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Edson Bor-Seng-Shu and Manoel Jacobsen Teixeira

Object.

The purpose of this prospective study was to evaluate the cumulative incidence, duration, and time course of cerebral vasospasm after traumatic brain injury (TBI) in a cohort of 299 patients.

Methods.

Transcranial Doppler (TCD) ultrasonography studies of blood flow velocity in the middle cerebral and basilar arteries (VMCA and VBA, respectively) were performed at regular intervals during the first 2 weeks posttrauma in association with 133Xe cerebral blood flow (CBF) measurements. According to current definitions of vasospasm, five different criteria were used to classify the patients: A (VMCA > 120 cm/second); B (VMCA > 120 cm/second and a Lindegaard ratio [LR] > 3); C (spasm index [SI] in the anterior circulation > 3.4); D (VBA > 90 cm/second); and E (SI in the posterior circulation > 2.5). Criteria C and E were considered to represent hemodynamically significant vasospasm. Mixed-effects spline models were used to analyze the data of multiple measurements with an inconsistent sampling rate.

Overall 45.2% of the patients demonstrated at least one criterion for vasospasm. The patients in whom vasospasm developed were significantly younger and had lower Glasgow Coma Scale scores on admission. The normalized cumulative incidences were 36.9 and 36.2% for patients with Criteria A and B, respectively. Hemodynamically significant vasospasm in the anterior circulation (Criterion C) was found in 44.6% of the patients, whereas vasospasm in the BA—Criterion D or E—was found in only 19 and 22.5% of the patients, respectively. The most common day of onset for Criteria A, B, D, and E was postinjury Day 2. The highest risk of developing hemodynamically significant vasospasm in the anterior circulation was found on Day 3. The daily prevalence of vasospasm in patients in the intensive care unit was 30% from postinjury Day 2 to Day 13. Vasospasm resolved after a duration of 5 days in 50% of the patients with Criterion A or B and after a period of 3.5 days in 50% of those patients with Criterion D or E. Hemodynamically significant vasospasm in the anterior circulation resolved after 2.5 days in 50% of the patients. The time course of that vasospasm was primarily determined by a decrease in CBF.

Conclusions.

The incidence of vasospasm after TBI is similar to that following aneurysmal subarachnoid hemorrhage. Because vasospasm is a significant event in a high proportion of patients after severe head injury, close TCD and CBF monitoring is recommended for the treatment of such patients.

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Sergio Brasil, Marcelo de-Lima-Oliveira, Edson Bor-Seng-Shu and Manoel Jacobsen Teixeira

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Edson Bor-Seng-Shu, Paulo Henrique Aguiar, Ricardo Jose de Almeida Leme, Mauricio Mandel, Almir Ferreira de Andrade and Raul Marino Jr.

Object

The authors present their experience in the management of posterior fossa epidural hematoma (PFEDH), which involved an aggressive diagnostic approach with the extensive use of head computerized tomography (CT) scanning.

Methods

The authors treated 43 cases of PFEDH in one of the largest health centers in Brazil. Diagnosis was established in all patients with the aid of CT scanning because the clinical manifestations were frequently nonspecific. Cases were stratified by clinical course, Glasgow Coma Scale score, and their radiological status. Based on clinical and radiological parameters the patients underwent surgical or conservative management.

Conclusions

Compared with outcomes reported in the available literature, good outcome was found in this series. This is primarily due to the broad use of CT scanning for diagnostic and observational purposes, which, in the authors' opinion, led to early diagnosis and prompt treatment.

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Oren Sagher

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Marcelo de Lima Oliveira, Juliana R. Caldas, Manoel Jacobsen Teixeira and Edson Bor-Seng-Shu

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Edson Bor-Seng-Shu, Roberto Hirsch, Manoel Jacobsen Teixeira, Almir Ferreira de Andrade and Raul Marino Jr.

Object

The use of decompressive craniectomy has experienced a revival in the previous decade, although its actual benefit on patients’ neurological outcome remains the subject of debate. A better understanding of the intracranial pressure dynamics, as well as of the metabolic and hemodynamic brain processes, may be useful in assessing the effect of this surgery on the pathophysiology of the swollen brain. The aim of this study was to use transcranial Doppler (TCD) ultrasonography to examine the hemodynamic changes in the brain after decompressive craniectomy in patients with head injury, in addition to examining the relationship between such hemodynamic changes and the patient’s neurological outcome.

Methods

Nineteen patients presenting with traumatic brain swelling and cerebral herniation syndrome who had undergone decompressive craniectomy with dural expansion were studied prospectively. The TCD ultrasonography measurements were performed bilaterally in both the middle cerebral artery (MCA) and in the distal portion of the cervical internal carotid artery (ICA) immediately prior to and after surgical decompression.

After surgery, the mean blood flow velocity (BFV) rose to 175 ± 209% of preoperative values in the MCA of the operated side, while rising to 132 ± 183% in the contralateral side; the difference between the mean BFV increase in in the MCA of both the decompressed and the opposite side reached statistical significance (p < 0.05). The mean BFV of the extracranial ICA increased to 91 ± 119% in the surgical side and 45 ± 60% in the opposite side. Conversely, the MCA pulsatility index (PI) values decreased, on average, to 33 ± 36% of the preoperative value in the operated side and to 30 ± 34% on the opposite side; the MCA PI value reductions were significantly greater in the decompressed side when compared with the contralateral side (p < 0.05). The PI of the extracranial ICA reduced, on average, to 37 ± 23% of the initial values in the operated side and to 24 ± 34%, contralaterally. No correlation was verified between the neurological outcome and cerebral hemodynamic changes seen on TCD ultrasonography.

Conclusions

Decompressive craniectomy results in a significant elevation of cerebral BFV in most patients with traumatic brain swelling and transtentorial herniation syndrome. The increase in cerebral BFV may also occur in the side opposite the decompressed hemisphere; the cerebral BFV increase is significantly greater in the operated hemisphere than contralaterally. Concomitantly, PI values decrease significantly postoperatively, mainly in the decompressed cerebral hemisphere, indicating reduction in cerebrovascular resistance.

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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

Object

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.

Methods

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.

Results

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).

Conclusions

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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Leonardo C. Welling, Eberval G. Figueiredo, Hung T. Wen, Marcos Q. T. Gomes, Edson Bor-Seng-Shu, Cesar Casarolli, Vinicius M. P. Guirado and Manoel Jacobsen Teixeira

OBJECT

The object of this study was to compare the clinical, functional, and aesthetic results of 2 surgical techniques, pterional (PT) and minipterional (MPT) craniotomies, for microsurgical clipping of anterior circulation aneurysms.

METHODS

Fifty-eight patients with ruptured and unruptured anterior circulation aneurysms were enrolled into a prospective randomized study. The first group included 28 patients who underwent the MPT technique, and the second group comprised 30 patients who underwent the classic PT craniotomy. To evaluate the aesthetic effects, patients were asked to grade on a rule from 0 to 100 the best and the worst aesthetic result. Photographs were also taken, assessed by 2 independent observers, and classified as showing excellent, good, regular, or poor aesthetic results. Furthermore, quantitative radiological assessment (percentage reduction in thickness and volumetric analysis) of the temporal muscle, subcutaneous tissue, and skin was performed. Functional outcomes were compared using the modified Rankin Scale (mRS). Frontal facial palsy, postoperative hemorrhage, cerebrospinal fistula, hydrocephalus, and mortality were also analyzed.

RESULTS

Demographic and preoperative characteristics were similar in both groups. Satisfaction in terms of aesthetic result was observed in 19 patients (79%) in the MPT group and 13 (52%) in the PT group (p = 0.07). The mean score on the aesthetic rule was 27 in the MPT group and 45.8 in the PT group (p = 0.03). Two independent observers analyzed the patient photos, and the kappa coefficient for the aesthetic results was 0.73. According to these observers, excellent and good results were seen in 21 patients (87%) in the MPT and 12 (48%) in the PT groups. The degree of temporal muscle, subcutaneous tissue, and skin atrophy was 14.9% in the MPT group and 24.3% in the PT group (p = 0.01). Measurements of the temporal muscle revealed 12.7% atrophy in the MPT group and 22% atrophy in the PT group (p = 0.005). The volumetric reduction was 14.6% in the MPT and 24.5% in the PT groups (p = 0.012). Mortality and mRS score were similar in both groups at the 6-month evaluation (p = 0.99).

CONCLUSIONS

Minipterional craniotomy provides clinical results similar to those of the PT technique. Moreover, it provides better cosmetic results. It can be used safely and effectively to surgically treat aneurysms of the anterior circulation instead of the PT approach.

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Edson Bor-Seng-Shu, Ricardo De Carvalho Nogueira, Eberval G. Figueiredo, Eli Faria Evaristo, Adriana Bastos Conforto and Manoel Jacobsen Teixeira

Object

Sonothrombolysis has recently been considered an emerging modality for the treatment of stroke. The purpose of the present paper was to review randomized clinical studies concerning the effects of sonothrombolysis associated with tissue plasminogen activator (tPA) on acute ischemic stroke.

Methods

Systematic searches for literature published between January 1996 and July 2011 were performed for studies regarding sonothrombolysis combined with tPA for acute ischemic stroke. Only randomized controlled trials were included. Data extraction was based on ultrasound variables, patient characteristics, and outcome variables (rate of intracranial hemorrhages and arterial recanalization).

Results

Four trials were included in this study; 2 trials evaluated the effect of transcranial Doppler (TCD) ultrasonography on sonothrombolysis, and 2 addressed transcranial color-coded duplex (TCCD) ultrasonography. The frequency of ultrasound waves varied from 1.8 to 2 MHz. The duration of thrombus exposure to ultrasound energy ranged from 60 to 120 minutes. Sample sizes were small, recanalization was evaluated at different time points (60 and 120 minutes), and inclusion criteria were heterogeneous. Sonothrombolysis combined with tPA did not lead to an increase in symptomatic intracranial hemorrhagic complications. Two studies demonstrated that patients treated with ultrasound combined with tPA had statistically significant higher rates of recanalization than patients treated with tPA alone.

Conclusions

Despite the heterogeneity and the limitations of the reviewed studies, there is evidence that sonothrombolysis associated with tPA is a safe procedure and results in an increased rate of recanalization in the setting of acute ischemic stroke when wave frequencies and energy intensities of diagnostic ultrasound systems are used.

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