Pneumatization of the Sphenoidal Sinus May Affect Endonasal Cranial Base Reconstruction.

OBJECTIVE: The aim of this study is to verify if the length of the nasoseptal flap is sufficient to cover the tuberculum sellae and planum sphenoidale of sphenoidal sinuses with varied degrees of pneumatization. METHODS: Retrospective study of paranasal sinus computed tomography comparing the potential length of the nasoseptal flap and the length of the nasoseptal flap required for reconstruction of transtuberculum and transplanum approaches in conchal, presellar, sellar, incomplete postsellar, and complete postsellar sphenoidal sinuses. RESULTS: The length of the nasoseptal flap required for reconstruction of transtuberculum and transplanum approaches was directly related to the degree of pneumatization of the sphenoidal sinus. The nasoseptal flap length was adequate to cover the cranial base after transtuberculum approaches of all cases from the conchal, presellar, and sellar groups and the majority of cases from postsellar pneumatization. For transplanum approaches, the nasosseptal flap was sufficient to reconstruct defects in most cases from conchal, pre-sellar, and sellar type sinuses and in 54,9% and 19,2% in incomplete and complete postsellar, respectively. CONCLUSIONS: In well pneumatized sphenoidal sinus, the nasoseptal flap may not be sufficient to cover the cranial base after transtuberculum and transplanum approaches.

Microsurgical anatomy and internal architecture of the brainstem in 3D images: surgical considerations.

OBJECT Brainstem surgery remains a challenge for the neurosurgeon despite recent improvements in neuroimaging, microsurgical techniques, and electrophysiological monitoring. A detailed knowledge of the microsurgical anatomy of the brainstem surface and its internal architecture is mandatory to plan appropriate approaches to the brainstem, to choose the safest point of entry, and to avoid potential surgical complications. METHODS An extensive review of the literature was performed regarding the brainstem surgical approaches, and their correlations with the pertinent anatomy were studied and illustrated through dissection of human brainstems properly fixed with 10% formalin. The specimens were dissected using the fiber dissection technique, under ×6 to ×40 magnification. 3D stereoscopic photographs were obtained (anaglyphic 3D) for better illustration of this study. RESULTS The main surgical landmarks and their relationship with the cerebellum and vascular structures were identified on the surface of the brainstem. The arrangements of the white matter (ascending and descending pathways as well as the cerebellar peduncles) were demonstrated on each part of the brainstem (midbrain, pons, and medulla oblongata), with emphasis on their relationships with the surface. The gray matter, constituted mainly by nuclei of the cranial nerves, was also studied and illustrated. CONCLUSIONS The objective of this article is to review the microsurgical anatomy and the surgical approaches pertinent to the brainstem, providing a framework of its external and internal architecture to guide the neurosurgeon during its related surgical procedures.

Clinical complications in patients with severe cervical spinal trauma: a ten-year prospective study.

OBJECTIVE: To determine the complications due to severe acrescentar sigla após o nome (CST). METHODS: Between 1997 and 2006, 217 patients (191 men and 26 women) were prospectively evaluated. The mean age was 36.75±1.06 years. RESULTS: Forty-five percent of the patients had medical complications. The most important risk factor was alcoholic beverage use. The most important associated injury was head trauma (HT). Patients with American Spine Injury Association (ASIA) A or B had a 2.3-fold greater relative risk of developing complications. Thirty-three patients (15.2%) died. Patients with neurological deficit had a 16.9-fold higher risk of death. There was no influence of age and time between trauma and surgery on the presence of complications. CONCLUSIONS: Of the patients, 45% had clinical complications and 7.5% had associated injuries; pneumonia was the most important complication; patient age and time between trauma and surgery did not influence the development of medical complications; neurological status was the most important factor in determining morbidity and mortality.

Clinical complications in patients with severe cervical spinal trauma: a ten-year prospective study / Complicações clínicas em pacientes com trauma raquimedular cervical grave: estudo prospectivo de dez anos

OBJECTIVE: To determine the complications due to severe acrescentar sigla após o nome (CST). METHODS: Between 1997 and 2006, 217 patients (191 men and 26 women) were prospectively evaluated. The mean age was 36.75±1.06 years. RESULTS: Forty-five percent of the patients had medical complications. The most important risk factor was alcoholic beverage use. The most important associated injury was head trauma (HT). Patients with American Spine Injury Association (ASIA) A or B had a 2.3-fold greater relative risk of developing complications. Thirty-three patients (15.2%) died. Patients with neurological deficit had a 16.9-fold higher risk of death. There was no influence of age and time between trauma and surgery on the presence of complications. CONCLUSIONS: Of the patients, 45% had clinical complications and 7.5% had associated injuries; pneumonia was the most important complication; patient age and time between trauma and surgery did not influence the development of medical complications; neurological status was the most important factor in determining morbidity and mortality.

OBJETIVO: Identificar complicações decorrentes do trauma raquimedular cervical grave. MÉTODOS: Avaliação prospectiva de 217 pacientes (191 homens e 26 mulheres) entre 1997 e 2006, com média de idade de 36,75±1,06 anos. RESULTADOS: Houve complicações em 45% dos pacientes. O fator de risco mais importante foi ingestão de bebida alcoólica. Trauma craniano foi a associação mais frequente. Pacientes com classificação A ou B da American Spine Injury Association (ASIA) tiveram 2,3 vezes maior chance de complicações. Faleceram 33 pacientes (15,2%), sendo a chance de óbito 16,9 vezes maior naqueles com déficit neurológico. Não houve influência da idade ou do tempo decorrido entre o trauma e a cirurgia. CONCLUSÕES: Dos pacientes, 45% apresentaram complicações e 7,5% apresentaram traumas associados; pneumonia foi a principal complicação clínica; a idade dos pacientes e o tempo entre o trauma e a cirurgia não influenciaram na frequência de complicações; o status neurológico após o trauma foi o fator de risco mais importante na determinação de morbidade e mortalidade.

Epidemiology of severe cervical spinal trauma in the north area of São Paulo City: a 10-year prospective study. Clinical article.

OBJECT: The main objective was to study the epidemiological data obtained in patients with cervical spinal trauma (CST) in the north area of São Paulo City between 1997 and 2006. METHODS: All patients with severe CST in the north area of São Paulo City were studied. The data analyzed were age, sex, incidence, causes of trauma, level of trauma, morbidity, deaths, and complications. Analytical tests were performed to study risks of trauma and complications. The chi-square and analysis of variance tests were used for analytical data (significance level p < 0.05). RESULTS: The study population consisted of 217 patients who were hospitalized for CST. The average incidence rate was 21.6 cases annually or 1.8 cases monthly. The mean patient age was 36.75 years. The 20-40-year-old age bracket was found to be most highly represented, corresponding to 52.6% of total patients. Patients were predominantly male; 191 patients (88.01%) were male compared with only 26 female patients (11.99%). The ratio of men to women was 7.35:1. Injuries in the craniocervical region corresponded to 43 (19.8%) of the cases; injuries in the cervical subaxial region corresponded to 174 (80.2%) of the cases and were associated with worse neurological lesions. Additionally, 40.6% of patients presented with complications in other organs and systems; several patients presented with multiple complications, and 33 patients (15.02%) died. During the hospitalization period, 4 patients presenting as Grade A on the American Spinal Injury Association (ASIA) Scale evolved to Grade C, 1 patient presenting as ASIA Grade A evolved to Grade B, and 2 patients evolved to Grade E. Two patients who had been admitted without neurological lesions evolved to ASIA Grade C (1 patient postsurgery and 1 patient post-traction). Two patients presenting initially as ASIA Grade E evolved to Grade D, and another to central cord syndrome. On average, patients with incomplete lesions improved 1 grade in ASIA classification during hospitalization. CONCLUSIONS: Data from severe CST observed in the current study suggest many differences in the characteristics described in the majority of published epidemiological studies and those found in patients in the north area of São Paulo City. It is likely that these differences reflect the urban and cultural habits and behaviors of the population specific to this area.

Anatomical study of the anterior interventricular septal branches and their relationship with the blood supply of the septomarginal trabecula

The aim of this study was to examine the morphological features of the anterior interventricular septal branches that supply blood to the septomarginal trabecula and to correlate the anatomical observations with the angiographic characteristics analyzed by hemodynamic procedures. Forty human hearts were dissected after injecting colored latex into the left coronary artery. The vascularization of the septomarginal trabecula was always derived from the anterior interventricular artery, via the first, second and third anterior interventricular septal branches in 21 hearts (52.5%), 17 hearts (42.5%) and two hearts (5%), respectively, and the distances from the left coronary artery ostium ranged from 22 to 51 mm. The external diameter of these vessels at their origin varied from 1.0 to 2.35 mm and the vessels were analyzed based on specific requirements for surgical and hemodynamic methods of myocardial revascularization. Myocardial bridges were located over or before the origin of the vessels studied.