Preoperative scale proposal based on clinical outcome for elderly patients with ruptured intracranial aneurysms undergoing microsurgery

INTRODUCTION

Life expectancy in individuals has increased in recent years. There is no consensus in the literature on the best treatment for a ruptured aneurysm in the elderly (> 60 years), but some places only have microsurgery as a therapeutic strategy. This work aims to develop a prognostic scale for ruptured intracranial aneurysms in the elderly.

MATERIAL AND METHODS

Two thousand five hundred thirty patients with subarachnoid hemorrhage were retrospectively evaluated in the last ten years, and 550 of them were elderly. We developed a prognostic scale from the analysis of medical records, clinical and tomographic features that had statistical significance. Glasgow Coma Outcome (GOS) was the outcome of interest and p value < 0,05 was considered statistically significant.

RESULTS

Five hundred fifty patients were evaluated, and the comorbidities that were independent variables for poor prognosis were smoking and arterial hypertension; clinical variables were Hunt-Hess, modified Rankin and Glasgow Coma Scale; tomographic was Fisher scale. Poor outcome was defined as GOS ≤ 3. Poor surgical outcomes were more remarkable in the high-risk factor categories, being 6.41 times higher among individuals who had 3 to 4 risk factors and 8.80 times higher among individuals with 5 to 6 risk factors.

CONCLUSION

In some vascular neurosurgery services worldwide, microsurgery is the only therapeutic option. This scale aimed at the elderly patient individualizes the treatment and can predict the clinical outcome in ruptured intracranial aneurysms.

Idiopathic Ventral Spinal Cord Herniation: Video Report and Systematic Review

BACKGROUND

Idiopathic ventral spinal cord herniation (ISCH) is a rare disease; however, it is an important differential diagnosis. Its treatment presents some controversies.

CASE DESCRIPTION

We report on a 55-year-old woman who had been presenting with relevant back pain and leg weakness for the past 3 years and urinary incontinence for the past 3 months. Clinical examination disclosed paresis on the right inferior limb and right foot, as well as a T6-level painful hypoesthesia. Magnetic resonance imaging disclosed a T4/T5 ISCH. The patient underwent surgical decompression. During the procedure, we opened the arachnoid and cut the dentate ligaments of the spine, which considerably improved the mobility and safety of the procedure. In the early follow-up, our patient presented a partial improvement regarding the paresis grades and hypoesthesia pain relief on the left side. A video showing the surgical procedure and case evolution is presented. We also assembled literature reviews to compare our case with others. ISCH is becoming a more recognized cause of progressive thoracic myelopathy. However, this condition is still frequently misdiagnosed. Magnetic resonance imaging is the key for diagnosis. The objective of surgical treatment is to prevent myelopathy progression. The technique presented in this report is an appropriate surgical option, once it is a safer way to identify and treat the defect. The neurologic condition usually improves greatly after surgical treatment, especially when the patient presents positive predictive factors.

CONCLUSIONS

ISCH is being more recognized. The technique presented is an appropriate surgical option.

Orbitofrontal sulcal and gyrus pattern in human: an anatomical study

The anatomical characterization of the orbitofrontal cortex in human is limited in literature instead of many functional and clinical studies involving it. Objective Anatomically define the orbitofrontal region aiming to possible neurosurgical treatments and unify the scientific nomenclature as well. Method We analyze eighty four human hemispheres using a surgical microscope. Then we chose four hemispheres and dissect them according to Klinger’ technique. Results We found five main sulcus: olfatory sulcus, orbital medial sulcus, orbital lateral sulcus, orbital transverse sulcus and orbital intermediate sulcus. These sulcus, excluding the intermediate sulcus, delimit five gyrus: rectus gurys, orbital medial gyrus, orbital anterior gyrus, orbital lateral gyrus and orbital posterior gyrus. The main sulcal configuration can be divided on four more frequently patterns. Conclusion Orbitofrontal cortex is associated with many psychiatric disorders. Better anatomical and functional characterization of the orbitofrontal cortex and its connections will improve our knowledge about these diseases.