A lobectomia frontal é um procedimento neurocirúrgico frequentemente realizado para o tratamento de tumores cerebrais, epilepsia refratária, e outras patologias que requerem remoção extensa do lobo frontal. Embora seja um procedimento relativamente comum, foram encontrados apenas alguns relatos na literatura acerca da técnica cirúrgica, com pouca consideração acerca da anatomia relevante para esse procedimento. OBJETIVOS: O principal objetivo desta tese é apresentar parâmetros anatômicos e considerações técnicas para a remoção da substância cinzenta do lobo frontal (decorticação do lobo frontal) como uma alternativa a lobectomia frontal. A finalidade deste estudo é a maximização da remoção cerebral, diminuindo a perda sanguínea, e evitando a abertura do corno frontal do ventrículo lateral. MATERIAIS E MÉTODOS: O estudo anatômico foi realizado em 15 cabeças cadavéricas adultas. Os dados clínicos foram baseados em 15 decorticações frontais realizadas de 2002 a 2014. RESULTADOS: A decorticação frontal envolve as superfícies lateral, medial e basal, e consiste em 5 passos principais: a) coagulação e secção dos ramos arteriais da superfície lateral do lobo frontal; b) ressecção subpial paramediana do lobo frontal até a localização do joelho do corpo caloso; c) ressecção da substância cinzenta da superfície lateral do lobo frontal sem entrar no corno frontal; d) identificação e preservação do trato olfatório; e) remoção da substância cinzenta da superfície basal do lobo frontal. Esta técnica cirúrgica foi aplicada em 15 casos, em nenhum deles o corno frontal do ventrículo lateral foi aberto, evitando complicações da abertura do mesmo. CONCLUSÃO: A decorticação frontal guiada por parâmetros anatômicos pode ser uma das técnicas cirúrgicas a ser considerada quando há necessidade da ressecação extensa do lobo frontal (especialmente substância cinzenta). A técnica proporciona máxima remoção do lobo frontal, preservação do corno frontal e da área motora suplementar, e redução da perda sanguínea / BACKGROUND: The frontal lobectomy is a frequently performed neurosurgical procedure for treating brain tumors, refractory epilepsy, and other disorders that require extensive removal of the frontal lobe. In spite of being a relatively common procedure, there are only few reports available regarding its surgical technique and little attention has been given to the anatomy relevant to this procedure. OBJECTIVES: The authors present the anatomical landmarks and technical nuances for removing the gray matter of the frontal lobe (frontal lobe decortication) as an alternative to frontal lobectomy. The goals are to maximize the brain removal, minimize the blood loss, and avoid opening the frontal horn of the lateral ventricle. MATERIAL AND METHODS: The anatomical study was performed in 15 adult cadaveric heads. The clinical data are based on 15 frontal resections performed from 2002 to 2014. RESULT: The frontal decortication involves the lateral, medial, and basal surfaces of the frontal lobe, and it consists of 5 main steps: a) coagulation and section of the arterial branches of the lateral surface of the frontal lobe; b) paramedian subpial resection of the frontal lobe until the genu of the corpus callosum is located; c) resection of the gray matter of the lateral surface of the frontal lobe without entering the frontal horn; d) identification and preservation of the olfactory tract; e) removal of the gray matter of the basal surface of the frontal lobe. This surgical technique was applied in 15 cases, and it was possible to preserve the frontal horn in all the patients when following this technique, avoiding complications resulted by its opening. CONCLUSION: The frontal decortication guided by intraoperative anatomical landmarks can be one of the surgical techniques to be considered when an extensive frontal lobe resection (especially gray matter) is needed. It offers maximum frontal lobe removal, preservation of the frontal horn and supplementary motor area, and reduced blood loss

Introdução: O risco do tratamento das malformações arteriovenosas encefálicas (MAVEs) é proporcional à sua graduação. O processo de seleção da técnica empregada depende, além da natureza e localização das MAVEs, das condições clínicas e idade dos doentes e da disponibilidade de profissionais treinados e de equipamentos apropriados no ambiente onde o doente é tratado. Objetivo: Avaliar a eficácia da radiocirurgia e da embolização prévia ao tratamento radiocirúrgico das MAVEs classificadas como graus 3A, 3B, 4 ou 5. Métodos e Resultados: O trabalho baseou-se na observação retrospectiva de prontuários clínicos e de arquivos de imagens de 90 doentes com diagnóstico de MAVEs classificadas como graus 3A, 3B, 4 ou 5 submetidos a tratamento com radiocirurgia precedida ou não de embolização no Departamento de Radioterapia e Radioterapia Estereotáctica, Neuroradiologia Intervencionista e Neurocirugia da Real e Benemérita Associação Portuguesa de Beneficência de São Paulo, de outubro de 1993 a outubro de 2008. As idades dos doentes variaram de sete a 60 anos (média de 30,6 anos ± 11,59 anos, mediana de 28 anos). Eram do sexo feminino 46 (51,1%) doentes. Todos foram submetidos a três exames de ressonância magnética (RM) ou tomografia computadorizada (TC) no primeiro ano de acompanhamento e a um exame de RM ou TC do encéfalo no segundo e terceiro anos. Quando um dos exames sugeriu oclusão da MAVE ou o período de acompanhamento foi maior que três anos, os doentes foram submetidos à angiografia digital do encéfalo. Em 51 (56,7%) dos 90 doentes tratados ocorreu oclusão completa da MAVE após a primeira radiocirurgia (1ª Rc), em 21 (23,3%) foram evidenciadas complicações clínica em 36 (40,0%), foram visibilizadas anormalidades no exame de RM. Em 30 (33,3%) doentes evidenciou-se hipersinal no encéfalo em T2 na RM xvi e, em seis (6,7%), radionecrose. Trinta e dois(82,0%) dos 39 doentes que não apresentaram oclusão completa da MAVE após a 1ª Rc foram submetidos à segunda radiocirurgia (2ª Rc). Ocorreu oclusão completa em 12 (37,5%) destes doentes, instalaram-se complicações clínicas em cinco (15,6%) e, anormalidades no exame de RM em oito (25,0%), ou seja, hipersinal em T2 na RM em três (9,5%) e radionecrose em cinco (15,6%). Conclusão: Concluiu-se que a radiocirurgia foi eficaz no tratamento das MAVEs graus 3A, 3B, 4 e 5, que as MAVEs classificadas como grau 3B devem tratadas, preferencialmente, apenas com radiocirurgia e que as MAVEs classificadas como 3A, 4 e 5 devem ser submetidas à embolização previamente à radiocirugia para reduzir-se sua graduação e seu fluxo sanguíneo / Introduction: The risk of treatment of the cerebral arteriovenous malformations (AVM) is proportional to their grade and is affected by the method used. The selection of the AVM therapeutic method depends of the vascular pattern and anatomical site, clinical condition and age of the patient, experience of the treating team and of the equipment available. Objectives: This study aimed the evaluation of the efficacy of the radiosurgical treatment of Grade 3A, 3B, 4 and 5 cerebral AVMs in patients previosly treated or not with embolization. Methods and Results: The data of the clinical notes and the computed tomography (CT) and magnetic ressonance (RM) images of the brain of 90 patients with Grade 3A, 3B, 4 or 5 cerebral embolised or not AVMs treated with radiosurgery at the Department of Radiotherapy, Stereotactic Radiotherapy, Interventional Neuroradiology and Neurosurgery at Real e Benemerita Associação Portuguesa de Beneficência de São Paulo were retrospectively reviewed. The ages of the patients ranged from 7 to 60 years of (average = 30.6 ± 11.59 years; median = 28 years) and 46 (51.1%) were female. During the first year after treatment three MR or CT scans of the brain were evaluated and one at the end of the 2nd and 3rd years after the treatment one MR or CT scan were re-evaluated respectively. When the brain scans suggest AVM occlusion, cerebral angiography was performed. In 51 of the 90 patients (56.7%) there was complete occlusion of the AVM after one radiosurgical treatment; 21 of the patients (23.3%) had clinical complications. In 36 patients (40.0%) new abnormalities of the MR became evident. Thirty (33.3%) presented T2 hypersignal and six (6.7%), had radionecrosis. From the 39 patients who did not had complete occlusion of the AVM, 32 (82.0%) had a second radiosurgical course of treatment; in 12 xviii (37.5%) the AVM became completely occluded but five (15.6%) had clinical complications. Eight (25.0%) of these patients presented new abnormalities at the MR scan of the brain; three (9.5%) had T2 hypersignal and five (15.6%) radionecrosis. Conclusions: Radiosurgery was effective in the treatment of Grade 3A, 3B, 4 and 5 cerebral AVMs , Grade 3B cerebral AVM should be treated only with radiosurgery without previous embolization, and Grade 3A, 4 and 5 AVMs should be treated with embolization to reduce their AVM grade and blood flow prior to radiosurgery

Introdução: o presente estudo demonstra a aplicação de um algoritmo para correção de distorções em imagens de RM em 3T. Métodos: foi utilizado um Modelo Tridimensional com Alvos (MTA) de acrílico (Micromar, São Paulo, Brasil) montado em uma plataforma com as dimensões e características de um arco estereotáctico. O MTA foi submetido à aquisição de imagens em uma bobina de crânio utilizando o aparelho Philips 3T Magnetom Sigma LX(TM) (Philips Medical Systems, Eindhoven, Netherlands). Para cada aquisição duas imagens foram obtidas, a normal e a reversa (nRM e rRM, respectivamente). Foi aplicado o protocolo de correção com gradiente reverso para produzir coordenadas x, y e z corrigidas. Após ter sido determinada a acurácia dos alvos, foram submetidos 20 pacientes ao mesmo protocolo para determinar a validade em indivíduos. Resultados: a análise dos dados demonstrou que as diferenças entre observadores não foram estatisticamente significantes. Além disso, os pontos obtidos após o processo de retificação das coordenadas no MTA revelou uma distorção média de 1,05 mm. Nos pacientes, a distorção pré correção variava de 0 a 5,6 mm; após a correção variou entre 0 e 3,5 mm. Conclusão: o presente estudo examinou uma técnica de retificação das distorções geométricas encontradas em imagens de RM. Esta mostrou-se bem sucedida em produzir resultados consistentemente acurados para registro de alvos estereotácticos. A técnica pode ser aplicada de maneira universal a todas as imagens de RM adquiridas em protocolo spin-echo e corrige as distorções geométricas presentes / The present work presents an application of a image distortion correction algorithm for 3T MR images. Methods: We used a phantom head model (Micromar, São Paulo, Brazil) mounted on a plataform with the dimensions and features of a stereotactic frame. The phantom was scanned within the head coil of a Philips 3T Magnetom Sigma LX(TM) (Philips Medical Systems, Eindhoven, Netherlands). For each scan, 2 images were obtained - the normal and the reversed image (nMR and rMR, respectively). We applied the inverted gradient correction protocol to produce a corrected x, y and z coordinate. After we ensure target accuracy we submitted 20 patients to the same protocol to exactitude evaluation in human subjects. Results: For all the analyzed data, the differences among the observers were not statistically significant. Moreover, the data rectification proved to be effective as the average distortion on phantom, after correction, was 1.05 mm. On patients the pre-correction distortion varied between 0 and 5.6mm, after correction it varied between 0 mm and 3.5 mm. Conclusion: This study examined a rectifying technique for correcting geometric distortions encountered in the MR images, and the technique proved to be highly successful in producing consistently accurate stereotactic target registration. The technique is universally applicable to all routinely employed spin-echo MR images, and corrects for geometric distortions

Submitted by Fabiana Gonçalves Pinto (benf@ndc.uff.br) on 2017-03-17T18:00:03Z No. of bitstreams: 1 Elsie Storch Borges.pdf: 2512078 bytes, checksum: 2735827c0b951deb2222cdf489425d26 (MD5) / Made available in DSpace on 2017-03-17T18:00:03Z (GMT). No. of bitstreams: 1 Elsie Storch Borges.pdf: 2512078 bytes, checksum: 2735827c0b951deb2222cdf489425d26 (MD5) Previous issue date: 2016 / Mestrado Profissional em Enfermagem Assistencial / Estudo metodológico com abordagem quantitativa, com o objetivo de elaborar instrumento de checagem fundamentado no levantamento das ações para avaliação e acompanhamento dos pacientes submetidos à neurocirurgia, com vistas ao controle das Infecções do Sítio Cirúrgico (ISC), entendendo que o seu preenchimento se constitui em ação de vigilância realizada pelos profissionais da Comissão de Controle de Infecção Hospitalar (CCIH). Para tanto, este instrumento foi construído e validado de conforme cinco etapas metodológicas: 1- Levantamento bibliográfico; 2- Construção da primeira versão do instrumento com base na literatura; 3- Coleta de dados com a validação de conteúdo por juízes-especialistas; 4-Análise e discussão da validação realizada pelos juízes-especialistas; 5- Produção da versão final do instrumento. Na primeira etapa foi realizado levantamento bibliográfico por meio de revisão integrativa, com busca nas bases de dados LILACS, CINAHAL, PUBMED, LILACS e portal CAPES. Foram selecionados 23 artigos. Desta busca emergiram três categorias as quais deram origem à primeira versão do instrumento de checagem que foi subdividido em: ações pré operatória, intra operatória e pós operatória, com 24 itens a serem checados quanto à sua adequação. Para a etapa de validação, foram selecionados juízes especialistas com atuação no pré, intra ou pós operatório de neurocirurgia entre enfermeiros e médicos, cada profissional avaliando as questões pertinentes à sua prática. Para obtenção do consenso dos especialistas, foi utilizado um questionário com Escala do tipo Likert de quatro pontos, numeradas de 1 a 4, onde 1 corresponde à menor concordância, e 4, à maior concordância. Utilizou-se a análise com o cálculo de Índice de Validade de Conteúdo (IVC), onde foi encontrado 0,96. O instrumento demonstrou validade de conteúdo na opinião de especialistas. Conclui-se que este instrumento poderá facilitar os processos de trabalho dos profissionais da CCIH, possibilitando a vigilância de potenciais riscos ao paciente submetido à neurocirurgia / Methodological study with quantitative approach, with the aim of drawing up a reasoned check instrument in the assessment of actions for evaluation and follow-up of patients undergoing neurosurgery, with views to the control of surgical site infections (ISC), understand that your filling is performed by professional surveillance action of hospital infection control Committee (CCIH). For both, this instrument has been built and validated as five methodological steps: 1-bibliographic survey; 2-construction of the first version of the instrument based on literature; 3-data collection with content validation by judges-experts; 4-analysis and discussion of the validation performed by the judges-experts; 5-production of the final version of the instrument. In the first phase was carried out bibliographical through integrative review, with search in the databases LILACS, CINAHAL, PUBMED, LILACS and portal CAPES. 23 articles were selected. This search three categories emerged which gave rise to the first version of the instrument that was subdivided into checking: pre-operative actions, intra operative and post operative, with 24 items to be checked for appropriateness. For the validation step, judges were selected experts with expertise in pre, intra or post-operative neurosurgery between nurses and doctors, each professional assessing the issues pertinent to your practice. For obtaining the consensus of experts, it was used a questionnaire with Likert type scale of four points, numbered from 1 to 4, where 1 corresponds to the lowest agreement, and 4, the larger agreement. Analysis was used to calculate content Validity index (CVI), where he was found 0.96. The instrument demonstrated content validity in the opinion of experts. It is concluded that this instrument may facilitate work processes of the CCIH professionals, enabling the monitoring of potential risks to the patient submitted to Neurosurgery

Bien que devenant un environnement de plus en plus riche technologiquement, la salle opératoire reste un endroit où la sécurité des patients n'est pas assurée à 100% comme le montre le nombre toujours conséquent d'erreurs chirurgicales. La nécessité de développer des systèmes intelligents au bloc opératoire apparait comme croissante. Un des éléments clés pour ce type de système est la reconnaissance du processus chirurgical, passant par une identification précise des outils chirurgicaux utilisés. L'objectif de cette thèse a donc porté sur la détection en temps-réel des outils chirurgicaux dans des vidéos 2D provenant de microscopes. Devant l'absence de jeux de données de référence, qui plus est dans un contexte neurochirurgical, la première contribution de la thèse a donc été la création d'un nouvel ensemble d'images de chirurgies du cerveau et du rachis cervical, mis à disposition en ligne. Comme seconde contribution, deux approches différentes ont été proposées permettant de détecter des outils chirurgicaux via des techniques d'analyse d'image. Tout d'abord, le SquaresChnFtrs adapté, basé sur une des méthodes de détection de piétons les plus performantes de la littérature. Notre deuxième méthode, le ShapeDetector, est une approche à deux niveaux n'utilisant aucune contrainte ou hypothèse a priori sur le nombre, la position, ou la forme des outils dans l'image. Par rapport aux travaux précédents du domaine, nous avons choisi de représenter les détections potentielles par des polygones plutôt que par des rectangles, obtenant ainsi des détections plus précises. Pour intégration dans des systèmes médicaux, une optimisation de la vitesse de calcul a été effectuée via un usage optimal du CPU, du GPU, et de méthodes ad-hoc. Pour des vidéos de résolution 612x480 pixels, notre ShapeDetector est capable d'effectuer les détections à une vitesse maximale de 8 Hz. Pour la validation de nos méthodes, nous avons pris en compte trois paramètres: la position globale, la position de l'extrémité, et l'orientation des détections. Les méthodes ont été classées et comparées avec des méthodes de référence compétitives. Pour la détection des tubes d'aspiration, nous avons obtenu un taux de manqué de 15% pour un taux de faux positifs par image de 0.1, comparé à un taux de manqué de 55% pour le SquaresChnFtrs adapté. L'orientation future du travail devra porter sur l'intégration des informations 3D, l'amélioration de la couche de labélisation sémantique, et la classification des outils chirurgicaux. Pour finir, un enrichissement du jeu de données et des annotations de plus haute précision seront nécessaires. / Despite modern-life technological advances and tremendous progress made in surgical techniques including MIS, today's OR is facing many challenges remaining yet to be addressed. The development of CAS systems integrating the SPM methodology was born as a response from the medical community, with the long-term objective to create surgical cockpit systems. Being able to identify surgical tools in use is a key component for systems relying on the SPM methodology. Towards that end, this thesis work has focused on real-time surgical tool detection from microscope 2D images. From the review of the literature, no validation data-sets have been elected as benchmarks by the community. In addition, the neurosurgical context has been addressed only once. As such, the first contribution of this thesis work consisted in the creation of a new surgical tool data-set, made freely available online. Two methods have been proposed to tackle the surgical tool detection challenge. First, the adapted SquaresChnFtrs, evolution of one of the best computer vision state-of-the-art approach for pedestrian detection. Our second contribution, the ShapeDetector, is fully data-driven and performs detection without the use of prior knowledge regarding the number, shape, and position of tools in the image. Compared to previous works, we chose to represent candidate detections with bounding polygons instead of bounding boxes, hence providing more fitting results. For integration into medical systems, we performed different code optimization through CPU and GPU use. Speed gain and accuracy loss from the use of ad-hoc optimization strategies have been thoroughly quantified to find an optimal trade-off between speed and accuracy. Our ShapeDetector is running in-between 5 and 8Hz for 612x480 pixel video sequences.We validated our approaches using a detailed methodology covering the overall tool location, tip position, and orientation. Approaches have been compared and ranked conjointly with a set of competitive baselines. For suction tube detections, we achieved a 15% miss-rate at 0.1 FPPI, compared to a 55% miss-rate for the adapted SquaresChnFtrs. Future works should be directed toward the integration of 3D feature extraction to improve detection performance but also toward the refinement of the semantic labelling step. Coupling the tool detection task to the tool classification in one single framework should be further investigated. Finally, increasing the data-set in diversity, number of tool classes, and detail of annotations is of interest.

Introdução: o presente estudo demonstra a aplicação de um algoritmo para correção de distorções em imagens de RM em 3T. Métodos: foi utilizado um Modelo Tridimensional com Alvos (MTA) de acrílico (Micromar, São Paulo, Brasil) montado em uma plataforma com as dimensões e características de um arco estereotáctico. O MTA foi submetido à aquisição de imagens em uma bobina de crânio utilizando o aparelho Philips 3T Magnetom Sigma LX(TM) (Philips Medical Systems, Eindhoven, Netherlands). Para cada aquisição duas imagens foram obtidas, a normal e a reversa (nRM e rRM, respectivamente). Foi aplicado o protocolo de correção com gradiente reverso para produzir coordenadas x, y e z corrigidas. Após ter sido determinada a acurácia dos alvos, foram submetidos 20 pacientes ao mesmo protocolo para determinar a validade em indivíduos. Resultados: a análise dos dados demonstrou que as diferenças entre observadores não foram estatisticamente significantes. Além disso, os pontos obtidos após o processo de retificação das coordenadas no MTA revelou uma distorção média de 1,05 mm. Nos pacientes, a distorção pré correção variava de 0 a 5,6 mm; após a correção variou entre 0 e 3,5 mm. Conclusão: o presente estudo examinou uma técnica de retificação das distorções geométricas encontradas em imagens de RM. Esta mostrou-se bem sucedida em produzir resultados consistentemente acurados para registro de alvos estereotácticos. A técnica pode ser aplicada de maneira universal a todas as imagens de RM adquiridas em protocolo spin-echo e corrige as distorções geométricas presentes / The present work presents an application of a image distortion correction algorithm for 3T MR images. Methods: We used a phantom head model (Micromar, São Paulo, Brazil) mounted on a plataform with the dimensions and features of a stereotactic frame. The phantom was scanned within the head coil of a Philips 3T Magnetom Sigma LX(TM) (Philips Medical Systems, Eindhoven, Netherlands). For each scan, 2 images were obtained - the normal and the reversed image (nMR and rMR, respectively). We applied the inverted gradient correction protocol to produce a corrected x, y and z coordinate. After we ensure target accuracy we submitted 20 patients to the same protocol to exactitude evaluation in human subjects. Results: For all the analyzed data, the differences among the observers were not statistically significant. Moreover, the data rectification proved to be effective as the average distortion on phantom, after correction, was 1.05 mm. On patients the pre-correction distortion varied between 0 and 5.6mm, after correction it varied between 0 mm and 3.5 mm. Conclusion: This study examined a rectifying technique for correcting geometric distortions encountered in the MR images, and the technique proved to be highly successful in producing consistently accurate stereotactic target registration. The technique is universally applicable to all routinely employed spin-echo MR images, and corrects for geometric distortions

Hintergrund: Im Rahmen intrakranieller Operationen kann die intraoperative Darstellung der Gehirndurchblutung die intraoperative Entscheidungsfindung unterstützen. Eine Alternative zu den etablierten Methoden der fluoreszenzgestützten Techniken und der Duplex-Sonographie stellt die intraoperative Perfusionsbildgebung auf Grundlage der Thermographie dar. Hiermit wird die temperaturabhängige, infrarote Strahlung des Gehirns gemessen, die annehmbar abhängig von der zerebralen Perfusion ist. Das Verfahren vereint die Vorteile des nebenwirkungsarmen, kontaktlosen, wiederholten und ökonomischen Einsatzes mit einem verhältnismäßig geringen apparativen Aufwand. Fragestellung/Hypothese: In der vorliegenden Arbeit sollen die intraoperativen Temperaturvariationen des Kortex thermographisch untersucht werden. Durch die intravenöse Applikation eines kalten Flüssigkeitsbolus kann ein systemischer Kältereiz erzeugt werden, der als thermographisches Kontrastmittel agiert. Die Untersuchung der Sensitivität der kortikalen Kältesignalerfassung in Abhängigkeit der Injektionsparameter des Flüssigkeitsbolus und anderer intraoperativer Variablen soll für die Etablierung eines robusten und klinisch nutzbaren Messaufbaus genutzt werden. Die gewonnenen Informationen sollen darüber hinaus zur Entwicklung eines Auswertungsalgorithmus für die automatisierte, thermographische Erfassung des kortikalen Kältesignals dienen. Abschließend werden potenzielle, klinische Anwendungsszenarien beschrieben. Material und Methoden: Die thermographischen Aufnahmen wurden mit ungekühlten Focal-Plane-Array-Kameras mit einer thermischen Auflösung von bis zu 20 mK durchgeführt. Es wurden 97 Patienten intraoperativ untersucht und insgesamt 210 Kältebolusinjektionen appliziert. Die zugrundeliegenden Pathologien waren größtenteils Glioblastome und zerebrale Metastasen sowie Gliome II°/III°, Hirninfarkte, arteriovenöse Malformationen und Aneurysmen. Nach chirurgischer Exposition des zerebralen Kortex wurde die thermographische Messung des Kortex gestartet. Es folgte die intravenöse Injektion der Kälteboli mit einer Temperatur von etwa 4°C aus physiologischer Kochsalzlösung und einem Volumen von 20 ml (59 % der Fälle) oder 50 ml (41 % der Fälle) über einen peripheren (76 % der Fälle) oder zentralen Venenkatheter (24 % der Fälle). Es wurden die Injektionsgeschwindigkeit und Vitalparameter registriert. Nachfolgend wurden die thermographischen Sequenzen einer Datenvorverarbeitung unterzogen, um das Signal-Rausch-Verhältnis zu verbessern. Es folgte die Auswertung der resultierenden Temperatur-Zeit-Reihen zur Kältesignaldetektion mit der Hauptkomponentenanalyse nach Steiner et al., dem Bigauss-Algorithmus nach Hollmach und einer manuellen Analyse (Steiner et al., 2011; Hollmach, 2016). Die Qualität der Auswertungsalgorithmen wurden auf Basis von 10 parallelen Kältebolus-ICG-Injektionen überprüft. Die ICG-Signale wurden als Referenz für die Kältesignaldetektionen genutzt. Die Beschreibung der Kältesignale erfolgte anhand der Parameter twash-in, tmin(T), trise, ttransit und ΔT. Ergebnisse: Die Thermographie kann kleinste Temperaturvariation des Kortex von bis zu 20 mK aufzeichnen. Periodische Temperaturänderungen können zum Teil durch physiologische Prozesse wie Atmung und Herzaktion erklärt werden, während andere spontane Temperaturschwankungen bisher keinen pathophysiologischen Äquivalenten zugewiesen werden können. Das systemische Kältesignal in Form des intravenösen Kältebolus kann bei der kortikalen Passage thermographisch als Temperatursenke registriert werden. Die Sensitivität der Kältesignalerfassung wird wesentlich durch die Injektionsparameter Bolusvolumen, Applikationsort und -geschwindigkeit bestimmt und lässt sich durch eine periphervenöse, 50 ml umfassende Bolusinjektion mit einer Geschwindigkeit von ≥ 5,4 ml/s auf über 70 % steigern. Die Vitalparameter beeinflussen die Kältesignaldetektion nicht. Die Validierung der Kältesignaldetektionen mittels paralleler Kältebolus-ICG-Injektionen offenbarte, dass die präexistenten Auswertungsalgorithmen der Hauptkomponentenanalyse und des Bigauss-Algorithmus eine hohe Sensitivität von 90 % hinsichtlich anteilig richtig-positiver Kältesignaldetektionen erzielen. Jedoch wurden in 90 % der Referenzfälle falsch-positive Kältesignale erkannt, sodass eine geringe Spezifität und ein geringer positiv-prädiktiver Wert resultiert. Beide Algorithmen weisen eine hohe Fehleranfälligkeit auf und sind ungeeignet, um intraoperativ das systemische Kältesignal zuverlässig zu erfassen. Aus den gewonnenen Erkenntnissen der manuellen Analyse der ICG-Kältebolus-Referenzfälle konnte der optimierte AKE-Auswertungsalgorithmus (Automatisierte Kältesignaldetektion nach Empirischem Vorwissen) entwickelt werden. Der AKE-Algorithmus besitzt in den Referenzfällen eine Sensitivität von 100 % und eine qualitativ deutlich verbesserte Spezifität. Der AKE-Algorithmus ist in der Lage, im intraoperativen Einsatz die Kältesignale innerhalb weniger Minuten nach der Kältebolusinjektion zuverlässig in Form zweidimensionaler Parameterkarten zu visualisieren. Auf Basis des AKE-Algorithmus wurden die Kältesignalerfassungen in verschiedenen intrakraniellen Pathologien untersucht. Die Kältesignalparameter in Glioblastomen präsentieren neben einer großen Heterogenität eine durchschnittlich erhöhte Perfusion im Vergleich zum peritumoralen Gewebe in Form einer verminderten twash-in und einer erhöhten ttransit. Jedoch ist eine Identifizierung der Tumorgrenzen anhand der Kältesignaldetektionen nicht möglich, weil die Kältesignalparameter intra- und peritumoralen Gewebes nicht signifikant differieren. Bei der thermographischen Untersuchung maligner Hirninfarkte können die Infarktkerne bereits als hypotherme Kortexregionen und durch eine negative Kältesignaldetektion erfasst werden. Kollateralkreisläufe werden registriert und die Kältesignalparameter korrelieren mit dem postoperativen NIHSS. Die Kältesignalerfassung gelingt zunehmend im Übergang von CT-morphologisch demarkierten zu nicht-demarkierten Hirnarealen und zeigt begleitend eine kürzere twash-in. Damit besteht potenziell die Möglichkeit, in weiteren Untersuchungen die Penumbra zu untersuchen und prognostische Informationen zu gewinnen. Die Kältesignalerkennung bei AVMs konnte sicher erfolgen und die Perfusion der pathologischen Gefäßanteile nachweisen. Somit kann die Thermographie die vollständige Ausschaltung oberflächlicher AVMs unterstützen und ist des Weiteren in der Lage, die Perfusion des umgebenden Parenchyms zu beurteilen. Ebenso kann die Kältesignaldetektion bei der Operation von Aneurysmen zur Erfolgskontrolle und zur Erfassung Clip-bedingter kortikaler Minderperfusionen dienen. Schlussfolgerungen: Die thermographische Detektion eines systemischen Kältereizes ist möglich und kann intraoperativ zusätzliche Informationen generieren, die in operative Entscheidungen oder wissenschaftliche Untersuchungen einfließen können. Um einen robusten und zuverlässigen, intraoperativen Einsatz der thermographischen Kältesignaldetektion zu ermöglichen, sollten zukünftig ausschließlich 50 ml Boli, periphervenöse Injektionen und eine Injektionsgeschwindigkeit ≥ 5,4 ml/s verwendet werden. Für eine schnelle und zuverlässige, intraoperative Ergebnisgenerierung und -darstellung sollte der AKE-Algorithmus bevorzugt werden. Die thermographische Kältesignaldetektion eignet sich insbesondere für die Untersuchung primär vaskulärer Pathologien, wie Hirninfarkte, AVMs oder Aneurysmen.:Inhaltsverzeichnis A Abbildungsverzeichnis B Tabellenverzeichnis C Abkürzungsverzeichnis 1 Einleitung 2 Medizinische Grundlagen 2.1 Präoperative Bildgebung in der Neurochirurgie 2.1.1 Konventionelles MRT, CT und Angiographie 2.1.1 Dynamisch-funktionelle MRT-Sequenzen 2.1.2 Neuronavigation 2.2 Intraoperative Bildgebung zur zerebralen Perfusionsvisualisierung 2.2.1 Fluoreszenzgestützte Techniken 2.2.2 Ultraschall 3 Thermographie 3.1 Physikalische Grundlagen 3.2 Anwendung der Thermographie in der Medizin 4 Zielstellung 5 Material und Methoden 5.1 Thermographische Messung 5.1.1 Messaufbau 5.1.2 Messinstrumentarium 5.1.3 Ablauf der Kältebolus-Messung 5.1.4 Simultane Erfassung des Infrarot- und ICG-Signals 5.2 Methoden der Datenverarbeitung 5.2.1 Vorverarbeitung der Daten 5.2.2 Hauptkomponentenanalyse 5.2.3 Bigauss-Algorithmus 5.3 Auswahl des Patientenkollektivs 6 Ergebnisse 6.1 Patientenkollektiv 6.2 Ergebnisse der Hauptkomponentenanalyse 6.3 Ergebnisse des Bigauss-Algorithmus 6.4 Manuelle Analyse und ICG-Fälle 6.4.1 Schlussfolgerungen der manuell analysierten ICG-Kälteboli 6.4.2 Ergebnisse aller manuell analysierten Kälteboli 6.5 Entwicklung des AKE-Algorithmus 6.6 Ergebnisse des AKE-Algorithmus 6.6.1 Allgemeine Kälteboluscharakteristik 6.6.2 Kältesignalparameter in Abhängigkeit der Injektionsparameter 6.6.3 Kältesignaldetektion als interpathologischer Vergleich 6.6.4 Kältesignaldetektion als intrapathologische Analyse 7 Diskussion 7.1 Vergleich der Verfahren der Kältesignaldetektion 7.2 Einflussfaktoren 7.2.1 Vitalparameter 7.2.2 Injektionsparameter 7.3 Bedeutung der Kältesignalparameter 7.4 Potential der Kältebolusdetektion in Pathologien mittels AKE-Algorithmus 7.4.1 Glioblastom 7.4.2 Maligner Hirninfarkt 7.4.3 Neurovaskuläre Pathologien 7.5 Thesen 8 Zusammenfassung / Summary 9 Literaturverzeichnis 10 Danksagung 11 Anlage 1 12 Anlage 2 / Background: In intracranial surgery, intraoperative imaging of cerebral blood flow can support intraoperative decision making. An alternative to established methods of fluorescence-based techniques and duplex sonography is intraoperative perfusion imaging based on thermography. It receives temperature-dependent, infrared radiation, which depends on cerebral perfusion. Thermography combines the advantages of low-side-effects, contactless, repeated and economical use with a relatively low outlay on equipment. Objective/Hypothesis: In the present work the intraoperative temperature variations of the cortex are to be examined thermographically. The intravenous application of a cold fluid bolus creates a systemic cold stimulus that acts as a thermographic contrast agent. By examining the sensitivity of the cortical cold signal acquisition depending on the injection parameters of the fluid bolus and other intraoperative variables, a robust and clinically usable measurement setup is to be established. The information obtained should also be used to develop an evaluation algorithm for the automated, thermographic detection of the cortical cold signal. Finally, potential clinical application scenarios are described. Material and Methods: The thermographic recordings were made with uncooled focal plane array cameras with a thermal resolution of up to 20 mK. 97 patients were examined intraoperatively and a total of 210 cold bolus injections were administered. The underlying pathologies were mostly glioblastomas and cerebral metastases as well as gliomas II° / III°, brain infarctions, arteriovenous malformations and aneurysms. After surgical exposure of the cerebral cortex, the thermographic measurement of the cortex was started. This was followed by intravenous injection of the cold 0,9% saline boluses with a temperature of about 4 °C and a volume of 20 ml (59% of cases) or 50 ml (41% of cases) via a peripheral (76% of cases) or central venous line (24% of cases). The injection rate and vital parameters were registered. The thermographic sequences were subsequently subjected to data preprocessing in order to improve the signal-to-noise ratio. The resulting temperature-time series are evaluated to find cold signals using the principal component analysis according to Steiner et al., the Bigauss algorithm according to Hollmach and a manual analysis (Steiner et al., 2011; Hollmach, 2016). The results were checked based on 10 parallel cold bolus ICG injections. The ICG signals were used as a reference for the cold signal detection. The cold signals were described by the parameters twash-in, tmin(T), trise, ttransit and ΔT. Results: Thermography can record smallest temperature variations of the cortex up to 20 mK. Periodic changes in temperature can be explained in part by physiological processes such as breathing and heart rate, while other spontaneous temperature fluctuations cannot yet be assigned to any pathophysiological equivalents. The systemic cold signal in the form of the intravenous cold bolus can be thermographically registered as a temperature drop during the cortical passage. The sensitivity of the cold signal detection is essentially determined by the injection parameters bolus volume, injection site and injection rate. It can be increased to more than 70% with a peripheral venous line, 50 ml bolus volume and an injection rate of ≥ 5.4 ml/s. The vital parameters do not influence the cold signal detection. The validation of the cold signal detection using parallel cold bolus and ICG injections revealed that the pre-existent evaluation algorithms of the principal component analysis and the Bigauss algorithm achieve a high sensitivity of 90 % with regard to proportionally correct-positive cold signal detection. However, false-positive cold signals were detected in 90% of the reference cases, resulting in low specificity and low positive-predictive value. Both algorithms are highly susceptible to errors and are unsuitable for reliably detection of the systemic cold signal intraoperatively. From the knowledge obtained from the manual analysis of the ICG - cold bolus reference cases, the optimized AKE evaluation algorithm (Automated Cold signal detection based on Empirical prior knowledge) was developed. In the reference cases, the AKE algorithm has a sensitivity of 100% and a qualitatively significantly improved specificity. The AKE algorithm is able to reliably visualize the cold signals in two-dimensional parameter maps within a few minutes after the cold bolus injection during intraoperative use. Based on the AKE algorithm, the cold signal recordings in various intracranial pathologies were examined. The cold signal parameters of glioblastomas showed a high degree of heterogeneity and on average an increased cerebral perfusion by reduced twash-in and increased ttransit compared to peritumoral tissue. However, an identification of the tumour borders based on the cold signal detection is not possible because the cold signal parameters of intra- and peritumoral tissue do not differ significantly. In the thermographic examination of malignant brain infarctions, the infarct cores can be detected as hypothermic cortex regions and by negative cold signal detection. Collateral circuits are registered thermographically and the cold signal parameters correlate with the postoperative NIHSS. The cold signal acquisition succeeds increasingly in the transition from CT-morphologically infarcted to non-infarcted brain areas and shows a smaller twash-in. Therefore, the cold bolus detection has the potential to investigate the penumbra and to obtain prognostic information. Cold signal detection in AVMs was carried out safely and the perfusion of the pathological vessels were demonstrated. Thus, thermography can support the complete elimination of superficial AVMs and is also able to assess the perfusion of the surrounding parenchyma. Cold signal detection can also be used in the operation of aneurysms to monitor complete elimination and clipping-related cerebral perfusion changes. Conclusions: The thermographic detection of the systemic cold stimulus is possible and can generate additional information intraoperatively, which can be incorporated into intraoperative decision making or scientific studies. In order to enable robust and reliable, intraoperative use of thermographic cold signal detection, further cold bolus examinations should be standardized with intravenous injection of 50 ml boluses via peripheral venous line and an injection rate ≥ 5.4 ml/s. The AKE algorithm should be preferred for fast and reliable, intraoperative result generation. Thermographic cold signal detection is particularly suitable for the investigation of primarily vascular pathologies such as brain infarctions, AVMs or aneurysms.:Inhaltsverzeichnis A Abbildungsverzeichnis B Tabellenverzeichnis C Abkürzungsverzeichnis 1 Einleitung 2 Medizinische Grundlagen 2.1 Präoperative Bildgebung in der Neurochirurgie 2.1.1 Konventionelles MRT, CT und Angiographie 2.1.1 Dynamisch-funktionelle MRT-Sequenzen 2.1.2 Neuronavigation 2.2 Intraoperative Bildgebung zur zerebralen Perfusionsvisualisierung 2.2.1 Fluoreszenzgestützte Techniken 2.2.2 Ultraschall 3 Thermographie 3.1 Physikalische Grundlagen 3.2 Anwendung der Thermographie in der Medizin 4 Zielstellung 5 Material und Methoden 5.1 Thermographische Messung 5.1.1 Messaufbau 5.1.2 Messinstrumentarium 5.1.3 Ablauf der Kältebolus-Messung 5.1.4 Simultane Erfassung des Infrarot- und ICG-Signals 5.2 Methoden der Datenverarbeitung 5.2.1 Vorverarbeitung der Daten 5.2.2 Hauptkomponentenanalyse 5.2.3 Bigauss-Algorithmus 5.3 Auswahl des Patientenkollektivs 6 Ergebnisse 6.1 Patientenkollektiv 6.2 Ergebnisse der Hauptkomponentenanalyse 6.3 Ergebnisse des Bigauss-Algorithmus 6.4 Manuelle Analyse und ICG-Fälle 6.4.1 Schlussfolgerungen der manuell analysierten ICG-Kälteboli 6.4.2 Ergebnisse aller manuell analysierten Kälteboli 6.5 Entwicklung des AKE-Algorithmus 6.6 Ergebnisse des AKE-Algorithmus 6.6.1 Allgemeine Kälteboluscharakteristik 6.6.2 Kältesignalparameter in Abhängigkeit der Injektionsparameter 6.6.3 Kältesignaldetektion als interpathologischer Vergleich 6.6.4 Kältesignaldetektion als intrapathologische Analyse 7 Diskussion 7.1 Vergleich der Verfahren der Kältesignaldetektion 7.2 Einflussfaktoren 7.2.1 Vitalparameter 7.2.2 Injektionsparameter 7.3 Bedeutung der Kältesignalparameter 7.4 Potential der Kältebolusdetektion in Pathologien mittels AKE-Algorithmus 7.4.1 Glioblastom 7.4.2 Maligner Hirninfarkt 7.4.3 Neurovaskuläre Pathologien 7.5 Thesen 8 Zusammenfassung / Summary 9 Literaturverzeichnis 10 Danksagung 11 Anlage 1 12 Anlage 2

Physicians encounter significant difficulty when faced with decisions related to withdrawal of life-sustaining therapy (WLST) in patients with devastating brain injury (DBI). The complexity of this decision-making process is multifactorial, including practitioner- and patient-specific variables, as well as surrogate decision-maker bias, inaccuracies in scoring systems, and inconsistencies in guidelines endorsed by professional societies; these issues all contribute to the significant uncertainty of these situations and variability in treatment paradigm. Solutions are complex; however, analyzing WLST with an urban bioethical lens — which emphasizes the principles of solidarity, agency, and social justice — can enhance physicians’ ability to navigate this uncertainty and ensure that potential solutions are patient-centered. / Urban Bioethics

In its general section, the thesis 'Rehabilitation of Pediatric Patients after Epilepsy Surgery with Postoperative Motor Deficits' discusses epilepsy, treatment of intractable epilepsy and epilepsy surgery. Furthermore, a chapter on possible complications of epilepsy surgery in relation to the locomotor apparatus is included in the general section. The special section deals with rehabilitation in neurology, selected physiotherapy concepts and the relationship between epilepsy and movement activity. The aim of this thesis is to assess the effectiveness of the chosen rehabilitation procedure in five pediatric patients with post-operative motor deficiency. The Gross Motor Function Measure - 88, the Barthel Index and the Box and Blocks Test were used for objective motor assessment.

Three-dimensional (3D) printing techniques for patient-individual medicine has found its way into veterinary neurosurgery. Because of the high accuracy of 3D printed specific neurosurgical navigation devices, it seems to be a safe and reliable option to use patient- individual constructions for sampling brain tissue. Due to the complexity and vulnerability of the brain a particularly precise and safe procedure is required. In a recent cadaver study a better accuracy for the 3D printed MRI-based patient individual stereotactic brain biopsy device for dogs is determined compared to the accuracies of other biopsy systems which are currently used in veterinary medicine. This case report describes the clinical use of this 3D printed MRI-based patient individual brain biopsy device for brain sampling in three dogs. The system was characterized by a simple handling. Furthermore, it was an effective and reliable tool to gain diagnostic brain biopsy samples in dogs with no significant side effects.