Derivo Embolization Device for the Treatment of Intracranial Aneurysms.

Background and Purpose- Flow diverter technology improvements are necessary to provide safe and good results and enable the treatment of a larger variety of aneurysms. We report a nationwide experience with the Derivo Embolization Device in the treatment of intracranial aneurysms. Methods- BRAIDED (Brazilian Registry of Aneurysms Assigned to Intervention With the Derivo Embolization Device) is a multicenter, prospective, interventional, single-arm trial of the Derivo Embolization Device for the treatment of intracranial aneurysms. The primary effectiveness end point was total aneurysm occlusion at 6- and 12-month angiographies. The secondary safety end point was the absence of serious adverse events during follow-up. Univariable and multivariable logistic regression was performed to identify predictors of aneurysm persistence, periprocedural complications, and adverse events during follow-up. Results- Between December 2016 and October 2018, 146 patients harboring 183 intracranial aneurysms were treated in 151 interventions at 7 centers. Derivo Embolization Device placement was technically successful in all patients. Most aneurysms (86.9%) were located at the internal carotid artery, and the mean diameter was 6.7 mm. At 6 months, 113 of 140 (80.7%) aneurysms met the study's primary end point, and 74 of 83 (89.2%) met the study's primary end point at 12 months. Saccular morphology of the aneurysm (odds ratio, 5.66; 95% CI, 1.01-31.77) and the presence of a branch arising from the sac (odds ratio, 6.36; 95% CI, 2.11-22.36) predicted persistence. A long duration of follow-up (odds ratio, 0.86; 95% CI, 0.78-0.95) predicted total occlusion. Of the 146 enrolled patients, 138 (94.5%) were treated without serious adverse events during follow-up. In the multivariable analysis, aneurysms located at a sidewall were less likely to experience these events than those located at bifurcations (odds ratio, 0.07; 95% CI, 0.01-0.51). Conclusions- The Derivo Embolization Device is a safe and effective treatment for intracranial aneurysms. Clinical Trial Registration- URL: http://plataformabrasil.saude.gov.br/login.jsf. Unique identifier: CAAE 77089717.7.1001.5125.

The role of coagulopathy on clinical outcome following traumatic brain injury in children: analysis of 66 consecutive cases in a single center institution.

INTRODUCTION: Head injury is a significant economic, social, and medical problem in developing countries and remains one of the leading causes of pediatric morbidity and mortality. The association of traumatic brain injury and coagulopathy in children is linked with an increase in mortality and poor functional outcomes. However, its impact on long-term outcome has not been discussed in the literature so far. OBJECTIVES: The aim of this paper was to investigate the effect of coagulopathy diagnosed by routine laboratory tests on neurological outcome following traumatic brain injury in children. METHODS: A retrospective review was carried out using medical records of children with a traumatic brain injury admitted at a level I trauma center, between January 2013 and December 2016, submitted to any neurosurgical procedures. Statistical analysis was performed accordingly to identify factors predicting unfavorable or favorable outcomes at 1- and 6-month follow-ups. Data regarding age, gender, trauma mechanism, Glasgow Coma Scale at admission and at discharge, highest and lowest stable intracranial pressure, serum glucose and coagulation assessment, radiological findings, and length of stay were analyzed. RESULTS: We identified 66 children with surgical head trauma. Mean age was 10.9 years (ranges from 3 months to 17 years), with male predominance (77.3%). Common mechanisms were road traffic accidents (66.7%), falls (19.7%), and blunt trauma (10.6%). Brain edema was detected in 68.2% of the patients, surgical fractures or intracranial bleeding in 75.8%. ICP monitoring was performed in 24.2% of the patients, and of these, 18.7% underwent consecutive decompressive craniectomy. Mean length of in-patient treatment was 16.3 ± 28.2 days. At 1- and 6-month follow-ups, favorable outcome was detected in 71.2 and 78.7% of the patients, respectively. The mortality rate was 12.1%. Routine coagulation assessments such as prothrombin time, fibrinogen levels, and thrombocyte count upon admission were potential prognostic variables identified. CONCLUSIONS: The present study concluded that a trauma-related coagulopathy is an important predictor of unfavorable neurological outcome following TBI in pediatric patients. Initial GCS score, age, and neuroradiological findings, such as severe brain edema and different types of intracranial bleeding, correlated with GOS in the first 6 months following TBI. Sustained intracranial hypertension also predicted unfavorable outcome and death in this series.

Pediatric neurocysticercosis.

BACKGROUND: Neurocysticercosis (NCC) is an infestation of the nervous system caused by encysted larvae of Taenia solium. NCC is an important acquired cause of epilepsy and other neurological manifestations especially in endemic areas. NCC in children has pleomorphic manifestations depending on the location, number, viability of the cysts, and host response. Even with advancing knowledge of the disease manifestations, many aspects related to diagnosis and treatment, particularly in children, still remain controversial and pose challenges to clinical practice. There is no gold standard test to diagnose NCC and the management recommendations are still emerging. This review provides an overview of diagnosis of NCC in children and its management with special focus on current challenges and future prospects. DISCUSSION: In developing countries, NCC is important not only because of its frequency but also because of high morbidity and mortality rates associated, especially in cases in which it progresses to increased intracranial pressure. Because of its pleomorphic presentation, NCC should be considered in the differential diagnosis of a number of neurological conditions. Treatment with cysticidal therapy leads to reduction in seizure frequency and a faster resolution of lesions. CONCLUSIONS: We have summarized the current approaches to diagnosis and treatment of NCC, recent advances in understanding the biology of NCC, and how one can take advantage of these new insights to formulate the next generation of clinical trials.

Hypertrophic olivary degeneration in children after posterior fossa surgery. An underdiagnosed condition.

BACKGROUND: Hypertrophic olivary degeneration (HOD) is a rare transsynaptic form of degeneration occurring after injury to the dentato-rubro-olivary pathway ("Guillain-Mollaret triangle"). The majority of studies have described HOD resulting from posterior fossa (PF) hemorrhage or infarction. HOD in patients undergoing PF surgery has not been well characterized. These lesions are rare and symptomatic children with HOD are even more uncommon. The purpose of this study was to evaluate HOD that develops after PF operations in children. MATERIALS AND METHODS: A literature review was carried out describing 37 pediatric cases of HOD in 13 articles. In addition, two new cases of our own experience were included. CONCLUSIONS: HOD is a rare complication related after PF tumors surgery and symptoms may be misdiagnosed with pediatric cerebellar mutism syndrome. Children with HOD usually do not develop palatal tremor but ataxia is common.

The supraorbital eyebrow approach for removal of craniopharyngioma in children: a case series.

OBJECTIVE: Craniopharyngiomas can be a surgical challenge for the pediatric neurosurgeon. Ideally, total removal must be achieved. However, the need to reduce surgical morbidity and preserve quality of life has led to a number of neurosurgical approaches in order to attain this goal. The aim of this article is to present an alternative surgical approach to these lesions and to provide the rationale for this technique. MATERIAL AND METHODS: Medical charts and operative records of eight pediatric patients harboring craniopharyngiomas who underwent surgical treatment using a supraorbital eyebrow approach (SOA) were reviewed from 2014 to 2016. Only patients younger than 18 years with a minimum follow-up of 12 months were included in this study. Using pre-operative magnetic resonance (MRI) scans, tumors were classified according to their degree of hypothalamic involvement. The surgical technique is also described in detail. RESULTS: The study group included six males and two females with a mean age of 10 years (range, 2-16 years). The SOA was used successfully in elective surgery of eight craniopharyngiomas. The hypothalamus was displaced by the tumor in three patients and severely involved in five patients. Subtotal resection was undertaken in six patients, whereas gross-total resection was achieved in two. Endoscopic assistance was used after standard microscopic visualization in two out of eight cases. Cosmetic outcomes were excellent, and the complication rate related to the surgical procedure was quite low, apart from diabetes insipidus (which occurred in three out of the eight patients). In one patient, a large subdural collection needed surgery for evacuation. Mean follow-up was 23.2 months (range, 12-36 months). Additionally, no CSF leak or wound infection was identified. CONCLUSIONS: The supraorbital eyebrow approach is an alternative route to operate on craniopharyngiomas in properly selected cases of all pediatric age ranges, from infants to teenagers. There is sufficient working space for the endoscope and all instruments, allowing for endoscopic assistance and bimanual surgical technique. Cosmetic results are excellent, and complications related to the approach are minimal.

Extending the indications for transvenous approach embolization for superficial brain arteriovenous malformations.

INTRODUCTION: Transarterial embolization is the standard endovascular treatment strategy for intracranial arteriovenous malformations (AVMs). The transvenous approach has been indicated for the embolization of deep AVMs meeting a set of strict eligibility criteria. The present study aims to assess the safety and efficacy of the transvenous approach for superficial AVMs. METHODS: A retrospective series of 12 patients presenting with cortical AVMs were treated by endovascular embolization using a transvenous approach with a curative intent. RESULTS: Nine patients (75%) had ruptured AVMs at admission. The mean nidus size was 1.9 cm, six patients (50%) had a nidus in eloquent areas and the median Spetzler-Martin grade was 2. The rate of immediate angiographic occlusion of the AVMs was 91.6% (11/12). One patient in whom immediate angiographic occlusion was not achieved showed spontaneous occlusion at the 6-month follow-up. No procedural or clinical complications were observed. The mean and median modified Rankin scale (mRS) scores at discharge were 1.7 and 2 (range 0-3, SD=0.96), and the mean and median mRS scores at 6 months were 1.6 and 2 (0-3, 1.16). Nine patients (75%) were independent (mRS ≤2) at discharge and 11 patients (91.6%) were independent (mRS ≤2) at the 6-month follow-up. CONCLUSIONS: The curative transvenous embolization of superficial intracranial AVMs is feasible and appears safe and effective when strict anatomical selection is respected. This technique extends the current indications for transvenous embolization of intracranial AVMs and may improve cure rates while reducing embolization-related complications.

Acidente vascular cerebral hemorrágico decorrente de ofidismo por bothrops sp: relato de caso / Hemorrhagic stroke due to bothrops sp snakebite: case report

Objetivo: relatar um caso de hemorragia cerebral consequente a ofidismo por serpente Bothrops sp. Relato do caso: mulher de 62 anos vítima de acidente ofídico por serpente do gênero Bothrops, evoluiu com quadro de hemorragias sistêmicas, déficit neurológico focal e rebaixamento do nível de consciência. Tomografia de crânio revelou hematomas cerebrais intraparenquimatosos. Recebeu soroterapia antibotrópica e suporte clínico, apresentando boa recuperação. Considerações Finais: distúrbios hemorrágicos decorrente de ofidismo são causas potenciais de acidente vascular cerebral.

Purpose: to report a case of cerebral hemorrhage resulting from ophidism by Bothrops sp snake. Case report: a 62-year-old woman, victim of snakebite by Bothrops sp, evolved with systemic hemorrhage, focal neurologic deficit and declining level of consciousness. Tomography of the brain revealed cerebral intraparenchymal hematoma. The victim received bothropic antivenom and clinical support, presenting good recovery. Final considerations: bleeding disorders caused by snakebite are potential causes of stroke.

Atresia duodenal associada a pâncreas anular: relato de caso / Duodenal atresia combined with annular pancreas: a case report

relatar o caso de um recém-nascido com síndrome de obstrução intestinal alta e múltiplas anomalias congênitas associadas. Relato do caso: neonato, pré-termo, apresentou quadro de vômitos biliosos e distensão abdominal progressiva, evoluindo com aspiração de conteúdo intestinal.Radiografia simples de abdome revelou o sinal da "dupla bolha". Foi submetido à laparotomia exploradora que identificou atresia duodenal e pâncreas anular associados à má-rotação intestinal. Realizou-se duodenojejunostomia com melhora do quadro clínico do paciente e evolução assintomática. Considerações Finais: a atresia duodenal e o pâncreas anular são importantes causas de obstrução intestinal neonatal e a combinação de ambas é rara.

to report the case of a newborn with intestinal obstruction syndrome and multiple congenital anomalies associated. Case Report: neonate, preterm, presented bilious vomiting and progressive abdominal distension,which evolved to aspiration of intestinal contens. Abdominal plain film showed the "double bubble" sign. The patient underwent an exploratory laparotomy that revealed duodenal atresia and annular pancreas associated with intestinal malrotation. Duodenojejunostomy was performed, with clinical condition improvement, whichevolved without symptoms. Final considerations: the annular pancreas and duodenal atresia are important causes of neonatal intestinal obstruction and the combination of both is rare.

Fístula bilio-pleuro-brônquica associada à doença de Caroli / Bilio-pleuro-bronchial fistula associated with Caroli's disease

Objetivo: relatar um caso de fístula bilio-pleuro-brônquica em um paciente portador de Doença de Caroli. Relato do caso: homem de 37 anos, com história de quadro grave de colangite há seis anos, quando foi submetido à derivação biliodigestiva, após diagnóstico de Doença de Caroli. Evoluiu com vários episódios de colangite e, recentemente, apresentou sinais de hepatopatia crônica e sintomas pneumônicos, apresentando posteriormente bilioptise. Exames de imagem revelaram a presença de abscesso pulmonar direito, múltiplos abscessos hepáticos e a existência de um trajeto fistuloso entre a via biliar intra-hepática e a árvore brônquica. Realizou-se pleurostomia em hemitórax direito e alça de Fung que possibilitaram a resolução do quadro. Considerações finais: a doença de Caroli pode apresentar-se com colangite que demonstrou ser fator predisponente a formação de fistula biliopleuro-brônquica.

Objective: to report the case of a patient with Caroli's disease who had developed bilio-pleuro-bronchial fistula. Case report: six years ago, a 37-year-old male presented with a severe picture of cholangitis when he underwent bilioenteric derivation after diagnosis of Caroli's disease. He developed several episodes of cholangitis, chronic hepatopathy and pneumonic symptoms, presenting bilioptysis later. Detection images revealed an abscess cavity in the right lung, multiple hepatic abscesses and a fistula connecting the bronchial tree and the intrahepatic biliary tract, through the diaphragm. It was performed pleurostomy on the right hemitorax and loop's Fung that made possible the clinical improvement. Final considerations: the Caroli's disease can come as cholangitis that demonstrated to be predisposing factor to formation of bilio-pleuro-bronchial fistula.