Midbrain Cavernous Malformation: Microsurgical Nuances and an Anatomoclinical Review 2-Dimensional Video.

Midbrain cavernous malformations (MCMs) are rare and dangerous taken the important structures and tracts located in this segment of the brainstem. MCM treatment is still controversial, and surgical resection is basically indicated in cases of recurrent hemorrhage and progressive neurologic deterioration. The optimal moment to operate ruptured MCM is in the subacute stage. Once indicated for surgical resection, preoperative planning needs to be individualized. There are various ways to access midbrain lesions, depending on the extension and predominant location: lateral subtemporal, posterior transtentorial, interhemispheric transcallosal, and anterior temporopolar approaches, or some of the alternatives. The aim of this Video 1 case is to review the surrounding anatomic structures and demonstrate the advantages of the semisitting position and the viability of the supracerebellar infratentorial approach for a tegmental midbrain lesion.1-10 In this 2-dimensional video, we present an 18-year-old man with a 4-year history of diplopia and third nerve palsy, which worsened 10 days before admission. He underwent microsurgical total resection of this MCM via extreme lateral supracerebellar infratentorial approach in a semisitting position. At the end, the surgical site and surrounding structures were reviewed microscopically and endoscopically. The patient tolerated the surgery well, and the perioperative course was uneventful. His recovery was smooth but he maintained the previous oculomotor nerve palsy. We discuss important steps of the surgical approach, local neuroanatomy, and the microsurgical techniques for the resection of these challenging MCM. The goal is total resection of the MCM with the preservation of the developmental venous anomaly and the surrounding white fiber tracts.

Minimally invasive guided endodontic microsurgery with Zekrya bur: A 48-month follow-up case report.

Endodontic microsurgery guided by navigation systems represents a precise and minimally invasive approach for retreatment of apical periodontitis following failed conventional endodontic therapy. Accurate localization and minimal access to the root apex are paramount for successful outcomes and preservation of anatomical structures. Workflow considerations, such as three-dimensional (3D) virtual planning and endodontic guidance represent new crucial aspects for addressing complex cases. This clinical case report presents the successful reintervention of a complex case using a Zekrya bur, operative microscopy, cone beam computed tomography and biocompatible materials. After a 48-month follow-up, complete healing of the treated area was observed. This minimally invasive technique, employing a simple instrument widely available globally, underscores the potential for efficient and predictable outcomes in complex endodontic microsurgical retreatment.

RANDOMIZED EXPERIMENTAL STUDY OF TOPICAL VASODILATORS IN MICROSURGERY WITH COST ANALYSIS.

Objective: Throughout microsurgical anastomosis, many surgeons use topical vasodilators in order to reduce pathological vasospasm. It was carried out an experimental study comparing the effectiveness of topical use of Nitroglycerin, Papaverine, Magnesium sulfate over a control group in the femoral artery and vein of rats, in reducing prolonged vasospasm. Methods: Randomized comparative experimental study in 15 rats, divided into four groups. The external diameter of the vases soaked in the randomized solution was measured. For statistical analysis, it was calculated the percentual increase in the external diameter of the vessels. Results: A statistically significant increase in arterial dilation was observed after 10 minutes of topical application of 10% magnesium sulfate compared to the control group, with p = 0.044 . No other drug showed a vasodilator effect superior to the control group. Magnesium sulfate at 10% is still not used in microsurgery and costs 15 times less than papaverine, the standard drug for topical vasodilation in clinical cases at our service. Conclusion: Magnesium sulfate had better vasodilating effects over the control group after 10 minutes of arterial microanastomosis. None of the tested drugs have presented superior vasodilating effects over each other nor the control group after venous microanastomosis. Level of evidence II, Experimental study, Randomized Trial.

Objetivo: Durante a anastomose microcirúrgica, muitos cirurgiões utilizam vasodilatadores tópicos para reduzir o vasoespasmo prolongado patológico, assim reduzindo o risco de complicações vasculares. Entretanto, ainda faltam dados experimentais para identificação da droga padrão-ouro para vasodilatadores tópicos em microcirurgia e sua avaliação de análise de custo, já que a droga geralmente utilizada para este objetivo é baseada, na maior parte dos casos, na experiência do cirurgião. Métodos: Foi realizado um estudo experimental comparativo randomizado, avaliando a eficácia do uso tópico de Nitroglicerina, Papaverina e Sulfato de Magnésio em relação a um grupo controle, na redução do vasoespasmo na artéria e veia femoral de ratos. Foram avaliados o diâmetro externo dos vasos embebidos em solução randomizada dos fármacos para vasodilatação. Após cálculo do aumento percentual no diâmetro externo dos vasos, foi realizada análise estatística. Resultados: Observou-se aumento estatisticamente significativo da dilatação arterial após 10 minutos de aplicação tópica de sulfato de magnésio a 10% em relação ao grupo controle, com p = 0,044. Nenhuma outra droga apresentou efeito vasodilatador superior ao grupo controle. O sulfato de magnésio a 10% ainda não é utilizado em microcirurgia e apresenta custo até 15 vezes menor quando comparado com a papaverina, droga padrão para vasodilatação tópica em casos clínicos em nosso serviço. Conclusão: O sulfato de magnésio apresentou melhor efeito vasodilatador quando comparado ao grupo controle, após 10 minutos da microanastomose arterial. Nenhum dos fármacos testados apresentou efeito vasodilatador superior após a microanastomose venosa. Nível de Evidência II, Estudo experimental, Ensaio Randomizado.

REPLANTATION OF THE THUMB OR REVISION OF AMPUTATION: AN EPIDEMIOLOGICAL STUDY.

OBJETIVE: This article presents a retrospective cohort study analyzing patients from IOT-FMUSP who underwent replantation or revision amputation procedures for traumatic thumb amputation between 2013 and 2020. METHODS: The study included 40 patients in the replanted group and 41 patients in the amputed group. The patients were divided according to the level of amputation and their medical records were analyzed. RESULTS: A total of 81 patients with digital amputation were analyzed, consisting of 79 males and 2 females, with mean ages of 43 and 49 for the amputed and replanted groups, respectively. According to the Biemer classification, 28.4% had proximal amputation, while 71.6% had distal amputation. The most common occupation was bricklayer (19.75%), and 80.24% were manual workers. Of the patients, 65% returned to their previous work, with 77.77% of them having amputation on their non-dominant hand, mostly caused by circular saw accidents (77.77%). The replantation success rate was 78%, with an average ischemia time of 9 hours and door-to-room time of 2 hours. CONCLUSION: the study findings revealed that traumatic thumb amputation predominantly affects working-age males with a low education level and the success rate of replantation was high in this ischemia time and door-to-room conditions. Level of Evidence II, Retrospective study.

OBJETIVO: Este artigo consiste em um corte retrospectivo que analisou vítimas de amputação traumática do polegar submetidas a reimplante ou procedimentos de regularização da amputação no Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medica da Universidade de São Paulo (IOT-FMUSP). Métodos: Foram analisados 40 pacientes reimplantados e 41 pacientes regularizados, que foram separados conforme o nível da amputação e, após, tiveram seus prontuários médicos analisados. RESULTADOS: Foram analisados 81 pacientes com amputação digital (79 homens e 2 mulheres), com idade média de 43 anos e 49 anos (Grupo Amputado e Grupo Reimplante, respectivamente) e 28,4% deles tinham amputação proximal, de acordo com a classificação de Biemer, enquanto 71,6% tinham amputação distal. A ocupação mais comum foi a de pedreiro (19,75%), mas 80,24% eram trabalhadores manuais. 65% dos pacientes retornaram ao trabalho anterior. 77,77% dos pacientes afetaram a mão não dominante, e a serra circular causou 77,77% das amputações. A taxa de sucesso para reimplantes foi de 78%. O tempo de isquemia foi de 9 horas e o tempo de porta-quarto foi de 2 horas. Conclusão: O estudo revelou que as taxas de reimplante foram altas nas condições de isquemia e tempo porta-sala, e a maioria dos pacientes vítimas de amputação traumática do polegar são homens em idade de trabalho e com baixa escolaridade. Nível de Evidência II, Estudo retrospectivo.

Adipose Tissue Derivatives in Peripheral Nerve Regeneration after Transection: A Systematic Review.

INTRODUCTION: Peripheral nerve injury (PNI) is increasingly prevalent and challenging to treat despite advances in microsurgical techniques. In this context, adipose tissue derivatives, such as adipose-derived stem cells, nanofat, and stromal vascular fraction have been gaining attention as potential allies in peripheral nerve regeneration. OBJECTIVES: This study aims to explore the use of adipose tissue derivatives in nerve regeneration following peripheral nerve transection in murine models. Thus, we assess and synthesize the key techniques and methods used for evaluating the obtained nerve regeneration to guide future experimental research and clinical interventions. METHODOLOGY: A systematic review was conducted in February 2024, adhering to the Cochrane and PRISMA 2020 guidelines, using the PubMed, SciELO, and LILACS databases. The focus was on experimental studies involving adipose tissue derivatives in nerve regeneration in animal models post-transection. Only experimental trials reporting nerve regeneration outcomes were included; studies lacking a comparator group or evaluation methods were excluded. RESULTS: Out of 273 studies initially identified from MEDLINE, 19 were selected for detailed analysis. The average study included 32.5 subjects, with about 10.2 subjects per intervention subgroup. The predominant model was the sciatic nerve injury with a 10 mm gap. The most common intervention involved unprocessed adipose-derived stem cells, utilized in 14 articles. CONCLUSIONS: This review underscores the significant potential of current methodologies in peripheral nerve regeneration, particularly highlighting the use of murine models and thorough evaluation techniques.

Transverse and vertical incisions affect the viability of in vitro-produced embryos submitted to a simplified microsurgery approach.

Integrating in vitro embryo production with embryonic microsurgery facilitates the generation of monozygotic twins. However, despite their potential benefits, these methods have not been widely adopted in commercial settings because of their substantial costs. Hence, there is a need to streamline the bisection procedure while ensuring efficient production of viable demi-embryos. In this study, we investigated the impact of different orientations of microsurgical incisions in relation to inner cell mass on embryonic development, morphology, viability, and expression of cell fate protein markers using a simplified microsurgery approach. Ovaries were transported from the slaughterhouse to the laboratory and aspirated to obtain oocytes that were selected and subjected to in vitro embryo production. The selected expanded blastocysts (n = 204) underwent microsurgery. The blastocysts were immobilized to facilitate incision using an adapted microblade, yielding demi-embryos (vertical incision) and viable embryonic fragments (transverse incision). The structures were then re-cultured for 12 h. Viability was assessed by measuring the re-expansion rate after re-culture, followed by immunofluorescence analysis of proteins (CDX2 and NANOG) and apoptosis analysis using terminal deoxynucleotyl transferase dUTP nick end-labeling (TUNEL). Microsurgically derived embryos exhibited remarkable plasticity, as evidenced by a slight reduction (P < 0.05) in the re-expansion rate (transverse 64.2 % and vertical 57.2 %) compared to that of the control group (blastocysts without microsurgery) (86.7 %). They also demonstrated the ability of morphological reconstitution after culturing. Despite the anticipated decrease (P < 0.05) in the total number of cells and embryo volume, microsurgery did not result in a significant increase (P > 0.05) in the number of apoptotic cells. Furthermore, microsurgery led to higher (P < 0.05) expression of markers associated with pluripotency, indicating its efficiency in preserving regenerative capacity. Moreover, microsurgery, whether followed by immunosurgery or not, made the isolation of embryonic cells easier. In conclusion, both transverse and vertical microsurgery incisions enabled the production of identical demi-embryos and served as tools for isolating embryonic cells without compromising the resumption of development and the apoptotic index.

Compressão intermitente imediata sobre anastomose vascular: Uma nova técnica para prevenir trombose? / Immediate intermittent compression over vascular anastomosis: a new technique to prevent thrombosis

Introdução: Este estudo tem o objetivo de avaliar o efeito da compressão intermitente imediata sobre anastomoses arteriais microcirúrgicas em comparação com compressão fixa e com utilização isolada de irrigação com soro fisiológico e heparina em laboratório experimental. Método: 12 ratos Wistar foram aleatoriamente divididos em três grupos para terem suas artérias femorais seccionas e anastomosadas de forma término-terminal, para comparação de patência com 30 minutos e 7 dias. Grupo I: foi realizada compressão intermitente imediata sobre a anastomose por 60 segundos; grupo II: uma compressão fixa foi mantida imediatamente após a anastomose, também por 60 segundos; grupo III, após o término da anastomose, não foi feita nenhuma intervenção adicional. Além da avaliação da patência, os animais foram pesados e medidos os diâmetros arteriais operados. Resultados: 24 artérias femorais foram abordadas. As médias de peso inicial dos ratos dos grupos I, II e III foram, respectivamente, de 243,8g, 254,6g e 260,4g, enquanto as finais foram de 264,4g, 281g e 282,1g (p<0,001). O diâmetro médio das artérias abordadas foi, respectivamente, de 0,89mm, 0,88mm e 0,90mm, e os tempos de anastomoses em minutos, de 25,6, 24,5 e 24,5, respectivamente; As patências finais após 7 dias foram, respectivamente, de 62,5% (p=0,07), 25% (p=0,48) e 50% (p=0,13). Conclusão: A compressão intermitente imediata pode ser realizada ao término de anastomoses arteriais microcirúrgicos sem prejuízo na patência final do procedimento.

Introduction: This study aims to evaluate the effect of immediate intermittent compression on microsurgical arterial anastomoses in comparison with fixed compression and only observation in an experimental laboratory. Methods: The two femoral arteries of twelve male Wistar rats were sectioned and reanastomosed to compare patency at 30 minutes and 7 days. Group I: immediate intermittent compression was performed over the anastomosis for 60 s; group II: a fixed compression was maintained immediately after the anastomosis for 60 s; group III: after completion of the anastomosis, no additional intervention was performed. In addition to the patency assessment, the animals were weighed and the operated arterial diameters were measured. Results: Twenty-four femoral arteries were examined. Initial average weights of the rats in groups I, II, and III were 243.8g, 254.6g, and 260.4g, respectively, while the final weights were 264.4g, 281g, and 282.1g (p<0.001), respectively; mean diameter of the approached arteries was 0.89, 0.88, and 0.90mm, respectively, and the anastomoses (time in minutes) were 25.6, 24.5, and 24.5, respectively; final patencies after 7 days were 62.5% (p=0.07), 25% (p=0.48), and 50% (p=0.13), respectively. Conclusion: Immediate intermittent compression can be performed at the end of microsurgical arterial anastomoses without affecting the final patency of the procedure.

Experiencia en reconstrucción del paciente gran quemado agudo con microcirugía

Introducción: Las quemaduras son un trauma frecuente de ocurrencia en todo el mundo, que ha experimentado importantes aumentos de sobrevida. Su manejo requiere la reposición de la barrera cutánea, lo que se logra en la mayoría de los casos con el uso de injertos dermo-epidérmicos. Sin embargo, existen algunas veces lesiones complejas que no logran sanar mediante injertos, arriesgando la funcionalidad o vitalidad del área comprometida, que requerirán reparaciones complejas con el uso de colgajos microqui- rúrgicos (CM). Metodología: Estudio descriptivo retrospectivo en que incluimos todos los pacientes gran quemados agudos admitidos en Hospital de Urgencia de la Asistencia Pública, Servicio de Quemados y Rehabilitación, desde abril de 2019 hasta diciembre de 2020 los que fueron manejados con colgajo micro- quirúrgico. Revisión de ficha clínica para obtención de variables demográficas y del procedimiento con análisis de frecuencia de ocurrencia. Resultados: En nuestro período de estudio hubo 376 ingresos y 21 pacientes recibieron 25 CM. La mayoría hombres (96%), edad promedio 40 años, superficie comprometida promedio 16%, mecanismo más frecuente electricidad (64%) y fuego (32%). La ubicación más frecuente del colgajo fue en extremidades inferiores (64%) y el colgajo más utilizado fue el anterolateral de muslo (80%). Tiempo medio a reconstrucción fueron 40 días, no hubo pérdida total del colgajo. Discusión: se realizó un CM en 5,6% de nuestros ingresos, la mayoría durante el intervalo primario tardío, sin pérdidas totales. Estos resultados representan la consolidación de la técnica que permite su uso en el paciente gran quemado durante su etapa aguda, permitiendo coberturas complejas y manteniendo riesgo quirúrgico y tasa de complicaciones adecuada con enfoque en rehabilitación precoz.

Introduction: Burns are the fourth most common trauma. Microsurgery has evolved as a valuable tool in the acute setting allowing early closure of complex wounds in order to avoid infection, maintain function or even for limb salvage in one stage reconstruction. We present our experience at our burn center in Chile. Method: We performed a retrospective analysis of all major burn patients admitted in the National Burn Center in Chile who received a microsurgical flap in the period between April 2019 to December 2020. Results: A total of 21 patients had 25 free flaps. All patients but one were male (96%), mean age 40 years (range 20-69 years). Total body surface area means 16% (range 1-64%). Most of the injuries were caused by high voltage electricity (64%) and fire (32%). 64% were performed in lower limbs and 36% in upper limbs. In 80% of the cases, anterolateral thing flap was chosen. Mean time to reconstruction was 40 days. We didn't experience a total flap lost in this series. Discussion: In the acute phase microsurgery proved to be safe and feasible albeit a small surgical indication. We performed a flap in 5.6% of our admissions, mostly during late primary interval with no flaps lost. Our results acknowledge the consolidation of the technique for its use in the acutely burned setting, allowing complex coverage while maintaining the surgical risk and an internationally acceptable rate of losses and complications.

The Art of Cerebral Revascularization: An Illustrative Case Series of Bypass Techniques for Complex Intracranial Aneurysms.

BACKGROUND: Complex intracranial aneurysms (CIAs) comprise a subset of lesions with defiant vascular architecture, difficult access, and prior treatment. Surgical management of CIAs is often challenging and demands an assessment on a case-by-case basis. The generational evolution of bypass surgery has offered a long-standing potential for effective cerebral revascularization. Herein, we aim to illustrate a single-center experience treating CIAs. METHODS: The authors conducted a retrospective analysis of clinical records of patients treated with cerebral revascularization techniques at Hospital Nacional Dos de Mayo, Lima, Peru, during 2018-2022. Relevant data were collected, including patient history, aneurysm features on imaging, preoperative complications, the intraoperative course, aneurysm occlusion rates, bypass patency, neurological function, and postoperative complications. RESULTS: Seventeen patients (70.59% female; median age: 53 years) with 17 CIAs (64.7% saccular; 76.5% ruptured) were included. The most common clinical presentation included loss of consciousness (70.6%) and headaches (58.8%). Microsurgical treatment included first-, second-, and third-generation bypass. In 47.1% of cases, an anastomosis between the superficial temporal artery and the M3 segment was predominantly used, followed by an A3-A3 bypass (29.4%), a superficial temporal artery-M2 bypass (17.6%), and an external carotid artery to M2 bypass (5.9%). The intraoperative aneurysm rupture rate was 11.8%. Postoperative complications included ischemia (40%), cerebrospinal fluid fistulas (26.7%), and pneumonia (20%). At hospital discharge, the median Glasgow Coma Scale score was 14 (range: 10-15). At the 6-month follow-up, 82.4% of patients had a modified Rankin Scale score ≤2, bypass patency was present in all cases, and the morbidity rate was 17.6%. CONCLUSIONS: CIAs represent a spectrum of defiant vascular lesions with a poor natural history. Bypass surgery offers the potential for definitive treatment. Our case series illustrated the predominant role of cerebral revascularization of CIAs with a critical case-by-case approach to provide optimal outcomes in a limited-resource setting.

Changes in inpatient brain arteriovenous malformation management in the United States following the ARUBA trial: analysis of an interrupted time series design.

The November 2013 online publication of ARUBA, the first multi-institutional randomized controlled trial for unruptured brain arteriovenous malformations (AVMs), has sparked over 100 publications in protracted debates METHODS: This study sought to examine inpatient management patterns of brain AVMs from 2009 to 2016 and observe if changes in U.S. inpatient management were attributable to the ARUBA publication using interrupted time series of brain AVM studies from the National Inpatient Sample data 2009-2016. Outcomes of interest were use of embolization, surgery, combined embolization and microsurgery, radiotherapy, and observation during that admission. An interrupted time series design compared management trends before and after ARUBA. Segmented linear regression analysis tested for immediate and long-term impacts of ARUBA on management. RESULTS: Elective and asymptomatic patient admissions declined 2009-2016. In keeping with the ARUBA findings, observation for unruptured brain AVMs increased and microsurgery decreased. However, embolization, radiosurgery, and combined embolization and microsurgery also increased. For ruptured brain AVMs, treatment modality trends remained positive with even greater rates of observation, embolization, and combined embolization and microsurgery occurring after ARUBA (data on radiosurgery were scarce). None of the estimates for the change in trends were statistically significant. CONCLUSIONS: The publication of ARUBA was associated with a decrease in microsurgery and increase in observation for unruptured brain AVMs in the US. However, inpatient radiotherapy, embolization, and combined embolization and surgery also increased, suggesting trends moved counter to ARUBA's conclusions. This analysis suggested that ARUBA had a small impact as clinicians rejected ARUBA's findings in managing unruptured brain AVMs.

Enhancing the quality of evidence, comparability, and reproducibility in brain arteriovenous malformations treated with open surgery research: a systematic review and proposal of a reporting guideline for surgical and clinical outcomes.

Brain Arteriovenous Malformations (bAVMs) are rare but high-risk developmental anomalies of the vascular system. Microsurgery through craniotomy is believed to be the mainstay standard treatment for many grades of bAVMs. However, a significant challenge emerges in the existing body of clinical studies on open surgery for bAVMs: the lack of reproducibility and comparability. This study aims to assess the quality of studies reporting clinical and surgical outcomes for bAVMs treated by open surgery and develop a reporting guideline checklist focusing on essential elements to ensure comparability and reproducibility. This is a systematic literature review that followed the PRISMA guidelines with the search in Medline, Embase, and Web of Science databases, for studies published between January 1, 2018, and December 1, 2023. Included studies were scrutinized focusing on seven domains: (1) Assessment of How Studies Reported on the Baseline Characteristics of the Patient Sample; (2) Assessment and reporting on bAVMs grading, anatomical characteristics, and radiological aspects; (3) Angioarchitecture Assessment and Reporting; (4) Reporting on Pivotal Concepts Definitions; (5) Reporting on Neurosurgeon(s) and Staff Characteristics; (6) Reporting on Surgical Details; (7) Assessing and Reporting Clinical and Surgical Outcomes and AEs. A total of 47 studies comprising 5,884 patients were included. The scrutiny of the studies identified that the current literature in bAVM open surgery is deficient in many aspects, ranging from fundamental pieces of information of methodology to baseline characteristics of included patients and data reporting. Included studies demonstrated a lack of reproducibility that hinders building cumulative evidence. A bAVM Open Surgery Reporting Guideline with 65 items distributed across eight domains was developed and is proposed in this study aiming to address these shortcomings. This systematic review identified that the available literature regarding microsurgery for bAVM treatment, particularly in studies reporting clinical and surgical outcomes, lacks rigorous scientific methodology and quality in reporting. The proposed bAVM Open Surgery Reporting Guideline covers all essential aspects and is a potential solution to address these shortcomings and increase transparency, comparability, and reproducibility in this scenario. This proposal aims to advance the level of evidence and enhance knowledge regarding the Open Surgery treatment for bAVMs.

Latex vascular injection as method for enhanced neurosurgical training and skills.

Background: Tridimensional medical knowledge of human anatomy is a key step in the undergraduate and postgraduate medical education, especially in surgical fields. Training simulation before real surgical procedures is necessary to develop clinical competences and to minimize surgical complications. Methods: Latex injection of vascular system in brain and in head-neck segment is made after washing out of the vascular system and fixation of the specimen before and after latex injection. Results: Using this latex injection technique, the vascular system of 90% of brains and 80% of head-neck segments are well-perfused. Latex-injected vessels maintain real appearance compared to silicone, and more flexible vessels compared to resins. Besides, latex makes possible a better perfusion of small vessels. Conclusions: Latex vascular injection technique of the brain and head-neck segment is a simulation model for neurosurgical training based on real experiencing to improve surgical skills and surgical results.

Surgical outcomes in patients with acromegaly: Microscopic vs. endoscopic transsphenoidal surgery.

Transsphenoidal resection of growth hormone-secreting pituitary neuroendocrine tumors remains the first-line treatment for acromegaly. This can be performed through microsurgery or endoscopic surgery. For the past decades, endoscopic surgery has become the preferred technique in an increasing number of centers worldwide. However, whether it offers superior clinical outcomes has yet to be determined. In this paper, we performed a narrative review of the literature comparing both techniques in the treatment of acromegaly. We critically assessed available comparative studies from an objective perspective to determine their suitability for defining superiority of either technique. Available evidence displays substantial methodological variations and reports conflicting findings. Although endoscopic surgery provides a wider exposure and enhanced visibility of the surgical field, this does not consistently translate into better clinical outcomes, as most tumors are equally accessible through both techniques. Postoperative outcomes such as remission and complication rates are similar between both techniques. The management of acromegaly should be performed by experienced pituitary neurosurgeons, regardless of the approach. The involvement of a multidisciplinary team in a dedicated pituitary center is critical to ensure optimal outcomes.

First-generation bypass surgery for a giant fusiform aneurysm of the middle cerebral artery: an illustrative case and surgical video.

Giant fusiform aneurysms of the middle cerebral artery (MCA) are complex and rare vascular lesions with a poor natural history and challenging treatment decision-making. We report the case of a 46-year-old male with a history of chronic hypertension and a transient ischemic attack who presented with left-sided hemiparesis. A cerebral angiotomography revealed an unruptured giant fusiform aneurysm in the M2 segment of the right MCA. After carefully evaluating the procedure's risks and benefits with the patient, he underwent a low-flow bypass surgery. An anastomosis between the superficial temporal artery and the M3 segment was performed with proximal clipping of the M2 segment. The postoperative course was uneventful, with preserved bypass patency. At follow-up, the patient was neurologically intact. This report illustrates the nuances and operative techniques for treating a giant fusiform aneurysm of the M2 segment that accounted for a preserved bypass patency and optimal patient neurological recovery.

Microsurgery for brain aneurysms in an accessory A2 and basilar arteries: a rare case presentation and surgical video.

We present the case of a 58-year-old male with a 3-day history of sudden onset headache, loss of consciousness, and uncontrolled vomiting. The patient had 3/5 quadriparesis and a Glasgow coma scale (GCS) score of 8, which merited neurocritical intensive care. Brain imaging suggested the presence of two lesions: (i) a fusiform aneurysm of 12 × 7 mm in an accessory A2 artery of the anterior cerebral artery and (ii) an unruptured saccular aneurysm of 3.3 × 2.8 mm in the distal segment of the basilar artery. He was deemed a candidate for microsurgical management. Postoperatively, he had 4/5 quadriparesis, paresis of the right oculomotor nerve, and a GCS score of 13. A 3-month follow-up showed a significant improvement in neurological function with a score of 2 on the modified Rankin scale. The presented case illustrates the relevance of a nuanced acquaintance to operate in diseased anatomical variants and complex pathologies of narrow corridors.

Dynamically guided transantral piezoelectric endodontic microsurgery: A case report with technical considerations.

AIM: Endodontic microsurgery (EMS) of maxillary molars may represent a complex challenge to the clinician due to the location of the roots and the proximity of the maxillary sinus floor. This report aimed to describe the simultaneous use of a computer-assisted dynamic navigation (C-ADN) system and piezoelectric bony-window osteotomy for the transantral microsurgical approach of a maxillary left first molar with adequate root canal filling and symptomatic apical periodontitis. SUMMARY: This case report highlights the importance of C-ADN to carry out a minimally invasive buccal surgical access to palatal roots affected by apical periodontitis and provides a practical example to help clinicians make treatment decisions based on the available evidence. Clinical and tomographic evaluations were performed before the surgical procedure and at 24-month follow-up. This case was treated using a C-ADN system fitted to a piezotome for the buccal approach of the buccal roots, maxillary sinus membrane lifting, and for transantral location, root-end resection, cavity preparation, and filling of the palatal root. The navigation system allowed to achieve an accurate apical canal terminus location and root-end filling of the three roots with a minimally invasive piezoelectric crypt approach. At the 24-month follow-up examination, the patient remains asymptomatic, with normal periapical structures, and regeneration of maxillary sinus walls. It was concluded that the combination of dynamic navigation with piezoelectric bony-window osteotomy offers enhanced accuracy, tissue preservation, diminished risk of iatrogenic complications, and could maximize success and survival rates in transantral EMS.

Topographical Systematization of Human Placenta Model for Training in Microneurosurgery.

BACKGROUND: Neurosurgical training continuously seeks innovative methods to enhance the acquisition of essential technical skills for neurosurgeons worldwide. While various training models have been employed, few truly replicate real-life conditions optimally. Human placenta is a good model for neurosurgical microsurgery training due to its anatomic similarities to neurovascular structures. Placental vessels exhibit a branching pattern and caliber comparable with intracranial vessels, making them suitable for practicing microsurgical techniques. The study aims to delineate the anatomic zones of the placenta and propose a segmented training model, resulting in a reproducible, cost-effective, and realistic neurosurgical microsurgery training environment. METHODS: Twenty human placentas were meticulously prepared, injected with dyes, and categorized into zones on the basis of anatomic features. Measurements of placental vessels were recorded and compared with cerebral vessels. The placenta was divided into 4 quadrants to facilitate specific training techniques. RESULTS: Our results revealed varying vessel diameters across placental zones, closely resembling cerebral vessels. Different microsurgical techniques were applied to specific placental zones, thereby optimizing training scenarios. The applicability section described exercises such as membrane dissection, vessel skeletonization, aneurysm creation, vascular bypass, and tumor dissection within the placental model, providing detailed guidance on the zones suitable for each exercise. CONCLUSIONS: Human placenta serves as an effective microsurgical training model for neurosurgery, enhancing neurosurgeons' skills through anatomic segmentation. Integrating this model into training programs can significantly contribute to skill acquisition and improved surgical outcomes. Further research is warranted to refine and expand its utilization, complemented by clinical experiences and other simulation tools.

Establishment and application of a new 4/6 infarct nephrectomy rat model for moderate chronic kidney disease

Purpose: To develop a new 4/6 infarct nephrectomy (INx) model rat mimicking moderate chronic kidney disease (CKD) and to evaluate its application. Methods: We modified the conventional 5/6 INx rat model to create the 4/6 INx model by ligating the renal artery branch to induce infarction of one-third of the left kidney after right kidney removal and compared biochemically and histologically both models. To demonstrate the application of the 4/6 INx model, the effects of a supplementary compound containing calcium carbonate, chitosan, palm shell activated charcoal etc., that is effective for both CKD and its complications, were compared between both models. Results: Impairment of renal function in the 4/6 INx group was significantly more moderate than in the 5/6 INx group (P < 0.05). The 4/6 INx group showed less histological damage in kidney than in the 5/6 INx group. The supplementary compound did not improve CKD in the 5/6 INx group, but ameliorated elevation of blood urea nitrogen in the 4/6 INx group. Conclusions: We developed the 4/6 INx model, which is more moderate than the conventional 5/6 INx model. This model could potentially demonstrate the effectiveness of drugs and supplements intended to prevent CKD and its progression.

A microscope in your pocket: can smartphones be used to perform microsurgery?

Purpose: To evaluate the use of the latest generation smartphone camera in performing arterial microanastomosis in rats. Methods: Ten Wistar rats were divided into 2 groups and underwent anastomosis of the right carotid artery with the aid of magnification from a microscope (group M) and a smartphone camera (group S), to compare patency in 72 hours, as well as to measure the weight of the animals, diameter of the carotid arteries and anastomosis time. Results: There was no statistical difference between the weight of the animals or the diameter of the carotid arteries. There was a statistical difference for the time spent on anastomoses, which was greater in group S, with higher rates of thrombosis (p < 0.05). Conclusions: Although our patency and anastomosis time results were statistically lower in the smartphone group, there was success in some cases. As the segment continues to progress, it is likely that the results will improve in line with the evolution of camera technology.

Randomized experimental study of topical vasodilators in microsurgery with cost analysis / Estudo experimental randomizado de vasodilatadores tópicos em microcirurgia com análise de custo

ABSTRACT Objective: Throughout microsurgical anastomosis, many surgeons use topical vasodilators in order to reduce pathological vasospasm. It was carried out an experimental study comparing the effectiveness of topical use of Nitroglycerin, Papaverine, Magnesium sulfate over a control group in the femoral artery and vein of rats, in reducing prolonged vasospasm. Methods: Randomized comparative experimental study in 15 rats, divided into four groups. The external diameter of the vases soaked in the randomized solution was measured. For statistical analysis, it was calculated the percentual increase in the external diameter of the vessels. Results: A statistically significant increase in arterial dilation was observed after 10 minutes of topical application of 10% magnesium sulfate compared to the control group, with p = 0.044 . No other drug showed a vasodilator effect superior to the control group. Magnesium sulfate at 10% is still not used in microsurgery and costs 15 times less than papaverine, the standard drug for topical vasodilation in clinical cases at our service. Conclusion: Magnesium sulfate had better vasodilating effects over the control group after 10 minutes of arterial microanastomosis. None of the tested drugs have presented superior vasodilating effects over each other nor the control group after venous microanastomosis. Level of evidence II, Experimental study, Randomized Trial.

RESUMO Objetivo: Durante a anastomose microcirúrgica, muitos cirurgiões utilizam vasodilatadores tópicos para reduzir o vasoespasmo prolongado patológico, assim reduzindo o risco de complicações vasculares. Entretanto, ainda faltam dados experimentais para identificação da droga padrão-ouro para vasodilatadores tópicos em microcirurgia e sua avaliação de análise de custo, já que a droga geralmente utilizada para este objetivo é baseada, na maior parte dos casos, na experiência do cirurgião. Métodos: Foi realizado um estudo experimental comparativo randomizado, avaliando a eficácia do uso tópico de Nitroglicerina, Papaverina e Sulfato de Magnésio em relação a um grupo controle, na redução do vasoespasmo na artéria e veia femoral de ratos. Foram avaliados o diâmetro externo dos vasos embebidos em solução randomizada dos fármacos para vasodilatação. Após cálculo do aumento percentual no diâmetro externo dos vasos, foi realizada análise estatística. Resultados: Observou-se aumento estatisticamente significativo da dilatação arterial após 10 minutos de aplicação tópica de sulfato de magnésio a 10% em relação ao grupo controle, com p = 0,044. Nenhuma outra droga apresentou efeito vasodilatador superior ao grupo controle. O sulfato de magnésio a 10% ainda não é utilizado em microcirurgia e apresenta custo até 15 vezes menor quando comparado com a papaverina, droga padrão para vasodilatação tópica em casos clínicos em nosso serviço. Conclusão: O sulfato de magnésio apresentou melhor efeito vasodilatador quando comparado ao grupo controle, após 10 minutos da microanastomose arterial. Nenhum dos fármacos testados apresentou efeito vasodilatador superior após a microanastomose venosa. Nível de Evidência II, Estudo experimental, Ensaio Randomizado.