Comparative evaluation between radiofrequency thermocoagulation and balloon compression neurotomy on long-term pain control in patients with idiopathic trigeminal neuralgia

Introdução: a neuralgia trigeminal, a despeito de reconhecida há séculos, continua sendo a síndrome dolorosa neuropática facial mais fascinante e desafiadora no que se refere ao seu tratamento. Apesar de sua primeira descrição formal ter ocorrido no século 18, os tratamentos mais eficazes surgiram somente após meados do século 20. Contudo, há uma escassez de dados em estudos comparativos com alto nível de evidência entre os métodos. Dessa forma, o presente estudo comparou a eficácia dos procedimentos percutâneos mais frequentemente utilizados no controle álgico dos pacientes com neuralgia trigeminal. Métodos: trata-se de um ensaio clínico prospectivo aleatorizado, duplamente encoberto, que incluiu 33 pacientes com diagnóstico de neuralgia trigeminal, em dois grupos: BC (neurotomia por balão) e RF (termocoagulação por radiofrequência). Os pacientes foram avaliados em seis momentos distintos: antes do procedimento (V0), sete (V1), 30 (V2), 60 (V3), 90 (V4) e 180 (V5) dias após. Foram utilizadas escalas para avaliação de dor (BPI, NPSI, DN4, SF-MPQ), quantidade de medicação utilizada (MQS), qualidade de vida (WHOQoL BREV) e funções psicológicas e humor (PCS e HADS). Dados sociodemográficos foram analisados entre os grupos. Foi utilizado, como desfecho primário, o terceiro item do BPI (escala numérica de dor nas últimas 24 horas). Após randomização, os pacientes foram submetidos ao procedimento sorteado. O desfecho primário foi analisado utilizando modelo de regressão linear. Teste t de Student foi usado para variáveis de distribuição normal e o teste de Mann-Whitney e qui-quadrado para variáveis de distribuição não-normal. Fora realizada análise interina pré-planejada com pelo menos metade dos pacientes planejados. Resultados: para a análise interina, dados de 33 pacientes estavam disponíveis. A idade média foi de 62,18 ± 9,4 anos. O objetivo primário não apresentou diferença estatisticamente significativa entre os grupos ao final do estudo. A taxa de complicação foi semelhante. A influência da dor nas atividades de vida diárias, as dimensões da dor, sintomas de dor neuropática, humor, quantidade de medicação em uso e qualidade de vida, avaliados com questionários específicos, também não apresentaram diferença estatisticamente significativa. O grupo de RF apresentou mais sintomas parestéticos do que o grupo BC (2,08±1,99; 3,97±1,96; p = 0,017) nos 30 dias subsequentes à intervenção, a despeito de não ter crises de dor (4,55±0,78, 5±0; p = 0,015). A presença do componente de dor contínua foi semelhante nos grupos. O estudo foi interrompido por insignificância clínica. Conclusão: os dois métodos possuem capacidade de controle de dor semelhante. Registro do ensaio no ClinicalTrials.gov NCT02427074Introduction: trigeminal neuralgia, despite being recognized for centuries, remains the most fascinating and challenging facial neuropathic painful syndromes in terms of its treatment. The most effective treatments appeared after the middle of the 20th century. However, well-designed studies comparing the main therapeutic methods are lacking. The aim of this study was to compared the effectiveness of the most frequently used percutaneous procedures for pain control in patients with trigeminal neuralgia. Methods: a prospective randomized, double-blind, intention-to-treat, clinical trial, was performed: 33 patients diagnosed with trigeminal neuralgia were available for the pre-planned interim analysis. Patients were randomized using an online program. After randomization, patients were divided in two groups: balloon compression (BC) and radiofrequency (RF). Patients were evaluated at six different times: before the procedure (V0), and 7 (V1), 30 (V2), 60 (V3), 90 (V4) and 180 (V5) days after the procedure. Scales were used to assess pain (BPI, NPSI, DN4, SFMPQ), quantity of medication used (MQS), quality of life (WHOQoL - BREV) and psychological functions and mood (PCS and HADS). Sociodemographic data were compared between the groups. The primary outcome was the third item of the BPI (numerical scale of the worst pain in the last 24 hours). The main outcome was assessed using generalized estimation equations. Student t-test was used for the normally distributed variables and Mann-Whitney and Pearsons chi-square test for the non-normally variables. A pre-planned interim analysis was performed when at least half of the estimated sample size was allocated. Results: thirty-three patients were available for the interim analysis (18 in BC and 15 in RF group). The average age was 62.18 ± 9.4 years. The primary objective showed no difference statistically significant between groups at the end of the study. Both groups presented similar complication rates. The influence of pain on daily activities of life, dimensions of pain, symptoms of neuropathic pain, mood, quantity of medication in use and quality of life, assessed with specific questionnaires, also showed no statistically significant difference. The RF group had more paresthetic symptoms than the BC group (2.08±1.99, 3.97±1.96; p=0.017) in the 30 days after the intervention, despite having no pain attacks (4.55±0.78, 5±0; p=0.015). The presence of continuous pain was similar in both groups. The study was interrupted due to futility. Conclusion: both methods show similar capacity in pain control. ClinicalTrials.gov Registry NCT0242707

Técnica de "clip-wrap" no tratamento de aneurismas rotos não clipáveis

Fusiform and dolichoectatic aneurysms are challenging lesions to treat with direct clipping. Treatment of these aneurysms often requires alternative surgical strategies, including extracranial-intracranial bypass, wrapping, or clip-wrap techniques. Nonetheless, these alternatives methods of treatment have been underused and frequently overlooked. OBJECTIVE: To report a series of nine cases of otherwise untreatable aneurysms managed using the clip-wrap technique and discuss its surgical nuances. METHOD: In the last four years, 9 cases of ruptured aneurysms treated by the clip-wrap techniques were identified in the Division of Neurological Surgery, University of São Paulo, School of Medicine. RESULTS: The aneurysms were located at middle cerebral artery (2), anterior choroidal artery (1), anterior communicating artery (1), carotid ophthalmic (3), posterior cerebral artery (1) and posterior-inferior cerebellar artery (1). Three were dolichoectatic, 4 were unsuitable to complete surgical clipping because parent or efferent vessels arises from the aneurysm sac (1 MCA, 1 AcomA, 1 CO, 1 PICA aneurysms) and two, although ruptured aneurysms, were too small (<2mm) to be directly clipped. No early or late rebleeding was observed after 2 years mean follow-up. One patient deceased due to pulmonary tromboembolism. CONCLUSION: Clip-wrap techniques for the treatment of fusiform and otherwise unclippable aneurysms seem to be safe and it can be associated with a low rate of acute or delayed postoperative complications. It can prevent rebleeding and represents an improvement when compared with the natural history.Aneurismas fusiformes são lesões de difícil tratamento e frequentemente necessitam de técnicas alternativas de tratamento, incluindo anastomose extra-intracranial ou técnicas de "clip-wrap". Contudo o uso destas técnicas é frequentemente esquecido e negligenciado. OBJETIVO: Descrever retrospectivamente casuística de nove casos de aneurismas não clipáveis tratados com a técnicas de "clip-wrap" e discutir as nuances cirúrgicas. RESULTADOS: Revisão dos últimos quatro anos da casuística da Divisão de Clínica Neurocirúrgica do HCFMUSP mostrou que 384 casos eram de aneurismas rotos. Destes, 9 eram de aneurismas não clipáveis tratados com a técnica de "clip-wrap". Destes, 2 aneurismas eram de artéria cerebral media, 1 de artéria coroidéia anterior, 1 de artéria comunicante anterior, 3 de artéria oftálmica, 1 de artéria cerebral posterior e 1 de PICA. Três eram lesões ectásicas, 4 não puderam ser completamente clipados devido a relação de aneurismas com vasos eferentes, aferentes ou perfurantes, e dois, apesar de rotos eram pequenos demais para serem clipados (<2,0 mm). Sangramento precoce ou tardio não foram observados, em um seguimento médio de 2 anos. CONCLUSÃO: A técnica descrita é segura e está associada com baixa incidência de complicações agudas ou tardias. Ela previne ressangramanto e representa um avanço em relação à história natural destas lesões

Good sensory recovery of the hand in brachial plexus surgery using the intercostobrachial nerve as the donor

ABSTRACT Objective: Restoration of the sensitivity to sensory stimuli in complete brachial plexus injury is very important. The objective of our study was to evaluate sensory recovery in brachial plexus surgery using the intercostobrachial nerve (ICBN) as the donor. Methods: Eleven patients underwent sensory reconstruction using the ICBN as a donor to the lateral cord contribution to the median nerve, with a mean follow-up period of 41 months. A protocol evaluation was performed. Results: Four patients perceived the 1-green filament. The 2-blue, 3-purple and 4-red filaments were perceptible in one, two and three patients, respectively. According to Highet's scale, sensation recovered to S3 in two patients, to S2+ in two patients, to S2 in six patients, and S0 in one patient. Conclusion: The procedure using the ICBN as a sensory donor restores good intensity of sensation and shows good results in location of perception in patients with complete brachial plexus avulsion

Short-term survival in extensive craniofacial resections

OBJECTIVES: Craniofacial resection (CFR) procedures for craniofacial tumors with cranial extension are often extensive. Although CFRs may yield good oncological results, there are concerns about high perioperative morbidity and mortality. This study aimed to determine risk factors for perioperative mortality after open CFR in terms of deaths occurring during index hospitalizations. METHODS: We conducted a retrospective analysis of CFRs conducted at a tertiary oncology hospital from May 2009 through December 2018. RESULTS: Our analysis included data from the medical records of 102 patients, the majority of whom were male (n=74, 72.5%). The mean age was 61 years (±18.3 years). Skin malignancies (n=64, 63.4%) accounted for nearly two-thirds of the treated tumors, and most of these were squamous cell carcinoma. Postoperative medical complications occurred in 33 patients (33%), and surgical complications occurred in 48 (47%). Multivariate analysis revealed the only independent risk factors for perioperative deaths to be the presence of intracranial tumor extension on preoperative imaging (hazard ratio [HR]=4.56; 95% confidence interval [CI]: 1.74–11.97; p=0.002) and the unexpected emergence of postoperative neurological dysfunction (HR=10.9; 95% CI: 2.21– 54.3; p=0.003). CONCLUSIONS: In our study, factors related to tumor extension were associated with a higher risk of perioperative death

Good sensory recovery of the hand in brachial plexus surgery using the intercostobrachial nerve as the donor

<div><p>ABSTRACT Objective: Restoration of the sensitivity to sensory stimuli in complete brachial plexus injury is very important. The objective of our study was to evaluate sensory recovery in brachial plexus surgery using the intercostobrachial nerve (ICBN) as the donor. Methods: Eleven patients underwent sensory reconstruction using the ICBN as a donor to the lateral cord contribution to the median nerve, with a mean follow-up period of 41 months. A protocol evaluation was performed. Results: Four patients perceived the 1-green filament. The 2-blue, 3-purple and 4-red filaments were perceptible in one, two and three patients, respectively. According to Highet's scale, sensation recovered to S3 in two patients, to S2+ in two patients, to S2 in six patients, and S0 in one patient. Conclusion: The procedure using the ICBN as a sensory donor restores good intensity of sensation and shows good results in location of perception in patients with complete brachial plexus avulsion.</p></div