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Ricardo Santos de Oliveira and Hélio Rubens Machado

Object

Hydrocephalus is a common disease process. Transcranial color-coded Doppler (TCCD) ultrasonography is an accepted noninvasive method with which to quantify intracranial blood flow in adults and children. The authors studied the applications of TCCD ultrasonography and the alterations of the flow velocity of the cerebral arteries in children with hydrocephalus.

Methods

One hundred thirty-five children were divided into three groups: Group 1 comprised 40 infants with asymptomatic hydrocephalus who had well-functioning ventriculoperitoneal (VP) shunts; Group 2 comprised 10 children with symptomatic hydrocephalus who had malfunctioning shunts that were replaced; and Group 3 was a control group of 85 healthy infants. All patients underwent sequential measurements of cerebral blood flow (CBF) velocities (systolic and diastolic velocities) and resistivity index (RI). One group of patients underwent functional tests (compression of the anterior fontanelle and CO2 vasoreactivity) to determine hemodynamic changes in cerebral circulation.

A significant statistical change in RI measurements, end diastolic CBF velocity, and percentage of change in RI was shown in patients with malfunctioning shunts, and in infants with a well-functioning VP shunt vasomotor reactivity was severely reduced.

Conclusions

Transcranial color-coded Doppler ultrasonography can be used to perform follow-up assessments of normal and malfunctioning shunts in children with hydrocephalus; the functional tests are a noninvasive tool for evaluating the cerebral compliance and the cerebral autoregulation in infants with hydrocephalus. The autoregulatory capacity may partly or completely be lost in cases of long-term shunt-treated hydrocephalus, and loss of cerebral vasoreactivity may be responsible for long-term deficits commonly observed in children, which help explain some of symptoms related to slit ventricles.

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Matheus Fernando Manzolli Ballestero, Luciano Furlanetti, and Ricardo Santos de Oliveira

OBJECTIVES

Coronavirus disease (COVID-19) is a potentially severe respiratory illness that has threatened humanity globally. The pediatric neurosurgery practice differs from that of adults in that it treats children in various stages of physical and psychological development and contemplates diseases that do not exist in other areas. The aim of this study was to identify the level of knowledge and readiness of the healthcare providers, as well as to evaluate new preventive practices that have been introduced, psychological concerns, and the impact of the COVID-19 pandemic on pediatric neurosurgical units in Brazil.

METHODS

Pediatric neurosurgeons were given an online questionnaire developed by the Brazilian Society of Pediatric Neurosurgery to evaluate the impact of the COVID-19 pandemic on their clinical practice.

RESULTS

Of a cohort of 110 active members of the Brazilian Society of Pediatric Neurosurgery, 76 completed the survey (69%). Ninety-six percent were aware of the correct use of and indication for the types of personal protective equipment in clinical and surgical practices, but only 73.7% of them had unrestricted access to this equipment. Ninety-eight percent of participants agreed or strongly agreed that the pandemic had affected their pediatric neurosurgical practice. The COVID-19 pandemic interfered with outpatient care in 88% of the centers, it affected neurosurgical activity in 90.7%, and it led to the cancellation of elective neurosurgical procedures in 57.3%. Concerning the impact of COVID-19 on surgical activity, 9.2% of the centers had less than 25% of the clinical practice affected, 46.1% had 26%–50% of their activity reduced, 35.5% had a 51%–75% reduction, and 9.2% had more than 75% of their surgical work cancelled or postponed. Sixty-three percent affirmed that patients had been tested for COVID-19 before surgery. Regarding the impact of the COVID-19 pandemic on the mental health of those interviewed, 3.9% reported fear and anxiety with panic episodes, 7.9% had worsening of previous anxiety symptoms, 60.5% reported occasional fear, 10.5% had sadness and some depressive symptoms, and 2.6% reported depressive symptoms.

CONCLUSIONS

The COVID-19 pandemic has posed unprecedented challenges to healthcare services worldwide, including neurosurgical units. Medical workers, pediatric neurosurgeons included, should be aware of safety measures and follow the recommendations of local healthcare organizations, preventing and controlling the disease. Attention should be given to the psychological burden of exposure to SARS-CoV-2 in healthcare workers, which carries a high risk of anxiety and depression.

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Ricardo Santos de Oliveira, Giuseppe Cinalli, Thomas Roujeau, Christian Sainte-Rose, Alain Pierre-Kahn, and Michel Zerah

Object

The authors of this retrospective review and analysis of the literature cover an institutional series of neurenteric cysts of the central nervous system in children treated in the magnetic resonance imaging era during a 14-year period.

Methods

Sixteen patients 20 days to 14 years of age are described. The most frequent signs and symptoms at presentation were acute spinal cord compression (11 patients), paresis of a cranial nerve (two patients), meningitis or infection (two patients), and intracranial hypertension (one patient). The locations of the cysts were as follows: in the spinal canal in 12 patients (75%), the clivus in two (12.5%), the cavernous sinus in one (6%), and the craniocervical junction in one (6%). The most common location was the ventral aspect of the spinal canal (seven patients). Associated spinal deformities were found in five patients. All patients underwent surgery, with a posterior approach used in all of the spinal cases. Total resection was achieved in 12 of the 16 cases and partial resection in four. Of the four patients who underwent subtotal resection, the cyst recurred in three, requiring further surgery.

Conclusions

Neurenteric cysts are uncommon congenital anomalies that can present acutely in the pediatric population. Total removal is usually possible and is associated with a good prognosis.

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Daniel A. N. Barbosa, Ricardo de Oliveira-Souza, Felipe Monte Santo, Ana Carolina de Oliveira Faria, Alessandra A. Gorgulho, and Antonio A. F. De Salles

The neurosurgical endeavor to treat psychiatric patients may have been part of human history since its beginning. The modern era of psychosurgery can be traced to the heroic attempts of Gottlieb Burckhardt and Egas Moniz to alleviate mental symptoms through the ablation of restricted areas of the frontal lobes in patients with disabling psychiatric illnesses. Thanks to the adaptation of the stereotactic frame to human patients, the ablation of large volumes of brain tissue has been practically abandoned in favor of controlled interventions with discrete targets.

Consonant with the role of the hypothalamus in the mediation of the most fundamental approach-avoidance behaviors, some hypothalamic nuclei and regions, in particular, have been selected as targets for the treatment of aggressiveness (posterior hypothalamus), pathological obesity (lateral or ventromedial nuclei), sexual deviations (ventromedial nucleus), and drug dependence (ventromedial nucleus). Some recent improvements in outcomes may have been due to the use of stereotactically guided deep brain stimulation and the change of therapeutic focus from categorical diagnoses (such as schizophrenia) to dimensional symptoms (such as aggressiveness), which are nonspecific in terms of formal diagnosis. However, agreement has never been reached on 2 related issues: 1) the choice of target, based on individual diagnoses; and 2) reliable prediction of outcomes related to individual targets. Despite the lingering controversies on such critical aspects, the experience of the past decades should pave the way for advances in the field. The current failure of pharmacological treatments in a considerable proportion of patients with chronic disabling mental disorders is reminiscent of the state of affairs that prevailed in the years before the early psychosurgical attempts.

This article reviews the functional organization of the hypothalamus, the effects of ablation and stimulation of discrete hypothalamic regions, and the stereotactic targets that have most often been used in the treatment of psychopathological and behavioral symptoms; finally, the implications of current and past experience are presented from the perspective of how this fund of knowledge may usefully contribute to the future of hypothalamic psychosurgery.

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Ricardo Santos de Oliveira, Marcelo Campos Moraes Amato, María Sol Brassesco, Elvis Terci Valera, Carlos Eduardo Barros Jucá, Luciano Neder, Luiz Gonzaga Tone, and Hélio Rubens Machado

The authors report the first case of an intracranial inflammatory myofibroblastic tumor (IMT) associated with the placement of a ventriculoperitoneal shunt, which occurred in a 7-year-old boy. Neuroradiological features showed a mass surrounding the ventricular catheter. The lesion was completely resected. Histological study revealed the mass to be an IMT. The patient's postoperative course was complicated by a local recurrence requiring a second surgery. Cytogenetic analysis of the sample by comparative genome hybridization revealed several chromosomal amplifications and regional losses. The occurrence of IMT in the CNS has rarely been reported. For treatment of this condition, the authors recommend a total removal of the shunt with a mass excision to prevent local recurrence.

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Marie Bourgeois, Darach William Crimmins, Ricardo Santos De Oliveira, Alexis Arzimanoglou, Matthew Garnett, Thomas Roujeau, Federico Di Rocco, and Christian Sainte-Rose

Object

The authors sought to analyze the success rate of surgery in the management of medically intractable epilepsy in children with Sturge–Weber syndrome and to determine whether the extent and timing of surgery affected seizure and developmental outcomes.

Methods

The authors performed a retrospective review of 27 children who underwent surgery at their institution for medically resistant epilepsy, and they examined the outcomes with regard to epilepsy control and neuropsychological development.

Seventeen children (63%) experienced onset of their epilepsy when they were younger than 1 year of age. These patients were significantly more likely to have hemiparesis (p ≤ 0.001) and status epilepticus (p ≤ 0.001) and be developmentally delayed (p ≤ 0.025) than children whose epilepsy started later in life. Eight patients underwent a hemispherectomy (either anatomical or functional), and complete resolution of epilepsy was noted in all. Of the 19 patients in whom a focal resection was performed, 11 (58%) became seizure free. The 10 children in whom there was residual disease were more likely to have continuing epilepsy than the nine whose lesions were completely excised (p ≤ 0.05). Seventeen children exhibited improvement in their developmental status following surgery. This improvement was significantly affected by completeness of resection (p ≤ 0.05) and age at surgery (p ≤ 0.009). Seizure freedom per se was not affected by the timing of surgery.

Conclusions

Medically intractable epilepsy in children can be treated effectively by surgery. The degree of resection or disconnection of diseased tissue, but not patient age at the time of surgery, is an important factor in achieving epilepsy control. Early surgery is more likely to improve developmental outcome.

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Giselle Coelho, Nicollas Nunes Rabelo, Eduardo Vieira, Kid Mendes, Gustavo Zagatto, Ricardo Santos de Oliveira, Cassio Eduardo Raposo-Amaral, Maurício Yoshida, Matheus Rodrigues de Souza, Caroline Ferreira Fagundes, Manoel Jacobsen Teixeira, and Eberval Gadelha Figueiredo

OBJECTIVE

The main objective of neurosurgery is to establish safe and reliable surgical techniques. Medical technology has advanced during the 21st century, enabling the development of increasingly sophisticated tools for preoperative study that can be used by surgeons before performing surgery on an actual patient. Laser-printed models are a robust tool for improving surgical performance, planning an operative approach, and developing the skills and strategy to deal with uncommon and high-risk intraoperative difficulties. Practice with these models enhances the surgeon’s understanding of 3D anatomy but has some limitations with regard to tactile perception. In this study, the authors aimed to develop a preoperative planning method that combines a hybrid model with augmented reality (AR) to enhance preparation for and planning of a specific surgical procedure, correction of metopic craniosynostosis, also known as trigonocephaly.

METHODS

With the use of imaging data of an actual case patient who underwent surgical correction of metopic craniosynostosis, a physical hybrid model (for hands-on applications) and an AR app for a mobile device were created. The hybrid customized model was developed by using analysis of diagnostic CT imaging of a case patient with metopic craniosynostosis. Created from many different types of silicone, the physical model simulates anatomical conditions, allowing a multidisciplinary team to deal with different situations and to precisely determine the appropriate surgical approach. A real-time AR interface with the physical model was developed by using an AR app that enhances the anatomic aspects of the patient’s skull. This method was used by 38 experienced surgeons (craniofacial plastic surgeons and neurosurgeons), who then responded to a questionnaire that evaluated the realism and utility of the hybrid AR simulation used in this method as a beneficial educational tool for teaching and preoperative planning in performing surgical metopic craniosynostosis correction.

RESULTS

The authors developed a practice model for planning the surgical cranial remodeling used in the correction of metopic craniosynostosis. In the hybrid AR model, all aspects of the surgical procedure previously performed on the case patient were simulated: subcutaneous and subperiosteal dissection, skin incision, and skull remodeling with absorbable miniplates. The pre- and postoperative procedures were also carried out, which emphasizes the role of the AR app in the hybrid model. On the basis of the questionnaire, the hybrid AR tool was approved by the senior surgery team and considered adequate for educational purposes. Statistical analysis of the questionnaire responses also highlighted the potential for the use of the hybrid model in future applications.

CONCLUSIONS

This new preoperative platform that combines physical and virtual models may represent an important method to improve multidisciplinary discussion in addition to being a powerful teaching tool. The hybrid model associated with the AR app provided an effective training environment, and it enhanced the teaching of surgical anatomy and operative strategies in a challenging neurosurgical procedure.