Awake craniotomy for eloquent pial arteriovenous fistula: anesthetic and surgical consideration of a rare case

Abstract Intracranial pial Arteriovenous Fistulas (AVFs) are rare cerebral vascular lesions composed of one or more arterial connections to a single venous channel. We report a 50-year-old patient with a ruptured pial AVF located in an eloquent area. Microsurgery for pial AVF occlusion was proposed with awake craniotomy for motor function and neurological evaluation. Awake craniotomy is a technique that is especially useful for cerebral vascular lesions in eloquent areas, where an occlusion often compromises or suppresses the blood supply, culminating in ischemia with consequent transient or definitive deficits in neurological function.

An economic study of neuro-oncological patients in a large developing country: a cost analysis.

BACKGROUND: Neuro-oncological patients require specialized medical care. However, the data on the costs incurred for such specialized care in developing countries are currently lacking. These data are relevant for international cooperation. OBJECTIVE: The present study aimed to estimate the direct cost of specialized care for an adult neuro-oncological patient with meningioma or glioma during hospitalization in the largest philanthropic hospital in Latin America. METHODS: The present observational economic analysis describes the direct cost of care of neuro-oncological patients in Santa Casa de São Paulo, Brazil. Only adult patients with a common primary brain tumor were included. RESULTS: Due to differences in the system records, the period analyzed for cost estimation was between December 2016 and December 2019. A group of patients with meningiomas and gliomas was analyzed. The estimated mean cost of neurosurgical hospitalization was US$4,166. The cost of the operating room and intensive care unit represented the largest proportion of the total cost. A total of 17.5% of patients had some type of infection, and 66.67% of these occurred in nonelective procedures. The mortality rate was 12.7% and 92.3% of all deaths occurred in emergency procedures. CONCLUSIONS: Emergency surgeries were associated with an increased rate of infections and mortality. The findings of the present study could be used by policymakers for resource allocation and to perform economic analyses to establish the value of neurosurgery in achieving global health goals.

ANTECEDENTES: Pacientes neuro-oncológicos demandam tratamento médico especializado. Em países em desenvolvimento, há falta de dados sobre custos em neurocirurgia. Estes dados são relevantes para ajudar na cooperação internacional. OBJETIVO: O presente estudo objetiva estimar o custo direto de um paciente neuro-oncológico adulto com meningioma ou glioma durante sua internação no maior hospital filantrópico da América Latina. MéTODOS: A presente análise econômica observacional descreve os custos diretos de um paciente neuro-oncológico da Santa Casa de São Paulo. Apenas pacientes adultos e com os dois tumores cerebrais primários mais comuns foram considerados. RESULTADOS: Devido a uma mudança no sistema de prontuários, para análise de custos o período analisado foi de dezembro de 2016 a dezembro de 2019. Uma amostra significativa de pacientes com gliomas e meningiomas foi analisada. O custo médio da hospitalização foi de U$ 4.166. O tempo de sala cirúrgica e os cuidados em terapia intensiva representaram a maior proporção dentro do custo total. Um total de 17.5% dos pacientes teve algum tipo de infecção e 66.67% delas ocorreram em procedimentos não eletivos. A taxa de mortalidade foi de 12.5% e 92.3% dos óbitos ocorreram em procedimentos de urgência. CONCLUSõES: Cirurgias de urgência foram mais associadas a taxas de infecção e mortalidade. Os achados do presente estudo podem ser usados por planejadores em política pública de saúde para alocação de recursos e para análise econômica para estabelecer o valor dos procedimentos neurocirúrgicos para atingir metas mundiais.

An economic study of neuro-oncological patients in a large developing country: a cost analysis / Um estudo de análise econômica dos pacientes neuro-oncológicos em um grande país em desenvolvimento: uma análise de custos

Abstract Background Neuro-oncological patients require specialized medical care. However, the data on the costs incurred for such specialized care in developing countries are currently lacking. These data are relevant for international cooperation. Objective The present study aimed to estimate the direct cost of specialized care for an adult neuro-oncological patient with meningioma or glioma during hospitalization in the largest philanthropic hospital in Latin America. Methods The present observational economic analysis describes the direct cost of care of neuro-oncological patients in Santa Casa de São Paulo, Brazil. Only adult patients with a common primary brain tumor were included. Results Due to differences in the system records, the period analyzed for cost estimation was between December 2016 and December 2019. A group of patients with meningiomas and gliomas was analyzed. The estimated mean cost of neurosurgical hospitalization was US$4,166. The cost of the operating room and intensive care unit represented the largest proportion of the total cost. A total of 17.5% of patients had some type of infection, and 66.67% of these occurred in nonelective procedures. The mortality rate was 12.7% and 92.3% of all deaths occurred in emergency procedures. Conclusions Emergency surgeries were associated with an increased rate of infections and mortality. The findings of the present study could be used by policymakers for resource allocation and to perform economic analyses to establish the value of neurosurgery in achieving global health goals.

Resumo Antecedentes Pacientes neuro-oncológicos demandam tratamento médico especializado. Em países em desenvolvimento, há falta de dados sobre custos em neurocirurgia. Estes dados são relevantes para ajudar na cooperação internacional. Objetivo O presente estudo objetiva estimar o custo direto de um paciente neuro-oncológico adulto com meningioma ou glioma durante sua internação no maior hospital filantrópico da América Latina. Métodos A presente análise econômica observacional descreve os custos diretos de um paciente neuro-oncológico da Santa Casa de São Paulo. Apenas pacientes adultos e com os dois tumores cerebrais primários mais comuns foram considerados. Resultados Devido a uma mudança no sistema de prontuários, para análise de custos o período analisado foi de dezembro de 2016 a dezembro de 2019. Uma amostra significativa de pacientes com gliomas e meningiomas foi analisada. O custo médio da hospitalização foi de U$ 4.166. O tempo de sala cirúrgica e os cuidados em terapia intensiva representaram a maior proporção dentro do custo total. Um total de 17.5% dos pacientes teve algum tipo de infecção e 66.67% delas ocorreram em procedimentos não eletivos. A taxa de mortalidade foi de 12.5% e 92.3% dos óbitos ocorreram em procedimentos de urgência. Conclusões Cirurgias de urgência foram mais associadas a taxas de infecção e mortalidade. Os achados do presente estudo podem ser usados por planejadores em política pública de saúde para alocação de recursos e para análise econômica para estabelecer o valor dos procedimentos neurocirúrgicos para atingir metas mundiais.

Awake craniotomy in brain tumors - Technique systematization and the state of the art.

The anesthesia for awake craniotomy (AC) is a consecrated anesthetic technique that has been perfected over the years. Initially used to map epileptic foci, it later became the standard technique for the removal of glial neoplasms in eloquent brain areas. We present an AC anesthesia technique consisting of three primordial times, called awake-asleep-awake, and their respective particularities, as well as delve into the anesthetic medications used. Its use in patients with low and high-grade gliomas was favorable for the resection of tumors within the functional boundaries of patients, with shorter hospital stay and lower direct costs. The present study aims to systematize the technique based on the experience of the largest philanthropic hospital in Latin America and discusses the most relevant aspects that have consolidated this technique as the most appropriate in the surgery of gliomas in eloquent areas.

Awake craniotomy for eloquent pial arteriovenous fistula - Anesthetic and surgical consideration of a rare case.

Intracranial pial Arteriovenous Fistulas (AVFs) are rare cerebral vascular lesions composed of one or more arterial connections to a single venous channel. We report a 50-year-old patient with a ruptured pial AVF located in an eloquent area. Microsurgery for pial AVF occlusion was proposed with awake craniotomy for motor function and neurological evaluation. Awake craniotomy is a technique that is especially useful for cerebral vascular lesions in eloquent areas, where an occlusion often compromises or suppresses the blood supply, culminating in ischemia with consequent transient or definitive deficits in neurological function.

Components from spider venom activate macrophages against glioblastoma cells: new potential adjuvants for anticancer immunotherapy.

Immunomodulation has been considered an important approach in the treatment of malignant tumours. However, the modulation of innate immune cells remains an underexplored tool. Studies from our group demonstrated that the Phoneutria nigriventer spider venom (PnV) administration increased the infiltration of macrophage in glioblastoma, in addition to decreasing the tumour size in a preclinical model. The hypothesis that PnV would be modulating the innate immune system led us to the main objective of the present study: to elucidate the effects of PnV and its purified fractions on cultured macrophages. Results showed that PnV and the three fractions activated macrophages differentiated from bone marrow precursors. Further purification generated 23 subfractions named low weight (LW-1 to LW-12) and high weight (HW-1 to HW-11). LW-9 presented the best immunomodulatory effect. Treated cells were more phagocytic, migrated more, showed an activated morphological profile and induced an increased cytotoxic effect of macrophages on tumour cells. However, while M1-controls (LPS) increased IL-10, TNF-alpha and IL-6 release, PnV, fractions and subfractions did not alter any cytokine, with the exception of LW-9 that stimulated IL-10 production. These findings suggest that molecules present in LW-9 have the potential to be used as immunoadjuvants in the treatment of cancer.

Safety and Efficacy of 980nm Diode Laser for Brain Tumor Microsurgery-A Pioneer Case Series.

BACKGROUND: Quality of life is essential for oncologic patients. Several tools are available to improve microsurgery and reduce morbidity. Diode laser is a precise and useful technology for microsurgery. The goal of this pioneer case series is to describe the oncologic use of the 980nm diode laser and the qualitative variables analyzed. Besides, review the current literature about lasers in neurosurgery. METHODS: A longitudinal prospective study described patients with meningioma or glioma submitted to neurosurgical laser-assisted procedures. Also, we performed a review in medical databases using the terms "diode laser" and "neurosurgery." RESULTS: No paper described the use of a diode laser in neurooncology. The 980nm diode laser was used in 15 patients. The device is thin, silent, and easy to handle. Excellent hemostasis was observed, especially in skull base meningiomas. Also, it was easy and fast to delimit tumor from normal brain tissue without damage to surrounding parenchyma. No postoperative complications occurred. CONCLUSIONS: The diode laser is a useful tool for brain tumor surgery, particularly concerning hemostasis. Surgical site coagulation is effective without damage to adjacent structures, especially in gliomas near eloquent regions. We consider this technique a suitable adjuvant resource for brain tumor surgeries to provide an excellent hemostasis and help cut and vaporize a lesion.

Myxoid glioneuronal tumour - report of three cases of a new tumour in a typical location and review of literature.

Formerly called dysembryoplastic neuroepithelial tumour (DNET) of the septum pellucidum, myxoid glioneuronal tumour (MGT) was recently recognized as a distinct entity. We report three cases of presumed MGT with typical location and image features.

Awake craniotomy in brain tumors - Technique systematization and the state of the art / Craniotomia em paciente acordado nos tumores cerebrais - Sistematização da técnica anestésica e o estado da arte

ABSTRACT The anesthesia for awake craniotomy (AC) is a consecrated anesthetic technique that has been perfected over the years. Initially used to map epileptic foci, it later became the standard technique for the removal of glial neoplasms in eloquent brain areas. We present an AC anesthesia technique consisting of three primordial times, called awake-asleep-awake, and their respective particularities, as well as delve into the anesthetic medications used. Its use in patients with low and high-grade gliomas was favorable for the resection of tumors within the functional boundaries of patients, with shorter hospital stay and lower direct costs. The present study aims to systematize the technique based on the experience of the largest philanthropic hospital in Latin America and discusses the most relevant aspects that have consolidated this technique as the most appropriate in the surgery of gliomas in eloquent areas.

RESUMO A anestesia para craniotomia em paciente acordado (CPA ou awake craniotomy) é técnica anestésica consagrada e aperfeiçoada ao longo dos últimos anos. Utilizada inicialmente para mapeamento de focos epilépticos, consolidou-se posteriormente como técnica padrão para a remoção de neoplasias de origem glial em áreas eloquentes cerebrais. A técnica de anestesia CPA apresentada constitui-se em três tempos primordiais denominados acordado-dormindo-acordado (asleep-awake-asleep) e respectivas particularidades, assim como o manejo quanto às medicações anestésicas utilizadas de forma pormenorizada. A utilização em gliomas de baixo e de alto grau se demonstrou favorável para a ressecção de tumores dentro dos limites funcionais dos pacientes, com menor tempo de internação hospitalar e de custos diretos. O presente estudo visa realizar a sistematização da técnica baseada na experiência do maior Hospital Filantrópico da América Latina e discute os aspectos mais relevantes que consolidaram essa técnica como a mais adequada na cirurgia dos gliomas em áreas eloquentes.

Spider venom components decrease glioblastoma cell migration and invasion through RhoA-ROCK and Na+/K+-ATPase ß2: potential molecular entities to treat invasive brain cancer.

BACKGROUND: Glioblastoma (GB) cells have the ability to migrate and infiltrate the normal parenchyma, leading to the formation of recurrent tumors often adjacent to the surgical extraction site. We recently showed that Phoneutria nigriventer spider venom (PnV) has anticancer effects mainly on the migration of human GB cell lines (NG97 and U-251). The present work aimed to investigate the effects of isolated components from the venom on migration, invasiveness, morphology and adhesion of GB cells, also evaluating RhoA-ROCK signaling and Na+/K+-ATPase ß2 (AMOG) involvement. METHODS: Human (NG97) GB cells were treated with twelve subfractions (SFs-obtained by HPLC from PnV). Migration and invasion were evaluated by scratch wound healing and transwell assays, respectively. Cell morphology and actin cytoskeleton were shown by GFAP and phalloidin labeling. The assay with fibronectin coated well plate was made to evaluate cell adhesion. Western blotting demonstrated ROCK and AMOG levels and a ROCK inhibitor was used to verify the involvement of this pathway. Values were analyzed by the GraphPad Prism software package and the level of significance was determinate using one-way analysis of variance (ANOVA) followed by Dunnett's multiple comparisons test. RESULTS: Two (SF1 and SF11) of twelve SFs, decreased migration and invasion compared to untreated control cells. Both SFs also altered actin cytoskeleton, changed cell morphology and reduced adhesion. SF1 and SF11 increased ROCK expression and the inhibition of this protein abolished the effects of both subfractions on migration, morphology and adhesion (but not on invasion). SF11 also increased Na+/K+-ATPase ß2. CONCLUSION: All components of the venom were evaluated and two SFs were able to impair human glioblastoma cells. The RhoA effector, ROCK, was shown to be involved in the mechanisms of both PnV components. It is possible that AMOG mediates the effect of SF11 on the invasion. Further investigations to isolate and biochemically characterize the molecules are underway.

Microsurgical Cisternostomy for Treating Critical Patients with Traumatic Brain Injury - An alternative Therapeutic Approach

Introduction Traumatic brain injury (TBI) is a major cause of mortality around the world. Few advances regarding surgical approaches have been made in the past few years to improve its outcomes. Microsurgical cisternostomy is a well-established technique used in vascular and skull base surgery and recently emerges as a suitable procedure with lesser costs and morbidity when compared with decompressive craniectomy in patients with diffuse TBI. This study aims to describe the technique, indications, and limitations of cisternostomy and to compare it with decompressive craniectomy (DC). Methods A prospective study is being conducted after obtaining approval of the local human ethics research committee. Once the inclusion and exclusion criteria are applied, the patients are submitted to microsurgical cisternostomy, pre and postoperative neurological status and brain computed tomography (CT) evaluation. A detailed review was also performed, which discusses diffuse TBI, DC, and cisternostomy for the treatment of TBI. Results Two patients were submitted to cisternostomy after TBI and the presence of acute subdural hematoma and hugemidline shift at admission computed tomography. The surgery was authorized by the family (the informed consent form was signed). Both patients evolved with a good recovery after the procedure, and had a satisfactory control brain CT. No further surgeries were required after the initial cisternostomy. Conclusions Cisternostomy is an adequate technique for the treatment of selected patients affected by diffuse TBI, and it is a proper alternative to DC with lesser costs and morbidity, since a single neurosurgical procedure is performed. A prospective study is being conducted for a better evaluation and these were the initial cases of this new protocol.

An Affordable Stereomicroscope for Microsurgery Training with Fluorescence Mode.

BACKGROUND: Laboratory training is a very important step on the development of the skills necessary for a neurosurgeon. This can be achieved using animal models and surgical microscopes or stereomicroscopes. Methods, like the use of fluorescein, increase the lifelike situation and allow anyone to assess the patency of an anastomosis and improve the quality of this training. METHODS: We report the use of a stereomicroscope with white light and a fluorescence mode used to perform dissection of small arteries and anastomosis using a chicken wing model. Using an affordable device, we could perform fluorescein videoangiography to asses the patency of those anastomosis and improve the quality of the training skills in microsurgery. RESULTS: The stereomicroscope is a useful tool for laboratory training and can be used as a substitute of a surgical microscope for microsurgery training. The fluorescence mode allowed us to perform fluorescein videoangiography with very a good quality of image. CONCLUSIONS: Microsurgery training is important part in the life of any neurosurgeon. Using a stereomicroscope with a fluorescence mode is an affordable method that can be reproduced in any laboratory in the world.

Simultaneous meningioma and brain metastasis from renal cell carcinoma - a rare presentation. Case report.

CONTEXT:: Brain metastases are the most common tumors of the central nervous system. Because of their high frequency, they may be associated with rare situations. Among these are tumor-to-tumor metastasis and an even a rarer situation called simultaneous brain tumors, which are more related to primary tumors of the reproductive and endocrine systems. CASE REPORT:: A 56-year-old male patient with a history of renal cell carcinoma (which had previously been resected) presented with a ventricular lesion (suggestive of metastatic origin) and simultaneous olfactory groove lesion (probably a meningioma). First, only the ventricular lesion was dealt with, but after a year, the meningothelial lesion increased and an occipital lesion appeared. Therefore, both of these were resected in a single operation. All the procedures were performed by the same neurosurgeon. The patient evolved without neurological deficits during the postoperative period. After these two interventions, the patient remained well and was referred for adjuvant treatment. CONCLUSIONS:: This study provides the first description of an association between these two tumors. Brain metastases may be associated with several lesions, and rare presentations such as simultaneity with meningioma should alert neurosurgeons to provide the best oncological treatment.

Simultaneous meningioma and brain metastasis from renal cell carcinoma - a rare presentation. Case report / Meningioma e metástase cerebral de carcinoma de células renais simultâneos - uma apresentação rara. Relato de caso

ABSTRACT CONTEXT: Brain metastases are the most common tumors of the central nervous system. Because of their high frequency, they may be associated with rare situations. Among these are tumor-to-tumor metastasis and an even a rarer situation called simultaneous brain tumors, which are more related to primary tumors of the reproductive and endocrine systems. CASE REPORT: A 56-year-old male patient with a history of renal cell carcinoma (which had previously been resected) presented with a ventricular lesion (suggestive of metastatic origin) and simultaneous olfactory groove lesion (probably a meningioma). First, only the ventricular lesion was dealt with, but after a year, the meningothelial lesion increased and an occipital lesion appeared. Therefore, both of these were resected in a single operation. All the procedures were performed by the same neurosurgeon. The patient evolved without neurological deficits during the postoperative period. After these two interventions, the patient remained well and was referred for adjuvant treatment. CONCLUSIONS: This study provides the first description of an association between these two tumors. Brain metastases may be associated with several lesions, and rare presentations such as simultaneity with meningioma should alert neurosurgeons to provide the best oncological treatment.

RESUMO CONTEXTO: As metástases cerebrais são os tumores mais comuns do sistema nervoso central e, devido à sua elevada frequência, podem estar associadas a situações raras. Entre estas estão as "tumor to tumor metastasis" e uma situação ainda mais rara chamada de tumores cerebrais simultâneos, mais relacionados a tumores primários dos sistemas endocrinológico e reprodutivo. RELATO DE CASO: Um homem de 56 anos com histórico de câncer de células renais (extirpado previamente) apresentou-se com lesão ventricular (sugestiva de origem metastática) e simultaneamente com uma lesão em topografia de goteira olfatória (provavelmente meningioma). Primeiramente, apenas a lesão ventricular foi abordada, porém após um ano, a lesão meningotelial aumentou e uma lesão occipital apareceu e então ambas foram ressecadas em uma única cirurgia. Todos os procedimentos foram realizados pelo mesmo neurocirurgião. O paciente evoluiu sem déficits neurológicos no período pós-operatório. Após essas duas intervenções, o paciente permaneceu bem, sendo encaminhado para tratamento adjuvante. CONCLUSÕES: O presente trabalho é a primeira descrição da associação encontrada entre esses dois tumores. As metástases cerebrais podem associar-se a várias lesões, e manifestações raras, tais como apresentação simultânea com meningioma, devem alertar o neurocirurgião a fornecer o melhor tratamento oncológico.

Low-Cost Device for Fluorescein-Guided Surgery in Malignant Brain Tumor.

BACKGROUND: Gross total resection for malignant brain neoplasms is challenging owing to the heterogeneity of these lesions and infiltration in eloquent areas. Gross total resection is a very important part of treatment of these patients and is a crucial prognostic factor. Fluorescence-guided surgery is an important tool that improves the rate of total resection. METHODS: We built a device to use in surgical microscopes with an excitation and a barrier filter to perform fluorescence-guided surgery. All patients received a standard dose of 500 mg of sodium fluorescein before skin incision. Surgical view under white light was compared with use of the light filters. RESULTS: In all cases with use of the filters, the tumors showed a high fluorescence contrasting with the normal surrounding brain, making it easier to identify the limits of the lesion and to achieve gross total resection. CONCLUSIONS: The use of fluorescence for malignant brain tumor resection increases the rate of gross total resection. It is an important tool that makes it possible to identify the lesion in areas where it looks like normal tissue under white light. This device is a low-cost option that has shown good results in our experience.

Comparative anatomical analysis of the transcallosal-transchoroidal and transcallosal-transforniceal-transchoroidal approaches to the third ventricle.

OBJECTIVE Access to the third ventricle is a veritable challenge to neurosurgeons. In this context, anatomical and morphometric studies are useful for establishing the limitations and advantages of a particular surgical approach. The transchoroidal approach is versatile and provides adequate exposure of the middle and posterior regions of the third ventricle. However, the fornix column limits the exposure of the anterior region of the third ventricle. There is evidence that the unilateral section of the fornix column has little effect on cognitive function. This study compared the anatomical exposure afforded by the transforniceal-transchoroidal approach with that of the transchoroidal approach. In addition, a morphometric evaluation of structures that are relevant to and common in the 2 approaches was performed. METHODS The anatomical exposure provided by the transcallosal-transchoroidal and transcallosal-transforniceal-transchoroidal approaches was compared in 8 fresh cadavers, using a neuronavigation system. The working area, microsurgical exposure area, and angular exposure on the longitudinal and transversal planes of 2 anatomical targets (tuber cinereum and cerebral aqueduct) were compared. Additionally, the thickness of the right frontal lobe parenchyma, thickness of the corpus callosum trunk, and longitudinal diameter of the interventricular foramen were measured. The values obtained were submitted to statistical analysis using the Wilcoxon test. RESULTS In the quantitative evaluation, compared with the transchoroidal approach, the transforniceal-transchoroidal approach provided a greater mean working area (transforniceal-transchoroidal 150 ± 11 mm2; transchoroidal 121 ± 8 mm2; p < 0.05), larger mean microsurgical exposure area (transforniceal-transchoroidal 101 ± 9 mm2; transchoroidal 80 ± 5 mm2; p < 0.05), larger mean angular exposure area on the longitudinal plane for the tuber cinereum (transforniceal-transchoroidal 71° ± 7°; transchoroidal 64° ± 6°; p < 0.05), and larger mean angular exposure area on the longitudinal plane for the cerebral aqueduct (transforniceal-transchoroidal 62° ± 6°; transchoroidal 55° ± 5°; p < 0.05). No differences were observed in angular exposure along the transverse axis for either anatomical target (tuber cinereum and cerebral aqueduct; p > 0.05). The mean thickness of the right frontal lobe parenchyma was 35 ± 3 mm, the mean thickness of the corpus callosum trunk was 10 ± 1 mm, and the mean longitudinal diameter of the interventricular foramen was 4.6 ± 0.4 mm. In the qualitative assessment, it was noted that the transforniceal-transchoroidal approach led to greater exposure of the third ventricle anterior region structures. There was no difference between approaches in the exposure of the structures of the middle and posterior region. CONCLUSIONS The transforniceal-transchoroidal approach provides greater surgical exposure of the third ventricle anterior region than that offered by the transchoroidal approach. In the population studied, morphometric analysis established mean values for anatomical structures common to both approaches.