Falcine meningioma: FEBAIR principles in a "Grade Zero" concept application - 2D operative video.

Background: Falcine meningiomas account for 5% of intracranial meningiomas. They may involve the eloquent cortex as well as vascular structures. Gross-total resection with additional margins has been shown to be beneficial to patients and has been associated with a reduction in disease recurrence. Case Description: A 57-year-old patient presented with recurrent frontal headaches that worsened when lying down. Magnetic resonance imaging showed a large lesion with homogeneous enhancement attached to the anterior third of the falx cerebri at the right frontal lobe, causing significant compression, and suggesting a meningioma. Conclusion: This operative video highlights the application of 1st-time, exposure, bone removal, arachnoid, irrigation, and reconstruction principles for safely and effectively removing a large falcine meningioma using the "grade zero" concept for maximal resection.

Meta-analysis of the Major Clinical Results of the Treatment with 1-Point Fixation in Fractures in the Zygomatic-Maxillary Complex: Success Rate and Complications.

Introduction: Fractures of the zygomatic-maxillary complex (ZMC) are common facial fractures. After adequate fracture reduction, it is important to maintain stability and rigid fixation to avoid functional impairment and aesthetic sequelae. In this sense, the fixation of just one point can provide sufficient stability of the ZMC fracture when the ZMC fracture is not crushed. Objective: To analyze the success rates of fracture stability of the ZMC, incidences of complications, and aesthetic satisfaction after 1-point fixation. Methods: This study followed the rules of PRISMA, with publications from 2010 to 2020. The chi-square test and the Poisson probability test were performed to the occurrence of complications Low = 1, Moderate = 2, and NO = 0, adopting the α-level less than 0.05 with a statistical difference for 95% CI. The R-sq (R 2) value was also analyzed among the complications variables. Results: The results of these studies showed in a general way that the use of 1-point fixation with open reduction presented good results in the short, medium, and long term, showing fracture stability. Complication rates were low and patients' satisfaction with aesthetics was considerable. Conclusion: The success rate of the 1-point fixation procedure for the zygomatic-maxillary complex is high, with minimal complications.

Purification, Characterization, and Assessment of Antimicrobial Activity and Toxicity of Portulaca elatior Leaf Lectin (PeLL).

Lectins are carbohydrate-binding proteins with several bioactivities, including antimicrobial properties. Portulaca elatior is a species found at Brazilian Caatinga and data on the biochemical composition of this plant are scarce. The present work describes the purification of P. elatior leaf lectin (PeLL) as well as the assessment of its antimicrobial activity and toxicity. PeLL, isolated by chromatography on a chitin column, had native liquid charge and subunit composition evaluated by electrophoresis. Hemagglutinating activity (HA) of PeLL was determined in the presence of carbohydrates or divalent cations, as well as after heating and incubation at different pH values. Changes in the lectin conformation were monitored by evaluating intrinsic tryptophan fluorescence and using the extrinsic probe bis-ANS. Antimicrobial activity was evaluated against Pectobacterium strains and Candida species. The minimal inhibitory (MIC), bactericidal (MBC), and fungicidal (MFC) concentrations were determined. Finally, PeLL was evaluated for in vitro hemolytic activity in human erythrocytes and in vivo acute toxicity in mice (5 and 10 mg/kg b.w. per os). PeLL (pI 5.4; 20 kDa) had its HA was inhibited by mannose, galactose, Ca2+, Mg2+, and Mn2+. PeLL HA was resistant to heating at 100 °C, although conformational changes were detected. PeLL was more active in the acidic pH range, in which no conformational changes were observed. The lectin presented MIC and MBC of 0.185 and 0.74 µg/mL for all Pectobacterium strains, respectively; MIC of 1.48 µg/mL for C. albicans, C. tropicalis, and C. krusei; MIC and MFC of 0.74 and 2.96 µg/mL for C. parapsilosis. No hemolytic activity or signs of acute toxicity were observed in the mice. In conclusion, a new, low-toxic, and thermostable lectin was isolated from P. elatior leaves, being the first plant compound to show antibacterial activity against Pectobacterium.

Clinoidal Meningioma with Cavernous Sinus Invasion.

We present a-49-year old female presenting headache and progressive right eye visual loss in the last 6 months. Magnetic resonance imaging showed a large clinoidal meningioma on the right side, invading the superior, lateral and medial aspects of the cavernous sinus, the optic canal, and the clinoidal segment of the internal carotid artery (ICA). A cranio-orbital approach was performed. The anterior clinoid process was removed extradurally to achieve devascularization of the anterior clinoidal meningioma, followed by the peeling of the middle fossa to decompress V2 and open the superior orbital fissure. We open the dura in a standard fronto-temporal flap to access the lower portion of the skull base allowing retractorless dissection. We complete the removal of the anterior clinoid process and optic strut through an intradural approach. It allows safer dissection of the clinoidal segment of the ICA and avoids its injury by adherent and hard consistency tumor. Intraoperative neurophysiological monitoring, sharp dissection, and avoiding the use of bipolar coagulation when dissecting the cavernous sinus are essential to minimize the risk of cranial nerve injury. We also like to point that cranial nerve deficit caused by surgical manipulation without primary lesion of the nerve can be recovered postoperatively. The link to the video can be found at: https://youtu.be/ozUCsnUGxyM .

Spheno-Orbital Meningioma with Cavernous Sinus Extension.

We present a case of a 37-year-old female, with progressive left eye proptosis and an extensive ipsilateral en plaque spheno-orbital meningioma, with diffuse involvement of the lateral wall of the cavernous sinus and the orbit. A cranio-orbital zygomatic approach was performed to reach all extension of the lesion. We made an extradural clinoidectomy and an extensive bone removal of the orbit, exposition of the superior and lateral walls of the cavernous sinus, unroofing of the optic canal, superior orbital fissure, foramen rotundum, and foramen ovale. We performed the peeling of the lateral wall of cavernous sinus with total removal and preservation of the cranial nerves anatomy and function. In this video, we illustrate the importance of the first time aggressive removal of such tumors. We also demonstrate the concept that secondary invasion of the cavernous sinus are suitable for removal with cranial nerve preservation. The link to the video can be found at https://youtu.be/GJmkqVa6jSs .

Magnetite-levan nanoparticles for lectin purification: A single-step strategy for protein isolation from the seeds extract of the plant Cratylia mollis.

The ability to reversibly bind carbohydrates is an incredible property from lectins. Such characteristic has led these molecules to be employed in several applications involving medical research and biotechnology. Generally, these proteins follow several steps towards purification. Here, the synthesis, physical characterization, and use of levan-coated magnetite nanoparticles (MNPs-levan) for lectin isolation is described. Canavalia ensiformis and Cratylia mollis were used as sources of Concanavalin A and Cramoll, respectively, that were purified by using MNPs-levan. Mass spectrometry, SDS-PAGE, and hemagglutinating activity were employed to assess the efficiency of the process. Moreover, by using mass spectrometry approaches, a novel lectin, similar to Canavalin, was also identified for C. mollis, corroborating the advantages of using nanoparticles over microparticles. MNPs-levan could also be recycled, making this a low-cost, scalable process that can be efficiently employed over crude samples.

Sphenoid Wing Meningiomas with Secondary Cavernous Sinus Invasion: Surgical Results and Algorithm for Treatment at a Single Brazilian Center.

BACKGROUND: Sphenoid wing meningiomas with cavernous sinus invasion (SWMCSI) are challenging tumors. The preservation of quality of life and cranial nerve function is one of the most relevant aspects of treating patients with SWMCSI. METHODS: A retrospective study was conducted for surgery performed between 2008 and 2021, including 36 patients presenting with SWMCSI. The data from surgical intervention, Simpson grade of resection, tumor location, and morbimortality related to the surgery was reviewed. We examined the medical records, operative reports, radiologic examinations, and follow-up information. RESULTS: The group comprised 29 women and 7 men with an average age of 61 years (range, 31-87 years). The mean follow-up period was 75 months (range, 1-170 months). Simpson grade I and II resections were obtained in 80% of cases. The meningiomas were World Health Organization (WHO) grade 1 in 94% of cases, WHO grade 2 in 3%, and WHO grade 3 in 3%. The overall mortality was 5.5%. Permanent cranial nerve deficits occurred in 8% of cases, transient cranial nerve deficits in 22%, cerebrospinal fistula in 16.5%, and hemiparesis in 2.7%. The recurrence/regrowth rate was 14% during the follow-up period. The Karnofsky Performance Status 100 and 90 was 92%. CONCLUSIONS: The surgical treatment of symptomatic SWMCSI is an effective treatment modality with low morbimortality and good long-term control of the disease. Visual impairment is the most common abnormality, affecting preoperative and postoperative quality of life of patients with SWMCSI. Training in the microsurgical laboratory is essential for safe surgical approaches in this area.

Anterior Petrosal Approach to Petrous Apex Meningioma: Climbing the Rock-Two-Dimensional Operative Video.

A 47-year-old woman was referred to the neurological surgery department after a self-limiting episode of dizziness and headache. Magnetic resonance imaging showed an extra-axial mass in the right petrous apex, suggesting a meningioma. We chose the anterior petrosal approach (APA) because meningioma is a benign tumor with brainstem compression, and our goal was total removal for potential cure of the disease. The APA is appropriate for lesions located in the superior petroclival region with a narrow dural tail, above cranial nerves VII and VIII. The posterior petrosal approach is for large petroclival meningiomas that cross the midline, involving the basilar artery and perforating branches, extending below cranial nerves VII and VIII and above the jugular foramen. The retrosigmoid approach is for lesions located in the petrous apex and petroclival regions. Limitations include working between the posterior fossa cranial nerves and removing extensions of the tumor to Meckel cave and middle fossa. The endoscopic endonasal approach is for petroclival lesions. Limitations are the longer distance, nasal disturbances, middle fossa dural tail removal, and cerebrospinal fluid fistula.1-8 We performed the APA through a suprapetrous craniotomy, which exposes the petrous temporal portion, to drill the posteromedial triangle of the middle fossa to create a surgical corridor to the posterior fossa after splitting the tentorium.1-8 Removal of the tumor through the APA leads to a direct route to the petrous apex, with short distance and predominant extradural dissection. We achieved gross total removal. The patient presented with transient cranial nerve IV and V disturbances, but recovered entirely in 6 weeks, returning to her professional activities with preserved quality of life (Video 1).

Comparison of piezosurgery and conventional rotary instruments in schneider's membrane sinus lifting: A pilot randomized trial.

BACKGROUND: The present study aimed to evaluate and compare the postoperative effects of the piezoelectric device and conventional rotary instruments in Schneider's membrane sinus lifting procedure. MATERIAL AND METHODS: Twenty patients requiring bilateral maxillary bone graft augmentation in the posterior maxillary region were selected. Piezoelectric surgery was performed on one side and conventional surgery with a rotary diamond bur on the other. Postoperative pain, swelling, edema, and mouth opening were evaluated at one hour and two and seven days after the procedures. All variables were submitted to Friedman or Wilcoxon tests at a 5% significance level. RESULTS: The comparison between groups showed that postoperative pain after one hour and two days was significantly lower (p< 0.05) in the piezoelectric device group. Regarding the edema, the results of both techniques were similar at all times assessed (p> 0.05). Piezosurgery was statistically associated (p< 0.05) with greater mouth opening only at the 48-hour evaluation. CONCLUSIONS: Osteotomy with a piezoelectric device causes less pain and greater mouth opening postoperatively compared with the conventional technique. Key words:Piezosurgery, sinus lift, edema, pain, rotative instruments.

The Role of Low-Cost Microsurgical Training Models and Experience with Exercises Based on a Bovine Heart.

BACKGROUND: Microscopic training is essential for development of neurosurgical skills. A range of models is reported in the literature for this purpose, including live animals, exvivo, and synthetic material. Among the factors involved in selection and development of a training station, cost is a decisive one. METHODS: We present a low-cost model to practice microvascular anastomoses using a bovine heart and an artificial perfusion system. We also present a brief review of laboratory models for microsurgical training, focusing on the costs and reproducibility of the different options. RESULTS: Exvivo models are a great bridging point between nonbiologic and living animal training models. These models have major similarities to human vessels, such as lumen size and malleability of the arteries. The bovine heart model allowed the residents to gain confidence in handling vascular tissue in a microscopic environment. CONCLUSIONS: Although these models do not resemble anatomic landmarks in the human brain, the bovine heart model allowed the residents to gain confidence in handling vascular tissue in a microscopic environment.

Development of a System Measurement Model of the Brazilian Hospital Accreditation System.

The purpose of this study is to develop and validate a measurement model that evaluates the Brazilian hospital accreditation methodology (ONA), based on a multivariate model using structural equation modeling (SEM). The information used to develop the model was obtained from a questionnaire sent to all organizations accredited by the ONA methodology. A model was built based on the data obtained and tested through a structural equation modeling (SEM) technique using the LISREL® software (Scientific Software International, Inc., Skokie, IL, USA). Four different tests were performed: Initial, calibrated, simulated, and cross-validation models. By analyzing and validating the proposed measurement model, it can be verified that the selected factors satisfy the required criteria for the development of a structural model. The results show that leadership action is one of the most important factors in the process of health services accredited by ONA. Although, leadership, staff management, quality management, organizational culture, process orientation, and safety are strongly linked to the development of health organizations, and directly influence the accreditation process.

Surgical Removal of Skull Base Meningiomas in Symptomatic Elderly Patients.

OBJECTIVE: Meningiomas frequently occur in elderly patients, and surgical treatment is hazardous owing to multiple comorbidities. We report a series of elderly patients who were treated with surgical removal of meningiomas and compare them with a group of younger patients with similar tumors. METHODS: A retrospective study of elderly patients with symptomatic skull base meningiomas and a matched control group of younger patients was performed. Medical records, operative reports, radiologic examinations, and follow-up data were reviewed. Main outcome measures were morbidity, mortality, and Simpson grade. RESULTS: The study included 46 patients (23 elderly [age >65 years], 23 younger [age <65 years]). Average age was 71 years in elderly patients and 48 years in younger patients. Mean follow-up period was 32 months and 49 months, respectively. Radical removal (Simpson grades I and II) was observed in 83% and 91%, respectively. Mortality was 8% and 4%, respectively. Definite cranial nerve lesions occurred in 8% and 26%, respectively; cerebrospinal fluid leaks occurred in 12.5% and 4%, respectively; hemiparesis occurred in 4% of patients in both groups. Glasgow Outcome Scale score of 5 was obtained in 87% and 65.2%, respectively. CONCLUSIONS: Elderly patients with symptomatic skull base meningiomas should be considered for surgical treatment owing to acceptable morbidity and mortality compared with younger patients. Previous comorbidities and involvement of neurovascular structures are important factors in the decision regarding extent of surgical resection.

Effectiveness of a 16-month multi-component and environmental school-based intervention for recovery of poor income overweight/obese children and adolescents: study protocol of the health multipliers program.

BACKGROUND: Excess of weight is a serious public health concern in almost all countries, afflicting people of different ages and socioeconomic backgrounds. Studies have indicated the need for developing treatment strategies that intervene directly in the obesogenic environment. This study aims to evaluate the effectiveness of a multi-component and environmental school-based intervention, lasting 16 months, on the recovery of the nutritional status of low-income children and adolescents with overweight/ obesity. METHODS/STUDY DESIGN: The study was conducted by the Center for Recovery and Nutritional Education (CREN) in São Paulo, Brazil. Two schools located in poor neighborhoods were selected for the intervention, between March 2016 and June 2017. The participants were all students aged 8 to 12 years from the two participating schools. At the beginning of the intervention, anthropometric measurements were carried out to assess the nutritional status of the students. For convenience, students from one of the schools were considered as the control group, while those from the other school formed the experimental group. The intervention in the experimental group (n = 438) consists of the following weekly activities at school: psychological counseling in groups, theoretical/practical nutrition workshops, and supervised physical education classes. In addition, theoretical and practical educational activities are held regularly for parents, teachers, and cooks. Students with excess of weight (≥1 body mass index [BMI] -for-age Z score, n = 138) received clinical and nutritional care periodically at the outpatient care at CREN. Students enrolled in the control group (n = 353) participated in psychological counseling groups and theoretical/practical nutrition workshops for 6 months held in the school environment to provide motivation to entire classrooms. In the following 10 months, students with excess of weight from the control group (n = 125) were invited to attend the routine outpatient care at CREN. DISCUSSION: This study is the first to assess the effectiveness of a multi-component and environmental school-based intervention for the recovery of low-income, overweight/obese children and adolescents. If positive, the results demonstrate the feasibility for the recovery of excess of weight in populations of similar conditions and age. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials - ReBEC Primary Id Number RBR-9t2jr8 . Registration Date: Nov. 30, 2016. Retrospectively registered. Protocol version: 3.

Classification of Meningiomas Based on Their Surgical Removal, World Health Organization Grade, and Cytogenetic Profile: A Treatment Algorithm.

BACKGROUND: Meningiomas are the most common primary intracranial tumor, but the lack of prospective randomized trials has led to different guidelines for their treatment. We proposed a classification of meningiomas that considers surgical removal, histology, and cytogenetic profile, based on a literature review of these 3 criteria. The classification can be used to guide adjuvant treatment and follow-up. METHODS: A retrospective literature review was performed of PubMed from 2007 to 2016. Search terms were "meningioma," "surgery," "WHO classification," "cytogenetic," and "algorithm." RESULTS: Meningiomas were classified into 5 groups (A-E) according to the Simpson resection grade, World Health Organization grade, and cytogenetic profile. Adjuvant therapy, follow-up magnetic resonance imaging, and management of recurrence and/or regrowth were proposed according to the classification. CONCLUSIONS: The proposed meningioma classification was based on our experience and retrospective evidence collated from the literature and supported by recommendations. The application of the classification criteria yielded an algorithm for treatment and follow-up of patients with meningioma.

Effect of the Spiritist "passe" energy therapy in reducing anxiety in volunteers: A randomized controlled trial.

BACKGROUND: In Brazil, one of the most used energy therapies is the Spiritist "passe", which is practiced by Spiritist healers. Although experimental studies have demonstrated the effectiveness of different energy therapies in reducing anxiety and pain, little is known about the effect of the Spiritist "passe" on health outcomes. Therefore, the present study aimed at evaluating the effectiveness of "passe" energy therapy in reducing anxiety symptoms. METHODS/DESIGN: In this prospective, randomized controlled trial, participants were randomly allocated into two groups: Intervention (8 weekly Spiritist "passe" sessions, n=23), and Control (8 weekly sham Spiritist "passe" sessions, n=27). Anxiety was assessed using the Trait Anxiety Inventory (STAI-trait). RESULTS: Of 97 individuals screened, 50 were included in the final analysis. Decreasing STAI-trait anxiety scores were observed in both groups throughout the study (p<0.0001). By the end of the study, 17% and 63% of intervention and control participants, respectively, still met the criterion for anxiety (p=0.001). However, anxiety reduction was more accentuated in the Spiritist "passe" group (p=0.02). CONCLUSION: In this small pilot study, anxiety was more markedly reduced in participants receiving the Spiritist "passe" than in controls, warranting larger trials. TRIAL REGISTRATION: NCT02376959.

Recurrence of Skull Base Meningiomas: The Role of Aggressive Removal in Surgical Treatment.

Objectives The recurrence of meningiomas is a crucial aspect that must be considered during the planning of treatment strategy. The Simpson grade classification is the most relevant surgical aspect to predict the recurrence of meningiomas. We report on a series of patients with recurrent skull base meningiomas who were treated with the goal of radical removal. Design A retrospective study. Setting Hospital Ernesto Dornelles, Porto Alegre, Brazil. Participants Patients with recurrent skull base meningiomas. Main Outcomes Measures The goal of obtaining aggressive resection (i.e., Simpson grades I and II). Results The average age was 54 years, the mean follow-up period was 52.1 months, and Simpson grades I and II were obtained in 82%. The overall mortality was 5.8%. Transient cranial nerve deficits occurred in 11.7%; the definitive morbidity was also 5.8%. A second recurrence occurred in 5.8%. Conclusions Radical removal of recurrent skull base meningiomas is achievable and should be considered an option with a good outcome and an acceptable morbidity. The common surgical finding that was responsible for recurrence in this study was incomplete removal during the first surgery. We recommend extensive dura and bone removal in the surgical treatment of such recurrent lesions.

Severe Edema and Venous Congestion Following Sphenoorbital Meningioma Resection in a Meningiomatosis Case: Importance of Predicting Venous Disturbances.

To achieve local disease control, radical removal is the best option for sphenoorbital meningiomas. Preservation of the venous system is crucial during the resection of skull base meningiomas. This vascular injury represents a major risk both for life and neurologic function. We present a case of a severe postoperative frontotemporal venous disturbance and cerebral edema following the radical removal of a giant sphenoorbital meningioma in a patient with meningiomatosis and occlusion of the superior sagittal sinus. The anatomical, radiologic, and surgical aspects are reviewed and discussed, with the aim of preventing such a serious complication.

Large and giant skull base meningiomas: The role of radical surgical removal.

BACKGROUND: The large and giant skull base meningiomas are challenging lesions, and the involvement of crucial neurovascular structures needs the surgical removal as the primordial treatment. The authors report on a series of patients with large and giant skull base meningiomas who were treated with the goal of radical removal. METHODS: A retrospective study including 49 patients with large and giant skull base meningiomas was carried out. Tumors presenting 3 cm or larger were included. RESULTS: The meningiomas in the sample included the following types: 10 olfactory groove, 8 sphenoorbital, 8 petroclival, 8 tentorial, 4 clinoidal, 4 cavernous sinus, 3 temporal floor, 2 tuberculum sellae and 2 foramen magnum. The average age was 53 years, the mean follow-up period was 52 months, Simpson Grades I and II were obtained in 75.5%. The overall mortality was 5%. Transient cranial nerve deficits occurred in 32% with definite cranial nerve lesion in 18%. Cerebrospinal fluid leak occurred in 14%. CONCLUSIONS: The surgical treatment is a mandatory option for large and giant skull base meningiomas. The radical removal is achievable and should be considered an alternative with a good outcome and an acceptable morbidity for such challenge lesions.

Sodium fluorescein in skull base meningiomas: a technical note.

OBJECTIVES: Skull base meningiomas are a neurosurgical challenge due to the involvement of neurovascular structures. In this study, the authors present the first study of the trans-operative use of sodium fluorescein (SF) to enhance skull base meningiomas and perform a quantitative digital analysis of the tumors' pigmentation. The goal of the study was to observe the SF enhancement of skull base meningiomas. PATIENTS AND METHODS: A prospective, within-subjects study was designed and performed. This study included twelve patients with skull base meningiomas. After an initial dissection, digital pictures were taken before and after systematic injections of SF using the same light-source used for the surgical microscope. These pictures were analyzed with software that calculated the wavelengths of the sodium fluorescein before and after the injection of the dye. RESULTS: The meningiomas in the sample included the following types: 1 cavernous sinus, 1 olfactory groove, 3 petroclival, 1 tuberculum sellae, 3 sphenoid wings, 1 anterior clinoid, and 2 temporal floor. The SF enhancement in all tumors was strongly positive. CONCLUSIONS: The low cost, universal availability and safety of SF indicate that this dye should be examined in further studies, and its applications in skull-base meningioma surgeries should be further assessed.