During dissection of paraspinal muscles in posterior surgical approaches, the spine surgeon usually holds a subperiosteal (Cobb) elevator in 1 hand and a monopolar cautery in the other hand. In such ...a scenario, both the surgical smoke generated by the monopolar and eventual bleeding constitute a significant hindrance to simultaneous bilateral dissection of the paraspinal muscles by 2 surgeons.
To address the identified shortcomings in the currently available instrumentation, we initially analyzed the most common surgical techniques employed by residents and fellows at our institution for paraspinal muscle dissection during posterior spinal approaches. Additionally, we collected trainees’ feedback regarding the efficacy of available strategies for dealing with surgical smoke.
A new coupled Cobb elevator-suction instrument was designed, manufactured, and tested by residents, fellows, and experienced spine surgeons, and small additional design modifications were performed.
We present what we believe is the first description of a new coupled Cobb-suction instrument that has been developed to enable simultaneous retraction and suction with 1 hand, while allowing the spine surgeon to use the monopolar cautery with the other hand. In our preliminary institutional experience, this new tool has been proven to be especially useful in long posterior spinal approaches in the thoracolumbar region.
Bilateral ophthalmic aneurysms are rare and involve two aneurysms in the ophthalmic arteries, one on each, leading to potential symptoms such as vision loss and headaches. The treatment options for ...aneurysms, ranging from surgery and endovascular embolization to observation, depend on various factors, including aneurysm size and the patient's health. Microsurgery, while presenting complexities due to the intricate anatomy of the anterior clinoid region, offers potential advantages such as enhanced decompression rates and reduced aneurysm recurrence. The presented surgical video illustrates the treatment of bilateral ophthalmic artery aneurysms via a single craniotomy. This method reduces surgical duration and trauma, facilitating quicker patient recovery. However, this method bears potential risks, especially to both optic nerves. As underscored in the video, the utmost anatomical understanding in the anterior clinoid area is pivotal for successful outcomes and reduced complications.
The authors present the first report of a fracture of the tip of a kyphoplasty curette inside the vertebral body, which occurred during a procedure in a patient with non‐osteoporotic fracture. This ...highlights the need of further biomechanical research focused on the shear load failure properties of such type of pre‐bent curettes
Further research on the shear load failure properties of prebent curettes as well as clinical studies are required before the use of such type of instrument can be recommended in nonosteoporotic patients.
Craniopharyngiomas are supra/parasellar lesions that often present with general, unspecific symptoms. Similarly, internal carotid artery (ICA) bifurcation giant aneurysms may also produce calcified, ...heterogeneous, parasellar expansive lesions, posing a relevant differential diagnosis due to their inherently different surgical strategies and risks. We report the case of a 54-year-old female presenting with progressive disorientation and apathetic behavior. CT and MRI reports described a suprasellar heterogenous mass with calcifications associated with an adjacent, laterally located fluid collection suggestive of a craniopharyngioma. During the surgical procedure, perfuse and unexplained arterial bleeding ensued, prompting the surgical team to review a previous contrast-enhanced CT scan. Careful inspection revealed an image suggestive of vascular pathology, with an area of continuous hyperdensity along the right ICA bifurcation. The Sylvian fissure was dissected, and an aneurysmal neck was encountered and successfully clipped. Giant intracranial aneurysms are rare but essential differential diagnoses to be considered during the workup and surgical approach toward parasellar mass lesions. This case illustrates the importance of performing a CT angiogram (CTA) for skull base lesions, even when the size is more suggestive of tumor pathology.
•Critically ill patients with ICH may benefit from primary decompressive craniectomies.•Decompressive craniectomies could be a damage control strategy for such patients.•Beneficial in low-resource ...scenarios and when transferring patients is not possible.•Delayed treatment of AVMs after decompressive craniectomies may be a safe strategy.
Arteriovenous malformations (AVMs) of the brain are abnormal connections between the arterial and venous cerebral vasculature that often lead to intracranial hemorrhage (ICH). The diagnosis of AVMs often takes place in the setting of ICH, however, there is no clear consensus on how to manage critically ill, comatose patients and whether it is best to treat the lesion initially. We present an initial treatment strategy that is focused on the management of intracranial hypertension by the means of decompressive craniectomy (DC) coupled with delayed AVM management. We retrospectively reviewed the medical records of three patients who arrived with ICH, obliterated cisterns, and midline shifts greater than 5mm from ruptured AVMs. Each of these patients received a DC, with later definite treatment for their AVMs and cranioplasties. We reported the preoperative and postoperative clinical status of patients using Glasgow Coma Scale (GCS) outcomes as well as physical exam findings. All three patients were transferred to the intensive care immediately after DC and had significant clinical improvement 15 days post-craniectomy. All patients underwent definitive AVM treatment within 6 weeks of the initial procedure. One patient was treated with endovascular-only embolization while the other two received surgical treatment. Patients showed a significant improvement in neurological status and clinical outcome. Decompressive hemicraniectomies may have a positive impact on mortality and neurological outcomes for select patients with cerebral hemorrhage originating from vascular malformations, especially in low-resource scenarios.
The localization of arteriovenous malformations (AVMs) intraoperatively in the setting of an acute intracerebral hemorrhage (ICH) is crucial to avoid damage of delicate vascular structures that may ...even further exacerbate the bleed. Currently, surgical mapping using preoperative angiographic is the standard of practice. We report the use of intraoperative ultrasound for the diagnosis and localization of an AVM in the case of a 61-year-old female with reported iodine contrast allergy and previous severe reaction, in a setting with limited resources, without other imaging options or timely transfer to another facility readily available. Immediate surgical care was warranted to avoid further deterioration of the patient; intraoperative diagnosis and localization of the suspected underlying lesion were done using ultrasound. The ultrasound display showed tubular anechoic intertwined structures that demonstrated bidirectional flow, which is suggestive of an AVM. The intraoperative diagnosis allowed the surgeon to avoid an inadvertent approach to the vascular malformation nidus or vessels, which could have further complicated the case. We believe that intraoperative ultrasound may be valuable for the neurosurgeons today in many settings. Despite the fact that this case occurred in a scenario with limited resources and no other imaging method (such as magnetic resonance imaging (MRI), magnetic resonance angiography (MRA)) available, we advise readers not to rely solely on intraoperative ultrasound.
E.L., a modern-day Phineas Gage: Revisiting frontal lobe injury de Freitas, Pedro H.M.; Monteiro, Ruy C.; Bertani, Raphael ...
Lancet Regional Health - Americas (Online),
October 2022, 2022-Oct, 2022-10-00, 20221001, 2022-10-01, Letnik:
14
Journal Article
Recenzirano
Odprti dostop
How the prefrontal cortex (PFC) recovers its functionality following lesions remains a conundrum. Recent work has uncovered the importance of transient low-frequency oscillatory activity (LFO; < 4 ...Hz) for the recovery of an injured brain. We aimed to determine whether persistent cortical oscillatory dynamics contribute to brain capability to support ‘normal life’ following injury.
In this 9-year prospective longitudinal study (08/2012-2021), we collected data from the patient E.L., a modern-day Phineas Gage, who suffered from lesions, impacting 11% of his total brain mass, to his right PFC and supplementary motor area after his skull was transfixed by an iron rod. A systematic evaluation of clinical, electrophysiologic, brain imaging, neuropsychological and behavioural testing were used to clarify the clinical significance of relationship between LFO discharge and executive dysfunctions and compare E.L.´s disorders to that attributed to Gage (1848), a landmark in the history of neurology and neuroscience.
Selective recruitment of the non-injured left hemisphere during execution of unimanual right-hand movements resulted in the emergence of robust LFO, an EEG-detected marker for disconnection of brain areas, in the damaged right hemisphere. In contrast, recruitment of the damaged right hemisphere during contralateral hand movement, resulted in the co-activation of the left hemisphere and decreased right hemisphere LFO to levels of controls enabling performance, suggesting a target for neuromodulation. Similarly, transcranial magnetic stimulation (TMS), used to create a temporary virtual-lesion over E.L.’s healthy hemisphere, disrupted the modulation of contralateral LFO, disturbing behaviour and impairing executive function tasks. In contrast to Gage, reasoning, planning, working memory, social, sexual and family behaviours eluded clinical inspection by decreasing LFO in the delta frequency range during motor and executive functioning.
Our study suggests that modulation of LFO dynamics is an important mechanism by which PFC accommodates neurological injuries, supporting the reports of Gage´s recovery, and represents an attractive target for therapeutic interventions.
Fundação de Amparo Pesquisa Rio de Janeiro (FAPERJ), Universidade Federal do Rio de Janeiro (intramural), and Fiocruz/Ministery of Health (INOVA Fiocruz).
Although fluorescein is widely used for intraoperative angiography, some of its side effects remain obscure. In this report, we present the case of a 41-year-old patient with chronic ischemia caused ...by moyamoya syndrome who underwent bypass revascularization with intraoperative fluorescein angiography (FA). Immediately after the surgery, the patient presented homogeneous fluorescence of the entire skin. We discuss this curious phenomenon as well as other side effects that may arise due to FA.
Sturge-Weber syndrome (SWS) is a capillary-venous malformation affecting the brain, the eye, and the adjacent trigeminal dermatomes of the skin. This illness is usually diagnosed during the first ...years of life. If left undiagnosed (and consequently untreated), the condition could develop into severe refractory seizures, ischemic strokes, visual loss, and early cognitive impairment.We report a case of a 23-year-old female patient with a port-wine facial stain, presenting her first convulsive episode in adulthood, associated with a moderate dilation of the deep venous system in the angiography, which raised the diagnostic of Sturge-Weber syndrome.
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