Microsurgery can cure most intracranial dural arteriovenous fistulae of the sinus and non-sinus type

There is consensus that intracranial dural arteriovenous fistulae (dAVF) with direct (non-sinus-type) or indirect (sinus-type) retrograde filling of a leptomeningeal vein should be treated due to the high risk of neurological deficits and hemorrhage. No consensus exists on treatment modality (surgery and/or embolization) and, if surgery is performed, on the best surgical strategy. This series aims to evaluate the role of surgery in the management of aggressive dAVFs. Forty-two patients underwent surgery. Opening and packing the sinus with thrombogenic material was performed in 9 of the 12 sinus-type dAVFs. In two sinus-type fistulae of the cavernous sinus and 1 of the torcular, microsurgery was used as prerequisite for subsequent embolization by providing access to the sinus. In the 30 non-sinus-type dAVFs, surgery consisted of interruption of the draining vein at the intradural entry point. In 41 patients undergoing 43 operations, elimination of the dAVF was achieved (97.6%). In one case, a minimal venous drainage persisted after surgery. The transient surgical morbidity was 11.9% (n = 5) and the permanent surgical morbidity 7.1% (n = 3). Our surgical strategy was to focus on the arterialized leptomeningeal vein in the non-sinus-type and on the arterialized sinus segment in the sinus-type dAVFs allowing us to obliterate all but one dAVF with a low morbidity rate. We therefore propose that microsurgery should be considered early in the treatment of both types of aggressive dAVFs. In selected cases of cavernous sinus dAVFs, the role of microsurgery is reduced to that of an adjunct to endovascular therapy

Pain measurement from the neurosurgical standpoint

A selective review of the current methods of pain measurement and validation (psychophysical methods, verbal and analogical scales, psychological tests) is presented with emphasis on patient selection for surgical pain relief, and analysis of outcome. The identification of homogeneous groups of patients with clinical and research objectives is prevented by the lack of a reliable pain scale, based on the assessment of objective and comprehensive parameters. This obstacle seems to be inherent to the complex nature of human pain experience. Psychiatric examination has proved important to elucidate the operative indications, particularly in cases of non-malignant obscure neuralgias. The importance of separate validation of the pain compliant and the psychiatric assessment is stressed. A critical comment is made on Hitchcock's pain scale and Lindqvist's psychiatric classification of candidates for surgery

Nevralgia vagoglossofaríngea

Revisão dos conceitos vigentes sobre a clínica, patogenia, diagnóstico diferencial e tratamento da neuralgia vagoglossofaríngea, e relato de três casos operados por neurotomia intracraniana do n. IX e n. X (parcial). A anatomia da inervação sensitiva das regiões profundas da face e transição cervicofacial, com suas implicações clínicas, e a teoria da compressão neurovascular na patogenia das disfunções ditas «hiperativas» dos nervos cranianos, são comentadas criticamente

Patient Organ Radiation Doses During Treatment for Aneurysmal Subarachnoid Hemorrhage

PURPOSE: The aim of this retrospective study was to estimate risk organ doses and to estimate radiation risks during the imaging work-up and treatment for aneurysmal subarachnoid hemorrhage (SAH). METHODS: The imaging procedures comprised computed tomography and digital subtraction angiography studies for diagnosis or endovascular interventional procedures in 50 consecutive patients. Equivalent organ doses (H(T)) to skin, brain, eye lens, salivary glands, thyroid and oral mucosa were measured using thermoluminescence dosimeters in an anthropomorphic head phantom. Picture archiving and communication system (PACS) and radiological information system (RIS) records were analyzed and the frequency of each imaging procedure was recorded as well as the registered individual kerma-length product (P(KL)) and the kerma-area product (P(KA)). The doses were computed by multiplying the recorded P(KL) and P(KA) values by the conversion coefficients H(T)/P(KL) and H(T)/P(KA) from the head phantom. RESULTS: The mean fluoroscopy time, P(KL) and P(KA) were 38 min, 7269 mGy cm and 286 Gy cm(2), respectively. The estimated mean equivalent doses were as follows: skin 2.51 Sv, brain 0.92 Sv, eye lens 0.43 Sv and salivary glands 0.23 Sv. Maximum organ doses were 2.3-3.5 times higher than the mean. Interventional procedures contributed 66 % to skin dose, 55 % to brain dose and 25 % to eye lens dose. Of the patients with an estimated skin dose exceeding 6 Sv, only 1 developed temporary epilation. CONCLUSION: The risk for radiation-induced cancer for SAH patients is low (2-3 cases per 1,000 patients, of which 90 % are expected to be benign types) compared with the risk of tissue reactions on the head such as skin erythema and epilation (1 temporary epilation per 50 patients)