P < 0,0001). CONCLUSÃO A incidência de reintubação nesses pacientes foi de 12,4%. A principal causa da reintubação foi o rebaixamento do nível de consciência. O sexo feminino e nível de consciência alterado no momento da extubação foram relacionados à maior incidência ...

Long term effects of Gamma knife Radiosurgery for treatment of cerebral arteriovenous malformations

The Gamma Knife Radiosurgery [GKR] is an established management option for Cerebral Arteriovenous Malformations [AVMS]. Therapeutic benefits of radiosurgery for arteriovenous malformations are complete obliteration of nidus with minimal neurological deficit. Radiosurgery was performed between February 2003 and April 2010 at Kamraniye day clinic, Tehran, Iran, using the Leksell gamma knife model B [Elektra Instruments AB, Stockholm, Sweden] on 82 consecutive patients with AVMs. The male-to-female ratio was 1.4:1 [48M, 34F]. The age of the patients ranged from 9 to 70 years [mean, 28.5 +/- 12 years]. The marginal dose to the AVM nidus was 45 to 85% [median, 60%] isodose and ranged from 14 to 30 Gy [mean, 20.57 +/- 13Gy].The maximum dose ranged between 20 to 60 Gy [mean, 37.5 Gy +/- 10.17Gy]. Follow up of patients for complete AVM obliteration and in the case of complications MRI were performed. Complete obliteration of AVM was achieved in 56 cases [68.29%]. It was marked in average 3.62 [SD=3.19] years [from 1 to 5 years] after GKR. Partial obliteration [>50% reduction of the nidus volume] was marked in 24 cases [31%], and less than 50% reduction of the nidus volume was marked in 2 cases [2.4%] with a follow-up of 5 years. Complete obliteration of AVM had statistically significant associations with smaller score of Spetzler-Martin arteriovenous malformation grading system for AVMs. [p< 0.05]. The Gamma Knife Radiosurgery can offer total and partial obliteration to acceptable percent of treated AVM with a low risk of morbidity. Higher success observed in patients with Spetzler-Martin Grade I and II AVMs, which was attributed to smaller volume of AVMs in this group

Meios contínuos em neurocirurgia vascular e neurorradiologia intervencionista. Parte I / Mechanics of continuous media in vascular neurosurgery and endovascular neuroradiological procedures

Os aneurismas e as placas de ateroma compartem não somente um elevado índice de morbimortalidade, como também sua localização. Isso sugere que fatores hemodinâmicos contribuam no seu desenvolvimento. A quantificação de forças hemodinâmicas é complicada, especialmente em vasos intracranianos; porém, avanços recentes em mecânica computacional têm permitido calcular sua magnitude e distribuição em modelos arteriais com ajuda de técnicas de dinâmica de fluidos computacionais. No entanto, a compreensão desses modelos e a verificação de sua validade e limitações dependem do conhecimento de seu desenho e dos parâmetros hemodinâmicos utilizados. Por outro lado, a determinação das propriedades mecânicas das paredes arteriais é crucial, não somente para a compreensão das alterações do sistema cardiovascular no tempo e das causas responsáveis que dão origem às lesões vasculares, bem como para a realização da angioplastia, o planejamento de pontes arteriais e a seleção de próteses endovasculares. Dessa forma, a mais importante contribuição que podemos obter do conhecimento da biomecânica, em geral, e da mecânica dos meios contínuos, em particular, se encontra no melhor entendimento da fisiologia. Nesta revisão, passamos pelos conceitos fundamentais utilizados na formulação dos problemas da mecânica dos meios contínuos, com ênfase na pesquisa biomecânica das lesões vasculares, no intuito de oferecer algumas definições que promovam a análise crítica dos resultados nesse campo.

Cerebral aneurysms and atherosclerosis share not only a high rate of morbidity and mortality, but also its location. It suggests that hemodynamic factors contribute to their development. Quantification of hemodynamic forces is complicated, especially in intracranial arteries. However, recent advances in computational mechanics have allowed calculating the magnitude and distribution of these forces in arterial models with the help of techniques of computational fluid dynamics. However, the understanding of these models and verification of their validity and limitations depend on the knowledge of its design and hemodynamic parameters. Furthermore, the determination of mechanical properties of the arterial walls is crucial, not only for the understanding of the changes of the cardiovascular system in time and the causes of the injuries that they develop, as well as to the realization of angioplasty, planning of arterial bypass or the selection of endovascular prosthesis, for example. Thus, concepts on mechanics of continuous media are needed in the body of knowledge of all interested in cerebrovascular disease. In this review, we look the fundamental concepts used in the formulation of the problems of the mechanics of continuous media, focusing on biomechanics research of vascular lesions, in order to provide some definitions that promote the critical analysis of the results in this . The most important contribution that we can get from the knowledge of biomechanics, in general, and from the mechanics of continuous media, in particular, is a better understanding of physiology.

Experiencia con el tratamiento endovascular de los aneurismas del tope de la arteria basilar / Experience with the endovascular treatment of vasilar tip aneurysms

Objetivo. Describir los resultados inmediatos obtenidos en una serie de pacientes con aneurismas del tope de la arteria basilar tratados por vía endovascular en relación con el tamaño del cuello y saco del aneurisma, la presencia o no de ruptura aneurísmática y la gravedad clínica. Método. Se realizó un estudio descriptivo en una cohorte retrospectiva de 37 pacientes adultos de ambos sexos con aneurismas del tope de la arteria basilar tratados por vía endovascular (período 1993-2006). Los pacientes fueron clasificados con la escala de Hunt-Hess. Los aneurismas fueron clasificados según su tamaño y ancho del cuello. El grado de oclusión se clasificó en 4 categorías: A(100), B(>95), C(>90), D(<90). Resultados. En el 68 se logró una oclusión grado A y en el 1 se logró una oclusión grado B. La morbilidad fue del 7 en el subgrupo sin HSA y del 28 en el subgrupo con HSA. Se encontró una morbilidad del 9 en el grado HH 0; 12,5 en el grado HH 1-2; 58 en el grado HH 3 y 50 en el grado HH 4-5. La oclusión fue grado A en el 75 de los aneurismas con saco pequeño y cuello angosto y en el 55 de los aneurismas con saco grande y cuello ancho. La morbilidad global fue del 24 y la mortalidad global fue del 5,4. Conclusión. En base a los resultados descriptos la vía endovascular fue una buena alternativa para el tratamiento en agudo de los aneurismas rotos e incidentales del tope de la basilar, sobre todo cuando tenían un saco pequeño y cuello angosto y presentaban una menor gravedad clínica. Palabras clave: aneurisma cerebral, tope de basilar, tratamiento endovascular.

Objective. We describe the early results obtained in a series of cases with basilar tip aneurysms treated by endovascular surgery with detachable coils. The results are compared according to the size of the neck and the sac of the aneurysms, the history of aneurysms rupture and neurological state. Method: A retrospective descriptive study was made in a cohort of 37 adults patients of both sexes with basilar tip aneurysms treated by endovascular surgery (period 1993-2006). Hunt-Hess scale was usedfor patients classification. The aneurysms were classified according to their size and the wide of the neck. The occlusion grade was classified in 4 categories: A(100), B(>95), C(>90), D(<90). Results: Occlusion grade A was obtained un 68 of patients and occlusion grade B was obtained in 18 of patients. The morbidity was 7 in the non-SHA group and 28 in the SAH group. Morbidity was 9 in HH 0, 12,5 in grade HH 1-2, 58 in grade HH 3 and 50 in grade HH 4-5. Occlusion was grade A in 75 of the aneurysms with small sac and narrow neck and in 55 fo the aneurysms with a huge sac an broad neck. Global morbidity was 24 and global mortality was 5.4. Conclusion: According with our results, endovascular surgery was a good alternative for acute ruptured basilar tip aneurysms and incidental ones too, mainly when they had smaller sacs, narrower necks and a better neurological state. Key words: basilar tip aneurysm - cerebral aneurysm - endovascular treatment.

Endartectomía carotídea microquirúrgica / Microsurgical carotid endarterectomy

La endarterectomía carotídea ha probado su efectividad en la reducción de riesgo para apoplejía. Existen controversias en relación a la técnica quirúrgica. Proponemos la realización de la endarterectomía microquirúrgica como una alternativa para el abordaje de las lesiones carotídeas. Para tal propósito reportamos nuestra experiencia en 56 casos

Tratamento cirúrgico das patologias vasculares cerebrais nos pacientes epilépticos / Surgical treatment of cerebral vascular pathologies in epileptic patients

A cirurgia das malformaçöes arteriovenosas (MAV) e dos cavernomas (angioma cavernoso) na maioria das vezes é indicada após episódios de sangramento. Como o desenvolvimento das técnicas de diagnóstico e cirúrgicas na epilepsia de difícil controle, passou a ser cada vez maior a indicaçäo cirúrgica destas lesöes vasculares. Apresentamos nove pacientes com lesöes vasculares cerebrais e crises muito frequentes, apesar do tratamento clínico adequado. A faixa etária variou de 12 a 42 anos de idade, com média de 25 anos; houve prevalência no sexo masculino (2:1). A cirurgia constitui na exérese da lesäo em todos os casos. Em quatro casos houve também ressecçäo da área irritativa perilesional, que foi demostrada pela eletrocorticografia. O estudo anatomopatológico das lesöes mostrou cinco casos de cavernoma, três de MAV e um angioma venoso. Quanto à localizaçäo, observamos três lesöes no lobo temporal, quatro no frontal e duas na regiäo parietal. O acompanhamento ambulatorial mostrou reduçäo das crises em todos os pacientes, sendo que sete evoluíram sem crises após a cirurgia.

Accidentes cerebrovasculares: recomendaciiones; manejo de fase aguda / Cerebrovascular accidents: recommendations; acute phase management

Deseamos aportar al médico no especializado en neurología, criterios y pautas objetivamente válidos, para el manejo de los accidentes cerebrovasculares en Fase aguda, basados en las recomendaciones obtenidas de las más amplias, confiables y recientes publicaciones y entidades. Nuestra finalidad es mejorar el pronóstico evolutivo de dichos pacientes como consecuencia de un manejo más adecuado y universal

Carotid endarterectomy: surgical prophylaxis for stroke

An experience of 28 carotid endarterctomy patients is being presented. Of these 18 were males and 10 females. Their ages ranged from 43-85 years, the mean age being 68.5 years. Twenty four patients presented with transient ischemic attacks, two had transient monocular blindness while the remaining two had partial stroke. All patients had colour duplex ultrasonography of their internal carotid arteries done pre-operatively which revealed 70-90% stenosis in their proximal part. Twenty seven patients had unilateral disease for which carotid endarterectomy was performed. The remaining one patient had bilateral carotid stenosis along with coronary artery disease. He underwent bilateral carotid endarterectomy and coronary artery bypass graft, all at the same time. Two patients developed venous bleeds postoperatively and one a partial stroke with complete recovery. There was no major stroke or death in this series

Endarterectomía carotídea: seguimiento tardío con ecodoppler / Carotid endarterectomy: follow-up for long period with ecodoppler

El objetivo de esta presentación fue evaluar por ecodoppler la incidencia de re-estenosis tardía en la endarterectomía carotídea (EC) y su repercusión en la clínica. Material y mátodos: entre julio de 1987 y junio de 1994 se operaron 87 pacientes sintomáticos, a quienes se les realizaron 99 EC por presentar estenosis significativas y/o placas ulceradas. La metodología de estudio se basó en la tríada ecodoppler de vasos de cuello, tomografía axial computada (TAC) cerebral y angiografía extra intracerebral. Todos fueron operados con anestesia general utilizando barbitúricos, shunts endoluminales y anticoagulación. El procedimiento consistió en EC con cierre primario y fijación de la íntima distal (40,4 por ciento). El control del ecodoppler se realizó a los 3 y 12 meses de la cirugía, repitiéndose anualmente. Resultados: 3 pacientes fallecieron en el postoperatorio (PO) inmediato (2 por accidente cerebrovascular (ACV) y 1 en PO de resección aneurismática toracoabdominal), 9 pacientes fallecieron en el PO alejado (1 por ACV homolateral y por causas no relacionadas), 8 se perdieron después del año. Hubo 2 ACV sin re-estenosis (1 contralateral). Ocho pacientes presentaron re-estenosis a partir del primer año (7,81 por ciento). De las mismas, 5 se mantuvieron estables, 2 retrogradaron y sólo 1 progresó hacia la oclusión, sin presentar manifestaciones neurológicas. Discusión: dado que la re-estenosis carotídea en general se produce tempranamente, es de comportamiento benigno y permanece estable durante un largo período de seguimiento, tal vez sea necesario redefinir nuevos criterios de evaluación postoperatoria, analizando la relación costo-beneficio de los mismos

Tratamento cirúrgico da doença aterosclerótica das artérias carótidas / Surgical treatment of carotid atherosclerosis

Os autores apresentam uma revisäo sobre a doença aterosclerótica das artérias carótidas, enfatizando os aspectos relativos à etiopatogenia, manifestaçöes clínicas, abordagem diagnóstica e sistemática atual do tratamento cirúrgico

Carotid endarterectomy

Carotid endarterectomy should be considered for patients with symptoms of focal cerebral ischemia, when it can be performed with a combined morbidity and mortality below the annual risk of stroke (5 per cent). The experience with 815 carotid endarterectomies performed from 1979 to 1992 is presented. There were 530 (65 per cent) men and 285 (35 per cent) women of ages from 34 to 82 (median 65); risk factors included diabetes mellitus 196 (24 per cent), hypertension 554 (68 per cent), and smoking 570 (70 per cent). Clinical presentation consisted of transient ischemic attacks 464 (57 per cent), cerebral infarction with minimal neurological residual 228 (28 per cent), stroke in evolution 2 (0.2 per cent), and asymptomatic stenosis 121 (15 per cent). By Sundt's classification of medical risk the groups were: grade I, 106 (13 per cent); grade II, 350 (43 per cent); grade III, 357 (44 per cent); grade IV, 2 (0.2 per cent). All patients received endotracheal anesthesia. Thiopental (3-5 mg/kg) and lidocaine (1 mg/kg) were given for induction and at 15 minutes intervals during carotid cross-clamping. Intraluminal shunts were used in 14 (2 per cent). A conventional (open) endarterectomy was performed in 379 (46 per cent) and a limited endarterectomy (closed) in 436 (54 per cent). Complications included 8 (1 per cent) deaths, 24 (3 per cent) developed a major neurological deficit that persisted, 24 (3 per cent) had perioperative TIA's which resolved completely. Of the patients with preoperative neurological deficits, 32 (4 per cent) recovered. Therefore, at one month after surgery, 782 (96 per cent) were either as well or better than preoperatively.Of 483 (59 per cent) postoperative angiograms, 40 (5 per cent) showed an internal carotid artery occlusion. Six of these patients developed and immediate postoperative cerebral infarction and one died. Non-neurologic complications were: cardiac 40 (5 per cent), peripheral nerve 24 (3 per cent), and local wound problems 16 (2 per cent). A carotid endarterectomy can be performed safely when it is done with meticulous attention to detail and consistent surgical technique.

Disección de carotida: reporte de 5 casos

Describimos cinco pacientes entre 14 y 33 años de edad que presentaron Enfermedad Cerebro Vascular Aguda secundaria a disección de la arteria carótidea interna. Cuatro pacientes tuvieron antecedentes traumáticos. El intervalo entre el trauma y la enfermedad Cerebro Vascular Aguda fue de 3 semanas. Todos los pacientes tuvieron en la Tomografía Cerebral infartos en el territrorio de la arteria cerebral media. La angiografía carotídea realizada hasta 10 meses después del evento vascular agudo mostró doble lumen en dos pacientes; signo de la cuerda en un paciente; oclusión total temprana en otro y en el restante oclusión total tardía. Cuatro pacientes recibieron antiagregación plaquetaria. Ningún paciente falleció y en cuatro pacientes la hemiparesia mejoró hasta permitirles una vida autónoma. Concluímos que la disección de la carótida, patología escasamente reportada en nuestro país puede ser causa de Enfermedad Cerebro Vascular Aguda especialmente en el adulto joven.

Tratamiento quirúrgico de la insuficiencia cerebro-vascular endarterectomía carotidea / Surgical treatment of the cerebrovascular insuficiency. Carotid endarterectomy

Se consigna el primer reporte a nivel nacional de pacientes portadores de insuficiencia vascular cerebral, tratados quirúrgicamente entre 1984 y 1989, realizándose 25 endarterectomías carotídeas en los 20 pacientes reportados, con una morbilidad del 4%y una mortalidad nula. La incidencia en hombres/mujeres fue en una relación de 3:1, con una edad promedio de 63 años. Se discuten los procedimientos de diagnóstico, las indicaciones quirúrgicas así como los factores de riesgo, para luego consignar nuestros resultados y compararlos exitosamente con series reportadas en el extranjero