RESUMO
Chiari Malformation Type I (CMI) is a prevalent neurosurgical condition characterized by the descent of cerebellar tonsils below the foramen magnum. Surgery, aimed at reducing symptomatology and syrinx size, presents risks, making intraoperative neuromonitoring (IONM) a potentially vital tool. Despite its widespread use in cervical spine surgery, the utility of IONM in CMI surgery remains controversial, with concerns over increased operative time, cost, restricted anesthetic techniques and tongue lacerations. This systematic review and meta-analysis followed the Cochrane Group standards and PRISMA framework. It encompassed an extensive search through PubMed, Embase, and Web of Science up to December 2023, focusing on clinical and surgical outcomes of IONM in CMI surgery. Primary outcomes included the use of various IONM techniques, complication rates, clinical improvement, reoperation, and mortality. The review, registered at PROSPERO (CRD42024498996), included both prospective and retrospective studies, with rigorous selection and data extraction processes. Statistical analysis was conducted using R software. The review included 16 studies, comprising 1358 patients. It revealed that IONM techniques predominantly involved somatosensory evoked potentials (SSEPs), followed by motor evoked potentials (MEPs) and Brainstem auditory evoked potentials (BAEPs). The estimated risk of complications with IONM was 6% (95% CI: 2-11%; I2 = 89%), lower than previously reported rates without IONM. Notably, the clinical improvement rate post-surgery was high at 99% (95% CI: 98-100%; I2 = 56%). The analysis also showed lower reoperation rates in surgeries with IONM compared to those without. Interestingly, no mortality was observed in the included studies. This systematic review and meta-analysis indicate that intraoperative neuromonitoring in Chiari I malformation surgery is associated with favorable clinical outcomes, including lower complication and reoperation rates, and high rates of clinical improvement.
Assuntos
Malformação de Arnold-Chiari , Monitorização Neurofisiológica Intraoperatória , Humanos , Malformação de Arnold-Chiari/fisiopatologia , Malformação de Arnold-Chiari/cirurgia , Potenciais Evocados Auditivos do Tronco Encefálico/fisiologia , Potencial Evocado Motor/fisiologia , Potenciais Somatossensoriais Evocados/fisiologia , Monitorização Neurofisiológica Intraoperatória/métodos , Procedimentos Neurocirúrgicos/efeitos adversos , Procedimentos Neurocirúrgicos/métodosRESUMO
BACKGROUND AND OBJECTIVES: Chronic subdural hematoma (CSDH) management involves various surgical techniques, with drainage systems playing a pivotal role. While passive drainage (PD) and active drainage (AD) are both used, their efficacy remains contentious. Some studies favor PD for lower recurrence rates, while others suggest AD superiority. A systematic review and meta-analysis were conducted to address this controversy, aiming to provide clarity on optimal drainage modalities post-CSDH evacuation. METHODS: This systematic review and meta-analysis followed preferred reporting items for systematic reviews guidelines, searching PubMed, Embase, and Web of Science until February 2024. Inclusion criteria focused on studies comparing active vs PD for subdural hematomas. Data extraction involved independent researchers, and statistical analysis was conducted using R software. The assessment of risk of bias was performed using the Risk of Bias in Non-Randomized Studies of Interventions framework and the Risk Of Bias 2 tool. RESULTS: In this meta-analysis, involving 1949 patients with AD and 1346 with PD, no significant differences were observed in recurrence rates between the active (13.6%) and passive (16.4%) drainage groups (risk ratio [RR] = 0.87; 95% CI: 0.58-1.31). Similarly, for complications, infection, hemorrhage, and mortality, no significant disparities were found between the 2 drainage modalities. Complication rates were 7.5% for active and 12.6% for PD (RR = 0.74; 95% CI: 0.36-1.52). Infection rates were available for 635 patients of the active group, counting for 2% and 2.6%, respectively (RR = 0.98; 95% CI: 0.24-4.01). Hemorrhage rates were also available for 635 patients of the active group, counting for 1.1% and 2.2%, respectively (RR = 0.44; 95% CI: 0.11-1.81). Mortality rates were 2.7% and 2.5%, respectively (RR = 0.94; 95% CI: 0.61-1.46). CONCLUSION: Our study found no significant difference between passive and AD for managing complications, recurrence, infection, hemorrhage, or mortality in CSDH cases. Further large-scale randomized trials are needed for clarity.
RESUMO
BACKGROUND: Intracranial pressure (ICP) monitoring plays a key role in patients with traumatic brain injury (TBI), however, cerebral hypoxia can occur without intracranial hypertension. Aiming to improve neuroprotection in these patients, a possible alternative is the association of Brain Tissue Oxygen Pressure (PbtO2) monitoring, used to detect PbtO2 tension. METHOD: We systematically searched PubMed, Embase and Cochrane Central for RCTs comparing combined PbtO2 + ICP monitoring with ICP monitoring alone in patients with severe or moderate TBI. The outcomes analyzed were mortality at 6 months, favorable outcome (GOS ≥ 4 or GOSE ≥ 5) at 6 months, pulmonary events, cardiovascular events and sepsis rate. RESULTS: We included 4 RCTs in the analysis, totaling 505 patients. Combined PbtO2 + ICP monitoring was used in 241 (47.72%) patients. There was no significant difference between the groups in relation to favorable outcome at 6 months (RR 1.17; 95% CI 0.95-1.43; p = 0.134; I2 = 0%), mortality at 6 months (RR 0.82; 95% CI 0.57-1.18; p = 0.281; I2 = 34%), cardiovascular events (RR 1.75; 95% CI 0.86-3.52; p = 0.120; I2 = 0%) or sepsis (RR 0.75; 95% CI 0.25-2.22; p = 0.604; I2 = 0%). The risk of pulmonary events was significantly higher in the group with combined PbtO2 + ICP monitoring (RR 1.44; 95% CI 1.11-1.87; p = 0.006; I2 = 0%). CONCLUSIONS: Our findings suggest that combined PbtO2 + ICP monitoring does not change outcomes such as mortality, functional recovery, cardiovascular events or sepsis. Furthermore, we found a higher risk of pulmonary events in patients undergoing combined monitoring.