Intraoperative Accidental Extubation during Thyroidectomy in a Known Difficult-Airway Patient: An Adult Simulation Case for Anesthesiology Residents.

Intraoperative accidental extubation on a known difficult-airway patient requires prompt attention. A good understanding of the steps to re-establish the airway is critical, especially when the patient is known to have a difficult airway documented or discovered on induction or acquires a difficult airway secondary to intraoperative events. The situation becomes even more complicated if the case has been handed off to another anesthesiologist, where specific and detailed information may not have been conveyed. This simulation was designed to train first-year clinical anesthesia residents. It was a 50 min encounter that focused on the management of complete loss of an airway during a thyroidectomy on a known difficult-airway patient. The endotracheal tube dislodgement was simulated by deliberate tube manipulation through the cervical access window of the mannequin. Learners received a formative assessment of their performance during the debrief, and most of the residents met the educational objectives. Learners were asked to complete a survey of their experience, and the feedback was positive and constructive. The response rate was 68% (17/25). Our simulation program helped anesthesiology residents develop intraoperative emergency airway management skills in a safe environment, as well as foster communication skills among anesthesiologists and the surgery team.

A Novel Automated Calculation of Basal Cistern Effacement Status on Computed Tomographic Imaging in Traumatic Brain Injury.

Introduction To predict patient outcomes in traumatic brain injury (TBI) lesions, various scores have been proposed, which use objective assessments. These scores, however, rely on the observer's ability to determine them. This study presents a comprehensive, reproducible, and more anatomically stratified objective measurement of the degree of basal cistern effacement in brain computed tomographic (CT) scan images. Methods Patients with TBI admitted from August 2015 to February 2016 were included. The control group consisted of non-trauma patients, who had normal brain CT scans. The images were analyzed by an automated volumetric compression ratio (CR) defined as the volume ratio between the parenchymal tissue and the cerebrospinal fluid (CSF) in the basal cisterns. This value was compared with the TBI severity recorded at each patient's admission and a consensus score of the basal cisterns' degree of effacement by manual analysis. Results Seventy-three TBI patients were admitted. The mean admission Glasow Coma Scale (GCS) score was 9. In the non-TBI control group, 29 patients were enrolled. The average kappa value for the inter-observer agreement was 0.583. The CR had an inverse linear relationship with the severity of the TBI and the degree of effacement of the basal cisterns. The correlation between the CR value in the midbrain and the specialists' consensus determination was statistically significant (p < 0.01). The CR also showed a difference between the TBI and the control groups (p 0.0001). Conclusions The automated CR is a useful objective variable to determine the degree of basal cistern effacement. The proposed ratio has a good correlation with the classical basal cistern effacement classification and TBI severity.

Metástasis craneal de tumor maligno de la vaina nerviosa periférica / Cranial metastasis of malignant tumor of the peripheral nerve sheath

Introducción: Los tumores malignos de la vaina nerviosa periférica (TMVNP) son tumores raros y heterogéneos, muy agresivos y localmente invasivos, siendo entre el 5 y 10% de todos los tumores de partes blandas. Alrededor del 50% de los tumores malignos de las vainas nerviosas se asocian a neurofibromatosis tipo 1. Caso clínico: Se presenta el caso de una paciente de 32 años portadora de neurofibromatosis tipo 1, que consulta por lesión ocupante de espacio en región axilar, encontrándose además en estudio por dolor neurálgico en región facial. Se realiza exéresis completa de la tumoración axilar con diagnóstico de Tumor Maligno de la Vaina Nerviosa Periférica (TMVNP). Debido a la falta de mejoría del dolor neurálgico y al agregado de alteraciones oculares se realiza nueva resonancia magnética por imágenes (RMI) de cráneo donde se visualiza lesión ocupante de espacio craneal. Se procede a la exéresis parcial de la lesión, cuyo diagnóstico anatomopatológico resulta en diagnóstico de neoplasia mesenquimática maligna de alto grado vinculable a Tumor maligno de la vaina nerviosa periférica. La paciente finalmente fallece 57 días post-operatorios. Conclusión: Los TMVNP poseen un mal pronóstico, con tasas de supervivencia a los 2 y 5 años aproximadamente, de 33 y 12%, siendo el tratamiento quirúrgico uno de los factores pronósticos independientes con mayor impacto en la supervivencia.

Introduction: Malignant peripheral nerve sheath tumors (MPNST) are rare and heterogeneous tumors, very aggressive and locally invasive, being between 5 and 10% of all soft tissue tumors. Clinical Case: A 32 year old patient with type 1 neurofibromatosis attends to the hospital with an axilar tumour. The patient was in study due to a trigeminal neuralgia. A complete remotion of the axilar lesion was achieved with the diagnosis of Malignant Peripheral Nerve Sheath Tumor (MPNST). Since the neuralgic symptom was worsening and new ophthalmological symptoms appeared, a new cerebral magnetic resonance imaging MRI was done. This study evidenced an intra-extra-cranial tumour. A partial resection of the mass was done. The pathological diagnosis was a mesenchymal tumor due to a MPNST metastasis. The patient died 57 days after the second surgery.Conclusion: Malignant peripheral nerve sheath tumors have a poor prognosis, with survival rates at 2 and 5 years of 33 and 12%, respectively, being surgical treatment one of the independent factors with more impact in outcome.

Complicaciones en craneoplastias: hueso autólogo criopreservado vs. polimetilmetacrilato. Análisis retrospectivo de 63 pacientes / Complications in cranioplasties: autologous bone cryopreserved vs. Polymethylmethacrylate. Retrospective analysis of 63 patients

Introducción: se define como craneoplastia a la reparación quirúrgica de los defectos óseos craneanos. En nuestro medio el material utilizado mayormente es el hueso autólogo criopreservado (HACp) y, en caso de no contar con dicho tejido, el Polimetilmetacrilato (PMMA) es de elección. Objetivo: Se plantea un estudio retrospectivo observacional a fin de analizar y comparar complicaciones en pacientes sometidos a craneoplastias con HACp en comparación a un grupo de pacientes a los que se les realizó craneoplastia con PMMA. Materiales y métodos: Se incluyeron pacientes que fueron sometidos a craneopatías durante un periodo de 5 años (2008-2013). El seguimiento delos pacientes fue de al menos 12 meses. Se analizaron variables relacionadas a complicaciones tempranas y tardías. Resultados: 63 pacientes recibieron craneoplastia con HACp (31 pacientes, 52%) o polimetilmetacrilato (31 pacientes, 49%). La tasa de complicación global fue del 36,6%. Doce pacientes (19,04%) requirieron tratamiento quirúrgico. Las complicaciones más frecuentes fueron las colecciones subcutáneas no infectadas (19%), seguidas por las infecciones de heridas (17%). No existen diferencias estadísticamente significativas en cuanto a para complicaciones, tanto globales como en las distintas categorías (p>0,05), para ambas técnicas quirúrgicas. Conclusión: Las craneoplastias tanto con HACp como aquellas con PMMA presentan una alta tasa de complicaciones. En nuestra serie no se hallaron diferencias entre ambos grupos estudiados.

Introduction: cranioplasty is defined as the surgical procedure to cover a skull bone defect. In our institution, we mainly use cryopreserved autologous bone graft (HACp), and if it is not available, polymethylmethacrylate is chosen (PMMA). Objective: We performed an observational retrospective study to assess complications in both groups of patients. Materials and Methods: Patients who underwent cranioplasty between 2008 and 2013 were included. Minimum follow up was 12 months. Variables related with early and late complications were analyzed. Results: 63 patients received cranioplasty consisting of autologous bone graft (32 patients, 52%) or PMMA (31 patients, 48%). The global complications rate was 36.6%. 12 patients (19.04%) required surgical treatment for these complications. The most common complications were sterile persistent subcutaneous fluid collection (19%) and wound infection (17%). No differences in complications rates were found between both groups (p>0.05). Conclusions: Cranioplasty following craniectomy is associated with a high complication rate. In our series, both groups showed no differences in complications rates.

Abordaje fronto-pterional a mucocele frontal con extensión intracraneana / Fronto-pterional approach to frontal mucocele with intracranial extension

INTRODUCCIÓN: los mucoceles craneales son lesiones pseudoquísticas, descriptas a principios del siglo XIX, que se originan en una o varias cavidades de los senos paranasales y su evolución depende de la velocidad de expansión de la lesión. El mucocele clásico es una lesión que se expande del seno paranasal debido a una obstrucción de su ostium de drenaje. CASO CLÍNICO: se presenta el caso de un paciente 26 años de edad, que consulta por cuadro de cefalea holocraneana de 72 hs. de evolución, acompañado de sensación subjetiva de fiebre, desorientación y trastornos de la conducta de 24 hs. de evolución, cuyo diagnóstico fue presentación infecciosa de mucocele frontal con extensión intracraneana. INTERVENCIÓN: se evaluó en conjunto con el servicio de otorrinolaringología y se decidió realizar exéresis de mucocele por abordaje fronto-pterional. CONCLUSIÓN: los mucoceles frontales son la variante más frecuente de esta patología. Debido a la anatomía del sector afectado es necesario un abordaje interdisciplinario con otorrinolaringólogos a fin de poder realizar un buen planeamiento quirúrgico y evitar posibles complicaciones

OBJECTIVE: cranial mucocele are cystic lesions that were described in the XIX century. It develops from the paranasal sinus and it´s evolution depends upon the growth rate of the lesion. Classic mucocele is a lesion that grows from the paranasal sinus due to an obstruction of the sinus ostium. CASE REPORT: we present a 26 years old man with a 72 hrs. headache, fever, disorientation and behavioral alteration. The diagnosis was an infectious presentation of a frontal mucocele with intracranial extension. INTERVENTION: the case was discussed with the ORL department and it was decided to remove the frontal mucocele by a fronto-pterional approach. CONCLUSION: frontal mucocele is the most common variation of this pathology. Due to the anatomy of the zone it is important a multi-disciplinary approach with ORL, for the surgery approach could be better planed in order to avoid complications

Ossification of the ligamentum flavum as cause of thoracic cord compression: Case report of a Latin American man and review of the literature.

BACKGROUND: Ossification of the ligamentum flavum is a widely described pathology in eastern Asia. Cases have been reported in northern Africa, the Middle-East, India, the Caribbean, Europe, and North America, but no cases from Latin America have been published in the literature. It affects mostly elderly men, with a possible association with obesity and type 2 diabetes. CASE DESCRIPTION: A 38-year-old previously healthy Latin American male presented to the emergency room department with severe functional disability and a 3/5 paraparesis. Blood reports showed no abnormalities. Computed tomography and magnetic resonance imaging showed a ligamentum flavum ossification with myelopathy. The patient underwent a T3-T9 laminotomy. At hospital discharge, the patient remained with a 3/5 paraparesis, mild hypoesthesia in both lower limbs and bladder incontinence. Rectal sphincter was continent. At 6 months, he was able to walk with a cane, with no sphincter or sensory alterations. CONCLUSIONS: Ligamentum flavum ossification is rare. To our understanding, this is the first case reported in the Latin American population.