Submitted by Angela Maria de Oliveira (amolivei@uepg.br) on 2018-11-14T19:55:13Z No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) Carolina Bacila.pdf: 1778129 bytes, checksum: 989392097051d1a2e9d03cf9eaeabcc0 (MD5) / Made available in DSpace on 2018-11-14T19:55:13Z (GMT). No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) Carolina Bacila.pdf: 1778129 bytes, checksum: 989392097051d1a2e9d03cf9eaeabcc0 (MD5) Previous issue date: 2018-07-31 / A disfunção temporomandibular (DTM) é responsável por alterações no aparelho mastigatório e é uma das principais causas de dor orofacial. Sua etiologia é um tratamento multifatorial e interdisciplinar. A craniotomia pterional é responsável pela atrofia do músculo temporal e disfunção da articulação temporomandibular em pacientes submetidos a essa abordagem neurocirúrgica. Objetivo: Avaliar qual o impacto na qualidade de vida de pacientes com disfunção temporomandibular secundária a craniotomias frontotemporoesfenoidais (pterionais e minipterionais) e se há associação entre o grau da atrofia do músculo temporal e disfunção da articulação temporomandibular mensurada pelo RDC/TMD em craniotomias frontotemporoesfenoidais (pterionais e minipterionais) e tomografia de crânio com aquisição volumétrica. Métodos: Foram avaliados 47 pacientes por meio do questionário e avaliação clínica de acordo com RDC / TMD, tomografia de crânio com aquisição volumétrica para avaliar o grau de atrofia do músculo temporal e questionário de qualidade de vida WHOQOL-BREF. Foram avaliadas cinco variáveis clínicas: grau de dor crônica, grau de depressao, sintomas fisicos não específicos, grau de atrofia e amplitude da abertura da boca. Resultados:observou-se como principal queixa dos pacientes dor e desconforto. O grau de atrofia avaliado foi de 22%. Metade dos indivíduos nao apresentaram depressão. Mais da metade dos indivíduos apresentaram sintomas físicos não específicos em grau severo. Conclusão: não houve correlação signiticativa entre grau de atrofia temporal com nenhuma variável estudada, apesar de haver impacto negativo na qualidade de vida dos pacientes. Houve correlação significativa entre o grau de dor crônica com amplitude da boca e entre grau de dor crônica com o grau de depressão. / Temporomandibular dysfunction (TMD) is responsible for changes in the masticatory apparatus and is one of the main causes of orofacial pain. Its etiology is a multifactorial and interdisciplinary treatment. The pterional craniotomy is responsible for temporal muscle atrophy and temporomandibular joint dysfunction in patients submitted to this neurosurgical approach. Objective: To evaluate the impact on the quality of life of patients with temporomandibular dysfunction secondary to frontotemporesphenoidal craniotomies (pterionals and minipterionals) and whether there is an association between the degree of temporal muscle atrophy and temporomandibular joint dysfunction measured by RDC / TMD in frontotemporoesfenoidal craniotomies ( pterionic and minipterional) and skull tomography with volumetric acquisition. Methods: A total of 47 patients were evaluated by means of a questionnaire and clinical evaluation according to CDR / TMD, skull tomography with volumetric acquisition to assess the degree of temporal muscle atrophy and WHOQOL-BREF quality of life questionnaire. Five clinical variables were evaluated: degree of chronic pain, degree of depression, non-specific physical symptoms, degree of atrophy and amplitude of mouth opening. Results: the main complaint of the patients was pain and discomfort. The degree of atrophy evaluated was 22%. Half of the subjects did not present with depression. More than half of the individuals presented non-specific physical symptoms to a severe degree. Conclusion: there was no significant correlation between the degree of temporal atrophy with any variable studied, although there was a negative impact on patients' quality of life. There was a significant correlation between the degree of chronic pain with mouth amplitude and between the degree of chronic pain and the degree of depression.

Made available in DSpace on 2015-07-22T20:49:36Z (GMT). No. of bitstreams: 0 Previous issue date: 2011-01-26 / A infecção do sítio cirúrgico (ISC) é uma das complicações que ocorre nos pacientes submetidos à craniotomia. A identificação dos fatores de risco relacionados ao paciente e ao procedimento cirúrgico e a avaliação dos indicadores do processo nos períodos pré-operatório, intraoperatório e pós-operatório facilitam as ações para prevenção a ISC. Objetivo: Determinar a incidência de infecção do sítio cirúrgico; avaliar os indicadores de processos dos períodos pré-operatórios, intraoperatório e pós-operatório e analisar os fatores de risco para desenvolvimento de infecções de sítio cirúrgico nos pacientes submetidos a craniotomia. Métodos: Coorte prospectivo, realizado nas Unidades de Terapia Intensiva e de Internação da Neurocirurgia do Hospital São Paulo, no período de maio de 2009 a junho de 2010, em pacientes submetidos à craniotomia eletiva e a vigilância cirúrgica foi realizada durante 30 dias de pós-operatório. Os indicadores de processo avaliados foram: as condições do paciente no pré-operatório; as condições de assepsia no intra-operatório e de estrutura do centro cirúrgico e do curativo cefálico no pós-operatório. Resultados: De um total de 100 pacientes incluídos, seis (6%) apresentaram infecção do sítio cirúrgico póscraniotomia. Houve 100% de conformidade para os indicadores do pré-operatório e pós-operatório; e 16,7% de não conformidade para o uso do gorro e da máscara pelos anestesistas no intraoperatório. O tempo médio de degermação do couro cabeludo foi de 4,0 minutos e houve associação estatisticamente significante com o desenvolvimento da infecção do sítio cirúrgico pós-craniotomia (OR = 2,70; IC 95% = 0,94-7,74; p = 0,006), ou seja, há uma tendência de que a cada minuto a mais no tempo de degermação do couro cabeludo aumenta em 2,70 vezes as chances de ter ISC em craniotomia eletiva. Conclusões: Neste estudo, encontrou-se uma taxa elevada de infecção do sítio cirúrgico. Nenhum indicador de processo para o período pré-operatório e intraoperatório e pós-operatório associou-se à infecção do sítio cirúrgico. A degermação foi o único fator preditor associado à infecção do sítio cirúrgico. / TEDE / BV UNIFESP: Teses e dissertações

The research performed in this thesis aims to improve our understanding about one of the most malignant tumors of the human brain – glioma. From the early stages of my career I was confronted with the cruel reality of losing patients due to this devastating disease. The studies performed over the last four years involve extensive data analysis in different clinical and laboratory settings. The direct application of different analysis methods and tools in order to investigate the glioma infiltration delineation has potentially lead to direct applications of our results in the clinical setting. The overall approach of the study is based on three primary outcome measures, i.e., neuronal, electrophysiological and genetic/molecular features for distinguishing infiltrated and non-infiltrated zones within specifically peritumoral tissue (PT) and, more extensively, across the radiologically-defined boundaries of healthy, peritumoral and tumoral tissues. As such, we propose for the first time an objective demarcation and characterization of the PT and we detail how the genetic and epigenetic alterations within the tumoral and peritumoral area are linked with macroscopic functional MRI results. We also describe scale-free features (power law exponent) as well as distinct spectral features and reactivity to external stimulus in the tumoral and adjacent tissue of patients and provide novel insights in terms of glioma’s electrophysiology. The insights gained from these empirical studies further improve our understanding about the pathophysiology of this disease at micro- and macroscopic scales allowing us to envisage novel management methods for patients affected by glioma.

This study explores the genesis of the presence of the fetus in American culture by examining the evolution of American medical attitudes towards the unborn (1800-1865) in the lead up to the Physicians Crusade Against Abortion in the mid 19th century. Specifically, it analyzes how American allopathic physicians reconciled their denunciation of abortions for reproductive limitation with their approval of abortions for medical reasons, shedding light on how American physicians resolved maternal-fetal conflict. The study begins with an exploration of the medicalization of childbirth in the 18th century and how it created medical concern for the fetus. The forceps could spare the pregnant woman the craniotomy operation (collapse of the fetal skull) and save the fetus. However, not all cases of obstructed labour could be solved with the forceps, and as physicians displaced midwives as the principal birth attendants, they were confronted with the prospect of performing craniotomy on a live fetus. As they dreaded this outcome, they proposed two operations to circumvent it: the Caesarean section and induced premature labour. This shows that medicalization created concern for the fetus, particularly in the later stages of pregnancy. With new embryological research in the 1820s, concern for the fetus was extended to all stages of pregnancy and expressed itself in advice to women to guarantee a healthy child. The publication of Alfred Velpeau’s Principles of Tokology and Embryology was influential because it both normalized the fusion of embryology and obstetrics, and it justified recourse to early abortion in cases of contracted pelvises. Indications for the medical use of abortion began to multiply as a result of this shift, even as physicians denounced clandestine abortion and sought to criminalize it. This study argued the medical ideology of vitalism, as articulated by Xavier Bichat, was key in resolving maternal-fetal conflict in favour of the pregnant woman. Vitalism characterized fetuses as having the same functions as a plant and this lower level of functioning justified the sacrificing of fetal life in certain circumstances. Vitalism also viewed women to as having more sensibility, more cerebral activity, and more social ties. Therefore, women were viewed as the more deserving human being in maternal-fetal conflict.

Though the current understanding of language processing is incomplete, it has been established that the left hemisphere is dominant for language in the majority of the population. Damage to language centers of the brain and to white matter tracts connecting these language centers results in a language deficit known as aphasia. Neuroplasticity in the brain can often compensate for these language deficits by strengthening neuronal connections between the right and left hemisphere, or by enhancing the neuronal connectivity of undamaged areas in the left hemisphere. Thus the brain can compensate for damaged language centers by using alternative cortical areas. These compensatory language areas may be homologous areas of the right hemisphere, or other undamaged portions of the left hemisphere. Various imaging techniques have been used to demonstrate this phenomenon. The current neuroimaging technique known as quantitative electroencephalographic brain imaging allows investigators to evaluate the functional anatomical location of language processing. When this mapping is overlaid on a magnetic resonance image, investigators are able to locate areas in the brain of the participant that are electrically activated during elicited speech tasks. This method was used in a single case study to examine the brain of an individual with a unique traumatic brain injury in which the anterior portion of the individual's left temporal lobe was surgically removed and considerable recovery of language subsequently occurred. The stimulus for the quantitative electroencephalography included identifying syntactically incorrect sentences. Imaging results from the participant with traumatic brain injury were compared to imaging results obtained from an age-matched control. Differences in quantitative electroencephalography between the two participants included a delayed P1-N1-P2 response and an absent P600 in the participant with traumatic brain injury. Behavioral results include an increased number of incorrect responses from the participant with traumatic brain injury as compared to the control participant. These results imply an interesting cortical distribution of language processing that could be further assessed by functional magnetic resonance imaging.

INTRODUÇÃO: A craniotomia pterional é uma das técnicas mais utilizadas em neurocirurgia. É uma craniotomia que tem constantemente sido comparada com técnicas alternativas utilizadas para acessar alvos anatômicos similares. Esta craniotomia, contudo, apresenta desvantagens, necessitando de dissecção completa do músculo temporal. Prognósticos estéticos desfavoráveis são comuns e atribuídos à atrofia do músculo temporal e do tecido adiposo adjacente ou à lesão do ramo frontal do nervo facial. A neurocirurgia moderna busca equilibrar o balanço entre o traumatismo cirúrgico tecidual e a exposição microcirúrgica. Algumas modificações técnicas têm sido sugeridas para reduzir o tamanho da craniotomia pterional, visando reduzir o traumatismo tecidual e melhorar os resultados estéticos. Entretanto, estas modificações não permitem exposição cirúrgica suficiente nem garante resultados cosméticos melhores. Esta tese descreve uma nova técnica, denominada craniotomia minipterional, e compara a exposição anatômica por ela proporcionada com a da craniotomia pterional convencional. MATERIAL E MÉTODOS: A exposição anatômica proporcionada pelas craniotomias pterional e minipterional foram comparadas em oito lados de cabeça de espécimes anatômicas usando um sistema computadorizado de localização estereotáxica (Optotrak 3020, Nothern Digital, Waterloo, ON, Canada) para medir uma área hexagonal pré-definida de exposição cirúrgica, um microscópio robótico (Surgiscope; Elekta Instruments, Inc, Atlanta, GA) para quantificar a exposição angular de três alvos anatômicos (bifurcações das artérias carótida interna e da artéria cerebral e o ponto médio da artéria comunicante anterior), e um sistema de neuronavegação (Medtronic Surgical Navigation Technologies, Louisville, CO) para avaliar os limites da exposição cirúrgica de cada craniotomia. Os dados foram submetidos à análise estatística utilizando análise de variância (ANOVA) RESULTADOS: Não houve diferenças estatísticas na área de exposição cirúrgica total entre as duas craniotomias (pterional=1524,7 +/- 305,0 mm2; minipterional = 1469,7 +/- 380,3 mm2; p>0,05) ou entre os componentes ipsilateral, intermédio e contralaterais da área total (p>0,05). Nenhuma diferença foi observada na exposição angular ao longo dos eixos longitudinal e transversal para os três alvos anatômicos considerados (bifurcações das artérias carótida interna e da artéria cerebral média e o ponto médio da artéria comunicante anterior) (p>0,05). Exceto para o segmento distal do compartimento opérculo-insular da cisterna sylviana, nenhuma diferença significativa nos limites da exposição cirúrgica das duas craniotomias foi evidenciada pelo sistema de neuronavegação. CONCLUSÃO: A craniotomia minipterional propicia exposição cirúrgica comparável àquela oferecida pela craniotomia pterional. / INTRODUCTION: Pterional craniotomy is one of the most used and versatile approaches in neurosurgery. It constitutes a standard against which alternative surgical techniques to the same anatomic targets have been compared for years. This technique, however, is not without disadvantages. It requires complete dissection of the temporalis muscle. Poor outcomes are common and can be attributed to atrophy of the temporalis muscle and superficial temporal fat pad or to injury of the frontal branch of the facial nerve. Contemporary neurosurgical techniques strive to balance the need to minimize tissue trauma and to maximize anatomic exposure. Many surgical modifications have been described to minimize the size of the pterional craniotomy in an effort to decrease tissue trauma and improve cosmetic outcomes. In many instances, however, these modifications neither ensure a sufficient anatomic exposure nor guarantee satisfactory aesthetic outcomes. This thesis describes a novel technique, the minipterional craniotomy, and compares its anatomic exposure with that provided by the pterional technique. MATERIALS AND METHODS: The anatomic exposure offered by the minipterional and pterional techniques were compared in eight sides of cadaver heads using a computerized tracking system (Optotrak 3020, Nothern Digital, Waterloo, ON, Canada) to measure a predefined hexagonal area of surgical exposure, a robotic microscope (Surgiscope; Elekta Instruments, Inc, Atlanta, GA) to quantify angular exposure in the transverse and longitudinal axis for three anatomic targets (bifurcations of internal carotid and middle cerebral arteries and the middle point of the anterior communicating artery), and an image-guidance system (Medtronic Surgical Navigation Technologies, Louisville, CO) to evaluate the limits of exposure for each craniotomy. Data were submitted to statistical analysis using ANOVA. RESULTS: There were no statistical differences in the total area of surgical exposure between the two craniotomies (pterional=1524.7 +/- 305.0 mm2; minipterional = 1469.7 +/- 380.3 mm2; p>0.05) or among the ipsilateral, middle, and contralateral components of the area (p>0.05). There were no differences in angular exposure along the longitudinal and transverse axis angles for the three selected targets, the bifurcations of internal carotid and middle cerebral arteries, and the anterior communicating artery (p> 0.05). Except for the distal portion of the operculoinsular compartment of the sylvian fissure, no significant differences in the limits of the surgical exposure through the pterional and minipterional were apparent on the image-guidance system. CONCLUSION: The minipterional craniotomy provides comparable surgical exposure to that offered by the pterional technique.

Resumo: A meningite é uma inflamação das membranas que revestem o sistema nervoso central. As principais etiologias desta doença são de origem infecciosa, podendo ser bacteriana, fúngica ou viral. A meningite pode ocorrer como uma infecção hospitalar e pode ser associada a trauma ou neurocirurgia. Quando diagnosticada após um procedimento neurocirúrgico, a maior parte dos agentes infecciosos causadores da meningite provem da microbiota endógena da pele e do cabelo. No entanto, existem casos no qual o agente etiológico não é diagnosticado pelas técnicas laboratoriais convencionais, como a cultura microbiológica e bacterioscopia, dificultando a prescrição de terapias adequadas. O objetivo deste estudo foi identificar os agentes causadores de meningite após neurocirurgia (MAN) utilizando técnicas de biologia molecular e comparando-as com a cultura microbiológica. Foram incluídas amostras de líquido cefalorraquidiano (LCR) de pacientes submetidos a neurocirurgia e pacientes submetidos a cirurgias eletivas com uso de raquianestesia durante o período de 2015 a 2016. A reação em cadeia da polimerase (PCR) foi utilizada para avaliação da presença do gene 16S do DNA ribossômico, comum em microrganismos de origem bacteriana, e o sequenciamento do mesmo para a identificação do agente etiológico. As amostras foram classificadas em 5 grupos de acordo com a suspeita clínica e dados quimiocitológicos do LCR: meningite bacteriana (MB) confirmada, MB possível, MB provável, MB improvável e sem MB, neste último grupo estão apenas pacientes submetidos a cirurgias eletivas. Das 51 amostras de LCR incluídas (43 pós-neurocirurgia e 8 pré-anestésica), 21 (41,2%) apresentaram cultura microbiológica negativa com PCR positiva, sendo: 3 (14,2%) MB possível, 4 (19,0%) MB provável, 13 (62,0%) MB improvável, 1 (4,8%) sem MB. Do total de 15 amostras positivas para PCR foi identificada ao menos a família filogenética, houve predomínio de microrganismos Gram negativos, somando 11 contra 4 Gram positivos. A identificação dos agentes etiológicos na MAN, incluindo os não detectados por métodos convencionais de identificação laboratorial, demonstraram que a biologia molecular pode complementar o diagnóstico colaborando de forma positiva, guiando o tratamento para o microrganismo específico ou sua família / Abstract: Meningitis is an inflammation of the membranes covering the central nervous system. The main causes of this disease are bacterial, fungal or viral agents. Meningitis may be associated with trauma or neurosurgery. When meningitis is diagnosed after a neurosurgical procedure, the most common microorganisms belong to skin and hair microbiota. However, there are cases in which the etiological agent is not diagnosed by conventional laboratory techniques, such as microbial culture and bacterioscopy, which makes it difficult to establish adequate therapies. The objective of this study is to identify agents causing meningitis after neurosurgery (MAN) using polymerase chain reaction (PCR) and sequencing of the 16S rRNA gene, compared to the conventional microbiological culture. Cerebrospinal fluid (CSF) was collected from 43 patients who had undergone neurosurgery and 8 patients during spinal anesthesia were included during the period from 2015 to 2016. Polymerase chain reaction (PCR) was used to evaluate the presence of the 16S ribosomal RNA gene, common in microorganisms of bacterial origin, and the sequencing of the same for the identification of the etiological agent. Samples were classified into five groups according to clinical data and CSF analysis: confirmed bacterial meningitis (MB), probable MB, possible MB, unlikely MB, no meningitis, in this last group are only patients submitted to elective surgeries. There were 51 CSF samples included (43 post neurosurgery and 8 pre-spinal anesthesia), 21 samples (41.2%) presented negative microbial culture and were PCR-positive, divided as: 3 (14.2%) probable MB, 4 (19%) possible MB, 13 (62%) unlikely MB and 1 (4.8%) no meningitis. From the total of 15 PCR-positive samples at least the phylogenetic family was identified with a predominance of Gram negative microorganisms, (11). The identification of etiologic agents in MAN, including those not detected by conventional laboratory identification methods, suggests molecular biology can complement the diagnosis and collaborate in guiding the treatment for the specific microorganism or its family

Introdução: A neurocirurgia minimamente invasiva já é uma realidade em muitos centros em todo o mundo. A aplicação de conceitos antigos com a incorporação de novas tecnologias permite o emprego de medidas menos invasivas, mas com a mesma eficácia e segurança. O real papel destas técnicas e o seu efeito sobre a evolução dos doentes ainda é nebuloso. Objetivos: avaliar a segurança e resultados da técnica minimamente invasiva na clipagem de aneurismas cerebrais de circulação anterior e determinar o momento seguro para alta hospitalar. Materiais: Cento e onze doentes adultos com diagnóstico de aneurismas não rotos de circulação anterior foram randomicamente distribuídos e submetidos a cirurgia por um acesso minimamente invasivo (grupo de estudo - 36 pelo acesso transpalpebral e 34 através de craniotomias minipterional reduzida) ou acesso pterional clássico (grupo controle - 41 doentes). O endoscópio acoplado a um telefone celular foi utilizado juntamente com o microscópio durante as cirurgias do grupo de estudo. Os doentes do grupo de estudo foram submetidos a um protocolo específico para avaliação da segurança da alta hospitalar precoce. Foram avaliados desfechos cirúrgicos, clínicos/funcionais, estéticos e sobre qualidade de vida. Resultados: Em ambos os grupos, os dados demográficos e as características dos aneurismas foram similares. O tempo médio das cirurgias foi menor no grupo de estudo (214 min. vs 292 min, p = 0,0008). A necessidade de transfusão sanguínea foi menor no grupo de estudo (1 doente vs 7 doentes, p = 0,018). O número de eventos isquêmicos foi menor no grupo de estudo (4 doentes vs 8 doentes, p = 0,07), mas os eventos com repercussão clínica foram semelhantes (2 doentes vs 3 doentes, p = 0,53). A presença de colo residual na angiografia controle foi menor no grupo de estudo (6 doentes vs 11, p = 0,021), mas foram todos colos pequenos, 1,75 ± 0,68 mm, sendo que apenas um doente do grupo controle foi reoperado. A paralisia do ramo frontal do nervo facial foi menor no grupo de estudo, tanto a temporária (3 vs 14, p = 0,008) quanto a definitiva (0 vs 4, p = 0,032). A atrofia do músculo temporal foi menos frequente e mais leve no grupo de estudo (9 vs 14, p = 0,012). No grupo de estudo, 91,4% dos doentes receberam alta precoce no dia seguinte da cirurgia e nenhum doente apresentou evento adverso por este motivo. Os doentes do grupo de estudo ficaram assintomáticos mais rapidamente no pós-operatório (pela avaliação da escala de Rankin, p = 0,0026), mas não houve diferença entre os grupos dentre as pontuações acima de 1 na escala de Rankin modificada. Um doente do grupo controle faleceu no pós-operatório (0,9%). Conclusões: Os resultados demonstraram que as alternativas minimamente invasivas propostas são seguras e tem resultados clínicos e cirúrgicos iguais ou superiores ao tratamento clássico em vários quesitos. A alta precoce nestes doentes é possível e segura. O acesso nanopterional ou transpalpebral é uma alternativa melhor em relação à craniotomia pterional clássica para tratar aneurismas não rotos da circulação anterior / Introduction: Minimally invasive neurosurgery is already a reality in many centers across the world. The application of old concepts with the incorporation of new technologies allows the use of less invasive measures with the same effectiveness and safety. However, the real role of these techniques and their effect on the outcome of patients is still obscure. Objectives: To evaluate the safety and results of minimally invasive techniques in brain aneurysm clipping and determine the possibility of early hospital discharge. Methods: 111 adult patients with unruptured anterior circulation aneurysms were randomized and underwent a minimally invasive surgical approach, (36 by transpalpebral approach and 34 through a reduced minipterional craniotomy) or classical pterional approach (41 patients). The endoscope coupled to a smart phone was used along with the microscope during surgery (study group only). Patients in the study group were subjected to a specific protocol for assessment of early hospital discharge. Surgical, clinical/functional and aesthetic outcomes were evaluated along with long term quality of life. Results: In both groups, the demographics and characteristics of aneurysms were similar. The average time of surgery was lower in the study group (214 min. vs. 292 min, p = 0.0008). The need for blood transfusion was lower in the study group (1 patient vs 7 patients, p = 0.018). The number of ischemic events was lower in the study group (patients 4 patients vs. 8, p = 0.07), but events with clinical significance were similar (3 patients vs. 2 patients, p = 0.53). The presence of residual neck on control angiography was lower in the study group (6 patients vs 11, p = 0.021), but only small ones were found, 1.75 ± 0.68 mm, and only one control group patient required reoperation for this reason. The paralysis of the frontal branch of the facial nerve was lower in the study group, both temporary (3 vs 14, p = 0.008) and definitive (0 vs. 4, p = 0.032). The atrophy of the temporal muscle was less frequent and less severe in the study group (9 vs 14, p = 0.012). Most patients in the study group (91.4%), were discharged on the next day of the surgery and no patients had any related adverse events. Patients in the study group got asymptomatic faster (assessed by the Rankin scale, p = 0.26), but there was no difference between the groups among scores above 1 on the modified Rankin scale. One control group patient died postoperatively (0,9%). Conclusions: The results showed that the proposed minimally invasive alternatives are safe. Clinical and surgical results are equal or superior to conventional treatment in several topics. Early discharge in these patients is possible and safe. The described approaches (nanopterional or transpalpebral) are better alternatives to the classical pterional craniotomy to treat unruptured aneurysms of the anterior circulation

Our brain, perhaps the most sophisticated and mysterious part of the human body, to some extent, determines who we are. However, it’s a vulnerable organ. When subjected to an impact, such as a traffic accident or sport, it may lead to traumatic brain injury (TBI) which can have devastating effects for those who suffer the injury. Despite lots of efforts have been put into primary injury prevention, the number of TBIs is still on an unacceptable high level in a global perspective. Brain edema is a major neurological complication of moderate and severe TBI, which consists of an abnormal accumulation of fluid within the brain parenchyma. Clinically, local and minor edema may be treated conservatively only by observation, where the treatment of choice usually follows evidence-based practice. In the first study, the gravitational force is suggested to have a significant impact on the pressure of the edema zone in the brain tissue. Thus, the objective of the study was to investigate the significance of head position on edema at the posterior part of the brain using a Finite Element (FE) model. The model revealed that water content (WC) increment at the edema zone remained nearly identical for both supine and prone positions. However, the interstitial fluid pressure (IFP) inside the edema zone decreased around 15% by having the head in a prone position compared with a supine position. The decrease of IFP inside the edema zone by changing patient position from supine to prone has the potential to alleviate the damage to axonal fibers of the central nervous system. These observations suggest that considering the patient’s head position during intensive care and at rehabilitation should be of importance to the treatment of edematous regions in TBI patients. In TBI patients with diffuse brain edema, for most severe cases with refractory intracranial hypertension, decompressive craniotomy (DC) is performed as an ultimate therapy. However, a complete consensus on its effectiveness has not been achieved due to the high levels of severe disability and persistent vegetative state found in the patients treated with DC. DC allows expansion of the swollen brain outside the skull, thereby having the potential in reducing the Intracranial Pressure (ICP). However, the treatment causes stretching of the axons and may contribute to the unfavorable outcome of the patients. The second study aimed at quantifying the stretching and WC in the brain tissue due to the neurosurgical intervention to provide more insight into the effects upon such a treatment. A nonlinear registration method was used to quantify the strain. Our analysis showed a substantial increase of the strain level in the brain tissue close to the treated side of DC compared to before the treatment. Also, the WC was related to specific gravity (SG), which in turn was related to the Hounsfield unit (HU) value in the Computerized Tomography (CT) images by a photoelectric correction according to the chemical composition of the brain tissue. The overall WC of brain tissue presented a significant increase after the treatment compared to the condition seen before the treatment. It is suggested that a quantitative model, which characterizes the stretching and WC of the brain tissue both before as well as after DC, may clarify some of the potential problems with such a treatment. Diffusion Weighted (DW) Imaging technology provides a noninvasive way to extract axonal fiber tracts in the brain. The aim of the third study, as an extension to the second study was to assess and quantify the axonal deformation (i.e. stretching and shearing)at both the pre- and post-craniotomy periods in order to provide more insight into the mechanical effects on the axonal fibers due to DC. Subarachnoid injection of artificial cerebrospinal fluid (CSF) into the CSF system is widely used in neurological practice to gain information on CSF dynamics. Mathematical models are important for a better understanding of the underlying mechanisms. Despite the critical importance of the parameters for accurate modeling, there is a substantial variation in the poroelastic constants used in the literature due to the difficulties in determining material properties of brain tissue. In the fourth study, we developed a Finite Element (FE) model including the whole brain-CSF-skull system to study the CSF dynamics during constant-rate infusion. We investigated the capacity of the current model to predict the steady state of the mean ICP. For transient analysis, rather than accurately fit the infusion curve to the experimental data, we placed more emphasis on studying the influences of each of the poroelastic parameters due to the aforementioned inconsistency in the poroelastic constants for brain tissue. It was found that the value of the specific storage term S_epsilon is the dominant factor that influences the infusion curve, and the drained Young’s modulus E was identified as the dominant parameter second to S_epsilon. Based on the simulated infusion curves from the FE model, Artificial Neural Network (ANN) was used to find an optimized parameter set that best fit the experimental curve. The infusion curves from both the FE simulations and using ANN confirmed the limitation of linear poroelasticity in modeling the transient constant-rate infusion. To summarize, the work done in this thesis is to introduce FE Modeling and imaging technologiesincluding CT, DW imaging, and image registration method as a complementarytechnique for clinical diagnosis and treatment of TBI patients. Hopefully, the result mayto some extent improve the understanding of these clinical problems and improve theirmedical treatments. / QC 20120201

To facilitate examination for osteogenesis and follow up after craniotomy similar head models called phantoms are made. The head phantom should emulate the tissues from a real head. This requires that the realistic head phantom have the same electrical properties as relative permittivity (dielectric constant) and conductivity. Both must be validated and matched for right frequency spectrum. Validation measurements are performed by a coaxial slim probe connected to an Agilent Technologies E8364B network analyzer. The range of frequency measured is from 1 to 50 GHz, but matching will only be processed for 1 to 10 GHz. The resonance frequency for the antenna or sensor, which later will be used, is 2.4 GHz. The end results of the head phantom consists of three different tissues or layers (skin, bone and brain). Cavities will be created in the bone and will act as different defects or stages of re-growing bone. Phantom cube is done for examining the influence of implant in bone. Insertions of cube samples are made to emulate intermediates between implant and bone. Keywords: agar, BMP, body morphogenetic protein, bone implant, brain phantom, craniosynostosis, craniotomy, cube phantom, phantom, re-growing bone, skin phantom, skull phantom, tissue.