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Eduardo Vieira, Igor V. Faquini, Jose L. Silva Jr., Maria F. L. Griz, Auricélio B. Cezar Jr., Nivaldo S. Almeida and Hildo R. C. Azevedo-Filho

Infectious intracranial aneurysms (IIAs) represent 2%–6% of all intracranial aneurysms and, classically, have been associated with bacterial or fungal agents. The authors report the case of a 42-year-old woman who presented with a typical history of subarachnoid hemorrhage. Digital subtraction angiography (DSA) showed an aneurysmal dilatation on the frontal M2 segment of the left middle cerebral artery (MCA). The patient was treated surgically, and multiple cysts were found in the left carotid and sylvian cisterns, associated with a dense inflammatory exudate that involved the MCA. The cysts were removed, and a fusiform aneurysmal dilatation was identified. The lesion was not amenable to direct clipping, so the authors wrapped it. Histopathological analysis of the removed cysts revealed the typical pattern of subarachnoid neurocysticercosis. The patient received cysticidal therapy with albendazole and corticosteroids, and she recovered uneventfully. Follow-up DSA performed 6 months after surgery showed complete resolution of the aneurysm. The authors performed a review of the literature and believe that there is sufficient evidence to affirm that the subarachnoid form of neurocysticercosis may lead to the development of an IIA and that Taenia solium should be listed among the possible etiological agents of IIAs, along with bacterial and fungal agents.

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Eduardo Vieira, Thiago C. Guimarães, Igor V. Faquini, Jose L. Silva Jr., Tammy Saboia, Rodrigo V. C. L. Andrade, Thaís L. Gemir, Valesca C. Neri, Nivaldo S. Almeida and Hildo R. C. Azevedo-Filho

OBJECTIVE

Decompressive craniectomy (DC) is a widely used procedure in neurosurgery; however, few studies focus on the best surgical technique for the procedure. The authors’ objective was to conduct a prospective randomized controlled trial comparing 2 techniques for performing DC: with watertight duraplasty and without watertight duraplasty (rapid-closure DC).

METHODS

The study population comprised patients ranging in age from 18 to 60 years who were admitted to the Neurotrauma Service of the Hospital da Restauração with a clinical indication for unilateral decompressive craniectomy. Patients were randomized by numbered envelopes into 2 groups: with watertight duraplasty (control group) and without watertight duraplasty (test group). After unilateral DC was completed, watertight duraplasty was performed in the control group, while in the test group, no watertight duraplasty was performed and the exposed parenchyma was covered with Surgicel and the remaining dura mater. Patients were then monitored daily from the date of surgery until hospital discharge or death. The primary end point was the incidence of surgical complications (CSF leak, wound infection, brain abscess, or subgaleal fluid collections). The following were analyzed as secondary end points: clinical outcome (analyzed using the Glasgow Outcome Scale [GOS]), surgical time, and hospital costs.

RESULTS

Fifty-eight patients were enrolled, 29 in each group. Three patients were excluded, leaving 27 in the test group and 28 in the control group. There were no significant differences between groups regarding age, Glasgow Coma Scale score at the time of surgery, GOS score, and number of postoperative follow-up days. There were 9 surgical complications (5 in the control group and 4 in the test group), with no significant differences between the groups. The mean surgical time in the control group was 132 minutes, while in the test group the average surgical time was 101 minutes, a difference of 31 minutes (p = 0.001). The mean reduction in total cost was $420.00 USD (a 23.4% reduction) per procedure in the test group.

CONCLUSIONS

Rapid-closure DC without watertight duraplasty is a safe procedure. It is not associated with a higher incidence of surgical complications (CSF leak, wound infection, brain abscess, or subgaleal fluid collections), and it decreased surgical time by 31 minutes on average. There was also a hospital cost reduction of $420.00 USD (23.4% reduction) per procedure.

Clinical trial registration no.: NCT02594137 (clinicaltrials.gov)

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Marcelo Magaldi Ribeiro de Oliveira, Carlos Eduardo Ferrarez, Taise Mosso Ramos, Jose Augusto Malheiros, Arthur Nicolato, Carla Jorge Machado, Mauro Tostes Ferreira, Fellype Borges de Oliveira, Cecília Félix Penido Mendes de Sousa, Pollyana Helena Vieira Costa, Sebastiao Gusmao, Giuseppe Lanzino and Rolando Del Maestro

OBJECTIVE

Surgery for brain aneurysms is technically demanding. In recent years, the process to learn the technical skills necessary for these challenging procedures has been affected by a decrease in the number of surgical cases available and progressive restrictions on resident training hours. To overcome these limitations, surgical simulators such as cadaver heads and human placenta models have been developed. However, the effectiveness of these models in improving technical skills is unknown. This study assessed concurrent and predictive validity of brain aneurysm surgery simulation in a human placenta model compared with a “live” human brain cadaveric model.

METHODS

Two human cadaver heads and 30 human placentas were used. Twelve neurosurgeons participated in the concurrent validity part of this study, each operating on 1 human cadaver head aneurysm model and 1 human placenta model. Simulators were evaluated regarding their ability to simulate different surgical steps encountered during real surgery. The time to complete the entire aneurysm task in each simulator was analyzed. The predictive validity component of the study involved 9 neurosurgical residents divided into 3 groups to perform simulation exercises, each lasting 6 weeks. The training for the 3 groups consisted of educational video only (3 residents), human cadaver only (3 residents), and human placenta only (3 residents). All residents had equivalent microsurgical experience with superficial brain tumor surgery. After completing their practice training, residents in each of the 3 simulation groups performed surgery for an unruptured middle cerebral artery (MCA) aneurysm, and their performance was assessed by an experienced vascular neurosurgeon who watched the operative videos.

RESULTS

All human cadaver heads and human placentas were suitable to simulate brain aneurysm surgery. In the concurrent validity portion of the experiment, the placenta model required a longer time (p < 0.001) than cadavers to complete the task. The placenta model was considered more effective than the cadaver model in simulating sylvian fissure splitting, bipolar coagulation of oozing microvessels, and aneurysm neck and dome dissection. Both models were equally effective in simulating neck aneurysm clipping, while the cadaver model was considered superior for simulation of intraoperative rupture and for reproduction of real anatomy during simulation. In the predictive validity portion of the experiment, residents were evaluated for 4 tasks: sylvian fissure dissection, microvessel bipolar coagulation, aneurysm dissection, and aneurysm clipping. Residents trained in the human placenta simulator consistently had the highest overall performance scores when compared with those who had trained in the cadaver model and those who had simply watched operative videos (p < 0.001).

CONCLUSIONS

The human placenta biological simulator provides excellent simulation for some critical tasks of aneurysm surgery such as splitting of the sylvian fissure, dissection of the aneurysm neck and dome, and bipolar coagulation of surrounding microvessels. When performing surgery for an unruptured MCA aneurysm, residents who had trained in the human placenta model performed better than residents trained with other simulation scenarios/models. In this age of reduced exposure to aneurysm surgery and restrictions on resident working hours, the placenta model is a valid simulation for microneurosurgery with striking similarities with real surgery.

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Marcelo Magaldi Ribeiro de Oliveira, Taise Mosso Ramos, Carlos Eduardo Ferrarez, Carla Jorge Machado, Pollyana Helena Vieira Costa, Daniel L. Alvarenga, Carolina K. Soares, Luiza M. Mainart, Pedro Aguilar-Salinas, Sebastião Gusmão, Eric Sauvageau, Ricardo A. Hanel and Giuseppe Lanzino

OBJECTIVE

Surgical performance evaluation was first described with the OSATS (Objective Structured Assessment of Technical Skills) and modified for aneurysm microsurgery simulation with the OSAACS (Objective Structured Assessment of Aneurysm Clipping Skills). These methods rely on the subjective opinions of evaluators, however, and there is a lack of objective evaluation for proficiency in the microsurgical treatment of brain aneurysms. The authors present a new instrument, the Skill Assessment in Microsurgery for Brain Aneurysms (SAMBA) scale, which can be used similarly in a simulation model and in the treatment of unruptured middle cerebral artery (MCA) aneurysms to predict surgical performance; the authors also report on its validation.

METHODS

The SAMBA scale was created by consensus among 5 vascular neurosurgeons from 2 different neurosurgical departments. SAMBA results were analyzed using descriptive statistics, Cronbach’s alpha indexes, and multivariate ANOVA analyses (p < 0.05).

RESULTS

Expert, intermediate-level, and novice surgeons scored, respectively, an average of 33.9, 27.1, and 16.4 points in the real surgery and 33.3, 27.3, and 19.4 points in the simulation. The SAMBA interrater reliability index was 0.995 for the real surgery and 0.996 for the simulated surgery; the intrarater reliability was 0.983 (Cronbach’s alpha). In both the simulation and the real surgery settings, the average scores achieved by members of each group (expert, intermediate level, and novice) were significantly different (p < 0.001). Scores among novice surgeons were more diverse (coefficient of variation = 12.4).

CONCLUSIONS

Predictive validation of the placenta brain aneurysm model has been previously reported, but the SAMBA scale adds an objective scoring system to verify microsurgical ability in this complex operation, stratifying proficiency by points. The SAMBA scale can be used as an interface between learning and practicing, as it can be applied in a safe and controlled environment, such as is provided by a placenta model, with similar results obtained in real surgery, predicting real surgical performance.