ABSTRACT
Estas recomendaciones clínicas delinean los criterios utilizados por el Equipo de Cirugía de los Trastornos Psiquiátricos del Hospital de Clínicas para la selección de candidatos a neurocirugía en pacientes con trastorno obsesivo compulsivo grave y refractario al tratamiento convencional. Los criterios de inclusión se enfocan en la cronicidad, la gravedad y la resistencia, considerando procedimientos ablativos o de neuromodulación. La gravedad se evalúa mediante la Escala Yale-Brown Obsessive Compulsive, junto con una evaluación integral del desempeño y la discapacidad. La refractariedad se define como la falta de respuesta, según criterios consensuados, a diversos tratamientos farmacológicos y no farmacológicos respaldados por evidencia científica significativa para el trastorno obsesivo compulsivo. Es esencial realizar una evaluación dimensional del desempeño global y estimar el pronóstico sin intervención quirúrgica. Los criterios de exclusión abarcan comorbilidades graves, trastornos de personalidad específicos y discapacidad intelectual. Además, se especifican pruebas paraclínicas necesarias, incluyendo evaluaciones sanguíneas, serológicas, cardíacas y neurológicas. Se detallan las tablas utilizadas para el registro de información necesaria para la evaluación. Todas las evaluaciones de neurocirugía culminan en un ateneo clínico conjunto entre el Equipo de Cirugía de los Trastornos Psiquiátricos del Hospital de Clínicas y la Unidad Académica de Psiquiatría de la Facultad de Medicina en donde se determinan las estrategias terapéuticas posibles.
These clinical recommendations outline the criteria used by the Psychiatric Disorders Surgery Team for selecting neurosurgery candidates among patients with severe Obsessive Compulsive Disorder refractory to conventional treatment. Inclusion criteria focus on chronicity, severity, and resistance. Ablative procedures or neuromodulation are taken into consideration. Severity is assessed by means of Yale-Brown Obsessive Compulsive Scale, and a comprehensive evaluation of performance and disability. Refractoriness is defined as lack of response, according to consensus criteria, to various pharmacological and non-pharmacological treatments for Obsessive Compulsive Disorder supported by significant scientific evidence. It is essential to conduct a dimensional assessment of overall performance and estimate prognosis without surgical intervention. Exclusion criteria encompass serious comorbidities, specific personality disorders, and intellectual disability. Furthermore, necessary paraclinical tests are specified, including blood, serological, cardiac, and neurological evaluations. Tables used for recording essential information for assessment are detailed. All neurosurgical assessments culminate in a joint clinical discussion of possible therapeutic strategies between the Psychiatric Disorders Surgery Team and the Psychiatry Academic Department (Facultad de Medicina) at the Hospital de Clínicas.
Subject(s)
Humans , Neurosurgical Procedures/standards , Obsessive-Compulsive Disorder/surgery , Catastrophic Illness , Chronic DiseaseABSTRACT
AIM: Describe our stereotactic brain biopsy (SBB) technique for intra-axial lesions of the posterior fossa, evaluate its effectiveness and safety, and compare them with other series. MATERIAL AND METHODS: Retrospective study in ten consecutive patients, whose variables were age, gender, location of the lesions, clinical, radiological, and histopathological diagnoses, complications, and mortality, for analysis using descriptive statistics and tests of concordance and diagnostic validity. RESULTS: Lesions were pontine in seven cases, and pontomedullary in three occasions, with histopathological diagnoses of four Grade II astrocytomas, two Grade IV astrocytomas, two infectious process, one neuroblastic tumor, and one cavernous malformation, whose frequency differs from the previous reports (χ2 = 0.07). The clinical-radiological concordance was poor (κ = 0.20). The validity of the clinical diagnosis had intermediate values (Sn = 66.7%, Sp = 75%), while radiological studies were more sensitive (Sn = 100%, Sp = 25%). A definitive diagnosis was obtained in all procedures, with no permanent morbidity or mortality because of the surgery. CONCLUSION: The SBB technique for posterior fossa implemented in our hospital shows high diagnostic yield, as well as absolute safety for the patient.
OBJETIVO: Describir nuestra técnica de biopsia cerebral estereotáctica (SBB) para lesiones intraaxiales de fosa posterior, evaluar su eficacia y seguridad y compararlas con otras series. MATERIAL Y MÉTODOS: Estudio retrospectivo en 10 pacientes consecutivos, cuyas variables fueron edad, sexo, localización de las lesiones, diagnósticos clínicos, radiológicos e histopatológicos, complicaciones y mortalidad, para análisis mediante estadística descriptiva y pruebas de concordancia y validez diagnóstica. RESULTADOS: Las lesiones fueron pontinas en 7 casos y pontomedulares en 3 ocasiones, con diagnósticos histopatológicos de 4 astrocitomas grado II, 2 astrocitomas grado IV, 2 procesos infecciosos, 1 tumor neuroblástico y 1 malformación cavernosa, cuya frecuencia difiere de reportes previos (χ2 = 0.07). La concordancia clínico-radiológica fue mala (κ = 0.20). La validez del diagnóstico clínico tuvo valores intermedios (Sn = 66.7%, Sp = 75%), mientras que los estudios radiológicos fueron más sensibles (Sn = 100%, Sp = 25%). Se obtuvo un diagnóstico definitivo en todos los procedimientos, sin morbimortalidad permanente por la cirugía. CONCLUSIÓN: La técnica SBB para fosa posterior implementada en nuestro hospital muestra un alto rendimiento diagnóstico, así como una seguridad absoluta para el paciente.
Subject(s)
Astrocytoma , Brain Neoplasms , Astrocytoma/diagnostic imaging , Astrocytoma/surgery , Biopsy/methods , Brain Neoplasms/diagnostic imaging , Brain Neoplasms/pathology , Hospitals , Humans , Retrospective Studies , Stereotaxic TechniquesABSTRACT
BACKGROUND: Stereotactic lesion in the Forel's field H (campotomy) was proposed in 1963 to treat Parkinson disease (PD) symptoms. Despite its rationale, very few data on this approach have emerged. Additionally, no study has assessed its effects on nonmotor symptoms, neuropsychological functions and quality of life. OBJECTIVE: To provide a prospective 2-yr assessment of motor, nonmotor, neuropsychological and quality of life variables after unilateral campotomy. METHODS: Twelve PD patients were prospectively evaluated using the Unified Parkinson's Disease Rating Scale (UPDRS), the Dyskinesia Rating Scale and the Parkinson's disease quality of life questionnaire (PDQ39) before campotomy, and after 6 and 24 mo. Nonmotor, neuropsychiatric, neuropsychological and quality of life variables were assessed. The impact of PD on global health was also rated. RESULTS: A significant reduction in contralateral rest tremor (65.7%, P < .001), rigidity (87.8%, P < .001), bradykinesia (68%, P < .001) and axial symptoms (24.2%, P < .05) in offmedication condition led to a 43.9% reduction in UPSDRS III scores 2 yr after campotomy (P < .001). Gait improved by 31.9% (P < .05) and walking time to cover 7 m was reduced by 43.2% (P < .05). Pain decreased by 33.4% (P < .01), while neuropsychiatric and neuropsychological functions did not change. Quality of life improved by 37.8% (P < .05), in line with a 46.7% reduction of disease impact on global health (P < .001). CONCLUSION: A significant 2-yr improvement of motor symptoms, gait performance and pain was obtained after unilateral campotomy without significant changes to cognition. Quality of life markedly improved in parallel with a significant reduction of PD burden on global health.
Subject(s)
Neuropsychological Tests , Parkinson Disease/psychology , Parkinson Disease/surgery , Quality of Life/psychology , Stereotaxic Techniques/psychology , Subthalamus/surgery , Aged , Cognition/physiology , Female , Gait/physiology , Humans , Male , Middle Aged , Parkinson Disease/diagnosis , Prospective Studies , Stereotaxic Techniques/trends , Subthalamus/physiology , Surveys and Questionnaires , Time Factors , Tremor/diagnosis , Tremor/psychology , Tremor/surgeryABSTRACT
Introducción: Para utilizar un meta-análisis de todos los casos reportados de la estimulación cerebral profunda (DBS) para ladistonía para determinar cuáles son los factores significativos resultados influencia relacionada con el destino. La escala demovimiento Burke-Fahn-Marsden (BFM), la medida más informado, fue elegida como la principal medida de resultado paraeste análisis. Material y Métodos: Una búsqueda en MEDLINE identificaron 137 pacientes que se sometieron a DBS para ladistonía en 24 estudios que tenían puntuaciones individuales BFM. Datos de los pacientes individuales, incluyendo la edad deinicio de la distonía, la edad de la cirugía, el género, la distribución de la distonía, la etiología de la distonía, la presencia decaracterísticas asociadas, anormalidad de las imágenes preoperatorias, cirugías estereotáxica anteriores, el núcleo estimulado,el tipo de anestesia que se utiliza, el tiempo de respuesta a la estimulación, y el momento de la evaluación de resultadosse introdujeron en una base de datos de SPSS para el análisis estadístico. Resultados: La media BFM cambio porcentual(mejora en la puntuación postoperatoria de la línea de base) fue 51,8% (rango - 34% a 100%). Significativamente se lograronmejores resultados con la estimulación del globo pálido interno (GPI) que con la estimulación de la parte posterior del núcleolateral ventral (VLP) del tálamo (p = 0,0001)...
Introduction: To use a meta-analysis on all reported cases of deep brain stimulation (DBS) for dystonia to reevaluate the good effect using the GPi as a target, which factors significant influence outcome related to the target. The Burke-Fahn-Marsden (BFM) movement scale, the most reported measure, was chosen as the primary outcome measure for this analysis. Material and Methods: Computerized MEDLINE searches on English literature search identified 137 patients who underwent BBS for dystonia in 24 studies that had individual BFM scores. The study was done with statistical analysis by intention to treat. Statistical analysis was made with a significant p- value of 0.05. For the comparison of pre- and postoperative scores, a test Wilcoxon signed was used. Results: The mean BFM percentage change (improvement in postoperative score from baseline) was 46.3 percent(range - 34 percent to 100 percent)...
Subject(s)
Humans , Male , Female , Dystonia/etiology , Dystonia/therapy , Deep Brain Stimulation/methods , Stereotaxic Techniques , Stereotypic Movement Disorder , Abnormal Involuntary Movement Scale , Electric Stimulation/methodsABSTRACT
Objective In recent years, technologies have advanced considerably in improving surgical outcome following treatment of lesions in eloquent brain areas. The aimof this study is to explore which method is best in the resection of motor area lesions. Methods Prospective, non-randomized study Evaluate on 74 patients who underwent surgery to remove lesions around the motor area. Results Total lesion removal was achieved in 68 patients (93.1%). Fifty-four patients (73.9%) presented normal motor function in the preoperative period; of these, 20 (37.3%) developed transitory deficits. Nevertheless, 85% of these patients later experienced a complete recovery. Nineteen patients presented with motor deficits preoperatively; of these, five presented deteriorating motor abilities. Intraoperative stimulation methods were used in 65% of the patients, primarily in cases of glioma. Conclusions The morbidity in patients submitted to resections of motor area lesions is acceptable and justify the surgical indication with the purpose of maximal resection. Intraoperative stimulation is an important tool that guides glioma resection in many cases.
Objetivo Nos últimos anos, consideráveis avanços tecnológicos têm surgido no sentido de melhorar os resultados cirúrgicos no tratamento de lesões em áreas eloquentes do cérebro. O objetivo deste estudo é investigar qual o melhor método para ressecção de lesões em área motora. Método Estudo prospectivo não aleatório que avaliou os resultados pós-operatórios em 74 pacientes submetidos à ressecção de lesões em área motora ou adjacente. Resultados A ressecção cirúrgica foi considerada total em 68 (93,1%) pacientes. 54 pacientes (73,9%) apresentavam força muscular normal no pré-operatório. Destes, 20 (37,3%) apresentaram déficit no pós-operatório imediato, sendo que 17 (85%) recuperaram completamente o déficit. 19 pacientes apresentavam déficit no préoperatório, sendo que 05 apresentaram piora do déficit no pós-operatório imediato. A estimulação intraoperatória foi utilizada em 65% dos casos, principalmente nos gliomas. Conclusão Amorbidade empacientes operados de lesões emáreamotora é bastante aceitável e justifica a indicação cirúrgica com objetivo de ressecção máxima. A estimulação intraoperatória é uma ferramenta importante para guiar a resseção dos gliomas em muitos casos.
Subject(s)
Humans , Male , Female , Child, Preschool , Child , Adolescent , Adult , Middle Aged , Aged , Aged, 80 and over , Postoperative Care , Preoperative Care , Motor Disorders/diagnosis , Insular Cortex/injuries , Intraoperative Care , Motor Cortex/injuries , Prospective Studies , Data Interpretation, Statistical , Treatment Outcome , Craniotomy/methods , Neuronavigation/methodsABSTRACT
Introducción y objetivos. Los métodos actuales de ablación conllevan sistemas de navegación manual y ablación cardiaca, y presentan ciertas limitaciones. El objetivo de este trabajo ha sido evaluar la eficacia y seguridad de los nuevos sistemas de navegación magnética intracardiaca. Métodos. Se hizo una revisión sistemática en las bases MedLine, Embase, Cochrane Library, CRD, ECRI, Hayes y bases de datos de HTA. Como términos Mesh se usaron: "electrophisiologic techniques", "magnetics", "stereotaxic techniques", "heart catheterization" y "catheter ablation". Los criterios de inclusión fueron estudios con adultos y lesiones cardíacas. La intervención fue el sistema de navegación magnética intracardiaca Niobe®. Los resultados medidos fueron: tiempos totales de procedimiento, tiempo de fluoroscopia, tiempo de colocación del catéter, tiempo de mapeo y tiempo de ablación. La calidad se evaluó con los cuestionarios CASPe y STROBE...
Introduction and objective: Current methods of ablation involving manual navigation systems and cardiac ablation have some limitations. The aim of this study was to evaluate the efficacy and safety of intracardiac magnetic navigation systems. Methods: Systematic review in MedLine, Embase, Cochrane Library, Center for Review and Dissemination, ECRI, Hayes and HTA databases was performed. The used Mesh terms were: electrophisiologic techniques, magnetic, stereotaxic techniques, heart catheterization, and catheter ablation. Inclusion criteria werestudies whose populations were adults with cardiac lesions. The intervention was intracardiac magnetic navigation system Niobe ® versus manual cardiacnavigation techniques and manual ablation. The outcomes were total procedure time, fluoroscopy time, time of catheter positioning, mapping and ablation time. Quality of studies was assessed by CASPe and STROBE...
Subject(s)
Atrial Fibrillation , Stereotaxic Techniques , Ablation TechniquesABSTRACT
OBJETIVO: avaliar a acurácia da biópsia com agulha grossa (BAG) orientada por estereotaxia nas lesões mamárias categoria BI-RADS® 4. MÉTODOS: realizou-se uma análise retrospectiva das lesões categoria BI-RADS® 4 que foram submetidas à BAG orientada por estereotaxia no período de junho de 1998 a junho de 2003. As pacientes com resultados benignos, mas com baixa suspeição à imagem radiográfica, foram orientadas a acompanhamento mamográfico. As pacientes com resultados malignos ou com lesões especiais (atipias e lesões papilíferas) foram submetidas ao tratamento padronizado. Aquelas com resultado benigno, mas que apresentavam imagem mamográfica de maior risco, foram encaminhadas para biópsia cirúrgica (BC). Foram considerados padrão-ouro (1) o acompanhamento radiográfico inalterado por, no mínimo, três anos daquelas lesões de baixa suspeição que resultaram benigno na BAG e (2) os resultados das biópsias cirúrgicas, quando essas foram realizadas (nas BAG cujos resultados foram malignos ou benignos com imagem de maior risco). Foram realizados os cálculos estatísticos de sensibilidade, especificidade e valor preditivo positivo e negativo do método. RESULTADOS: das 118 lesões não palpáveis categoria BI-RADS® 4 submetidas à BAG orientada por estereotaxia, 27 casos correspondiam à doença maligna, 81 eram benignas e 10 eram lesões com atipia ou papilíferas. Para a análise estatística, foram selecionados 108 pacientes (excluídas as lesões com atipia e papilíferas). A sensibilidade da BAG foi de 87,1 por cento e a especificidade foi de 100 por cento. O valor preditivo positivo foi de 100 por cento e o negativo, de 95,1 por cento. A acurácia da BAG nessa casuística foi de 96,3 por cento. A taxa de falso-negativo foi de 3,7 por cento (4/108). A prevalência de diagnóstico de malignidade nas lesões BI-RADS® 4 nessa amostra foi de 29,7 por cento (31/118). CONCLUSÕES: a biópsia estereotáxica com agulha grossa mostrou-se uma alternativa segura à BC. Quando...
PURPOSE: to assess the accuracy (rate of correct predictions) of stereotactic core needle biopsy (CNB) of risk category BI-RADS® 4 breast lesions. METHODS: a retrospective analysis of category BI-RADS® 4 breast lesions that had been submitted to a stereotactic core-needle biopsy from June 1998 to June 2003. Patients with histological benign results consistent with the radiographic image were referred to mammographic follow-up. Patients with malign diagnosis and papillary lesions were submitted to standard specific treatment. Excisional biopsies were performed when results were benign, but in disagreement with the mammographic image. It was considered as a gold-standard attendance: (1) the mammographic follow-up of low suspicion lesions with benign results at CNB, which stayed unchanged for, at least, three years, and (2) surgical resection when specimen results were malign or benign, but with a high suspicion on mammography. Sensitivity (S) specificity (E) and overall accuracy of stereotactic CNB were statistically analyzed. RESULTS: among the 118 non-palpable lesions of category BI-RADS® 4 submitted to CNB, the results obtained were: 27 malign cases, 81 benign, and ten lesions with atypical or papillary lesions. The statistical analysis comprised 108 patients (atypical and papillary lesions were excluded). CNB sensitivity was 87.1 percent and specificity 100 percent. The positive predictive value was 100 percent and the negative, 95.1 percent. False negatives occurred in 3.7 percent (4/108) of cases. The prevalence of malign diagnostics in the BI-RADS® 4 lesions of this sample was 29.7 (31/118).The accuracy of this method in this casuistic was 96.3 percent. CONCLUSIONS: these results support stereotactic CNB as an extremely reliable alternative to open biopsy, in the diagnosis and definition of breast lesions. In positive results, it is possible to indicate the appropriate therapy, and, in negative (when mammography shows low suspicion)...