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Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / The purpose of this study was to isolate the adjacent epaxial musculature from exposed spinal cord by modified dorsal laminectomy in dogs with aluminum implant and whether the muscles contribute to form fibrosis epidural and influence of neurological signs. Ten dogs were submitted to modified dorsal laminectomy, five dogs just surgery technical (GI) and other five dogs the aluminum implant was placed between the musculature and defect (GII). Daily neurological examination until 180 days, myelography at 15, 30 and 60 days postoperatively and macroscopic evaluation of the implant at six months were performed. There was no difference at the neurological examination. Two qualified persons evaluated latero-laterally, ventro-dorsally, right and left oblique myelography incidences. There was statistics difference in degree of compression only 15 day postoperatively. During the implant of macroscopic evaluated was observed the musculature was not in contact with epidural fibrosis, differently the control group. The implant was removed easily with some degree of deformity. The results showed the adjacent musculature of the spinal cord submitted a modified dorsal laminectomy in dogs is isolated by aluminum implant, without contact with epidural fibrosis and influence in neurological signs. / O objetivo deste experimento foi isolar a musculatura epaxial da medula espinhal de cães submetidos à laminectomia dorsal modificada e averiguar se os músculos influenciaram na formação da fibrose epidural, na compressão medular e no aparecimento dos sinais neurológicos. Para isso, foram utilizados dez cães hígidos, sem raça definida, pesando entre 10 e 20 quilos e submetidos à laminectomia dorsal modificada entre as vértebras T13 e L1. Após, foram distribuídos aleatoriamente em dois grupos de igual número denominados de I (controle) onde a medula espinhal permaneceu exposta sem a presença de implante e II (tratado), onde foi colocado um implante a base de alumínio entre a musculatura epaxial adjacente e a medula espinhal exposta pela laminectomia. Foram realizados exames clínicos e neurológicos diários até os 60 dias de pós-operatório (PO) e observações gerais até 180 dias de PO. Decorridos 15, 30 e 60 dias de PO, os cães foram submetidos à mielografia para avaliar o grau de compressão medular e após seis meses, por avaliação macroscópica mediante a reintervenção cirúrgica. Aos 15 dias de pós-operatório, foi verificado, na mielografia, que o grau de compressão da linha de contraste foi maior no grupo tratado (P<0,05) quando comparado ao grupo controle, não havendo diferença dos demais tempos estudados. Na avaliação macroscópica, pode-se observar que no grupo II, a musculatura epaxial adjacente à medula espinhal não estava em contato com a fibrose epidural, diferentemente do grupo controle. O implante pôde ser removido facilmente e apresentava discreto grau de deformidade crânio-dorsal. Com exceção de um cão do grupo II, não foi verificada deficiências neurológicas até os 60 dias de PO. Pode-se concluir que a musculatura epaxial adjacente é isolada da medula espinhal pelo implante à base de alumínio em cães submetidos à laminectomia dorsal modificada, e esta não influencia na formação da fibrose epidural, compressão medular e no aparecimento dos sinais neurológicos.

INTRODUCTION: Cancers of the gastrointestinal tract are the second most prevalent malignancy with 289,610 new cases last year and the second most common cause of cancer-related death with 150,000 deaths last year in the United States. Prognosis for patients with these malignancies is poor and worsens significantly once the cancer has metastasized to the brain. We evaluated the outcome of patients following Stereotactic Radiosurgery (SRS) for brain metastases (BM) in individuals with GI cancers to identify safety and effectivity of treatment and we assessed prognostic factors that affect tumor control and survival. OBJECTIVES: By the conclusion of this session, participants should be able to: 1) Identify an effective treatment for brain metastases from GI cancers in terms of increasing survival; 2) Identify which treatment provides the best local and distant control of CNS disease; 3) Discuss the effects of different prognostic factors on local control and survival. METHODS: This is a retrospective analysis of 58 brain metastases from 18 consecutive patients who underwent SRS treatment at BIDMC between 2006 and 2013. 11/18 patients underwent prior microsurgical resection for their metastases and 3/18 patients had undergone Whole Brain Radiation Therapy (WBRT). Overall Survival (OS), Local Control (LC), Distal control (DC), and prognostic factors such as age, number of brain metastases (BM), Karnofsky Performance Status (KPS), Recursive Partition Analysis (RPA) and Disease Specific Graded Prognostic Assessment (Ds-GPA) class were evaluated. RESULTS: The median overall survival (mOS) for the entire cohort was 14 months after the diagnosis of BM. The mOS for patients receiving only SRS, Surgical Resection + SRS, and WBXRT + SRS were 8 months, 18 months, and 13 months respectively. The difference in overall survival between treatment groups was not found to be statistically significant. Increasing number of BM was a factor shown to negatively influence survival. Local control was achieved in 55% of lesions after SRS, and in 75% of lesions that were surgically resected followed by SRS boost to the resection cavity. The difference in local control between SRS alone vs. Surgery + SRS was found to be statistically significant (p = 0.013). CONCLUSION: With a higher overall survival and significantly better local control rates, Surgery followed by SRS boost to the resection cavity should be considered as the treatment of choice in this specific subgroup of cancer patients as this study shows that they benefit from this more aggressive treatment option.

Complex network models of functional connectivity have emerged as a paradigm shift in brain mapping over the past decade. Despite significant attention within the neuroimaging and cognitive neuroscience communities, these approaches have hitherto not been extensively explored in neurosurgery. The aim of this thesis is to investigate how the field of connectomics can contribute to understanding the effects of focal brain lesions and to functional brain mapping in neurosurgery. This datasets for this thesis include a clinical population with focal brain tumours and a cohort focused on healthy adolescent brain development. Multiple network analyses of increasing complexity are performed based upon resting state functional MRI. In patients with focal brain tumours, the full complement of resting state networks were apparent, while also suggesting putative patterns of network plasticity. Connectome analysis was able to identify potential signatures of node robustness and connections at risk that could be used to individually plan surgery. Focal lesions induced the formation of new hubs while down regulating previously established hubs. Overall these data are consistent with a dynamic rather than a static response to the presence of focal lesions. Adolescent brain development demonstrated discrete dynamics with distinct gender specific and age-gender interactions. Network architecture also became more robust, particularly to random removal of nodes and edges. Overall these data provide evidence for the early vulnerability rather than enhanced plasticity of brain networks. In summary, this thesis presents a combined analysis of pathological and healthy development datasets focused on understanding the functional effects of focal brain lesions at a network level. The coda serves as an introduction to a forthcoming study, known as Connectomics and Electrical Stimulation for Augmenting Resection (CAESAR), which is an evolution of the results and methods herein.

Introdução: A extubação é o último passo do processo de desmame da ventilação mecânica. Em pacientes com lesões neurológicas esta decisão pode ser dificultada pelas limitações dos métodos de avaliação de capacidade de proteção da via aérea. Objetivos: Avaliar a capacidade de atender a comandos motores simples, como preditores de risco para falha na extubação de pacientes neurocríticos. Método: Estudo de coorte prospectivo. Foram avaliados 132 pacientes ventilados mecanicamente por mais de 24 horas e que passaram no teste de ventilação espontânea. Valores preditivos da capacidade de atender a comando motores, com resposta motora apendicular e protusão da língua, foram estabelecidos como resultados primários. Duração da ventilação mecânica, tempo de permanência na Unidade de Terapia Intensiva e no hospital, mortalidade e incidência de pneumonia associada à ventilação mecânica foram resultados secundários. Resultados: Após a regressão logística, a incapacidade de executar resposta motora simples e realizar protusão da língua foram fatores de risco independentes para falha na extubação em pacientes neurocríticos. (R.R.=1.57; 95% intervalo de confiança 95% 1.01-2.44; p< 0.045 e R.R.=6.84; intervalo de confiança 95% 2.49-18.8, p<0.001, respectivamente). Não foram observadas diferenças significativas quanto ao sexo, idade, Escala de Coma de Glasgow na admissão ou diagnóstico, e variáveis hemodinâmicas e ventilatórias durante o teste de ventilação espontânea. Escore APACHE II, Escala de Coma de Glasgow na extubação, melhor resposta para abertura ocular, pressões inspiratória e expiratória máximas e índice de respiração superficial apresentaram diferenças significativas entre o grupo sucesso e falha. O tempo de permanência na UTI e no hospital, assim com a taxa de pneumonia associada à ventilação mecânica, foram significativamente mais elevados no grupo de falha na extubação. Conclusão: A incapacidade de atender a comandos motores e realizar protusão da língua são preditores de falha na extubação simples e fáceis para avaliação à beira do leito em pacientes neurocríticos, podendo ser usados como teste de triagem fácil e rápido para seleção de pacientes neurocríticos candidatos a extubação. / Background: Extubation is the last step of the weaning process of mechanical ventilation. Patients with neurological injuries may make this decision hampered by the limitations of the assessment methods for protection of the airway. Objective: To evaluate ability to follow simple motor commands as predictors of risk for extubation failure in critically ill neurological patients. Methods: Prospective cohort study. 132 intubated patients receiving mechanical ventilation for at least 24 hours who were deemed ready to undergo a spontaneous breathing trial. Predictive value of ability to follow simple motor commands and to protrude tongue for successful extubation (primary endpoint). Duration of mechanical ventilation, length of stay in the intensive care unit, length of hospital stay, mortality, and incidence of ventilator-associated pneumonia (secondary endpoints). Results: After logistic regression, incapacity for executing simple motor tasks and for tongue protusion were independent risk factors for extubation failure in critically ill neurological patients (R.R.=1.57; 95% confidence interval 1.01-2.44; p< 0.045 and R.R.=6.84; 95% confidence interval 2.49-18.8, p<0.001, respectively). No significant differences were observed regarding sex, age, Glasgow Coma Scale score at admission or at diagnosis, and hemodynamic or ventilatory variables during the spontaneous breathing trial. Acute Physiology and Chronic Health Evaluation II score, Glasgow Coma Scale score at extubation, eye opening response, maximal inspiratory pressure, maximal expiratory pressure, and the rapid shallow breathing index showed significant differences between success and failure groups. The length of stay in ICU and hospital, as well as the rate of pneumonia associated to the mechanical ventilation were significantly higher in the group of extubation failure. Conclusion: The inability to respond simple motor commands and to tongue protrusion are easy and simple bedside assessment predictors for extubation failure in critically ill neurological patients, could be used as an easy and quick screening test for the selection of neurocritical patients candidates to extubation.

Este trabalho tem como objetivo relatar as implicações da técnica cirúrgica de corpectomia vertebral cervical no diâmetro do canal medular de cadáveres caninos anteriormente congelados através da avaliação mielográfica. Para a padronização da técnica de mielografia cervical foram utilizados 30 cadáveres de cães. Os espécimes foram submetidos a quatro posicionamentos radiográficos para avaliação conjunta: laterolateral neutro, laterolateral em hiperextensão, laterolateral em hiperflexão e ventrodorsal. A opacificação do espaço subaracnóide, a confecção de duas linhas de contraste e a formação de artefatos foram mensurados qualitativamente e depois seu grau de concordância foi avaliado. Na segunda etapa 20 cadáveres foram divididos em dois grupos: o primeiro grupo foi submetido à corpectomia da terceira vértebra cervical, enquanto o segundo grupo à corpectomia da quinta vértebra cervical. Previamente ao procedimento cirúrgico, os cadáveres foram submetidos a um exame mielográfico. Posteriormente foram realizados exames radiográficos seriados após o procedimento de corpectomia cervical e de estabilização vertebral. As projeções radiográficas utilizadas foram as mesmas supracitadas. O diâmetro da medula espinhal foi medido ao longo do canal medular e correlacionado com o comprimento do assoalho vertebral. A corpectomia e a estabilização vertebral alteraram significativamente o diâmetro do canal medular apenas em posições de estresse, permitindo supor que a corpectomia vertebral cervical é um método viável de descompressão medular para a região cervical em cães, proporcionando um acesso adequado ao canal medular do corpo vertebral com mínima manipulação do tecido nervoso. / The aim of this paper is to report the implication of the cervical vertebral corpectomy in the myelography medullary diameter in canine cadavers. In order to standardize the myelograph technique thirty canine bodies were used. The subaracnoid space opacification, the visualization of contrast columns and artifact formation were evaluated in four radiographic projections: laterolateral in neutral position, laterolateral in hyperflexion, laterolateral in hyperextension and ventrodorsal in neutral position. The agreeing ratio was measured. Thereafter, twenty specimens were divided in two groups according to the cervical vertebra in which the procedure would be performed. In the first group the corpectomy was performed in the third cervical vertebrae and in the second group in the fifth vertebrae. Before the surgical procedure, a myelogram was performed. Radiograph exams were done after the corpectomy and after the instrumentation of the cervical spine. The same projections previously described were used. The medullary diameter was measured through the spinal canal. Afterwards, it was correlated to the length of the vertebral floor. The corpectomy and cervical instrumentation changed the medullar diameter solely in stress positions. In addition, it granted proper vertebral channel access with minimal spinal cord manipulation. Therefore, we concluded that the cervical vertebral corpectomy is a viable decompressive surgical technique.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / The aim of this study was to investigate if surgical manipulation of the spinal cord in dogs submitted to thoracolumbar dorsolateral hemilaminectomy influences the development of neurological and myelographic signs at immediate postoperative time. For this reason, fourteen healthy mongrel dogs were used, weighing from 7 to 10 kilos and submitted to hemilaminectomy between T13 and L1 vertebrae and distributed randomly in three groups, denominated as GI or control (n=4), GII or 15 movements (n=5) and GIII or 30 movements (n=5). The dogs in GI were only submitted to thoracolumbar dorsolateral hemilaminectomy surgical technique, on the left side. The dogs in GII and GIII were submitted to the same procedure as GI, followed by 15 and 30 movements, respectively, over the dorsal, left lateral and ventral surfaces of the spinal cord. Neurological exams were carried out 24 and 72 hours after surgery and after these periods, the dogs were submitted to myelography to evaluate filling and irregular delineation of the contrast line in the subarachnoid space. The myelographic evaluation results in lateral and ventrodorsal positions did not show significant difference, even though there was variation between the groups. In the neurological exam, the animals did not demonstrate neurological deficiencies in any of the days of evaluation at PO. According to the proposed experimental model and the results obtained, it can be concluded that the surgical manipulation of the spinal cord in healthy dogs submitted to thoracolumbar hemilaminectomy does not influence the development of neurological deficiencies at immediate postoperative time and the proposed myelography technique, via cisterna magna, presents limitations in evaluating alterations of the spinal cord at the thoracolumbar region. / O objetivo deste trabalho foi investigar se a manipulação cirúrgica da medula espinhal em cães submetidos à hemilaminectomia toracolombar dorsolateral influencia no aparecimento de sinais neurológico e mielográfico no pós-operatório imediato. Para isto, foram utilizados quatorze cães hígidos, sem raça definida, pesando entre 7 e 10 quilos e submetidos à hemilaminectomia entre as vértebras T13 e L1 e distribuídos aleatoriamente em três grupos, denominados de GI ou controle (n= 4), GII ou 15 movimentos (n=5) e GIII ou 30 movimentos (n=5). Os cães do GI foram submetidos apenas à técnica cirúrgica de hemilaminectomia dorsolateral toracolombar, lado esquerdo. Os cães dos GII e GIII foram submetidos ao mesmo procedimento do GI seguido, respectivamente, de 15 e 30 movimentos sobre as superfícies dorsal, lateral esquerda e ventral da medula espinhal. Foram realizados exames neurológicos 24 e 72 horas após a cirurgia e decorridos estes períodos, os cães foram submetidos à mielografia para avaliar o preenchimento e desvio da linha de contraste no espaço subaracnóide. Os resultados das avaliações mielográficas nas posições lateral e ventro-dorsal não apresentaram diferença significativa, mesmo havendo variação entre os grupos. No exame neurológico, os animais não demonstraram deficiências neurológicas em nenhum dia de avaliação no PO. De acordo com o modelo experimental proposto e dos resultados obtidos, pode-se concluir que a manipulação cirúrgica da medula espinhal em cães hígidos submetidos à hemilaminectomia toracolombar não influencia no aparecimento de deficiências neurológicas no pós-operatório imediato e a técnica proposta de mielografia, via cisterna magna apresenta limitações em avaliar alterações da medula espinhal na região toracolombar.

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No. of bitstreams: 1 roscamp_m_me_jabo.pdf: 9443012 bytes, checksum: 69bacbdda807a3e9fee0f785465385c3 (MD5) Previous issue date: 2017-10-09 / A cirurgia piezoelétrica ou piezocirurgia é utilizada há várias décadas, porém em medicina veterinária são escassos os artigos publicados utilizando esta modalidade em cirurgias descompressivas da coluna vertebral de cães e gatos. Assim, aventou-se com esse trabalho investigar a aplicabilidade da mesma na realização da espondilectomia parcial ventral cervical (EPVC), comparando-a com a técnica convencional que utiliza brocas esféricas de alta rotação para o desgaste ósseo, utilizando o coelho (Oryctolagus cuniculus) como modelo experimental de cães e gatos. Para tanto foi utilizado o aparelho médico Mastersonic®, que possui duas peças de mão, uma piezoelétrica com ponteira ultrassônica tipo cinzel delicado (T1) e na outra, motor de alta rotação com brocas esférica de 2 mm (técnica convencional) (T2). A EPVC foi realizada entre a terceira e quarta vértebras cervicais e cada técnica foi realizada em 15 animais, devidamente anestesiados, os quais foram avaliados quanto à duração de cada etapa da cirurgia, variações de temperatura durante a execução da EPVC, visibilidade do campo cirúrgico, complicações trans e pós-operatórias e monitoração anestésica. Aos 14, 28 e 56 dias de pós-operatório (PO), cinco animais de cada tratamento foram submetidos à eutanásia e realizado estudo histopatológico do local da cirurgia, avaliando à resposta inflamatória, à cicatrização óssea e as lesões medulares. Os resultados mostraram que T1 demandou mais tempo para a execução da curetagem e maior perda de temperatura no foco cirúrgico durante a cirurgia. O tempo de acesso cirúrgico reduziu progressivamente em torno de 50% até o oitavo procedimento de cada tratamento (T1 e T2), e após isso se manteve com a mesma duração nos dois tratamentos. O tempo de uso do aparelho foi mais homogêneo em T1 e diminuiu progressivamente em T2, mas ao avaliar o tempo total da técnica de EPVC, não houve diferença entre os tratamentos. O T1 proporcionou melhor visibilidade do campo cirúrgico, com apenas um caso de sangramento ósseo, contra seis casos em T2. Observaram-se quatro casos de hemorragia de seio venoso vertebral durante a curetagem no T1 e dois casos no T2. Também ocorreram três casos de déficits proprioceptivos transitórios, com duração de até 72 horas no T1. A temperatura corporal e a taxa de uso do isoflurano decaíram com o tempo nos dois tratamentos, assim como a frequência cardíaca em T1. No estudo histopatológico observou-se resposta inflamatória mais ativa em T1 aos 14 dias de PO, porém aos 28 e 56 dias de PO foi semelhante entre os tratamentos, assim como a cicatrização óssea. Ainda houve mais lesões medulares com a piezocirurgia (T1), principalmente aos 14 e 28 dias de PO, com presença de malácia, esferócitos e células “Gitter”. Enquanto que na técnica convencional (T2), notou-se discreta degeneração Walleriana, apenas aos 14 dias de PO. Conclui-se que a piezocirurgia é aplicável na realização da EPVC com excelente visibilidade do campo operatório, facilidade de manuseio e rápida curva de aprendizagem, no entanto, demandou maior tempo para execução da espondilectomia e provocou mais complicações cirúrgicas e de lesões medulares, quando comparada à técnica convencional. / Piezoelectric surgery or piezosurgery has been used for several decades, but in veterinary medicine, articles published using this modality in decompressive surgery of the spine of dogs and cats are scarce. The aim of this study was to investigate the applicability of this technique to the performance of cervical ventral partial spondylectomy (CVPS), comparing it with the conventional technique using high-rotation spherical drills for bone wear using rabbit (Oryctolagus cuniculus) as an experimental model of dogs and cats.. For this was used Mastersonic® medical device that has two hand pieces, one piezoelectric type with ultrasonic delicate chisel tip (T1) and the other, high speed engine with spherical drills 2 mm (conventional technique) (T2). The CVPS was held between the third and fourth cervical vertebrae and each technique was performed on 15 animals, under anesthesia, which were evaluated for the duration of each stage of surgery, temperature variations during the execution of CVPS, the surgical field visibility, trans and postoperative complications and anesthetic monitoring. At 14, 28 and 56 postoperative days (PO), five animals per treatment were euthanized, and histological studies were carried to the surgical site by assessing the inflammatory response, and bone healing spinal injuries. The results showed that T1 required more time for curettage execution and highest loss of temperature at the surgical focus during surgery. Surgical access time progressively reduced by 50% until the eighth procedure of each treatment (T1 and T2), and after that it remained the same duration in both treatments. The time of use of the device was more homogeneous in T1 and progressively decreased in T2, but when evaluating the total time of the CVPS technique, there was no difference between treatments. The T1 provided better visibility of the surgical field, with only one case of bone bleeding, against six cases in T2. Four cases of vertebral venous sinus hemorrhage were seen during curettage in T1 and two cases in T2. There were also three cases of transient proprioceptive deficits, lasting up to 72 hours in T1. Body temperature and the rate of use of isoflurane declined over time in both treatments, as did heart rate in T1. Histopathological study there was more active inflammatory response in T1 at 14 days postoperatively, but after 28 and 56 days postoperatively was similar among treatments, as well as to bone healing. There were still more spinal cord injuries with the piezosurgery (T1), especially at 14 and 28 days of PO, with presence of malacia, spherocytes and Gitter cells. While the conventional technique (T2), it was noted discrete Wallerian degeneration, only at 14 days postoperatively. It is concluded that the piezosurgery is applicable in the performance of the CVPS with excellent visibility of the operative field, ease of handling and rapid learning curve, however, demanded more time for the execution of the spondylectomy and caused more surgical complications and spinal cord injuries, when compared to the conventional technique.

Este trabalho tem como objetivo relatar as implicações da técnica cirúrgica de corpectomia vertebral cervical no diâmetro do canal medular de cadáveres caninos anteriormente congelados através da avaliação mielográfica. Para a padronização da técnica de mielografia cervical foram utilizados 30 cadáveres de cães. Os espécimes foram submetidos a quatro posicionamentos radiográficos para avaliação conjunta: laterolateral neutro, laterolateral em hiperextensão, laterolateral em hiperflexão e ventrodorsal. A opacificação do espaço subaracnóide, a confecção de duas linhas de contraste e a formação de artefatos foram mensurados qualitativamente e depois seu grau de concordância foi avaliado. Na segunda etapa 20 cadáveres foram divididos em dois grupos: o primeiro grupo foi submetido à corpectomia da terceira vértebra cervical, enquanto o segundo grupo à corpectomia da quinta vértebra cervical. Previamente ao procedimento cirúrgico, os cadáveres foram submetidos a um exame mielográfico. Posteriormente foram realizados exames radiográficos seriados após o procedimento de corpectomia cervical e de estabilização vertebral. As projeções radiográficas utilizadas foram as mesmas supracitadas. O diâmetro da medula espinhal foi medido ao longo do canal medular e correlacionado com o comprimento do assoalho vertebral. A corpectomia e a estabilização vertebral alteraram significativamente o diâmetro do canal medular apenas em posições de estresse, permitindo supor que a corpectomia vertebral cervical é um método viável de descompressão medular para a região cervical em cães, proporcionando um acesso adequado ao canal medular do corpo vertebral com mínima manipulação do tecido nervoso. / The aim of this paper is to report the implication of the cervical vertebral corpectomy in the myelography medullary diameter in canine cadavers. In order to standardize the myelograph technique thirty canine bodies were used. The subaracnoid space opacification, the visualization of contrast columns and artifact formation were evaluated in four radiographic projections: laterolateral in neutral position, laterolateral in hyperflexion, laterolateral in hyperextension and ventrodorsal in neutral position. The agreeing ratio was measured. Thereafter, twenty specimens were divided in two groups according to the cervical vertebra in which the procedure would be performed. In the first group the corpectomy was performed in the third cervical vertebrae and in the second group in the fifth vertebrae. Before the surgical procedure, a myelogram was performed. Radiograph exams were done after the corpectomy and after the instrumentation of the cervical spine. The same projections previously described were used. The medullary diameter was measured through the spinal canal. Afterwards, it was correlated to the length of the vertebral floor. The corpectomy and cervical instrumentation changed the medullar diameter solely in stress positions. In addition, it granted proper vertebral channel access with minimal spinal cord manipulation. Therefore, we concluded that the cervical vertebral corpectomy is a viable decompressive surgical technique.