Myomectomy complicated by thrombotic microangiopathy

[spa] Presentamos a una paciente que fue intervenida de miomectomía laparoscópica que desarrolló anemia hemolítica microangiopática grave en el post operatorio, desembocando en fallo renal, insuficiencia respiratoria aguda parcial y trombocitopenia. Reisamos los diferentes tipos de microangiopatía trompetica, la dificultad de llegar al diagnóstico y los posibles tratamientos.[eng] We present a patient who underwent a laparotomy myomectomy that developed severe microangiopathic hemolytic anemia post-operatively, leading to acute renal failure, acute partial respiratory failure and thrombocytopenia. We discuss the different types of MAT, the difficulty of reaching the diagnose and the possible treatment

Beyond Classic Anastomoses Training Models: Overview of Aneurysm Creation in Rodent Vessel Model.

Nowadays, due to the decline in the number of microsurgical clippings for cerebral aneurysms and revascularization procedures, young neurosurgeons have fewer opportunities to participate and train on this type of surgery. Vascular neurosurgery is a demanding subspecialty that requires skills that can only be acquired with technical experience. This background pushes the new generations to be ready for such challenging cases by training hard on different available models, such as synthetic tubes, chicken wings, or placenta vessels. Although many training models for vascular neurosurgery have been described worldwide, one of the best is the rodent vessels model. It offers pulsation, coagulation, and real blood flow conditions in a physiologic atmosphere that mimics perfectly the intracranial human vessels environment, especially in terms of size. However, the current differences in governmental different regulations about the use of living animals in medical experimentation and the social awareness, as well as the lack of financial support, cause more difficulties for neurosurgeons to start with that kind of training. In this review, we describe the tools and techniques as basic steps for vascular microsurgery training by using rodent models, that provide an accurate copy of brain vessels environment under stable conditions. The initial three classical known microanastomoses for neurosurgeons are end-to-end, end-to-side, and side-to-side, but in literature, there have been described other more complex exercises for training and investigation, such as aneurysm models. Although there is still little data available, we aim to summarize and discuss aneurysm\u27s training models and reviewed the current literature on the subject and its applications, including a detailed description of the techniques

Case Report: Decompressive Craniectomy for COVID-19 Malignant Cerebral Artery Infarction. Is Surgery a Good Option?

SARS-CoV2 infection can lead to a prothrombotic state. Large vessel occlusion, as well as malignant cerebral stroke have been described in COVID-19 patients. In the following months, given the increase in COVID-19 cases, an increase in malignant cerebral SARS-CoV2 associated strokes are expected. The baseline situation of the patients as well as the risk of evolution to a serious disease due to the virus, depict a unique scenario. Decompressive craniectomy is a life-saving procedure indicated in patients who suffer a malignant cerebral stroke; however, it is unclear whether the same eligibility criteria should be used for patients with COVID-19. To our knowledge seven cases of decompressive craniectomy and malignant cerebral stroke have been described to date. We report on a 39-year-old female with no major risk factors for cerebrovascular disease, apart from oral contraception, and mild COVID-19 symptoms who suffered from left hemispheric syndrome. The patient underwent endovascular treatment with stenting and afterward decompressive craniectomy due to a worsening neurological status with unilateral unreactive mydriasis. We present the case and provide a comprehensive review of the available literature related to the surgical treatment for COVID-19 associated malignant strokes, to establish whether the same eligibility criteria for non-COVID-19 associated strokes should be used. Eight patients, including our case, were surgically managed due to malignant cerebral stroke. Seven of these patients received decompressive craniectomy, and six of them met the eligibility criteria of the current stroke guidelines. The mortality rate was 33%, similar to that described in non-COVID-19 cases. Two patients had a left middle cerebral artery (MCA) and both survived after decompressive craniectomy. Our results support that decompressive craniectomy, using the current stroke guidelines, should be considered an effective life-saving treatment for COVID-19-related malignant cerebral strokes

Assessment of overall survival in glioma patients as predicted by metabolomic criteria

© 2019 Gandía-González, Cerdán, Barrios, López-Larrubia, Feijoó, Palpan, Roda and Solivera.[Objective]: We assess the efficacy of the metabolomic profile from glioma biopsies in providing estimates of postsurgical Overall Survival in glioma patients.[Methods]: Tumor biopsies from 46 patients bearing gliomas, obtained neurosurgically in the period 1992–1998, were analyzed by high resolution 1H magnetic resonance spectroscopy (HR- 1H MRS), following retrospectively individual postsurgical Overall Survival up to 720 weeks.[Results]: The Overall Survival profile could be resolved in three groups; Short (shorter than 52 weeks, n = 19), Intermediate (between 53 and 364 weeks, n = 19) or Long (longer than 365 weeks, n = 8), respectively. Classical histopathological analysis assigned WHO grades II–IV to every biopsy but notably, some patients with low grade glioma depicted unexpectedly Short Overall Survival, while some patients with high grade glioma, presented unpredictably Long Overall Survival. To explore the reasons underlying these different responses, we analyzed HR-1H MRS spectra from acid extracts of the same biopsies, to characterize the metabolite patterns associated to OS predictions. Poor prognosis was found in biopsies with higher contents of alanine, acetate, glutamate, total choline, phosphorylcholine, and glycine, while more favorable prognosis was achieved in biopsies with larger contents of total creatine, glycerol-phosphorylcholine, and myo-inositol. We then implemented a multivariate analysis to identify hierarchically the influence of metabolomic biomarkers on OS predictions, using a Classification Regression Tree (CRT) approach. The CRT based in metabolomic biomarkers grew up to three branches and split into eight nodes, predicting correctly the outcome of 94.7% of the patients in the Short Overall Survival group, 78.9% of the patients in the Intermediate Overall Survival group, and 75% of the patients in the Long Overall Survival group, respectively.[Conclusion]: Present results indicate that metabolic profiling by HR-1H MRS improves the Overall Survival predictions derived exclusively from classical histopathological gradings, thus favoring more precise therapeutic decisions.This work was supported in part by grants PI2017/00361 from Instituto de Investigación Carlos III to JR, grant B2017/BMD-3688 from the Community of Madrid to JR and SC, and grant PI-0143-2016 from the Regional Ministry of Health of the Regional Government of Andalucía to JS

Treatment of cervical myelopathy by posterior approach: Laminoplasty vs. laminectomy with posterior fixation, are there differences from a clinical and radiological point of view?

INTRODUCTION: Cervical degenerative myelopathy is a variable and progressive degenerative disease caused by chronic compression of the spinal cord. Surgical approaches for the cervical spine can be performed anteriorly and/or posteriorly. Regarding the posterior approach, there are 2 fundamental techniques: laminoplasty and laminectomy with posterior fixation (LPF). There is still controversy concerning the technique in terms of outcome and complications. The aim of the present work is to analyze from the clinical and radiological point of view these 2 techniques: laminoplasty and LPF. MATERIALS AND METHODS: A historical cohort of 39 patients was reviewed (12 LFP and 27 laminoplasty) including patients operated in a 10 years period at the Hospital Universitario La Paz with a follow-up of 12 months after surgery was carried out. The clinical results were analyzed and compared using the Nurick scale and the modified Japanese Orthopaedic Association Scale (mJOA) and the radiological results using the Cobb angle, Sagittal Vertical Axis, T1 Slope and alignment (measured by Cobb-T1 Sloppe). RESULTS: Significant differences were observed in the postoperative improvement of the Nurick scale (p = 0.008) and mJOA (p = 0.018) in the laminoplasty group. In LFP there is a tendency to a greater improvement, but statistical significance is not reached due to the low sample size of this group. No statistically significant differences were observed in the radiological variables. Regarding the total number of complications, a higher number was observed in the laminoplasty group (7 cases) versus LFP (one case), but no statistically significant differences were observed. CONCLUSIONS: Laminoplasty and LFP are both safe and effective procedures in the treatment of cervical degenerative myelopathy. The findings of our study demonstrate statistically significant clinical improvement based on the Nurick and mJOA scales with laminoplasty. No significant differences in terms of complications or radiological variables were observed between the 2 techniques

Successful Optimization of Adalimumab Therapy in Refractory Uveitis Due to Behçet's Disease.

To assess efficacy, safety, and cost-effectiveness of adalimumab (ADA) therapy optimization in a large series of patients with uveitis due to Behçet disease (BD) who achieved remission after the use of this biologic agent. Open-label multicenter study of ADA-treated patients with BD uveitis refractory to conventional immunosuppressants. Sixty-five of 74 patients with uveitis due to BD, who achieved remission after a median ADA duration of 6 (range, 3-12) months. ADA was optimized in 23 (35.4%) of them. This biologic agent was maintained at a dose of 40 mg/subcutaneously/2 weeks in the remaining 42 patients. After remission, based on a shared decision between the patient and the treating physician, ADA was optimized. When agreement between patient and physician was reached, optimization was performed by prolonging the ADA dosing interval progressively. Comparison between optimized and nonoptimized patients was performed. Efficacy, safety, and cost-effectiveness in optimized and nonoptimized groups. To determine efficacy, intraocular inflammation (anterior chamber cells, vitritis, and retinal vasculitis), macular thickness, visual acuity, and the sparing effect of glucocorticoids were assessed. No demographic or ocular differences were found at the time of ADA onset between the optimized and the nonoptimized groups. Most ocular outcomes were similar after a mean ± standard deviation follow-up of 34.7±13.3 and 26±21.3 months in the optimized and nonoptimized groups, respectively. However, relevant adverse effects were only seen in the nonoptimized group (lymphoma, pneumonia, severe local reaction at the injection site, and bacteremia by Escherichia coli, 1 each). Moreover, the mean ADA treatment costs were lower in the optimized group than in the nonoptimized group (6101.25 euros/patient/year vs. 12 339.48; P ADA optimization in BD uveitis refractory to conventional therapy is effective, safe, and cost-effective