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Letter to the Editor. Shunt dysfunction and constipation

Weston Northam, Kristi Hildebrand, Scott Elton, and Carolyn Quinsey

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Letter to the Editor: Substantia nigra hyperechogenicity and Parkinson's disease surgery

Edson Bor-Seng-Shu, Daniel Ciampi de Andrade, Marcelo de Lima Oliveira, Erich Talamoni Fonoff, Egberto Reis Barbosa, and Manoel Jacobsen Teixeira

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Endoscopic-guided percutaneous radiofrequency cordotomy

Technical note

Erich Talamoni Fonoff, Ywzhe Sifuentes Almeida de Oliveira, William Omar Contreras Lopez, Eduardo Joaquim Lopes Alho, Nilton Alves Lara, and Manoel Jacobsen Teixeira

The authors present the first clinical implementation of an endoscopic-assisted percutaneous anterolateral radiofrequency cordotomy. The aim of this article is to demonstrate the intradural endoscopic visualization of the cervical spinal cord via a percutaneous approach to refine the spinal target for anterolateral cordotomy, avoiding undesired trauma to the spinal tissue or injury to blood vessels. Initially, a lateral puncture of the spinal canal in the C1–2 interspace is performed, guided by fluoroscopy. As soon as CSF is reached by the guide cannula (17-gauge needle), the endoscope can be inserted for visualization of the spinal cord and its surrounding structures. The endoscopic visualization provided clear identification of the pial surface of the spinal cord, arachnoid membrane, dentate ligament, dorsal and ventral root entry zone, and blood vessels. The target for electrode insertion into the spinal cord was determined to be the midpoint from the dentate ligament and the ventral root entry zone. The endoscopic guidance shortened the fluoroscopy usage time and no intrathecal contrast administration was needed. Cordotomy was performed by a standard radiofrequency method after refining of the neurophysiological target. Satisfactory analgesia was provided by the procedure with no additional complications or CSF leak. The initial use of this technique suggests that a percutaneous endoscopic procedure may be useful for particular manipulation of the spinal cord, possibly adding a degree of safety to the procedure and improving its effectiveness.

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Letter to the Editor. Are small aneurysms a giant problem?

Nícollas Nunes Rabelo, Manoel Jacobsen Teixeira, and Eberval Gadelha Figueiredo

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Letter to the Editor. Simplifying the use of prognostic information in patients with traumatic brain injury

Davi J. Fontoura Solla, Manoel Jacobsen Teixeira, and Wellingson Silva Paiva

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Sensory abnormalities and masticatory function after microvascular decompression or balloon compression for trigeminal neuralgia compared with carbamazepine and healthy controls

Michelle Cristina Ichida, Antonio Nogueira de Almeida, Jose Claudio Marinho da Nobrega, Manoel Jacobsen Teixeira, José Tadeu Tesseroli de Siqueira, and Silvia R. D. T. de Siqueira


Idiopathic trigeminal neuralgia (iTN) is a neurological condition treated with pharmacotherapy or neurosurgery. There is a lack of comparative papers regarding the outcomes of neurosurgery in patients with iTN. The objective of this study was to investigate sensory thresholds and masticatory function in 78 patients with iTN who underwent microvascular decompression (MVD) or balloon compression (BC), and compare these treatments with carbamazepine and 30 untreated healthy controls.


The authors conducted a case-controlled longitudinal study. Patients were referred to 1 of 3 groups: MVD, BC, or carbamazepine. All patients were evaluated before and after treatment with a systematic protocol composed of a clinical orofacial questionnaire, Research Diagnostic Criteria for temporomandibular disorders, Helkimo indices, and a quantitative sensory-testing protocol (gustative, olfactory, cold, warm, touch, vibration, superficial, and deep pain thresholds).


Both MVD and BC were effective at reducing pain intensity (p = 0.012) and carbamazepine doses (p < 0.001). Myofascial and articular complaints decreased in both groups (p < 0.001), but only the patients in the MVD group showed improvement in Helkimo indices (p < 0.003). Patients who underwent MVD also showed an increase in sweet (p = 0.014) and salty (p = 0.003) thresholds. The sour threshold decreased (p = 0.003) and cold and warm thresholds increased (p < 0.001) in patients after MVD and BC, but only the patients who underwent BC had an increase in touch threshold (p < 0.001).


Microvascular decompression and BC resulted in a reduction in myofascial and jaw articular complaints, and the impact on masticatory function according to Helkimo indices was greater after BC than MVD. MVD resulted in more gustative alterations, and both procedures caused impairment in thermal thresholds (warm and cold). However, only BC also affected touch perception. The sensorial and motor deficits after BC need to be included as targets directly associated with the success of the surgery and need to be assessed and relieved as goals in the treatment of iTN.

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Letter to the Editor. Glasgow Coma Scale–Pupils Score: opening the eyes to new ways of predicting outcomes in TBI

Nícollas Nunes Rabelo, Bruno Braga Sisnando da Costa, Gabriel Reis Sakaya, Manoel Jacobsen Teixeira, and Eberval Gadelha Figueiredo

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Decompressive craniectomy: a meta-analysis of influences on intracranial pressure and cerebral perfusion pressure in the treatment of traumatic brain injury

A review

Edson Bor-Seng-Shu, Eberval G. Figueiredo, Robson L. O. Amorim, Manoel Jacobsen Teixeira, Juliana Spelta Valbuza, Marcio Moyses de Oliveira, and Ronney B. Panerai


In recent years, the role of decompressive craniectomy for the treatment of traumatic brain injury (TBI) in patients with refractory intracranial hypertension has been the subject of several studies. The purpose of this review was to evaluate the contribution of decompressive craniectomy in reducing intracranial pressure (ICP) and increasing cerebral perfusion pressure (CPP) in these patients.


Comprehensive literature searches were performed for articles related to the effects of decompressive craniectomy on ICP and CPP in patients with TBI. Inclusion criteria were as follows: 1) published manuscripts, 2) original articles of any study design except case reports, 3) patients with refractory elevated ICP due to traumatic brain swelling, 4) decompressive craniectomy as a type of intervention, and 5) availability of pre- and postoperative ICP and/or CPP data. Primary outcomes were ICP decrease and/or CPP increase for assessing the efficacy of decompressive craniectomy. The secondary outcome was the persistence of reduced ICP 24 and 48 hours after the operation.


Postoperative ICP values were significantly lower than preoperative values immediately after decompressive craniectomy (weighted mean difference [WMD] −17.59 mm Hg, 95% CI −23.45 to −11.73, p < 0.00001), 24 hours after (WMD −14.27 mm Hg, 95% CI −24.13 to −4.41, p < 0.00001), and 48 hours after (WMD −12.69 mm Hg, 95% CI −22.99 to −2.39, p < 0.0001). Postoperative CPP was significantly higher than preoperative values (WMD 7.37 mm Hg, 95% CI 2.32 to 12.42, p < 0.0001).


Decompressive craniectomy can effectively decrease ICP and increase CPP in patients with TBI and refractory elevated ICP. Further studies are necessary to define the group of patients that can benefit most from this procedure.

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Glibenclamide in aneurysmal subarachnoid hemorrhage: a randomized controlled clinical trial

Bruno Braga Sisnando da Costa, Isabela Costola Windlin, Edwin Koterba, Vitor Nagai Yamaki, Nícollas Nunes Rabelo, Davi Jorge Fontoura Solla, Antonio Carlos Samaia da Silva Coelho, João Paulo Mota Telles, Manoel Jacobsen Teixeira, and Eberval Gadelha Figueiredo


Glibenclamide has been shown to improve outcomes in cerebral ischemia, traumatic brain injury, and subarachnoid hemorrhage (SAH). The authors sought to evaluate glibenclamide’s impact on mortality and functional outcomes of patients with aneurysmal SAH (aSAH).


Patients with radiologically confirmed aSAH, aged 18 to 70 years, who presented to the hospital within 96 hours of ictus were randomly allocated to receive 5 mg of oral glibenclamide for 21 days or placebo, in a modified intention-to-treat analysis. Outcomes were mortality and functional status at discharge and 6 months, evaluated using the modified Rankin Scale (mRS).


A total of 78 patients were randomized and allocated to glibenclamide (n = 38) or placebo (n = 40). Baseline characteristics were similar between groups. The mean patient age was 53.1 years, and the majority of patients were female (75.6%). The median Hunt and Hess, World Federation of Neurosurgical Societies (WFNS), and modified Fisher scale (mFS) scores were 3 (IQR 2–4), 3 (IQR 3–4), and 3 (IQR 1–4), respectively. Glibenclamide did not improve the functional outcome (mRS) after 6 months (ordinal analysis, unadjusted common OR 0.66 [95% CI 0.29–1.48], adjusted common OR 1.25 [95% CI 0.46–3.37]). Similar results were found for analyses considering the dichotomized 6-month mRS score (favorable score 0–2), as well as for the secondary outcomes of discharge mRS score (either ordinal or dichotomized), mortality, and delayed cerebral ischemia. Hypoglycemia was more frequently observed in the glibenclamide group (5.3%).


In this study, glibenclamide was not associated with better functional outcomes after aSAH. Mortality and delayed cerebral ischemia rates were also similar compared with placebo.

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Letter to the Editor. Endovascular management of epidural hematomas

Raghu Samala, Kanwaljeet Garg, Shweta Kedia, and Guru Dutta Satyarthee