Fetoscopic two-layer closure of open neural tube defects.

OBJECTIVE: Fetoscopy for closure of open neural tube defects (NTD) remains controversial, as the use of patches or single-layer closure is not considered to meet the standards of good neurosurgical reconstruction. In this study, we describe a fetoscopic two-layer (myofascial and skin) closure technique for the treatment of NTD in five patients and report the preliminary anatomical outcome at birth. METHODS: From February to September 2017, five pregnant women with a fetus with a NTD, including three cases of myelomeningocele and two cases of myelocele, were operated on using a fetoscopic two-layer closure technique. In this technique, with the uterus exteriorized and using three 10-Fr ports, the placode is dissected from the surrounding tissue and detethered, removing the cystic tissue. The skin is undermined by blunt dissection and the defect is sutured to the midline in two layers (myofascial and skin) using a running 4/0 resorbable barbed suture. RESULTS: Median gestational age at the procedure was 24 + 3 (range, 23 + 5 to 27 + 3) weeks. Surgery was successful in all cases, without any intraoperative complications. Median time in surgery was 180 (range, 140-180) min and median time for fetoscopy was 105 (range, 65-120) min. In terms of obstetric complications, three cases of premature rupture of membranes and one case of chorioamnionitis were recorded. Median gestational age at delivery was 34 + 1 (range, 25 + 4 to 37 + 2) weeks and two patients delivered vaginally. The closed defect was watertight with good quality tissue in all cases. CONCLUSION: Fetoscopic two-layer closure of NTD may improve the quality of the tissue covering the defect, diminishing the need for postnatal surgical revision, and preserving the well-documented beneficial effects of prenatal closure on the neural tissue and hindbrain herniation. However, this technique may not be appropriate for those cases with wide diastasis of the myofascial layer or with a low quantity of available tissue. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Increased intracranial pressure in myelomeningocele (MMC) patients never shunted: results of a prospective preliminary study.

STUDY DESIGN: In some young adults non-shunted myelomeningocele (MMC) patients without symptoms or with unspecific clinical findings, moderate or severe stabilised ventriculomegaly are observed in control CT scans. Physicians are then faced with the so-called 'Arrested Hydrocephalus' (AH) syndrome. The present study is part of a prospective protocol in which patients with hydrocephalus associated with MMC and long-term clinical diagnosis of AH were included. OBJECTIVES: To evaluate myelomeningocele patients never shunted with clinical and/or CT scan criteria compatible with AH. SETTING: Multidisciplinary Spina Bifida Unit in a tertiary university hospital in Barcelona, Spain. METHODS: Fourteen MMC patients were selected, in all of them, continuous intracranial pressure (ICP) monitoring was performed. Analysis of the ICP records was done using the method described by Borgesen in mmHg. All patients were also studied by intelligence quotient (IQ) testing before and after shunting. RESULTS: The CT in all the study cases showed an Evans ratio

[A controlled, double-blind, randomized pilot clinical trial of nicardipine as compared with a placebo in patients with moderate or severe head injury]. / Ensayo clínico piloto, controlado, doblemente ciego, aleatorizado de nicardipino frente a placebo en pacientes afectados de traumatismo craneal grave o moderado.

INTRODUCTION: One of the factors involved in the occurrence of ischemic cerebral lesions following head injury is cerebral vasospasm. We analyze the effect of intravenous nicardipine on the prevention and treatment of posttraumatic cerebral vasospasm. PATIENTS AND METHODS: We made a placebo-controlled, randomised, double-blind pilot study of the effect of nicardipine (intravenously 5 mg/hour for one week) on patients with moderate or severe head injury who presented with cerebral vasospasm, defined as an average Doppler flow velocity (DFV) of 100 cm/second or more. The main variable assessed was the evolution of the DFV and the secondary criteria were the evolution of the arterial blood pressure, coma scales, the findings on the Glasgow Coma Scale and the safety of the drug. RESULTS: Eleven patients were included in each homogeneous group. The DFV was found to have become normal on the first day of treatment with nicardipine and on the third day with the placebo (p = 0.023). During the first day of treatment the percentage of cerebral hemispheres diagnosed as having suspected spasm was 11.1% for nicardipine and 64.3% for the placebo (p = 0.02881). The average time for recovery (DFV < 100 cm/second) was 3.33 days with the placebo and 1.22 days with nicardipine (p = 0.0039). The patients treated with nicardipine had 8.89 times more chance of recovery from vasospasm. The incidence of adverse effects was greater with the placebo (p = 0.014). CONCLUSION: Nicardipine is effective in the reversal and prevention of increased Doppler flow velocity in patients with moderate or severe head injury.

Ensayo clínico piloto, controlado, doblemente ciego, aleatorizado de nicardipino frente a placebo en pacientes afectados de traumatismo craneal grave o moderado / A controlled, doublé-blind, randomized pilot clinical trial of nicardipine as compared with a placebo in patients with moderate or severe head injury

Introducción y objetivo. Uno de los factores implicados en la aparición de lesiones isquémicas cerebrales tras un traumatismo craneal es el vasoespasmo cerebral. Se analiza el efecto de nicardipino iv en la prevención y tratamiento del vasoespasmo cerebral postraumático. Pacientes y métodos. Se trata de un estudio piloto, doblemente ciego, aleatorizado y controlado por placebo, del efecto de nicardipino (5 mg/h, durante una semana, iv) en pacientes con traumatismo craneal grave o moderado que presentan vasoespasmo cerebral, definido por una velocidad media Doppler de flujo (DFV) superior o igual a 100 cm/s. La variable principal de valoración fue la evolución de las DFV y las criterios secundarios fueron la evolución de la presión arterial, las escalas de coma y de resultados en la escala de Glasgow y la seguridad del fármaco. Resultados. Se incluyeron 11 pacientes en cada grupo homogéneo. Se observó la normalización de las DFV con nicardipino en el primer día de tratamiento y con placebo, al tercer día (p= 0,023). Durante el primer día de tratamiento el porcentaje de hemisferios con el diagnóstico de sospecha de espasmo fue del 11,1% para nicardipino y del 64,3% para placebo (p= 0,02881). El tiempo medio para la recuperación (DFV <100 cm/s) es de 3,33 días para placebo y de 1,22 días para nicardipino (p= 0,0039). Los pacientes tratados con nicardipino tuvieron una posibilidad de recuperación del vasoespasmo 8,89 veces superior. La incidencia de efectos adversos fue superior con placebo (p= 0,014). Conclusión. El nicardipino es eficaz en revertir y prevenir las velocidades Doppler elevadas en pacientes con traumatismo craneoencefálico moderado o grave (AU)

Introduction. One of the factors involved in the occurrence of ischemic cerebral lesions following head injury is cerebral vasospasm. We analyze the effect of intravenous nicardipine on the prevention and treatment of posttraumatic cerebral vasospasm. Patients and methods. We made a placebo-controlled, randomised, double-blind pilot study of the effect of nicardipine (intravenously 5 mg/hour for one week) on patients with moderate or severe head injury who presented with cerebral vasospasm, defined as an average Doppler flow velocity (DFV) of 100 cm/second or more. The main variable assessed was the evolution of the DFV and the secondary criteria were the evolution of the arterial blood pressure, coma scales, the findings on the Glasgow Coma Scale and the safety of the drug. Results. Eleven patients were included in each homogeneous group. The DFV was found to have become normal on the first day of treatment with nicardipine and on the third day with the placebo (p= 0.023). During the first day of treatment the percentage of cerebral hemispheres diagnosed as having suspected spasm was 11.1% for nicardipine and 64.3% for the placebo (p= 0.02881). The average time for recovery (DFV< 100 cm/second) was 3.33 days with the placebo and 1.22 days with nicardipine (p= 0.0039). The patients treated with nicardipine had 8.89 times more chance of recovery from vasospasm. The incidence of adverse effects was greater with the placebo (p= 0.014). Conclusion. Nicardipine is effective in the reversal and prevention of increased Doppler flow velocity in patients with moderate or severe head injury (AU)