Current State of Brazilian Neurosurgery: Evaluation of Burden of Care and Case Volume.

BACKGROUND: Low- and middle-income countries (LMICs) bear a heavier burden of neurosurgical diseases than high-income countries. Brazil, a growing middle-income country, holds promise as a health care market. However, there exists a lack of information to characterize the state of neurosurgical practice and access to care in Brazil. This study aimed to characterize neurosurgical practice in Brazil and identify barriers to care. METHODS: A collaborative survey was developed with Brazilian neurosurgeons and distributed by the Brazilian Society of Neurosurgery. The survey gathered demographic information, practice characteristics, case volume, referral patterns, income sources, and assessed barriers using a Likert scale. Descriptive statistics were employed for data analysis. RESULTS: One-hundred and forty-nine neurosurgeons participated (response rate: 17.5%), representing various states in Brazil. Neurosurgeons practiced in more than 4 different hospital systems on average, with most consultations and procedures occurring in public hospitals. Common procedures included tumor surgeries, general neurosurgery, spine surgeries, trauma surgeries, and hydrocephalus management. Equipment shortage and systemic issues were identified as major barriers to care. CONCLUSIONS: Neurosurgical practice in Brazil exhibits diverse age distribution, widespread distribution across states, and involvement in both public and private hospitals. Survey insights shed light on neurosurgical workload and neurosurgical practice characterization. Lack of equipment and inadequate postoperative resources pose significant barriers to care. The findings highlight the need for investments in equipment, critical care facilities, and improved health care system coordination to enhance access to neurosurgical care in Brazil.

Ictal fear is associated with anxiety symptoms and interictal dysphoric disorder in drug-resistant mesial temporal lobe epilepsy.

Interictal dysphoric disorder (IDD) is a poorly understood psychiatric disorder of epilepsy patients. Interictal dysphoric disorder is characterized by depressive, somatoform, and affective symptoms observed in up to 5.9% of drug-resistant mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS). This study aimed to evaluate the association between ictal fear (IF) and the psychiatric symptoms and diagnosis in MTLE-HS patients. We included 116 (54.3% male) consecutive adult patients (36 ±â€¯11 years) with MTLE-HS. Anxiety and depression symptoms were evaluated by the Hospital Anxiety and Depression Scale (HADS) and the psychiatric diagnosis were according to Fourth Edition of the Diagnosis and Statistical Manual of Mental Disorders (DSM-IV). The independent association between the occurrence of IF aura and the psychiatric diagnosis was determined by binary regression. When compared to those with other auras or without aura, patients reporting IF have higher HADS anxiety, but not HADS depression, scores. Ictal fear was independently associated with the diagnosis of interictal dysphoric disorder (OR, IC 95% = 7.6, 1.3-43.2, p = 0.02), but not with the diagnosis of anxiety (OR, CI 95% = 0.72, 0.08-6.0, p = 0.73), depression (OR, CI 95% = 0.94, 0.19-4.8, p = 0.94) or psychotic disorders (p = 0.99). Only patients with drug-resistant MTLE-HS were included and the small number of cases with DD diagnosis in the sample. In MTLE-HS patients, the occurrence of IF is associated with higher levels of anxiety symptoms and IDD. The results provide insights about fear-related neural network connections with anxiety symptoms and the IDD in MTLE-HS.

How predictable is cognitive performance in Brazilian patients with pharmacoresistant mesial temporal lobe epilepsy?

OBJECTIVE: The objective of the study was to investigate the independent association between clinical, demographic, psychiatric, radiologic, electrophysiological, and pharmacologic variables and cognitive performance of Brazilian patients with pharmacoresistant mesial temporal lobe epilepsy (MTLE). METHODS: Ninety-three patients with pharmacoresistant MTLE related to hippocampal sclerosis (HS) were included in the study. Multiple linear regressions were done to identify predictor variables for 24 cognitive tests. Independent variables analyzed were sex, hand dominance, age, years of education, marital status, work activity, history for an initial precipitant injury (IPI), family history of epilepsy, lesion side, antiseizure medication (ASM) treatment type, ASM serum levels, benzodiazepine (BDZ) treatment, age at epilepsy onset, disease duration, monthly frequency of seizures, and Hospital Anxiety and Depression Scale (HADS) scores. RESULTS: Years of education was an independent and positive predictor in 22 of the 24 cognitive tests evaluated. Male sex was also a positive predictor of one cognitive test. Variables negatively associated with cognitive performance were left side lesion (10 tests), disease duration (5 tests), polytherapy (3 tests), ASM serum levels (3 tests), and BDZ treatment or not working (1 test each). The regression model explained between 6% and 44% of the cognitive test scores variation. SIGNIFICANCE: In Brazilian patients with pharmacoresistant MTLE-HS, up to 44% of cognitive test scores variation is predictable by clinical, demographic, psychiatric, radiologic, electrophysiology, and pharmacological variables. The identification of predictors of cognitive performance may be helpful for better planning of patient care.

Predictors of Pain Recurrence After Lumbar Facet Joint Injections.

INTRODUCTION: Facet joint injections (FJIs) of anesthetic and corticosteroids are useful for the diagnosis and treatment of low back pain (LBP). In the current study, we evaluated the efficacy of FJI on LBP treatment and the predictive variables of pain recurrence after FJI. METHODS: We included and followed prospectively forty-three consecutive patients with chronic LBP treated with FJI. Clinical assessments were carried out at a baseline 1 week before FJIs and after a 6-month follow-up visit using the visual analog scale (VAS) for pain, Oswestry Disability Index (ODI) for disability-specific measure and MacNab criteria for global effectiveness, and compared through analysis using paired-samples "t" tests. Multiple cox-regression analysis was used to identify the presurgical variables independently associated with pain recurrence anytime during the follow-up. In addition to the demographic, clinical, and surgical data, we also analyzed psychometric scales: Pain Catastrophizing Scale (PCS), Beck Anxiety Inventory (BAI), and Beck Depression Inventory (BDI). RESULTS: After a 6-month follow-up, thirty-two patients (74.4%) showed a clinically significant reduction of pain and twenty-seven (62.8%) reported a clinically significant improvement of disability. Presurgical catastrophizing (PCS score ≥ 5, adjusted HR 4.4, CI 95% 1.7-11.3, p = 0.002) and smoking (Adjusted HR 12.5, CI 95% 1.1-138.9, p = 0.04) remains associated with pain recurrence. CONCLUSION: FJI reduces LBP and disability of patients with unresponsive LBP. Pain-related cognitive and behavioral factors determined by pain catastrophizing and smoking were independently associated with pain recurrence after lumbar FJI. The results support the need of a multidisciplinary approach for presurgical evaluation of patients with chronic pain.

Determinants for Meaningful Clinical Improvement of Pain and Health-Related Quality of Life After Spinal Cord Stimulation for Chronic Intractable Pain.

OBJECTIVES: Previous studies demonstrated significant improvement in mean pain scores and quality of life (QOL) scales in patients with chronic pain who underwent spinal cord stimulation (SCS). However, the number of individuals who experience relevant improvements in QOL, termed the meaningful clinical improvement (MCI), is not known. The present study investigated changes in pain measurements based on MCI after SCS. MATERIALS AND METHODS: Thirty-four patients with chronic intractable pain completed scales of pain (visual analogue scale [VAS]), QOL (SF-36), and psychological dimensions during a 22-month follow-up period (mean). Patient-centered MCI of the VAS and SF-36 domain scores were determined based on the MacNab criteria of surgical global effectiveness. Independent presurgical predictors for MCI in the VAS and SF-36 domains were analyzed using multiple binary logistic regression. RESULTS: There was significant improvement of pain and QOL after the SCS (p < 0.00001). Twenty-three patients (67.6%) reached an MCI of pain, and 16 (47.7%)-23 (67.7%) reported an MCI of QOL. Predictors of MCI included ≥80% paresthesia coverage of the painful area, lower levels of anxiety and catastrophizing symptoms, shorter pain duration, female gender and no use of opioids before surgery. MCI of pain and QOL was observed in 50%-70% of patients with chronic pain after SCS. CONCLUSIONS: The identification of determinants for MCI is a challenge to improve the accuracy of prognostic models in SCS for patients with chronic pain. Our results, if confirmed in other populations with a larger sample size, have implications for patients with chronic pain who are candidates for SCS treatment.

Electrochemotherapy to Metastatic Spinal Melanoma: A Novel Treatment of Spinal Metastasis?

STUDY DESIGN: Preliminary report of new antitumor treatment. OBJECTIVE: To evaluate the effectiveness of electrochemotherapy as a novel treatment of spinal metastasis. SUMMARY OF BACKGROUND DATA: Electrochemotherapy is a new antitumor treatment that combines systemic bleomycin with electric pulses delivered locally at the tumor site. These electric pulses permeabilize cell membranes in the tissue, allow bleomycin delivery diffusion inside the cells, and increase bleomycin cytotoxicity. Previous clinical studies have demonstrated the effectiveness of electrochemotherapy in the treatment of several primary and metastatic solid tumors. METHODS: Treatment planning for electrode positioning and electrical pulse parameters was prepared for 4 needle electrodes. Mini-open surgery with a left L5 laminectomy was performed to introduce the eletrodes. The patient was treated according to the established Electrochemotherapy Protocol with Bleomycin. Clinical efficacy of electrochemotherapy was evaluated according to a visual analog scale of pain, Oswestry Disability Index 2.0, the Karnofsky Performance Scale, and Response Evaluation Criteria in Solid Tumors. RESULTS: The assessed follow-up period was 48 months after the electrochemotherapy procedure. Neither serious electrochemotherapy-related adverse events, nor bleomycin toxicity were reported. Overall improvement in pain according to Oswestry Disability Index 2.0 and Karnofsky Performance Scale outcomes was better. CONCLUSION: Our case represents, to our knowledge, the first one to test the potential role of electrochemotherapy as treatment of spinal metastasis. Electrochemotherapy allowed a successful treatment of metastatic spinal melanoma. However, we believe that there is a strong scientific rationale to support the potential utility of electrochemotherapy as a novel treatment of spinal metastasis, regardless of the histological types. LEVEL OF EVIDENCE: 5.

Case report: Curetting osteoid osteoma of the spine using combined video-assisted thoracoscopic surgery and navigation.

BACKGROUND: A spinal osteoid osteoma is a rare benign tumor. The usual treatment involves complete curettage including the nidus. In the thoracic spine, conventional open surgical treatment usually carries relatively high surgical risks because of the close anatomic relationship to the spinal cord, nerve roots, and thoracic vessels, and pulmonary complications and postoperative pain. CASE REPORT: We report the case of a 16-year-old girl with a symptomatic osteoid osteoma at the T9 level whose lesion was currettaged using video-assisted thoracoscopic surgery (VATS) guided by a navigation system (VATS-NAV). There were no complications and the patient had immediate relief of the characteristic pain after surgery and was asymptomatic at 5 months' followup. LITERATURE REVIEW: Progressive advances in the technology of spinal surgery have evolved to offer greater safety and less morbidity for patients. The advent of minimally invasive surgery has expanded the indications for VATS for anterior spinal disorders. Spinal navigation systems have become useful tools allowing localization and excision of the nidus of osteoid osteomas with minimal bone resection and without radiation exposure. CLINICAL RELEVANCE: The VATS-NAV combination in our patient allowed accurate localization and guidance for complete excision of a spinal osteoid osteoma through a minimally invasive approach without compromising spinal stability.

Bilateral subthalamic nucleus stimulation for generalized dystonia after bilateral pallidotomy.

BACKGROUND: Thalamotomies and pallidotomies were commonly performed before the deep brain stimulation (DBS) era. Although ablative procedures can lead to significant dystonia improvement, longer periods of analysis reveal disease progression and functional deterioration. Today, the same patients seek additional treatment possibilities. METHODS: Four patients with generalized dystonia who previously had undergone bilateral pallidotomy came to our service seeking additional treatment because of dystonic symptom progression. Bilateral subthalamic nucleus DBS (B-STN-DBS) was the treatment of choice. The patients were evaluated with the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) and the Unified Dystonia Rating Scale (UDRS) before and 2 years after surgery. RESULTS: All patients showed significant functional improvement, averaging 65.3% in BFMDRS (P = .014) and 69.2% in UDRS (P = .025). CONCLUSIONS: These results suggest that B-STN-DBS may be an interesting treatment option for generalized dystonia, even for patients who have already undergone bilateral pallidotomy.

Trigeminal Neuralgia due to Vertebrobasilar Dolichoectasia.

We presented a case of drug-resistant trigeminal neuralgia attributed to vertebrobasilar dolichoectasia, a rare condition characterized by enlargement, tortuosity, or elongation of intracranial arteries. Dolichoectatic vessels can cause dysfunction of cranial nerves through direct vascular compression. The relationships of vertebrobasilar dolichoectasia with the particularities of neurovascular conflict and images findings are discussed.

Spinal intradural arteriovenous fistula mimicking intramedullary tumor and associated with a giant intracranial aneurysm / Fístula arteriovenosa intradural espinhal mimetizando tumor intramedular e associado com aneurisma intracraniano gigante

Spinal intradural arteriovenous fistulas (AVFs) are a rare type of neurovascular malformation. Many a time hemodynamic disturbs associated to these entities can cause edema with subsequent myelopathy. On MRI study, this edema can mimic an intramedullary tumor. We report a rare case of spinal intradural AVFs mimicking an intramedullary tumor, which also were surprisingly associated with a giant intracranial aneurysm. We highlight in detail the MRI findings in intramedullary lesions, and also emphasize that these entities requires as careful differential diagnosis as supplementary investigation of the neuroaxis looking for other simultaneous neurovascular pathologies.

Fístulas arteriovenosas espinhais intradurais são um tipo raro de malformação neurovascular. Muitas vezes, distúrbios hemodinâmicos associados a essa entidade podem causar edema com subsequente mielopatia. Em estudos de ressonância magnética, esse edema pode mimetizar um tumor intramedular. Relata-se um caso raro de fistula arteriovenosa espinhal intradural mimetizando um tumor intramedular, que também estava associado a um aneurisma cerebral gigante. Destacam-se em detalhes os achados de RM nas lesões intramedulares, assim como se enfatiza que essas entidades requerem tanto um diagnóstico diferencial criterioso quanto uma investigação complementar do neuroeixo procurando por outras patologias neurovasculares associadas.

Infarto cerebral hemisférico: algoritmo de tratamento baseado em evidência / Hemispheric ischemic stroke: evidence-based management algorithm

O infarto cerebral hemisférico maligno tem mortalidade de 80%, apesar do tratamento conservador. Ele representa infarto de mais de 50% do território da artéria cerebral média (ACM), entretanto, nem todos os pacientes irão desenvolver o curso maligno. O objetivo desta revisão foi encontrar os fatores preditivos do curso maligno do edema cerebral maligno e, a partir desses fatores, propor um algoritmo de tratamento e tomadas de decisões para o infarto cerebral hemisférico. Os preditores foram pesquisados em artigos no PubMed. Com base nos preditores encontrados com valor estatístico significativo, estruturou-se um algoritmo de gerenciamento para o infarto cerebral hemisférico. Os fatores preditivos de curso maligno foram: NIHSS > 15 hemisfério dominante e > 20 não dominante; oclusão da artéria carótida interna (ACI) ipsilateral à malformação do círculo de Willis; circulação colateral deficiente; tomografia computadorizada (TC) hipodensidade > 50% e ressonância magnética (RM) difusão > 145 cm3 do território da ACM; outro território vascular envolvido; perda da autorregulação; potencial evocado auditivo patológico; pressão intracraniana (PIC) > 35 mmHg e valores de pico de aminoácidos excitatórios medidos na microdiálise. Entretanto, esses dois últimos fatores aparecem apenas depois que o paciente está herniado. Os trials europeus definiram nível de evidência 1 para craniectomia descompressiva. Craniectomia descompressiva é o tratamento de primeira escolha para os pacientes < 60 anos com curso maligno do infarto hemisférico < 48h. Os fatores preditivos são importantes ferramentas para tomada de decisão quanto à indicação cirúrgica precoce.

Massive hemispheric infarctions (MHI) constitute 10% of all ischemic strokes and have a mortality rate of 80%, under conservative treatment. This stroke presents a hypodensity covering more than 50% of the middle cerebral artery (MCA) territory, however, not all the patients develop the malignant course of hemispheric infarctions. The goal of this study was to determine the predictors of fatal brain edema and to propose an evidence-based management algorithm. Search for predictors of MHI with malignant edema was performed in PubMed and Cochrane data base. An evidence-based management algorithm was structured from this study. Different predictors of fatal brain edema formation have been identified: NIHSS > 15 dominant and > 20 non dominant hemisphere; carotid occlusion with abnormal ipsilateral circle of Willis; collateral deficit; early computed tomography (CT) hypodensity involving > 50% or DWI > 145 cm3 of the MCA territory; involvement of additional vascular territories; impaired cerebral autoregulation; pathological auditory potentials evoked; ICP > 35 mmHg; microdialysis with peak values of the excitatory amino acids. Decompressive hemicraniectomy is the first choice to treatment for MHI with malignant brain edema in patients > 60 years and < 48 hours after stroke. To know predictors with evidence level are important tools to make decision about surgical indication.

A prospective study of 39 patients with trigeminal neuralgia treated with percutaneous balloon compression.

OBJECTIVE: Trigeminal neuralgia is the most common facial pain. It may be treated with percutaneous balloon compression (PBC), which is considered to be a safe and efficient procedure. The purpose of this study was to review our results with PBC and to assess the factors influencing the outcome. METHOD: A multivariate analysis was used to study 39 patients during a 50-month postoperative period. RESULTS: There was predominance of the female gender (54%), the right side of the face (84%) and V2V3 roots of trigeminal nerve (33%). The mean age was 62.3 years. No major complications or deaths occurred. Among all variables, postoperative hypoesthesia was the single prognostic factor capable of positively influencing the results (p=0.02). Most patients (80%) were pain-free after 50 months with a 90% satisfaction rate. CONCLUSION: PBC was a safe procedure with low morbidity, no mortality, high approval ratings, and was an important improving on patients' quality of life.

A prospective study of 39 patients with trigeminal neuralgia treated with percutaneous balloon compression / Estudo prospectivo de 39 pacientes com neuralgia do trigêmeo tratados com compressão por balão percutâneo

OBJECTIVE: Trigeminal neuralgia is the most common facial pain. It may be treated with percutaneous balloon compression (PBC), which is considered to be a safe and efficient procedure. The purpose of this study was to review our results with PBC and to assess the factors influencing the outcome. METHOD: A multivariate analysis was used to study 39 patients during a 50-month postoperative period. RESULTS: There was predominance of the female gender (54 percent), the right side of the face (84 percent) and V2V3 roots of trigeminal nerve (33 percent). The mean age was 62.3 years. No major complications or deaths occurred. Among all variables, postoperative hypoesthesia was the single prognostic factor capable of positively influencing the results (p=0.02). Most patients (80 percent) were pain-free after 50 months with a 90 percent satisfaction rate. CONCLUSION: PBC was a safe procedure with low morbidity, no mortality, high approval ratings, and was an important improving on patients' quality of life.

OBJETIVO: A neuralgia do trigêmeo é a dor facial mais comum. Ela pode ser tratada através da compressão percutânea com balão, que é considerado procedimento seguro e eficaz. A proposta deste estudo foi avaliar nossos resultados e os fatores que influenciariam o seguimento. MÉTODO: Foi utilizada análise multivariada para estudar 39 pacientes submetidos ao procedimento, com seguimento de 50 meses. RESULTADOS: Houve predominância do sexo feminino (54 por cento), lado direito (84 por cento) e dos ramos V2V3 (33 por cento). A idade média foi de 62,3 anos. Não houve complicações maiores ou óbito. Dentre todas as variáveis, a única capaz de influenciar positivamente os resultados foi a hipoestesia pós-operatória (p=0,02). A maioria dos pacientes (80 por cento) estava livre da dor após 50 meses de seguimento, com 90 por cento de satisfação. CONCLUSÃO: Este procedimento foi considerado seguro, com baixa morbidade, sem mortalidade, com alta taxa de aprovação e representou melhora importante na qualidade de vida dos pacientes.

Sporadic intramedullary spinal cord hemangioblastoma in a newborn.

BACKGROUND: Hemangioblastomas (HB) are rare lesions accounting for 2% of all spinal cord tumors. They are highly vascular, benign tumors that occur either sporadically or in the presence of von Hippel-Lindau disease. Spinal cord HB are usually diagnosed in adult patients and their incidence in early infancy is an extreme rarity. METHODS: We present a case of a 1-month-old male with a back deformity and left leg hypomotility. MRI of the spine revealed an intramedullary tumor extending from level T6 to T12. RESULTS: The tumor was excised completely, using standard microsurgical techniques via a posterior approach. The histological diagnosis was spinal cord HB. CONCLUSION: A review of the literature revealed that this neoplasm is composed of 3 major cell types: endothelial cells, pericytes and stromal cells. Complete microsurgical removal is the treatment of choice for spinal cord HB because the tumor is benign. To the best of our knowledge, sporadic spinal cord HB at this age has not been reported so far.