The Extra-Extended Translabyrinthine Approach for Resection of Large Acoustic Neuroma: 2-Dimensional Operative Video.

The extended translabyrinthine approach to acoustic neuroma (AN) was created to allow improved visualization and access to larger tumors.1,2 The dural opening, however, remained confined to the presigmoid space. Other authors have introduced modifications to increase the dura exposure around the internal auditory canal (IAC).3-5 The extra-extended translabyrinthine approach was conceptualized by the senior author (CC) to maximize AN exposure and early cranial nerve identification. The tentorial peeling was added to allow extradural mobilization of the temporal lobe.6 This allows further safe bone removal around the IAC and petrous apex and consistent opening of the facial canal at IAC fundus. This modification creates 280-to-360-degree dura exposure at the IAC. The dural opening extends to the petrous apex superiorly and the prepontine arachnoid cistern inferiorly and includes resection of a tentorium dural flap created by the tentorial peeling.6 This exposure allows for near circumferential exposure of the tumor and early identification of the glossopharyngeal nerve in the cochlear aqueduct area, the trigeminal nerve at the porus trigeminal, and the facial nerve (FN) at IAC fundus. In addition, this ample exposure permits identification of the FN trajectory in the tumor capsule before any tumor dissection. We present a detailed video of extra-extended translabyrinthine approach technique in a patient with a large left AN (Hannover classification T4B).7 This video does not involve any human research projects not requiring Institutional Review Board/ethic committee approval. The patient consented to the procedure and to the publication of his image. Complete resection was obtained. The FN function was House-Brackman I/VI.

Dynamics aspects and bifurcations of a tumor-immune system interaction under stationary immunotherapy.

We consider a three-dimensional mathematical model that describes the interaction between the effector cells, tumor cells, and the cytokine (IL-2) of a patient. This is called the Kirschner-Panetta model. Our objective is to explain the tumor oscillations in tumor sizes as well as long-term tumor relapse. We then explore the effects of adoptive cellular immunotherapy on the model and describe under what circumstances the tumor can be eliminated or can remain over time but in a controlled manner. Nonlinear dynamics of immunogenic tumors are given, for example: we prove that the trajectories of the associated system are bounded and defined for all positive time; there are some invariant subsets; there are open subsets of parameters, such that the system in the first octant has at most five equilibrium solutions, one of them is tumor-free and the others are of co-existence. We are able to prove the existence of transcritical and pitchfork bifurcations from the tumor-free equilibrium point. Fixing an equilibrium and introducing a small perturbation, we are able to show the existence of a Hopf periodic orbit, showing a cyclic behavior among the population, with a strong dominance of the parental anomalous growth cell population. The previous information reveals the effects of the parameters. In our study, we observe that our mathematical model exhibits a very rich dynamic behavior and the parameter µÌƒ (death rate of the effector cells) and p̃1 (production rate of the effector cell stimulated by the cytokine IL-2) plays an important role. More precisely, in our approach the inequality µÌƒ2>p̃1 is very important, that is, the death rate of the effector cells is greater than the production rate of the effector cell stimulated by the cytokine IL-2. Finally, medical implications and a set of numerical simulations supporting the mathematical results are also presented.

Partial Labyrinth Removal Restricted to the Superior Semicircular Canal in Focal Combined Transpetrosal Approach: Description and Illustrative Cases.

BACKGROUND AND OBJECTIVES: The labyrinthine structures obstruct the surgical view of the deep petroclival region in the transpetrosal approach. Historically, labyrinthectomy and removal of all 3 semicircular canals, with resultant deafness, was used in patients with ipsilateral functional hearing deficits to improve access. The advent and systematization of superior and posterior semicircular canal removal (transcrusal approach) with good rates of hearing preservation has allowed a redefinition of the possibility of partial labyrinthectomy in patients without previous hearing deficits. The present manuscript is intended to describe a technical refinement of partial labyrinthectomy during focal combined petrosectomy, offering a customization of the approach through the selective removal of the superior semicircular canal for specific types of tumors. METHODS: The use of the technique is demonstrated through surgical drawings, pictures, and videos. The rationale to indicate this new approach is discussed based on clinical cases. RESULTS: Three illustrative clinical cases (petroclival meningiomas) are demonstrated. Functional hearing on the approach side has been preserved in all of them. CONCLUSION: The focal combined transpetrosal approach associated with the superior semicircular canal resection has been a promising surgical technique in the treatment of selected petroclival tumors. It has the potential to further decrease the risks of postoperative auditory and vestibular dysfunctions associated with labyrinthectomies.

Increase of the clivus-canal angle in patients with basilar invagination, without atlantoaxial displacement, treated with a simple maneuver of indirect decompression of the odontoid with the head clamp, during posterior occipitocervical arthrodesis.

BACKGROUND: Basilar invagination (BI) can be defined as the insinuation of the content of the craniovertebral junction through the foramen magnum toward the posterior fossa. BI is a prevalent condition in Northeast Brazil. The present study describes the changes in the clivus-canal angle (CCA) in the postoperative period in patients with symptomatic BI operated by a posterior approach, using a simple technique of indirect reduction of the odontoid associated with occipitocervical fixation. METHODS: Patients underwent radiological evaluations by magnetic resonance imaging in the pre and postoperative periods, where the height of the odontoid tip was measured in relation to the Chamberlain line and the ACC. All patients underwent posterior occipitocervical fixation with specific maneuvers of distraction and extension of the cephalic segment with the aid of a head clamp with three fixation points for anterior reduction of the odontoid. RESULTS: Among the 8 patients evaluated in the series, all had increased ACC in the postoperative period, with a mean of 14.81 ± 1.54°, and statistically significant difference between the pre and postoperative periods (P < 0.05). CONCLUSION: The indirect surgical reduction of the odontoid process by a posterior approach through the manipulation (distraction-extension) of a "Mayfield" type of head clamp followed by occipitocervical fixation proved to be effective in improving the ACC, being easily reproducible.

Comparative study between minimally invasive supraorbital craniotomy and pterional craniotomy for treating anterior circulation cerebral aneurysms in a low-resource setting.

The challenges encountered in performing minimally invasive approaches, such as supraorbital minicraniotomy (SOMC), in services without adequate equipment are rarely reported in the literature. This study analyzes the viability of SOMC in the treatment of cerebral aneurysms, using exactly the same resources as pterional craniotomy (PC). The results of these two techniques are compared. 35 patients underwent SOMC, compared to 50 patients underwent CP (100 aneurysms in total), using the same microsurgical instruments. The following variables were compared: operative time, angiographic cure, length of intensive care unit stay during the post-operative period, surgical complications, length of hospital stay after surgery until hospital discharge, intraoperative aneurysm rupture, aesthetic satisfaction with the scar, and neurological status at discharge. SOMC had a significantly shorter operative time in relation to PC (213.9 ± 11.09 min and 268.6 ± 15.44 min, respectively) (p = 0.0081).With respect to the cosmetic parameters assessed by the Visual Analog Scale, the average for SOMC was 94.12 ± 1.92 points, and the average for PC was 83.57 ± 4.75 points (p = 0.036). SOMC was as effective as PC in relation to successful aneurysm clipping (p = 0.77). The SOMC technique did not show advantages over PC in any other variable. Even in a general neurosurgery service lacking a specific structure for minimally invasive surgeries, SOMC was feasible and effective for treating intracranial aneurysms, using the same set of microsurgical instruments used for PC, obtaining better results in operating time and cosmetic satisfaction.

Hearing preservation middle fossa approach for intracanalicular vestibular schwannoma in a NF2 patient.

Hearing preservation is a cornerstone in the management of intracanalicular vestibular schwannomas. This video demonstrates a middle fossa approach to an intracanalicular schwannoma and highlights some technical and anatomical nuances relevant to the procedure. The patient had sustained hearing preservation in the postoperative period. There are potential benefits in favor of the middle fossa when the tumor reaches the fundus of the internal auditory canal, but the surgeon's individual experience plays a decisive role in the choice of approach. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID21121.

Tentorial Peeling: Surgical Extradural Navigation to Protect the Temporal Lobe in the Focused Combined Transpetrosal Approach.

BACKGROUND: Transpetrosal approaches have been used for treatment of tumors in the petroclival region for many years. Injury to the temporal lobe, however, has been a potential drawback of the techniques described to date. OBJECTIVE: To describe modifications of the transpetrosal surgical technique, which allows extradural manipulation of the temporal lobe during the focused combined transpetrosal approach. This extra layer of protection avoids mechanical brain retraction, direct trauma to the temporal lobe and disruption of the local venous structures. METHODS: The present manuscript describes an innovative technical nuance based on the combination of the focused combined transpetrosal approach, the peeling of the dural layers of the tentorium, and the reverse peeling of the middle fossa dura mater. Ample illustrative material is provided and illustrative cases are presented. CONCLUSION: Peeling of the dural layers of the tentorium is a promising modification of the transpetrosal approach to increase the safety of the temporal lobe manipulation.

Chiari 1 Malformation Surgery: Comparing Non-violation of the Arachnoid versus Arachnoid Opening and Thermocoagulation of the Tonsils.

OBJECTIVE: Evidence is lacking concerning the myriad surgical techniques for type 1 Chiari malformation. This study evaluated the impact of arachnoid violation with tonsil thermocoagulation during surgical craniovertebral junction decompression. METHODS: The evaluation included aspects of the neurologic examination and parameters of cerebrospinal fluid flow on magnetic resonance imaging during preoperative and postoperative periods. All patients underwent craniovertebral junction decompression and opening of the dura mater. Patients were divided into 2 study groups. Patients in group 1 did not undergo arachnoid violation. Patients in group 2 underwent tonsil manipulation and systematic opening of the fourth ventricle outlet. RESULTS: There were 16 patients enrolled in each group (total of 32 patients). Regarding clinical improvement, there were no significant differences between groups in the postoperative period. Group 2 had more adverse events (relative risk 2.45, 95% confidence interval 1.55-3.86). In terms of cerebrospinal fluid flow parameter analyses, patients in group 1 achieved better results (P < 0.05). CONCLUSIONS: For treatment of symptomatic type 1 Chiari malformation, craniovertebral junction decompression with arachnoid preservation (i.e., without tonsillar manipulation) seems more suitable than the addition of arachnoid opening and thermocoagulation of the tonsils.

[Lung infection by lophomonas spp. in a female patient with acute myeloid leukemia]. / Infección pulmonar por Lophomonas sp en una paciente con leucemia mieloide aguda.

Protozoic infections are prevalent worldwide, particularly in immunosuppressed patients. We reported the case of a patient from the city of Viña del Mar, Chile, a carrier of acute myeloid leukemia in whom an infection by Lophomonas sp. was confirmed by bronchoalveolar lavage. She was treated with antibiotics but died of complications of the underlying disease. There is little literature available on this microorganism. We conclude that Lophomonas sp. should be considered as a diagnostic possibility if protozoa are found in bronchoalveolar lavage of immunosuppressed patients.

Las infecciones por protozoos son prevalentes a nivel mundial, en particular en pacientes inmunosuprimidos. Comunicamos el caso de una paciente procedente de la ciudad de Viña del Mar, Chile, portadora de leucemia mieloide aguda en quiense confirmó una infección por Lophomonas sp. en lavado bronquioalveolar. Se manejó con antibióticos, pero falleció decomplicaciones de su enfermedad de base. Existe poca literatura disponible respecto a este microorganismo. Concluimos que debe considerarse a Lophomonas sp. como posibilidad diagnóstica si se encuentran protozoos en lavados bronquioalveolares de pacientes inmunosuprimidos.

Infección pulmonar por Lophomonas sp en una paciente con leucemia mieloide aguda / Lung infection by lophomonas spp. in a female patient with acute myeloid leukemia

RESUMEN Las infecciones por protozoos son prevalentes a nivel mundial, en particular en pacientes inmunosuprimidos. Comunicamos el caso de una paciente procedente de la ciudad de Viña del Mar, Chile, portadora de leucemia mieloide aguda en quiense confirmó una infección por Lophomonas sp. en lavado bronquioalveolar. Se manejó con antibióticos, pero falleció decomplicaciones de su enfermedad de base. Existe poca literatura disponible respecto a este microorganismo. Concluimos que debe considerarse a Lophomonas sp. como posibilidad diagnóstica si se encuentran protozoos en lavados bronquioalveolares de pacientes inmunosuprimidos.

ABSTRACT Protozoic infections are prevalent worldwide, particularly in immunosuppressed patients. We reported the case of a patient from the city of Viña del Mar, Chile, a carrier of acute myeloid leukemia in whom an infection by Lophomonas sp. was confirmed by bronchoalveolar lavage. She was treated with antibiotics but died of complications of the underlying disease. There is little literature available on this microorganism. We conclude that Lophomonas sp. should be considered as a diagnostic possibility if protozoa are found in bronchoalveolar lavage of immunosuppressed patients.

Pyramidal and Proprioceptive Dysfunctions as the Main Neurologic Features in Symptomatic Type I Chiari Malformation Patients

Objective Broader access to magnetic resonance imaging (MRI) has increased the diagnosis of tonsillar ectopia, with most of these patients being asymptomatic. The early diagnosis and treatment of type I Chiari malformation (CM I) patients has impact on the prognosis. This study supplements information about the neurologic exam of symptomatic patients with CM I. Methods The sample was composed of 32 symptomatic patients with CM I diagnosed by a combination of tonsil herniation of more than 5 mm below the magnum foramen (observed in the sagittal T2 MRI) and at least one of the following alterations: intractable occipital headache, ataxia, upper or lower motor neuron impairment, sensitivity deficits (superficial and deep) or lower cranial nerves disorders. Results Occipital headache was the most frequent symptom (53.12%). During the physical exam, the most common dysfunctions were those from the pyramidal system (96.87%), followed by posterior cord syndrome (87.5%). Discussion In this study, patients became symptomatic around the fifth decade of life, which is compatible with previous descriptions. Patients withmore than 2 years of evolution have worse responses to treatment. Occipital headache, symptoms in the upper limbs, gait and proprioceptive disorders are common findings in patients with CM I. Conclusion Deep tendinous reflexes and proprioception disorders were the main neurologic features found in symptomatic CM I patients.

Results of an international drug testing service for cryptomarket users.

INTRODUCTION: User surveys indicate that expectations of higher drug purity are a key reason for cryptomarket use. In 2014-2015, Spain's NGO Energy Control conducted a 1-year pilot project to provide a testing service to cryptomarket drug users using the Transnational European Drug Information (TEDI) guidelines. In this paper, we present content and purity data from the trial. METHODS: 219 samples were analyzed by gas chromatography associated with mass spectrometry (GC/MS). Users were asked to report what substance they allegedly purchased. RESULTS: 40 different advertised substances were reported, although 77.6% were common recreational drugs (cocaine, MDMA, amphetamines, LSD, ketamine, cannabis). In 200 samples (91.3%), the main result of analysis matched the advertised substance. Where the advertised compound was detected, purity levels (m±SD) were: cocaine 71.6±19.4%; MDMA (crystal) 88.3±1.4%; MDMA (pills) 133.3±38.4mg; Amphetamine (speed) 51.3±33.9%; LSD 123.6±40.5µg; Cannabis resin THC: 16.5±7.5% CBD: 3.4±1.5%; Ketamine 71.3±38.4%. 39.8% of cocaine samples contained the adulterant levamisole (11.6±8%). No adulterants were found in MDMA and LSD samples. DISCUSSION: The largest collection of test results from drug samples delivered from cryptomarkets are reported in this study. Most substances contained the advertised ingredient and most samples were of high purity. The representativeness of these results is unknown.

Surgical treatment of type I Chiari malformation: the role of Magendie's foramen opening e tonsils manipulation.

The treatment for type 1 Chiari malformation (CM 1) is one of the most controversial topics in the neurosurgical field. The present study evaluated two of the most applied surgical techniques to treat CM 1. Method 32 patients were evaluated and divided in two groups: group 1 had 16 patients that were submitted to decompression of occipital bone and dura mater of the craniovertebral junction (CVJ); group 2 also had 16 patients and in addition to the previous procedure, they were submitted to Magendie's foramen opening e tonsils manipulation. The comparison between the groups included neurological exam and cerebrospinal fluid flow imaging during pre and postoperative periods. Results Both techniques were equivalents in terms of neurological improvement of the patients (p > 0.05), but the group 2 had more surgical complications, with relative risk of 2.45 (CI 1.55-3.86) for adverse events. Whatever the cerebrospinal fluid flow at CVJ, the patients of the group 1 achieved greater amount of flow than the group 2 (p < 0.05) during the postoperative period. Conclusion The cranial and dural decompression of the CVJ without arachnoidal violation was the best surgical intervention for treatment of CM 1, between these two compared techniques.

Factores asociados a irn fuera de rango terapéutico en usuarios de terapia anticoagulante oral con antagonistas de vitamina k / Factors determining inadequate inr values in patients receiving chronic anticoagulant treatment with vitamin k antagonists

Introducción: La terapia anticoagulante oral es una herramienta esencial para prevenir eventos tromboembólicos. Los fármacos más utilizados para este propósito son los antagonistas de vitamina K, cuyo efecto se monitoriza con el International Normalized Ratio (INR). Existen varios factores que afectan el nivel de anticoagulación. Objetivo: Identificar los factores asociados a un INR fuera de rango terapéutico. Metodología: Estudio observacional de corte transversal que analizó los datos de pacientes en TACO, controlados en un policlínico especializado del Hospital Naval Almirante Nef. Resultados: Se analizaron los datos de 374 pacientes, correspondiendo 196 a hombres (52,4 por ciento). La edad promedio fue de 74 +/- 12 años. Un total de 272 pacientes presentaron un INR en rango terapéutico (72,7 por ciento), 102 usuarios tenían un INR no adecuado para su patología (27.3 por ciento). Los principales motivos asociados a un INR fuera de rango fueron: Olvido en la toma de medicamentos (35,3 por ciento), alteraciones dietarias (16,7 por ciento) e interacciones farmacológicas (14,7 por ciento). Se encontró asociación estadísticamente significativa con una edad > 80 años y un INR fuera de rango terapéutico (p=0,03). Discusión: Los pacientes en TACO controlados en el policlínico especializado del Hospital Naval Almirante Nef, presentan una frecuencia mayor de INR dentro de rango terapéutico que lo reportado por la literatura. Los factores reportados como probables causas de presentar un nivel de anticoagulación fuera de rango terapéutico coinciden con los descritos en diversos estudios. Finalmente, queda de manifiesto la importancia del cuidado de los adultos mayores, dado que son los más susceptibles de presentar un control inadecuado, particularmente aquellos que tienen 80 o más años.

Introduction: Oral anticoagulant therapy is an essential tool for prevention of thromboembolic events. The drugs most commonly used for this purpose are the vitamin K antagonists, which are monitored through the International Normalized Ratio (INR). Several factors affect the level of anticoagulation. Aim: To identify factors associated with an INR outside the therapeutic range. Methods: Cross-sectional observational study that analyzed data from patients in oral anticoagulant therapy, controlled at the anticoagulant clinic of the Almirante Nef Naval Hospital. Results: We analyzed data from 374 patients, 196 of them men (52.4 percent). Mean age was 74 +/- 12 years. 272 patients (72.7 percent) had an INR within the therapeutic range; 102 (27.3 percent) had an inadequate INR. Major factors associated with an INR out of range were: forgetting to take the medication (35.3 percent), alterations in diet (16.7 percent) and drug interactions (14.7 percent). A statistically significant association was found between age over 80 years and an INR outside the therapeutic range (p = 0,03). Conclusions: Patients followed for oral anticoagulant therapy at a specialized clinic have an INR within therapeutic range most of the time. Factors reported as probable causes of inadequate INR were consistent with those described in several studies. Special attention should be paid to elderly patients, as they are the most susceptible to inadequate control.

Craniovertebral junction malformation in Northeastern Brazil: the myth of the Dutch colonization.

The high prevalence of craniovertebral junction malformation in Northeastern Brazil is historically associated with brachycephalic biotype (flat head), also common in this region. It has been postulated that this trait was introduced to this region by the Dutch during the colonial period in Brazil's history. Based on the confrontation of this paradigm against some historical facts, the authors concluded that the brachycephalic phenotype was inherited from prehistoric ancestors (Amerindians) who were already living in this region when white European men arrived.

Craniovertebral junction malformation in Northeastern Brazil: the myth of the Dutch colonization / Malformação da junção craniovertebral no Nordeste do Brasil: o mito da colonização Holandesa

The high prevalence of craniovertebral junction malformation in Northeastern Brazil is historically associated with brachycephalic biotype (flat head), also common in this region. It has been postulated that this trait was introduced to this region by the Dutch during the colonial period in Brazil's history. Based on the confrontation of this paradigm against some historical facts, the authors concluded that the brachycephalic phenotype was inherited from prehistoric ancestors (Amerindians) who were already living in this region when white European men arrived.

A alta prevalência de malformação da junção craniovertebral no Nordeste do Brasil é historicamente associada ao biótipo braquicefálico (cabeça chata), também comum nessa região. Postula-se que essa característica tenha sido introduzida na região pelos holandeses durante o período colonial da história do Brasil. Com base na confrontação desse paradigma com alguns fatos históricos, os autores concluem que o fenótipo braquicefálico foi herdado de ancestrais pré-históricos (ameríndios) que já habitavam a região no momento da chegada do homem branco europeu.